Ultrafast Electron-Electron Scattering in Metallic Phase of 2H-NbSe_{2} Probed by High Harmonic Generation

Electron-electron scattering on the order of a few to tens of femtoseconds plays a crucial role in the ultrafast electron dynamics of conventional metals. When mid-infrared light is used for driving and the period of light field is comparable to the scattering time in metals, unique light-driven states and nonlinear optical responses associated with the scattering process are expected to occur. Here, we use high-harmonics spectroscopy to investigate the effect of electron-electron scattering on the electron dynamics in thin film 2H-NbSe_{2} driven by a mid-infrared field. We observed odd-order high harmonics up to 9th order as well as a broadband emission from hot electrons in the energy range from 1.5 to 4.0 eV. The electron-electron scattering time in 2H-NbSe_{2} was estimated from the broadband emission to be almost the same as the period of the mid-infrared light field. A comparison between experimental results and a numerical calculation reveals that competition and cooperation between the driving and scattering enhances the nonperturbative behavior of high harmonics in metals, causing a highly nonequilibrium electronic state corresponding to several thousand Kelvin.

Changes in the composition of molecular species of covalently bound and free ceramides [EOS], and their correlation with disease severity in atopic dermatitis

Ceramides are major constituents of stratum corneum (SC) intercellular lipids involved in skin barrier function. The ratio of molecular species of ceramides and their correlation with disease severity was examined in patients with atopic dermatitis (AD). Thirty-eight patients with AD and 32 healthy controls (HCs) were assessed for transepidermal water loss, SC collection and clinical assessment. The ceramide content of different molecular species in the samples was quantified using high-performance liquid chromatography coupled with tandem mass spectrometry. Unsaturated acyl chains of both covalently bound and free ceramides [EOS] were higher in AD lesional skin than those in AD non-lesional or normal HC skin. The proportion of unsaturated acyl chains (C30:1, C32:1 and C34:1) was higher than other ceramide molecular species among covalently bound and free ceramides [EOS] in patients with AD. The proportion of unsaturated acyl chains in covalently bound ceramides was positively correlated with transepidermal water loss (r = 0.600) when considering the total number of non-lesional and lesional skin. Additionally, thymus and activation-regulated chemokine (TARC) showed a positive correlation with unsaturated acyl chains proportion in AD non-lesional (r = 0.676) and lesional (r = 0.503) skin. Our study is the first to show the increase in unsaturated acyl chains of both covalently bound and free ceramides [EOS] in lesional and non-lesional skin in AD for each molecular species. This increase is associated with dryness and impaired barrier function, which correlates with TARC levels, a marker for the degree of type 2 inflammation. We speculate that type 2 inflammation exacerbation leads to abnormal epidermal lipid metabolism in the skin of patients with AD.

Dosimetric Comparison of Nodal Clinical Target Volume for Locally Advanced Non-Small Cell Lung Cancer: Options for Geometric Expansion vs. Lymph Node Stations

PURPOSE/OBJECTIVE(S)

We investigated whether dosimetric differences existed in nodal clinical target volume (CTV) using options for geometric expansion and lymph node stations based on the European Society for Radiotherapy and Oncology (ESTRO) guideline for locally advanced non-small cell lung cancer (NSCLC).

MATERIALS/METHODS

With treatment planning computed tomographic images in 17 patients who underwent radiotherapy for cT4N2M0 NSCLC from 2017 to 2022 at our institution, we retrospectively contoured nodal CTVs based on the guideline's options of: (1) geometric expansion, CTV including the nodal gross tumor volume plus 5 mm margin: (2) lymph node stations, CTV including the affected lymph node stations. The 5 mm margins for planning target volume (PTV) were added to the nodal and primary tumors' CTVs. Treatment planning of 60 Gy in 30 fractions to the PTV D50% was performed using volumetric modulated arc therapy; Dn% was irradiated dose to n% of volume of the structure; VnGy was percentage of volume of the structure at least irradiated n Gy. We compared dose-volume parameters between the two options using Wilcoxon rank sum test.

RESULTS

Primary tumors were located in the right and left lobes in 12 and five patients, and in the upper and lower lobes in 13 and four patients, respectively. Median PTV size/D95% of the options for geometric expansion and lymph node stations were 569 cc (range, 149-2005 cc)/58.2 Gy (range, 57.5-58.7 Gy) and 635 cc (range, 184-2109 cc)/58.1 Gy (range, 57.5-58.7 Gy), respectively. Median mean dose of the esophagus/heart in the two options were 12.2 Gy (range, 6.6-24.9 Gy)/3.3 Gy (range, 0.6-19.1 Gy) and 16.1 Gy (range, 13.6-30.5 Gy)/4.6 Gy (range, 0.7-18.9 Gy), respectively. Median V20 Gy/mean dose of the lungs in the options for geometric expansion and lymph node stations were 20.5% (range, 14.8-33.9%)/12.2 Gy (range, 8.7-18.4 Gy) and 24.0% (range, 15.1-36.7%)/13.5 Gy (range, 9.5-19.4 Gy), respectively. In the eight patients (47%) with lymph node metastases in stations 2 or 3, a significant dosimetric difference between the two options existed on V20 Gy of the lungs; median values of the difference were 2.8% and 0.5% with and without lymph node metastases in stations 2 or 3, respectively (p = 0.027).

CONCLUSION

Of the ESTRO guideline for the nodal CTV, using the option for geometric expansion might be able to reduce V20 Gy of the lungs in patients with lymph node metastases in stations 2 or 3.

Evaluation of the Possibility of Dose Realignment Adaptation by Shifting the Isocenter in Proton Beam Therapy for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

In pancreatic cancer, a tumor is surrounded by the gastrointestinal (GI) tract, which is subject to changes in location, shape, and contents. Due to these inter-fractional changes, proton beam therapy (PBT) for pancreatic cancer may result in unintentionally high doses to the GI tract. Daily adaptive re-planning can solve this problem, but is not yet established with PBT due to its resource intensive characteristics. This study aims to evaluate the GI tract dose using weekly computed tomography (CTw) and the possibility of dose realignment adaptation by shifting the isocenter (IC) of the PBT plan, which does not require re-planning.

MATERIALS/METHODS

We retrospectively analyzed 6 consecutive patients with unresectable pancreatic cancer treated with real-time-image gated PBT using a fiducial marker. The planning CT was scanned at the natural expiration of respiration and a PBT plan of 60 GyE in 25 fractions (baseline plan, PLANbase) was created. The CTw images were acquired the day before start of PBT and once a week during the PBT course thereafter. The PLANbase was rigidly transferred to the CTw based on the relationship between the three-dimensional coordinates of the fiducial marker and those of the IC in the PLANbase. The PLANeval was created by recalculating the PLANbase on the CTw. We evaluated the doses to the stomach, duodenum, and intestines in the PLANeval according to the following criteria: Dmax of the stomach < 60 GyE, duodenum and intestines < 55 GyE, and D1cc of the stomach < 55 GyE, duodenum and intestines < 54 GyE. In addition, we investigated the GI tract dose realignment adaptation for the PLANeval with its IC shifted 2mm, 4mm, and 6mm in each of 6 directions (right, left, ventral, dorsal, cranial, and caudal), respectively.

RESULTS

A total of 35 PLANeval were created for the CTw. In the PLANbase of the 6 patients, the average of Dmax and D1cc of the stomach, duodenum and intestines were 50.7 GyE (range, 46.7-53.6) and 50.0 GyE (45.0-53.2), 49.2 GyE (44.3-51.7) and 48.8 GyE (43.7-51.5), and 49.2 GyE (44.8-52.0) and 48.9 GyE (44.6-51.8), respectively. In the PLANeval, the average of Dmax and D1cc of the stomach, duodenum, and intestines were 53.3GyE (43.8-61.4) and 52.8 GyE (43.2-61.1), 51.0 GyE (36.1-60.0) and 50.3 GyE (35.4-59.8), and 52.5 GyE (36.6-61.0) and 51.9 (34.4-60.9) GyE, respectively. Twenty-two of the 35 PLANeval (63 %) did not meet at least one of the GI tract dose criteria. In 11 of 22 PLANeval with higher doses to the GI tract, the IC shift resulted in GI dose reductions and all dose criteria were met. The minimum amount of the IC shift required to meet the criteria was 2 mm for 8 plans and 4 mm for 3 plans. The remaining 11 PLANeval did not meet the criteria using dose realignment adaptation by shifting the isocenter.

CONCLUSION

Adaptive replanning is necessary for PBT for pancreatic cancers due to excessive GI tract doses in more than 60% of the plans. Dose realignment adaptation by shifting the IC, which does not require re-planning, may be an option in adaptive treatment strategies.

A Risk Prediction Model for Severe Radiation Induced Lymphopenia in Patients with Pancreatic Cancer Treated with Concurrent Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

In pancreatic cancer, radiation induced lymphopenia (RIL) is associated with a poor prognosis. However, normal tissue complication probability (NTCP) models predicting RIL in pancreatic cancer treated with concurrent chemoradiotherapy (CCRT) have yet to be developed. This study aims to develop a least absolute shrinkage and selection operator (LASSO)-based multivariate NTCP model to predict severe RIL in patients with pancreatic cancer during CCRT and to validate the model internally.

MATERIALS/METHODS

We retrospectively reviewed patients with localized pancreatic cancer who underwent CCRT using three-dimensional conformal radiation therapy from 2013 to 2021. The exclusion criteria were patients with distant metastasis; patients who did not complete RT due to tumor progression; patients who did not have absolute lymphocyte count (ALC) data available before or during RT. An ALC of < 0.5 K/μL during CCRT was defined as severe RIL. A NTCP model of severe RIL was developed by LASSO-based multivariate analysis. We used age, sex, Karnofsky performance status, maximum tumor size, carbohydrate antigen 19-9 level before RT, ALC before RT, volume of planning target volume (PTV), and dosimetric parameters for surrounding organs (including spleen, vertebrae, liver, bilateral kidneys, gastrointestinal tracts) as variables for LASSO. In addition, internal validation was performed by the bootstrap method. The predictive performance of the model was evaluated by the area under the curve (AUC) of the receiver operating characteristic curve and scaled Brier score.

RESULTS

Of the 131 patients included in the study, the median age was 68 years (range, 42-84), and 55% were male. The median ALC before RT was 1.37 K/µL (0.52-3.50). The median PTV volume was 315.4 ml (86.3-1079.3). The median dose of radiotherapy was 50.4 Gy (16.2-50.4), with 1.8 Gy per fraction. Combination chemotherapy was S-1 in 99 cases (75.6%) and gemcitabine in 32 cases (24.4%). Induction chemotherapy before CCRT was performed in 39 patients (29.8%). Severe RIL was observed in 84 (63.6%) patients. The LASSO showed that low baseline ALC (p = 0.0002), large PTV volume (p < 0.0001), and a large kidney V5 defined as the percentage of bilateral kidneys receiving 5 Gy or more (p = 0.0338) were selected as parameters of the prediction model for severe RIL (AUC = 0.917) and scaled Brier score was 0.511. As a result of internal validation by the bootstrap method, the average AUC was 0.918 (95% confidence interval, 0.849-0.954).

CONCLUSION

Severe RIL occurred frequently during CCRT for pancreatic cancer, and a NTCP model for severe RIL developed and validated internally in this study showed good predictive performance. External validation is needed before this NTCP model can be used as a benchmark for treatment planning to reduce the risk of severe RIL and for considering future treatment approaches.

Durvalumab with or without tremelimumab versus the EXTREME regimen as first-line treatment for recurrent or metastatic squamous cell carcinoma of the head and neck: KESTREL, a randomized, open-label, phase III study

BACKGROUND

Patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) have a poor prognosis. The phase III KESTREL study evaluated the efficacy of durvalumab [programmed death-ligand 1 (PD-L1) antibody] with or without tremelimumab [cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibody], versus the EXTREME regimen in patients with R/M HNSCC.

PATIENTS AND METHODS

Patients with HNSCC who had not received prior systemic treatment for R/M disease were randomized (2 : 1 : 1) to receive durvalumab 1500 mg every 4 weeks (Q4W) plus tremelimumab 75 mg Q4W (up to four doses), durvalumab monotherapy 1500 mg Q4W, or the EXTREME regimen (platinum, 5-fluorouracil, and cetuximab) until disease progression. Durvalumab efficacy, with or without tremelimumab, versus the EXTREME regimen in patients with PD-L1-high tumors and in all randomized patients was assessed. Safety was also assessed.

RESULTS

Durvalumab and durvalumab plus tremelimumab were not superior to EXTREME for overall survival (OS) in patients with PD-L1-high expression [median, 10.9 and 11.2 versus 10.9 months, respectively; hazard ratio (HR) = 0.96; 95% confidence interval (CI) 0.69-1.32; P = 0.787 and HR = 1.05; 95% CI 0.80-1.39, respectively]. Durvalumab and durvalumab plus tremelimumab prolonged duration of response versus EXTREME (49.3% and 48.1% versus 9.8% of patients remaining in response at 12 months), correlating with long-term OS for responding patients; however, median progression-free survival was longer with EXTREME (2.8 and 2.8 versus 5.4 months). Exploratory analyses suggested that subsequent immunotherapy use by 24.3% of patients in the EXTREME regimen arm contributed to the similar OS outcomes between arms. Grade 3/4 treatment-related adverse events (TRAEs) for durvalumab, durvalumab plus tremelimumab, and EXTREME were 8.9%, 19.1%, and 53.1%, respectively.

CONCLUSIONS

In patients with PD-L1-high expression, OS was comparable between durvalumab and the EXTREME regimen. Durvalumab alone, and with tremelimumab, demonstrated durable responses and reduced TRAEs versus the EXTREME regimen in R/M HNSCC.

Multicentric Carpotarsal Osteolysis: a Contemporary Perspective on the Unique Skeletal Phenotype

PURPOSE OF REVIEW

Multicentric carpotarsal osteolysis (MCTO) is an ultra-rare disorder characterized by osteolysis of the carpal and tarsal bones, subtle craniofacial deformities, and nephropathy. The molecular pathways underlying the pathophysiology are not well understood.

RECENT FINDINGS

MCTO is caused by heterozygous mutations in MAFB, which encodes the widely expressed transcription factor MafB. All MAFB mutations in patients with MCTO result in replacement of amino acids that cluster in a phosphorylation region of the MafB transactivation domain and account for a presumed gain-of-function for the variant protein. Since 2012, fewer than 60 patients with MCTO have been described with 20 missense mutations in MAFB. The clinical presentations are variable, and a genotype-phenotype correlation is lacking. Osteolysis, via excessive osteoclast activity, has been regarded as the primary mechanism, although anti-resorptive agents demonstrate little therapeutic benefit. This paper appraises current perspectives of MafB protein action, inflammation, and dysfunctional bone formation on the pathogenesis of the skeletal phenotype in MCTO. More research is needed to understand the pathogenesis of MCTO to develop rational therapies.

Role of glycerophosphodiester phosphodiesterase in rice leaf blades in elevated CO2 environments

Glycerophosphodiester phosphodiesterase (GDPD; EC 3.1.4.46) is involved in plant phosphate (Pi) utilization and its expression is upregulated under phosphorus (P)-deficient conditions. Although rice was grown under P-sufficient conditions, the transcript levels of specific OsGDPD were upregulated in mature rice leaf blades (LB) in elevated CO₂ (eCO₂ ) environments. Expression and subcellular localization of GDPD, and contents of Pi, sugar phosphates and carbohydrates were analysed to clarify the physiological function of GDPD in rice under eCO₂ . Under eCO₂ , expression of specific OsGDPD increased only in mature rice LB in which low Pi concentrations were observed. Moreover, eCO₂ -induced OsGDPD2 and OsGDPD3 were localized in the plastid, indicating that GDPD2 and GDPD3 may be related to plastidic functions, such as carbon assimilation. Although rice LB contained more carbohydrates under eCO₂ than under ambient CO₂ , the phosphoglucose content decreased under eCO₂ , suggesting that the need for excess phosphoglucose to synthesize carbohydrates under eCO₂ causes a local Pi deficiency. Furthermore, we confirmed that glycerol-3-phosphate produced by the catalysis of GDPD from glycerophosphodiester contributes to carbohydrate accumulation in rice LB. Our findings suggest that local Pi deficiency due to excess carbohydrate accumulation under eCO₂ influences GDPD to enhance glycerophosphodiester hydrolysis.

Diversity in the characteristics of spontaneous ruptured aortic plaques

Background

Spontaneous ruptured aortic plaques (SRAPs) act as emboli for systemic organs because SRAPs might contain CCs which cause inflammation besides mechanical obstruction. The purpose of the study is to clarify the difference of the characteristics of representative SRAPs, puff rupture and puff-chandelier rupture sampled by non-obstructive general angioscopy. (NOGA)

Methods

A total of 177 puff-chandelier ruptures which blown out spontaneously and glittered against the light of the angioscopic fiber and 105 puff ruptures which did not glitter were sampled by NOGA in patients having or suspected coronary artery disease. Sampled plaques were analyzed two kinds of methods, conventional Hematoxylin-eosin stain and methods without solvents. Samples were diagnosed if the component of atheroma was detected with either method. The percentage of content of CCs, the number of CCs, the longer and shorter diameters were compared between blood sampled from puff and puff-chandelier rupture.

Results

Samples were diagnosed as atheroma 56% of puff-chandelier rupture and 27% of puff- rupture. (p&lt;0.0001) Higher number of CCs was included in puff-chandelier rupture than in puff-rupture. (12,955 [3,977, 25,795] vs. 3,182 [909, 7,273]) The longer and shorter diameters of plaque components of puff rupture were smaller than those of puff-chandelier rupture. (p=0.0259 and p=0.0286, respectively.) CCs were tended to be included puff-chandelier rupture than puff-rupture. (53% vs. 16%, respectively; p&lt;0.0001) Visible debris was obtained only 13% of puff rupture and 26% of puff-chandelier rupture.

Conclusions

Diversity of SRAPs were shown as that puff rupture had less CCs and more fibrin than puff-chandelier rupture, suggesting that potentially less inflammation and more fibrinolytic.

Funding Acknowledgement

Type of funding sources: None.

Effects of liquid diet intake on nerve growth in salivary glands of growing rats

BACKGROUND

The growth of parotid glands is inhibited by liquid diet intake during growing period, while that of submandibular glands is not affected. This study examined how liquid diet intake affects nerve growth in the parotid and submandibular glands of growing rats, because nerves are closely involved in the maintenance of salivary gland structure.

MATERIALS AND METHODS

Male Wistar rats were weaned at 21 days of age. Then, rats were fed a pellet diet and a liquid diet in the control group and experimental group, respectively. At 0, 2, 4, or 8 weeks, they were euthanised by isoflurane overdose, and parotid and submandibular glands were removed. The frozen sections were made and immuno-stained with anti-protein gene product 9.5 (PGP 9.5) antibody (general nerve marker), anti-tyrosine hydroxylase (TH) antibody (sympathetic nerve marker), or anti-neuronal nitric oxide synthase (nNOS) antibody (parasympathetic nerve marker).

RESULTS

In control parotid glands, scattered punctate or short linear patterns of PGP 9.5-positive sites were observed at week 0. After 2 weeks, PGP 9.5-positive sites, some of which were arranged in long linear patterns, increased in number. There were some TH-positive sites at week 0. After 2 weeks, there were increasing numbers of TH-positive sites, often in long linear patterns. At week 0, there were very few nNOS-positive sites, and nNOS immunoreactivity increased over time. After week 4, they demonstrated linear patterns. In the experimental parotid glands, there were fewer PGP 9.5- and nNOS-positive sites than in control parotid glands at each time point, although TH immunoreactivity was similar between two groups at each time point. In control submandibular glands, few punctate exhibited PGP 9.5-positive site were observed at week 0. At week 4, PGP 9.5 immunoreaction increased and showed linear patterns. TH-positive sites demonstrated punctate or short linear patterns at week 0, and thereafter TH immunoreactivity increased and were arranged in long linear patterns. There were few nNOS-positive sites at week 0, and they gradually increased after week 4. The immunoreactivities of all antibodies in the experimental submandibular glands were similar to those in the control at each time point.

CONCLUSIONS

Parasympathetic nerve growth in rat parotid glands was inhibited by liquid diet intake during the growth period, while liquid diet intake did not affect parasympathetic nerve growth nor sympathetic nerve growth in rat submandibular glands.

Pooled analysis of drug-related interstitial lung disease and/or pneumonitis in nine trastuzumab deruxtecan monotherapy studies

Introduction

This pooled analysis of nine phase I and II trastuzumab deruxtecan (T-DXd) monotherapy studies described drug-related interstitial lung disease (ILD)/pneumonitis in patients treated with T-DXd.

Methods

Patients who received T-DXd across nine studies were included. Investigator-assessed ILD/pneumonitis events were retrospectively reviewed by an independent adjudication committee; events adjudicated as drug-related ILD/pneumonitis are summarized.

Results

The analysis included 1150 patients (breast cancer, 44.3%; gastric cancer, 25.6%; lung cancer, 17.7%; colorectal cancer, 9.3%; other cancer, 3.0%). Median treatment duration was 5.8 (range, 0.7-56.3) months, with a median of 4 (range, 1-27) prior lines of therapy. The overall incidence of adjudicated drug-related ILD/pneumonitis was 15.4% (grade 5, 2.2%). Most patients with ILD/pneumonitis experienced low-grade events (grade 1 or 2, 77.4%); 87.0% had their first event within 12 months [median, 5.4 (range, <0.1-46.8) months] of their first dose of T-DXd. Based on data review, adjudicated ILD/pneumonitis onset occurred earlier than identified by investigators for 53.2% of events [median difference in onset date, 43 (range, 1-499) days]. Stepwise Cox regression identified several baseline factors potentially associated with increased risk of adjudicated drug-related ILD/pneumonitis: age <65 years, enrollment in Japan, T-DXd dose >6.4 mg/kg, oxygen saturation <95%, moderate/severe renal impairment, presence of lung comorbidities, and time since initial diagnosis >4 years.

Conclusions

In this pooled analysis of heavily treated patients, the incidence of ILD/pneumonitis was 15.4%, with most being low grade and occurring in the first 12 months of treatment. The benefit–risk of T-DXd treatment is positive; however, some patients may be at increased risk of developing ILD/pneumonitis, and further investigation is needed to confirm ILD/pneumonitis risk factors. Close monitoring and proactive management of ILD/pneumonitis are warranted for all.

•

Interstitial lung disease (ILD)/pneumonitis is a significant adverse event related to trastuzumab deruxtecan (T-DXd).

•

This pooled analysis of nine T-DXd monotherapy studies evaluated ILD/pneumonitis risk in 1150 heavily pretreated patients.

•

Overall incidence of adjudicated T-DXd-related ILD/pneumonitis was 15.4% (grade 1 or 2, 77.4%; grade 5, 2.2%).

•

Within 12 months of their first T-DXd dose, 87.0% of patients had their first event [median, 5.4 (range, <0.1-46.8) months].

•

Proactive monitoring and prompt diagnosis and management are important to improving ILD/pneumonitis event outcomes.

Identification of the amino acid residues involved in the species-dependent differences in the pyridoxine transport function of SLC19A3

Recent studies have shown that human solute carrier SLC19A3 (hSLC19A3) can transport pyridoxine (vitamin B6) in addition to thiamine (vitamin B1), its originally identified substrate, whereas rat and mouse orthologs of hSLC19A3 can transport thiamine but not pyridoxine. This finding implies that some amino acid residues required for pyridoxine transport, but not for thiamine transport, are specific to hSLC19A3. Here, we sought to identify these residues to help clarify the unique operational mechanism of SLC19A3 through analyses comparing hSLC19A3 and mouse Slc19a3 (mSlc19a3). For our analyses, hSLC19A3 mutants were prepared by replacing selected amino acid residues with their counterparts in mSlc19a3, and mSlc19a3 mutants were prepared by substituting selected residues with their hSLC19A3 counterparts. We assessed pyridoxine and thiamine transport by these mutants in transiently transfected HEK293 cells. Our analyses indicated that the hSLC19A3-specific amino acid residues of Gln⁸⁶, Gly⁸⁷, Ile⁹¹, Thr⁹³, Trp⁹⁴, Ser¹⁶⁸, and Asn¹⁷³ are critical for pyridoxine transport. These seven amino acid residues were found to be mostly conserved in the SLC19A3 orthologs that can transport pyridoxine, but not in orthologs that are unable to transport pyridoxine. In addition, these residues were also found to be conserved in several SLC19A2 orthologs, including rat, mouse, and human orthologs, which were all found to effectively transport both pyridoxine and thiamine, exhibiting no species-dependent differences. Together, these findings provide a molecular basis for the unique functional characteristics of SLC19A3 and also of SLC19A2.

The orthostatic hypotension in patients with Stanford type A aortic dissection after surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Orthostatic hypotension (OH) is sometimes observed during cardiac rehabilitation in patients with surgery for aortic dissection. However, little is known about the primary determinant of OH and influence of surgical range on incidence of OH.

Purpose

The aim of this study was to elucidate the incidence of OH in patients with surgery for aortic dissection, and compare it between the patients with ascending aortic replacement surgery (ascending group) and those with ascending aorta and hemiarch or total arch replacement surgery (arch group).

Methods

We analyzed 59 patients who underwent emergent surgery due to Stanford type A aortic dissection from January 2014 to March 2018, and compared the incidence of OH between ascending group (n = 28, age 69.8 ± 11.3 years) and arch group (n = 31, age 64.1 ± 13.0 years).

Results

The incidence of OH in total patients was 30.5%. There were no significant differences in patient characteristics including body tall, body weight, antihypertensive use and progress of rehabilitation between 2 groups. The arch group showed a significant higher incidence of OH as compared with ascending group (arch group: 46.4% vs. ascending group: 16.1%, p = 0.03). Moreover, the patients who occurred OH were significantly taller than those who did not occur OH.

Conclusions

OH was observed in about one third of patients with surgery for aortic dissection and it showed a close relationship with patient’s height and the range repaired by surgical operation. More careful cardiac rehabilitation is needed for tall patients with large area replacement of aorta.

Open-label phase II study of the efficacy of nivolumab for cancer of unknown primary

BACKGROUND

Cancer of unknown primary (CUP) has a poor prognosis. Given the recent approval of immune checkpoint inhibitors for several cancer types, we carried out a multicenter phase II study to assess the efficacy of nivolumab for patients with CUP.

PATIENTS AND METHODS

Patients with CUP who were previously treated with at least one line of systemic chemotherapy constituted the principal study population. Previously untreated patients with CUP were also enrolled for exploratory analysis. Nivolumab (240 mg/body) was administered every 2 weeks for up to 52 cycles. The primary endpoint was objective response rate in previously treated patients as determined by blinded independent central review according to RECIST version 1.1.

RESULTS

Fifty-six patients with CUP were enrolled in the trial. For the 45 previously treated patients, objective response rate was 22.2% [95% confidence interval (CI), 11.2% to 37.1%], with a median progression-free survival and overall survival of 4.0 months (95% CI, 1.9-5.8 months) and 15.9 months (95% CI, 8.4-21.5 months), respectively. Similar clinical benefits were also observed in the 11 previously untreated patients. Better clinical efficacy of nivolumab was apparent for tumors with a higher programmed death-ligand 1 expression level, for those with a higher tumor mutation burden, and for microsatellite instability-high tumors. In contrast, no differences in efficacy were apparent between tumor subgroups based on estimated tissue of origin. Adverse events were consistent with the known safety profile of nivolumab. No treatment-related death was observed.

CONCLUSIONS

Our results demonstrate a clinical benefit of nivolumab for patients with CUP, suggesting that nivolumab is a potential additional therapeutic option for CUP.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.

AB0136 ASSESSING THE RELATIONSHIP AMONG OBESITY, GENETIC POLYMORPHISM, AND CLINICAL PARAMETERS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Several study suggested body mass index(BMI) may influence development of rheumatoid arthritis(RA). There are conflicting reports concerning the impact of high BMI on development of RA, but several reports of obese on drug resistance and functional impairment. The relationship of genetic polymorphism on obesity is unclear in RA.

Objectives:

To examine the relationship among BMI, genetic polymorphism of obesity, disease activity of RA, laboratory parameters, and therapeutic agent of RA.

Methods:

We have carried out a retrospective observational study by systematically analyzing medical records of total 289 patients diagnosed with RA in Shinko Hospital between March 2016 and December 2019. We also conducted genotyping single nucleotide polymorphisms (SNPs) including FTO (rs1558902 and rs9939609), UCP1 (rs1800592), ADR2(rs1042713) and ADR3(rs4994) after informed consent. Obesity was defined as BMI over than 25 and patients were divided between obese (“Ob”) and non-obese (“non-Ob”). These SNPs, DAS28CRP, laboratory parameters, methotrexate dose, use of biological DMARDs were compared between Ob and non-Ob patients.

Results:

Of these 289 patients, 82.7% was female, mean age was 61.9 years and BMI was 22.4. Univariate logistic regression showed differences (p<0.1) between Ob and non Ob groups in UCP1 gene mutation(63.6% vs 78%, P=0.018), DAS(2.24 vs 1.99, P=0.033),triglyceride abnormality(23.8% vs 9.3%, P=0.021), HDL(56 vs 71, P=0.00009), HbA1c abnormality(26.5% vs 12.1%, P=0.019),γGTP(32 vs 21, P=0.00037), ALP (253 vs 230, P=0.0058), ALT (26.5 vs 20, P=0.029),and MTX dose(6 vs 8, P=0.066). Multivariate logistic regression showed that Ob group was significantly associated with HDL(OR=0.976, 95%CI 0.958 to 0.995), UCP1 gene mutation(OR=0.446, 95%CI 0.202 to 0.984), γGTP(OR=2.321, 95%CI 1.269 to 4.245), and MTX dose(OR=0.866, 0.784 to 0.957).

Conclusion:

Obesity in patients with RA had significant positive correlation with γGTP, and negative correlation with HDL, UCP gene mutation and MTX dose.

Disclosure of Interests:

None declared

POS0868 THE FORMULA TO PREDICT TACROLIMUS CONCENTRATION ACCORDING TO GENOTYPING OF CYP3A5 IS USEFUL FOR EFFECTIVE TREATMENT IN INTERSTITIAL LUNG DISEASE WITH DERMATOMYOSITIS

Background:

Tacrolimus (TAC), an immunosuppressant, can be used in second-line maintenance therapy for interstitial lung disease (ILD) in patients with dermatomyositis (DM) [1]. Although some studies reported the clinical efficacy of initial high-trough levels of TAC in combination with GC and IVCY in induction therapy for severe DM-ILD [2], there have been no useful clinical tools for deciding suitable initial dose of TAC. Genotype of polymorphisms in cytochrome P450 (CYP) 3A5 enzyme was reported to play an important role in pharmacokinetics of TAC [3], and we made a formula for deciding initial dose of TAC according to CYP3A5 genotypes in our previous study.

Objectives:

In our previous study (retrospective study), we set the target trough according to the severity for nine DM-ILD patients, six of whom were CYP3A5 *3/*3 and investigated the dose of TAC that could attain the trough using their CYP3A5 genootyping. Using these results, we developed a formula for deciding initial daily dose of TAC (target trough*weight / [(151.1, if CYP3A5 *3/*3) or (86.5, if CYP3A5 *1 allele)]). In this study, we prospectively examined the usefulness and accuracy of this formula.

Methods:

We introduced TAC for new six DM-ILD patients who visited our hospital between November 2019 and May 2020 (prospective study). The starting dose of TAC was decided by using the formula. We assessed the association between predicted and observed trough concentration of TAC at first measurement date (from day 2 to day4), using linear regression analysis. We also assessed the days for attaining the target trough concentration between the patients using the formula (prospective group) and six patients with CYP3A5 *3/*3 (retrospective group).

Results:

CYP3A5 genotype of all six DM-ILD patients were *3/*3 and underwent the TAC treatment by using the formula. The predicted and observed trough concentration of first measurement date were significantly correlated in the patients (r 2= 0.897, p=0.0041) (Fig.1). Compared with our retrospective study, target trough was more quickly attained in patients of the prospective study (Fig.2).

Conclusion:

The formula which we made for attainment target trough concentration based on CYP3A5 genotype was useful for deciding the starting dose of TAC. We also showed that we could attain the target trough concentration at early stage of initial treatment by using the formula.

References:

[1]Oddis CV and Aggarwal R. Nat Rev Rheumatol 2018;14(5):279-89.

[2]Suzuka T et al. Int J Rheum dis 2019;22: 303-13.

[3]Y. Muraki et al. Exp Ther Med 2018;15:532-38.

Figure 1.

Correlation of predicted and observed tacrolimus trough concentration at first measurement in the prospective study

Figure 2.

Days to attain the target trough concentration of tacrolimus in the prospective group and the retrospective group

Disclosure of Interests:

None declared

Conduction gaps after pulmonary vein isolation due to high contact force ablation in patients with atrial fibrillation

Background

Catheter ablation for atrial fibrillation (AF) with high contact force (CF) has been reported to lead to the gaps after pulmonary vein isolation (PVI), and the appearance of the gaps depends on the site in the left atrium (LA).

Purpose

The aim of this study is to clarify the relationship between the gaps appearance and high CF.

Methods

In the clinical study, 74 consecutive patients (39 males, age 71±9, 46 with paroxysmal AF) underwent conventional PVI with a point-by-point radiofrequency (RF) ablation using a CF sensing catheter (TactiCath SETM). RF energy (J), number of RF point, Lesion index (LSI), force-time integral (FTI), average CF (g), and the degree of LA depression with high CF were evaluated. In the experimental study (figure), the relationship between the ablation area and the degree of depression with high CF using bovine left ventricular wall.

Results

In the clinical study, the gaps were found in 175 of 1182 sites after first path PVI ablation. The CF in the gap sites was higher than without the gap sites in RPV roof, anterior RSPV and anterior RPV carina (18.9±6.8 vs 15.0±5.7g p=0.0262, 26.4±11.6 vs 19.5±6.0g p=0.0029, 22.7±6.4 vs 19.1±5.5g, p=0.0161). Meanwhile, there were no differences in RF energy, number of RF point, LSI, FTI. High CF (≥30g) showed a depression of 3 mm or more in only RPV roof and anterior RPV (figure). In the experimental study, the ablation range narrowed as the indentation deepened with more than 30g CF (r=0.6417, p=0.0625).

Conclusion

Catheter ablation for AF with high contact force might lead to the gaps in RPV roof and anterior RPV site by the reduction of the ablation area due to depression caused by the pressure.

Extension of each contact force

Funding Acknowledgement

Type of funding source: None

Sex-related differences in geometry, plaques and shear stress related plaque-progression in human coronary arteries

Background

Atherosclerosis manifests itself differently in women compared to men. Since the pathophysiology of atherosclerotic plaques is known to be related to endothelial shear stress (ESS), it was hypothesized that female compared to male coronary arteries demonstrate a different i) ESS and ii) ESS related plaque progression.

Methods

1183 coronary arteries (male/female:944/239) from the PREDICTION trial were studied for differences in vessel geometry (plaque area (PA) and lumen area (LA)), hemodynamic parameters (flow, minimal ESS over 90 degree arc (minESS) and maximal ESS over 90 degree arc (maxESS)) and ESS related plaque progression (1 year follow up) measured as change in maximal plaque thickness and plaque burden comparing female to male arteries. Arterial geometry and ESS measures were derived from IVUS-based vascular profiling and reported per 3 mm segments. For plaque progression studies minESS was subdivided into low, mid and high (&lt;1,1–1.7,&gt;1.7 Pa). To test statistical differences univariate anova or linear mixed models were used.

Results

13030 3mm-segments (m/f: 10.465/2565) were analyzed. Female compared to male coronary arteries were smaller and presented with less plaque area (Table I). No differences in average ESS, minESS and maxESS were found for male versus female coronary arteries, partly explained by the lower flows in female arteries (Table I). The ESS-related plaque growth showed for both sexes an significant inverse relationship between maximal wall thickness (Figure, left) and plaque burden (Figure, right) and the three minESS categories. However, ESS-related plaque growth was not different for male vs females.

Conclusion

Our data demonstrated that vessel and plaque size are smaller in female compared to male coronary arteries. However, ESS and ESS related plaque progression were not different.

Shear stress related plaque progression

Funding Acknowledgement

Type of funding source: None

Coronary plaque natural history displays significant longitudinal heterogeneity along the length of individual coronary plaques

Background

The natural history of plaque growth is, among other systemic risk factors, related to the blood flow induced local shear stress. Especially at regions of low shear stress plaques are initiated. Upon plaque encroachment into the lumen, plaques will be exposed to high shear stress. Interestingly, it has been observed that individual plaques are very heterogeneous regarding the local shear stress exposure and remodeling patterns along the plaque length. However no information is available on the spatial heterogeneity of temporal changes in plaques burden. We studied the longitudinal spatial heterogeneity of plaque burden progression, regression, quiescence in human coronary plaques.

Methods

591 coronary arteries from 302 patients with coronary artery disease who presented with an acute coronary syndrome from the PREDICTION study were investigated for local plaque progression, regression, quiescence patterns after 6–10 months follow up. Arterial geometry was derived from angiography/IVUS-based vascular profiling and reported in 3 mm segments. Plaques were defined as &gt;3 consecutive segments with maximal wall thickness&gt;0.5 mm. Plaque progression was defined as &gt;5% increase, regression as &lt;−5% decrease, and quiescence as no change in plaque burden (plaque area/ total vessel area * 100%). Logistic mixed model regression analysis was performed with plaque progression features as outcome and plaque length as independent variable with vessel as random factor to account for clustering of the data.

Results

5658 3mm-segments of 661 plaques were analyzed. Plaque burden changes over time ranged from −22% to +20%, with an average of −0.4%±4% which was not significant different from 0. Among all plaques, 56% showed segments with plaque progression of more than 5%, 60% with plaque regression (&lt;−5%) and 96% of the plaques had segments that did not change over time (quiescence). On average, 17% of the plaque length displayed plaque progression, 20% regression and 63% was quiescent. The presence and number of features (progression, regression, quiescence) within the plaque were significantly related to the plaque length (figure).

Conclusion

Plaques are very heterogeneous in plaque progression patterns. Most of the plaques show within the plaque length simultaneously more than one plaque progression feature (segments that do not change in plaque burden, segments that regress or progress). The number of observed plaque progression features was related to the plaque length.

Funding Acknowledgement

Type of funding source: None

Chronotropic incompetence and exercise capacity after mitral valve surgery: the importance of blood hemoglobin level

Background

Chronotropic incompetence (CI) is sometimes observed during exercise training of cardiac rehabilitation in patients with cardiac surgery, however, little is known concerning the differences between patients with mitral valve (MV) and aortic valve (AV) surgery.

Purpose

Because the possibility exists that cardiac sympathetic nerves might be impaired by left atrium incision, we hypothesized that the incidence of CI was higher in patients with MV surgery (Mitral Valve Replacement and Mitral Valvuloplasty) as compared with patients with AV surgery (Aortic Valve Replacement). And if so, which factor determines the exercise capacity of patients after MV surgery. We thus aimed this study to elucidate the hypothesis with cardiopulmonary exercise testing (CPX).

Methods

We performed CPX by ramp loading with ergometer exercise in total 61 patients who had undergone elective cardiac valve operation (25 patients with MV surgery, age 59.2±9.9 years; 36 patients with AV surgery, age 64.6±12.3 years). We analyzed chronotropic response index (CRI), peak oxygen uptake (peak VO2/W), anaerobic threshold (AT), and peak oxygen pulse (peak VO2/HR) with CPX, and blood hemoglobin concentration (Hb).

Results

The value of CRI was significantly decreased in the patients with MV surgery compared with those with AV surgery (MV; 0.19±0.10 vs. AV; 0.41±0.17, p&lt;0.001). Peak VO2, peak VO2/HR and Hb were not significantly different between patients with MV and those with AV surgery. Patients with MV surgery showed correlations between peak VO2 and Hb (r=0.45, p&lt;0.05), AT and Hb (r=0.52, p&lt;0.01), and a strong correlation between peak VO2 and peak VO2/HR (r=0.63, p&lt;0.001), but not in those with AV surgery.

Conclusions

The present study demonstrated that higher incidence of CI was shown in patients with MV surgery as compared with those with AV surgery. The exercise capacity of patients with MV surgery was determined by peak VO2/HR and Hb. These results suggest that 1) left atrium incision impairs cardiac sympathetic nerves and causes CI, 2) peak VO2/HR which is consisted of arterio-venous oxygen difference and Hb is critical indicator for exercise capacity in patients with MV surgery with CI.

Main results

Funding Acknowledgement

Type of funding source: None

The natural course of the paravertebral muscles after the onset of osteoporotic vertebral fracture

This study revealed the change in the paravertebral muscles in patients with osteoporotic vertebral fracture. Increased pain is likely to be the driver for reduced activity, reduced activities of daily living, and consequent increase in fat infiltration of the paravertebral muscles, assumed to be secondary to reduced activity level or, conversely, partial immobilization.

INTRODUCTION

To reveal the time courses and impact of the paravertebral muscles (PVMs) on the healing process of osteoporotic vertebral fractures and risk factors for PVM decrease.

METHODS

Consecutive patients with symptomatic osteoporotic vertebral fractures were enrolled in 11 hospitals. At enrollment and 3- and 6-month follow-up, PVMs, including the multifidus and erector spinae, were examined using magnetic resonance imaging (MRI). The PVM cross-sectional area (CSA) and fat signal fraction (FSF) were measured at L3. Low back pain (LBP), activities of daily living (ADLs), and risk factors for PVM decrease at the 6-month follow-up were investigated. PVM decrease was defined as > 1 standard deviation decrease of the CSA or > 1 standard deviation increase of the FSF.

RESULTS

Among 153 patients who completed the 6-month follow-up, 117 (92 women, 79%) had MRI of L3 at enrollment and 3- and 6-month follow-up (mean age at enrollment, 78.5 years). The CSA did not change 6 months from onset (p for trend = 0.634), whereas the FSF significantly increased (p for trend = 0.033). PVM decrease was observed in 30 patients (26%). LBP was more severe, and delayed union was more frequent in patients with PVM decrease (p = 0.021 mixed-effect model and p = 0.029 chi-square test, respectively). The risk factors for PVM decrease were ADL decline at the 3-month follow-up (adjusted odds ratio = 5.35, p = 0.026).

CONCLUSION

PVM decrease was significantly related to LBP and delayed union after osteoporotic vertebral fracture onset. ADL decline at the 3-month follow-up was a risk factor for PVM decrease. Therefore, restoring ADLs within 3 months after onset is important.

FRI0129 DEVELOPMENT OF A PREDICTION MODEL FOR MAXIMUM METHOTREXATE (MTX) DOSE WITHOUT HEPATOTOXICITY USING AN INDEX OF ERYTHROCYTE MTX-POLYGLUTAMATE (MTXPG) LEVELS SPECULATED BY CLINICAL AND GENETIC MARKERS

Background:

MTX is transported into cells and retained long after polyglutamation. MTXPG level can predict response and possibly adverse effects of MTX. We reported erythrocyte MTXPG concentrations efficiently discriminated patients with and without hepatotoxicity1. We also developed genetic and clinical prediction models for efficacy and hepatotoxicity of MTX2. In the present study, we firstly investigated the effects of clinical and secondly genetic variables on the concentration of total MTXPG and determined oral maximum MTX dose without hepatotoxicity using these variables.

Objectives:

To develop a prediction model for maximum MTX dose without hepatotoxicity.

Methods:

Concentrations of erythrocyte MTX-PG (PG1 to PG4) were detected by LC-MS/MS and calculated total MTXPG as sum of them. MTX-PGn levels were measured in 265 RA patients including 40 patients with elevated AST or ALT (≥ 60 U/L; 1.5 times of upper limits) and the 6 SNPs of 6 gens related to MTXPG metabolism were identified by RT-PCR.

Results:

Total concentrations of MTXPG were 141.3 ± 86.5 and 87.6 ± 47.8 nmol/L (mean±SD) in 40 RA patients with hepatotoxicity and 225 patients without, respectively (p<0.0001). By ROC analysis, the two groups were most efficiently discriminated with cutoff concentration of 100.0 nmol/L (AUC 0.731). Next, genetic and clinical model to speculate the MTXPG concentration was established by multivariate analysis using 4 clinical and 3 genetic variables which were selected from 20 clinical and 6 genetic variables by univariate analysis (p<0.1). Finally, a speculation model for MTXPG concentration by 4 clinical variables (MTX dose, BMI, RBC count, and creatinine) and one genetic variable (GGH c.452C>T) was developed (Figure). When MTXPG concentration of 100 nmol/L was applied to the model, maximum MTX dose without hepatotoxicity was calculated for each patient asMTX dose (mg) = {100 (MTXPG) – 96 + 1.7*BMI + 28*RBC - 120*creatinine - 19.3*GGH(C/T)} / 7.7. Real dose of oral MTX exceeded the calculated dose in 23 of 40 patients (57.5%) with hepatotoxicity, whereas it exceeded in 95 of 223 patients (42.6%) without hepatotoxicity (OR 1.82, p=0.081).

Conclusion:

Maximum MTX dose without hepatotoxicity was speculated by several clinical and genetic markers without measurement of erythrocyte MTX-PG concentrations.

References:

[1]Takahashi M, et al: Clinical Pathology (Rinsho Byori), 67:433-442, 2019.

[2]Onishi A, et al: The Pharmacogenomics J, doi.org/10.1038/s41397-019-0134-9, 2019

Disclosure of Interests:

Shunichi Kumagai Grant/research support from: Astellas, Chugai, Mitsubishi Tanabe Co.Ltds, Consultant of: Sysmex Co.Ltd, Speakers bureau: many companies, Soshi Takahashi: None declared, Miho Takahashi: None declared, Toshiharu Saito: None declared, Katsuyuki Yoshida: None declared, Motoko Katayama: None declared, Saki Mukohara: None declared, Norihiko Amano: None declared, Akira Onishi Speakers bureau: AO received a speaker fee from Chugai, Ono Pharmaceutical, Eli Lilly, Mitsubishi-Tanabe, Asahi-Kasei, and Takeda, Masakazu Shinohara: None declared, Saori Hatachi: None declared

SAT0011 COMBINED INHIBITION OF AUTOPHAGY AND GLUTAMINE METABOLISM SUPPRESSES CELL GROWTH OF RA SYNOVIOCYTES AND AMELIORATES ARTHRITIS IN SKG MICE

Background:

Immunometabolism is now recognaized to be crucial in the pathogenesis of rheumatoid arthritis (RA). We have recently shown that the expression of glutaminase 1 (GLS1), a key enzyme in glutaminolysis, is upregulated in fibroblast-like synoviocytes from RA patients (RA-FLS) and that GLS1 inhibition suppresses RA-FLS proliferation (1). However, glutaminolysis has been known to suppress autophagy by activating mTORC1 or counteracting ROS production (2). Given the possibility of autophagy upregulation following glutamiolysis inhibition, therapies targeting both autophagy and glutaminolysis may be more effective in suppressing cell growth of RA-FLS, yet the relation between glutaminolysis and autophagy in RA-FLS has not been investigated.

Objectives:

To examine the effects of inhibiting both glutaminolysis and autophagy on RA-FLS and autoimmune arthritis in SKG mice.

Methods:

GLS1 inhibitor, compound 968 (C968), was used to suppress glutaminolysis, and Chloroquine (CQ) was used to inhibit autophagy. To detect autophagy, the expression of ATG5 and LC3B was measured by real-time PCR and the production of LC3-II was analyzed by Western blotting. The formation of autophagic vacuoles was identified by immunfluorescense. Cell growth was evaluated by BrdU assay. Apoptosis was analyzed by flow cytometry staining with Annexin V-FITC and PI. C968 and CQ were administered subcutaneously to Zymosan A-injected SKG mice.

Results:

C968 upregulated the expression of ATG5 and LC3B, and increased the protein level of LC3-II in RA-FLS. C968 also facilitated autophagosome formation. These results suggested that inhibition of glutaminolysis promoted autophagy in RA-FLS. The combined treatment with C968 and CQ significantly suppressed cell proliferation of RA-FLS more strongly than did C968 or CQ alone. In addition, C968 combined with CQ increased the apoptosis rate, whereas either C968 or CQ alone did not. Furthermore, combination of C968 and CQ significantly attenuated the degree of arthritis in SKG mice, while C968 or CQ monotherapy did not (Figure).

Conclusion:

The GLS1 inhibitor C968 promotes autophagy in RA-FLS. C968 in combination with CQ reduces proliferation and enhances apoptosis in RA-FLS, and ameliorates the arthritis in SKG mice. Suppressing C968-induced autophagy may be a promising therapy for arthritis.

References:

[1] Takahashi S., et al. Arthritis Res Ther. 2017 Apr 11;19(1):76.

[2] Villar VH., et al. Autophagy. 2015;11(8):1198-208.

Acknowledgments :

None

Disclosure of Interests:

None declared

SAT0154 EXAMINATION OF CYP3A5 GENOTYPE IS USEFUL FOR INTRODUCTION OF TACROLIMUS TREATMENT IN OUTPATIENTS WITH RHEUMATIC DISEASES

Background:

Though several studies showed the efficacy of tacrolimus (TAC) in patients with rheumatoid arthritis (RA) in a dose-depending manner [1], the relationship between efficacy and concentration of TAC remained unclear. Genetic polymorphisms of cytochrome P450 (CYP) 3A5 were reported not only to play an important role in pharmacokinetics of TAC but also to have an influence on clinical outcomes in patients of rheumatic diseases. Several reports showed that the blood concentration of TAC in patients with a CYP3A5 *1 allele (EX, expressor) was lower than that of patients with a CYP3A5 *3/*3 (NEX, non-expressor) [2].

Objectives:

To assess the relationship between efficacy and concentration of TAC in patients with RA, and to examine the usefulness of CYP3A5 genotype screening to detect outpatients suitable for TAC treatment.

Methods:

We examined the relationship between disease activity score (DAS) 28-CRP and concentration of TAC in patients with RA. TAC was taken after the evening meal and blood samples were taken 12±4h after TAC administration. Next we investigated the relationship between genotype frequencies of CYP3A5 and concentration of TAC in patients with rheumatic disease without having renal dysfunction (eGFR<60) and also investigated the influence of concomitant drugs, such as strong inhibitors of CYP3A4/5 or metabolized by CYP3A4/5, to C/D value in each NEX and EX group. The blood concentration of TAC normalized to the corresponding dose per body weight (C/D, ng/ml per mg/kg) was analyzed according to genetic variation in CYP3A5. Furthermore we investigated the relationship between genotype frequencies of CYP3A5 and concentration of TAC in patients with rheumatic disease at first visit and second visit after starting TAC administration to assess the possibility for making rapid attainment of enough concentrations of TAC in early stage of treatment.

Results:

The concentration of TAC tended to be negatively correlated with the disease activity of RA. The C/D value in the NEX group (n=16) was 124.7±62.1, which was significantly higher than that in the EX group (n=23; 67.7±29.8;P<0.001). When comparing patients using concomitant drugs which are strong inhibitors of CYP3A4/5 or metabolized by CYP3A4/5 with patients not using those drugs, the each C/D value of NEX group was 122.9±52.3 (n=9) and 126.9±77.3 (n=7), and that of EX group was 71.3±32.2 (n=12) and 63.8±28.0 (n=11). There were no significant differences between these groups. In NEX group, when comparing concentration of TAC at first visit and second visit after starting TAC administration, the each concentration of TAC was 3.14±2.06 ng/ml and 3.80±2.20 ng/ml in NEX group (n=10), and that of TAC was 1.82±0.82 ng/ml and 2.69±1.52 ng/ml (n=11) in EX group (Figure).

Conclusion:

TAC showed efficacy in patients with RA in a concentration-dependent manner. EX patients may be impossible to achieve enough concentration of TAC even though using TAC of 3mg/day, approved dose for patients with RA in Japan, and NEX patients could make rapid attainment of enough concentrations of TAC in early stage of treatment, suggesting that we should consider induction of TAC only in NEX outpatients. Furthermore, drugs only slightly affected concentration of TAC in this study, suggesting that we can use TAC without any special attention to concomitant drugs.

References:

[1]Furst DE et al. Arthritis Rheum 2002;46:2020-28.

[2]Y. Muraki et al. Exp Ther Med 2018;15:532-38.

Acknowledgments:

none

Disclosure of Interests:

Soshi Takahashi: None declared, Shinji Horibata: None declared, Saori Hatachi: None declared, Miho Takahashi: None declared, Motoko Katayama: None declared, Saki Mukohara: None declared, Norihiko Amano: None declared, Katsuyuki Yoshida: None declared, Kennosuke Yorifuji: None declared, Shunichi Kumagai Grant/research support from: Astellas, Chugai, Mitsubishi Tanabe Co.Ltds, Consultant of: Sysmex Co.Ltd, Speakers bureau: many companies

FRI0246 GENOTYPING OF CYP3A5 IS USEFUL FOR TREATMENT WITH TACROLIMUS IN INTERSTITIAL LUNG DISEASE IN DERMATOMYOSITIS

Background:

Tacrolimus (TAC), an immunosuppressant, can be used in second-line maintenance therapy of interstitial lung disease (ILD) in patients with dermatomyositis (DM) [1]. In Japan, TAC is approved for DM-ILD and often used as induction therapy for severe cases, especially in patients with anti-MDA5-Ab (melanoma differentiation-associated gene 5 antibody) positive, in combination with glucocorticoids (GC) and intravenous cyclophosphamide (IVCY). Some studies reported the clinical efficacy of initial high-trough level TAC for DM-ILD in combination with GC and IVCY [2]. Adjustment to target concentration of TAC in early stage of treatment is important for controlling disease activity. The concentration of TAC depends on genetic polymorphisms in cytochrome P450 (CYP) 3A5 enzyme expression and several reports showed that the bioavailability and concentration of TAC in patients with a CYP3A5 *1 allele (*1) was lower than those with a CYP3A5 *3/*3 (*3/*3) [3].

Objectives:

To examine the usefulness of CYP3A5 polymorphisms in decision of initial dose to achieve the target concentration of TAC and to evaluate the clinical efficacy in patients of DM-ILD who achieved the enough concentration of TAC in early stage of treatment.

Methods:

We investigated CYP3A5 polymorphisms and TAC concentration in 9 patients of DM-ILD without renal dysfunction (eGFR>60). TAC was taken after both morning and evening meals and blood samples were taken 12h after TAC administration. The blood concentration of TAC normalized to the corresponding dose per body weight (C/D, ng/ml per mg/kg) was analyzed according to genetic variation in CYP3A5. Based on the retrospective analyzation, we chose proper dose of TAC in initial treatment for an anti-MDA5-Ab positive DM-ILD patient, whose genotype was *3/*3.

Results:

The C/D value in the *3/*3 group (n=6) was 154.6±25.6, which was significantly higher than that in the *1 group (n=3;79.0±2.8; P =0.028). When the target concentration was set at 5-10 ng/ml, the required dose was (0.0316 to 0.0633) mg/kg in the *1 group and (0.0162 to 0.0324) mg/kg in the *3/*3 group. The *1 group needs more dose than that of the *3/*3 group to achieve the same target trough of TAC, suggesting that the examination of CYP3A5 genotype is useful for deciding initial dose of TAC (Fig.1). We started TAC 6mg/day with setting target concentration at 15-20 ng/ml to a *3/*3 patient of DM-ILD with anti-MDA5-Ab positive, resulting in good clinical course with making rapid attainment of target concentration in early stage of treatment (Fig.2).

Conclusion:

To examine the CYP3A5 genotype is valuable for deciding the initial dose of TAC, especially in patients who need achievement to target concentration rapidly.

References:

[1]Oddis CV and Aggarwal R. Nat Rev Rheumatol 2018;14(5):279-89.

[2]Suzuka T et al. Int J Rheum dis 2019;22: 303-13.

[3]Y. Muraki et al. Exp Ther Med 2018;15:532-38.

Acknowledgments:

none

Disclosure of Interests:

motoko katayama: None declared, Shinji Horibata: None declared, Soshi Takahashi: None declared, Miho Takahashi: None declared, Saki Mukohara: None declared, Norihiko Amano: None declared, Katsuyuki Yoshida: None declared, Saori Hatachi: None declared, Kennosuke Yorifuji: None declared, Shunichi Kumagai Grant/research support from: Astellas, Chugai, Mitsubishi Tanabe Co.Ltds, Consultant of: Sysmex Co.Ltd, Speakers bureau: many companies