A machine-learning model based on dynamic contrast-enhanced MRI for preoperative differentiation between hepatocellular carcinoma and combined hepatocellular-cholangiocarcinoma

AIM

To establish a machine-learning model based on dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) to differentiate combined hepatocellular-cholangiocarcinoma (cHCC-CC) from hepatocellular carcinoma (HCC) before surgery.

MATERIALS AND METHODS

Clinical and MRI data of 194 patients with histopathologically diagnosed cHCC-CC (n=52) or HCC (n=142) were analysed retrospectively. ITK-SNAP software was used to delineate three-dimensional (3D) lesions and extract high-throughput features. Feature selection was carried out based on Pearson's correlation coefficient and least absolute shrinkage and selection operator (LASSO) regression analysis. A radiomics model (radiomics features), a clinical model (i.e., clinical-image features), and a fusion model (i.e., radiomics features + clinical-image features) were established using six machine-learning classifiers. The performance of each model in distinguishing between cHCC-CC and HCC was evaluated with the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), sensitivity, and specificity.

RESULTS

Significant differences in liver cirrhosis, tumour number, shape, edge, peritumoural enhancement in the arterial phase, and lipid were identified between cHCC-CC and HCC patients (p<0.05). The AUC of the fusion model based on logistic regression was 0.878 (95% CI: 0.766-0.949) in the arterial phase in the test set, and the sensitivity/specificity was 0.844/0.714; however, the AUC of the clinical and radiomics models was 0.759 (95% CI: 0.663-0.861) and 0.838 (95% CI: 0.719-0.921) in the test set, respectively.

CONCLUSION

The fusion model based on DCE-MRI in the arterial phase can significantly improve the diagnostic rate of cHCC-CC and HCC as compared with conventional approaches.

Dietary Supplementation of Astragalus membranaceus Extract Affects Growth Performance, Antioxidant Capacity, Immune Response, and Energy Metabolism of Largemouth Bass (Micropterus salmoides)

The present study investigated the effects of Astragalus membranaceus extract (AME) on growth performance, immune response, and energy metabolism of juvenile largemouth bass (Micropterus salmoides). Seven diets containing 0%, 0.1%, 0.2%, 0.3%, 0.4%, 0.5%, and 0.6% AME (Con, AME0.1, AME0.2, AME0.3, AME0.4, AME0.5, and AME0.6 groups) were formulated and fed to M. salmoides for 8 weeks. Final body weight (FBW), feed intake (FI), weight gain (WG), and specific growth rate (SGR) were all significantly higher in AME0.4 group than in Con group (P < 0.05). Feed conversion rate (FCR) was significantly improved in AME0.5 group compared with Con group (P < 0.05). Whole-body crude protein contents were significantly increased in AME0.2 group (P < 0.05). Whole-body crude lipid contents were significantly lower in AME0.2 and AME0.3 groups, while muscle lipid was upregulated by dietary AME (P < 0.05). Hepatic malondialdehyde (MDA) contents were significantly lowered in AME0.3 and AME0.4 groups, and catalase (CAT) activities were significantly increased in AME0.1 and AME0.2 groups (P < 0.05). Plasma aspartate aminotransferase (AST) level was significantly lowered in AME0.5, and AME0.6 groups, and alanine aminotransferase (ALT) level was lowered in AME0.5 groups (P < 0.05). Plasma triglyceride was declined in AME0.6 group, and glucose was decreased by 0.3%-0.5% AME (P < 0.05). Significantly higher hepatocyte diameter, lamina propria width, and submucosal layer thickness were recorded in AME0.6 groups, while the longest villi height was obtained in AME0.2 and AME0.3 groups (P < 0.05). The mRNA expression levels of insulin-like growth factor 1 (igf1) revealed the growth-promoting effect of AME. The anti-inflammatory and antiapoptotic effects of AME were demonstrated by transcription levels of interleukin 8 (il-8), tumor necrosis factor-alpha (tnf-a), caspase, B-cell lymphoma-xl (Bcl-xl), bcl-2 associated x (Bax), and bcl-2-associated death protein (Bad). The transcription levels of lipid metabolism and gluconeogenesis related genes, including acetyl-CoA carboxylase alpha (acc1), fatty acid synthase (fasn), fatty acid binding protein 1 (fabp1), phosphoenolpyruvate carboxykinase 2 (pepck2), and glucose-6-phosphatase catalytic subunit 1a (g6pc), were reduced by AME treatment, while the levels of glycolysis-related genes, including glucokinase (gck) and pyruvate kinase (pk), were the highest in AME0.2 and AME0.3 groups (P < 0.05). According to polynomial regression analysis of SGR, WG, FCR, whole-body crude lipid, MDA, and ALT, the optimal AME supplementation level was estimated to be 0.320%-0.429% of the diet. These results provided insights into the roles of AME in regulating immunity and metabolism, which highly indicated its potential as immunostimulants and metabolic regulators in diverse aquatic animals.

The potential of aryl hydrocarbon receptor as receptors for metabolic changes in tumors

Cancer cells can alter their metabolism to meet energy and molecular requirements due to unfavorable environments with oxygen and nutritional deficiencies. Therefore, metabolic reprogramming is common in a tumor microenvironment (TME). Aryl hydrocarbon receptor (AhR) is a ligand-activated nuclear transcription factor, which can be activated by many exogenous and endogenous ligands. Multiple AhR ligands can be produced by both TME and tumor cells. By attaching to various ligands, AhR regulates cancer metabolic reprogramming by dysregulating various metabolic pathways, including glycolysis, lipid metabolism, and nucleotide metabolism. These regulated pathways greatly contribute to cancer cell growth, metastasis, and evading cancer therapies; however, the underlying mechanisms remain unclear. Herein, we review the relationship between TME and metabolism and describe the important role of AhR in cancer regulation. We also focus on recent findings to discuss the idea that AhR acts as a receptor for metabolic changes in tumors, which may provide new perspectives on the direction of AhR research in tumor metabolic reprogramming and future therapeutic interventions.

Head-to-head comparison between [68Ga]Ga-DOTA-NOC and [18F]DOPA PET/CT in a diverse cohort of patients with pheochromocytomas and paragangliomas

PURPOSE

To compare the detection ability of 68Ga-labelled DOTA-l-Nal3-octreotide ([68Ga]Ga-DOTA-NOC) and 6-[18F]fluoro-L-3,4-dihydroxyphenylalanine ([18F]DOPA) in patients with phaeochromocytomas and paragangliomas (PPGLs) of different origins and gene mutations, such as germline succinate dehydrogenase complex genes (SDHx).

METHODS

Eighty-five patients with histopathologically confirmed PPGLs who underwent both [68Ga]Ga-DOTA-NOC and [18F]DOPA PET/CT from March 2017 to June 2023 were enrolled in this retrospective study. For comparative analyses, PPGLs were classified as phaeochromocytoma (PCC), sympathetic paraganglioma (sPGL), and head/neck paraganglioma (HNPGL). Detection rates were analyzed on per-patient and per-lesion bases and compared using the Chi-square/Fischer's exact test.

RESULTS

Among 85 patients with PPGLs (48 males; 43 years ± 17 [SD]), the patient-based detection rates of [68Ga]Ga-DOTA-NOC and [18F]DOPA PET/CT were 87.1% (74/85) and 89.4% (76/85), respectively (p = 0.634), and the lesion-based detection rates were 80.8% (479/593) and 71.2% (422/593), respectively (p < 0.001). Only one patient with a recurrent PCC presented double-negative imaging, while 66 patients exhibited double-positive imaging. The remaining patients were either [68Ga]Ga-DOTA-NOC-negative/[18F]DOPA-positive (n = 10) or [68Ga]Ga-DOTA-NOC-positive/[18F]DOPA-negative (n = 8). In subgroup analyses, [68Ga]Ga-DOTA-NOC PET/CT detected significantly more metastases of sPGL (91.1%, 236/259) and SDHx-related PPGL (89.6%, 86/96) than [18F]DOPA PET/CT (48.6%[126/259] and 50.0%[48/96], respectively; both p < 0.001). However, [18F]DOPA showed significantly higher detection rates of PCC in both primary/recurrent and metastatic lesions (94.3%[50/53] vs. 62.3%[33/53] and 87.9%[174/198] vs. 69.2%[137/198], respectively; both p < 0.001). Regarding metastases in different organs, [68Ga]Ga-DOTA-NOC PET/CT detected more lesions than [18F]DOPA PET/CT in bone (96.2%[176/183] vs. 66.1%[121/183]; p < 0.001) and lymph nodes (82.0%[73/89] vs. 53.9%[48/89]; p < 0.001) but less lesions in peritoneum (20%[4/20] vs. 100%[20/20]; p < 0.001).

CONCLUSION

[68Ga]Ga-DOTA-NOC and [18F]DOPA are complementary in diagnosing PPGL under the appropriate clinical setting. [68Ga]Ga-DOTA-NOC should be considered as the ideal first-line tracer for detecting metastases of sPGL and SDHx-related tumours, whereas [18F]DOPA may be the optimal tracer for evaluating non-SDHx-related PCC, especially in detecting primary lesions and monitoring recurrence.

Aryl hydrocarbon receptor: An emerging player in breast cancer pathogenesis and its potential as a drug target (Review)

Breast cancer is the most common malignancy in women. Metastatic breast cancer is incurable and is a major cause of shortened patient survival. The different molecular types of breast cancer make targeted therapy difficult and a complex challenge. Aryl hydrocarbon receptor (AhR) is an evolutionarily conserved transcription factor that has been implicated in the metabolism of xenobiotic ligands. AhR is activated by numerous exogenous and endogenous ligands and participates in multiple physiological processes, including proliferation, migration, invasion and apoptosis. AhR expression is upregulated in certain breast cancer subtypes, including estrogen receptor‑positive breast cancer, and has been implicated in the development and progression of breast cancer. Over the last two decades, AhR and its ligands have emerged as novel biological targets for the treatment of breast cancer. Both AhR agonists and antagonists may be effective in inhibiting critical activities of breast cancer. The present review evaluates the role and underlying mechanisms of AhR and its ligands in breast cancer and demonstrates the potential of exploiting AhR as a novel target for breast cancer therapy.

Effects of dietary supplementation of Bacillus subtilis DSM 32315 on growth, immune response and acute ammonia stress tolerance of Nile tilapia (Oreochromis niloticus) fed with high or low protein diets

Aquatic animals have benefited from Bacillus subtilis-based probiotics over the past few decades. This study evaluated the effects of B. subtilis DSM 32315 probiotics as a feed additive on growth, immune response and resistance to acute ammonia challenge in Nile tilapia. Specifically, four supplemental levels (0%, 0.1%, 0.2%, and 0.3%) of B. subtilis probiotics were tested under two dietary protein levels (32% and 28%). Five replicate tanks were randomly allotted to each dietary treatment, with each tank containing 30 Nile tilapia. After 8 weeks of feeding, Nile tilapia in each tank were exposed to 43.61 mg/L of total ammonia nitrogen for 48 h. The results revealed that reducing protein levels from 32% to 28% did not affect growth performance or antioxidant capacity. However, the low protein diet tended to induce an inflammatory effect shown by increased expressions of TGF-β and IFN-γ genes (P < 0.05) in the liver. The impact was alleviated by the probiotic supplementation. Compared with the non-supplemented group, 0.1% probiotic supplementation remarkably increased plasma lysozyme activity, total antioxidant capacity and complement C3 and interleukin-10 mRNA levels (P < 0.05) in the 28% protein diet, while higher supplementation of probiotics (0.3%) was shown to be beneficial for the high protein diet (32%). In both the dietary protein levels, 0.1% supplementation of probiotics promoted the antioxidant capacity of Nile tilapia before exposure to ammonia stress but higher probiotic supplementation (0.3%) proved to be necessary under ammonia stress as evidenced by higher fish survival rate. Results exhibited that supplementation with B. subtilis probiotics had a better effect on the intestinal morphology (villi height and width) regardless of protein levels. In conclusion, dietary supplementation of B. subtilis DSM 32315 probiotics at 0.1% in the low protein diet and up to 0.3% in the high protein diet showed beneficial effects on the growth, immunity, and antioxidant capacity of Nile tilapia. Under ammonia stress conditions, the higher supplementation of B. subtilis DSM 32315 probiotics at 0.3% improves stress tolerance of Nile tilapia despite the two dietary protein levels (32%; 28%).

Diet supplementation of organic zinc positively affects growth, antioxidant capacity, immune response and lipid metabolism in juvenile largemouth bass, Micropterus salmoides

Zn is an important trace element involved in various biochemical processes in aquatic species. An 8-week rearing trial was thus conducted to investigate the effects of Zn on juvenile largemouth bass (Micropterus salmoides) by feeding seven diets, respectively, supplemented with no Zn (Con), 60 and 120 mg/kg inorganic Zn (Sul60 and Sul120), and 30, 60, 90 and 120 mg/kg organic Zn (Bio30, Bio60, Bio90 and Bio120). Sul120 and Bio120 groups showed significantly higher weight gain and specific growth rate than Con group, with Bio60 group obtaining the lowest viscerosomatic index and hepatosomatic index. 60 or 90 mg/kg organic Zn significantly facilitated whole body Zn retention. Up-regulation of hepatic superoxide dismutase, glutathione peroxidase and catalase activities and decline of malondialdehyde contents indicated augmented antioxidant capacities by organic Zn. Zn treatment also lowered plasma aminotransferase levels while promoting acid phosphatase activity and hepatic transcription levels of alp1, acp1 and lyz-c than deprivation of Zn. The alterations in whole body and liver crude lipid and plasma TAG contents illustrated the regulatory effect of Zn on lipid metabolism, which could be possibly attributed to the changes in hepatic expressions of acc1, pparγ, atgl and cpt1. These findings demonstrated the capabilities of Zn in potentiating growth and morphological performance, antioxidant capacity, immunity as well as regulating lipid metabolism in M. salmoides. Organic Zn could perform comparable effects at same or lower supplementation levels than inorganic Zn, suggesting its higher efficiency. 60 mg/kg supplementation of organic Zn could effectively cover the requirements of M. salmoides.

Effects of Low-Fish-Meal Diet Supplemented with Coenzyme Q10 on Growth Performance, Antioxidant Capacity, Intestinal Morphology, Immunity and Hypoxic Resistance of Litopenaeus vannamei

The aim of this study was to evaluate the effects of a low-fish-meal diet supplemented with coenzyme Q10 on the growth, antioxidant capacity, immunity, intestinal health and hypoxic resistance of Litopenaeus vannamei. L.vannamei with an initial weight of 0.66 g were fed with the experimental diets for 56 days. Diets D1 (20% FM level) and D2-D7 (15% FM level), supplemented with 0%, 0.002%, 0.004%, 0.006%, 0.008% and 0.01% coenzyme Q10 were formulated. In terms of growth performance, the weight gain and specific growth rate in the D2 diet were significantly lower than those in the D1 diet (p < 0.05). The final body weight, weight gain and specific growth rate in the D2-D7 diets had an upward trend, and the condition factor in the D2-D7 diets was lower than those in the D1 diet (p < 0.05). There were no significant differences in the crude protein and crude lipid levels in the whole body among all diet treatments (p > 0.05). In terms of hepatopancreas antioxidant parameters, the D5 and D6 diets significantly promoted the total antioxidant capacity and total superoxide dismutase activity, and significantly decreased the malondialdehyde content (p < 0.05). The expression levels of cat, mnsod and gpx in shrimp fed with the D5 and D6 diets were significantly higher than those of shrimp fed with the D2 diet (p < 0.05). In addition, the mRNA level of ProPO was increased in the D4 and D5 diets, and LZM expression was increased in the D6 diet compared with the D1 diet (p < 0.05). The villus height of shrimp fed with diets supplemented with coenzyme Q10 was significantly increased (p < 0.05), and the intestinal thickness and submucosal thickness of shrimp fed with the D6 diet were the highest (p < 0.05). After acute hypoxia stress, lethal dose 50 time in the D3-D7 diets was significantly increased compared with the D1 and D2 diets (p < 0.05), and the highest value was found in the D4 diet (p < 0.05). After stress, the expression levels of TLR pathway-related genes (Toll, Myd88, Pelle, TRAF6 and Dorsal) in the D4 and D6 diets were significantly increased compared with the D2 diet. In general, Litopenaeus vannamei fed with the D6 diet achieved the best growth, antioxidant capacity, immunity, and intestinal morphology among all low FM diets and D4-D6 diets improved hypoxic resistance.

Use of speckle tracking echocardiography in evaluating cardiac dysfunction in patients with acromegaly: an update

In recent years, cardiovascular disease has garnered increasing attention as the second leading cause of death in individuals with acromegaly, following malignancy. Identifying cardiac dysfunction early in acromegaly patients for timely intervention has become a focal point of clinical research. Speckle tracking echocardiography, a well-established ultrasound technique, surpasses conventional Doppler ultrasound in its sensitivity to assess both local and global cardiac mechanics. It can accurately detect subclinical and clinical myocardial dysfunction, including myocardial ischemia, ventricular hypertrophy, and valvular changes. Over the past five years, the use of speckle tracking echocardiography in acromegaly patients has emerged as a novel approach. Throughout the cardiac cycle, speckle tracking echocardiography offers a sensitive evaluation of the global and regional myocardial condition by quantifying the motion of myocardial fibres in distinct segments. It achieves this independently of variations in ultrasound angle and distance, effectively simulating the deformation of individual ventricles across different spatial planes. This approach provides a more accurate description of changes in cardiac strain parameters. Importantly, even in the subclinical stage when ejection fraction remains normal, the strain parameters assessed by speckle tracking echocardiography hold a good predictive value for the risk of cardiovascular death and hospitalization in acromegaly patients with concomitant cardiovascular disease. This information aids in determining the optimal timing for interventional therapy, offering important insights for cardiac risk stratification and prognosis. In the present study, we comprehensively reviewed the research progress of speckle tracking echocardiography in evaluating of cardiac dysfunction in acromegaly patients, to pave the way for early diagnosis of acromegaly cardiomyopathy.

Comprehensive analysis of BTNL9 as a prognostic biomarker correlated with immune infiltrations in thyroid cancer

BACKGROUND

Thyroid cancer (THCA) is the most common type of endocrine cancers, and the disease recurrences were usually associated with the risks of metastasis and fatality. Butyrophilin-like protein 9 (BTNL9) is a member of the immunoglobulin families. This study investigated the prognostic role of BTNL9 in THCA.

METHODS

Gene enhancers of BTNL9 were identified by interrogating H3K27ac ChIP-seq and RNA-seq data of papillary thyroid cancer (PTC) and benign thyroid nodule (BTN) tissues. Meanwhile, BTNL9 expression level was verified by qRT-PCR in 30 pairs of primary THCA and adjacent normal tissues. Clinicopathological and RNA sequencing data were obtained from The Cancer Genome Atlas (TCGA) and Genotype-Tissue Expression (GTEx) to analyze the relations between BTNL9 expression and immune cell infiltration, chemokines/cytokines, immune checkpoint genes, clinical parameters and prognosis values. Besides, survival analysis combining BTNL9 expression and immune cell infiltration scores was conducted. Functional enrichment analysis was performed to investigate the potential biological mechanisms. Cox regression analyses were used to explore independent clinical indicators, and a nomogram model incorporating BTNL9 expression with clinical parameters was established.

RESULTS

BTNL9 showed significantly stronger H3K27ac modifications in BTN than PTC tissues at the promoter region (chr5: 181,035,673-181,047,436) and gene body (chr5: 181,051,544-181,054,849). The expression levels of BTNL9 were significantly down-regulated in THCA samples compared to normal tissues, and were strongly associated with different tumor stages, immune cell infiltrations, chemokines/cytokines and immune checkpoint genes in THCA. Functional enrichment analyses indicated that BTNL9 was involved in immune-related and cancer-related pathways. The Kaplan-Meier analysis showed lower BTNL9 expression was associated with poorer progression-free interval (PFI). BTNL9 expression and pathologic stages were independent prognostic indicators of PFI in THCA.

CONCLUSIONS

The results implied an important role of BTNL9 in the tumor progression, with the possibility of serving as a novel prognostic biomarker and a potential therapeutic target for THCA.

Pneumonitis After Concurrent Chemoradiation and Immune Checkpoint Inhibition in Patients with Locally Advanced Non-small Cell Lung Cancer

AIMS

Pneumonitis is a common and potentially deadly complication of combined chemoradiation and immune checkpoint inhibition (CRT-ICI) in patients with locally advanced non-small cell lung cancer (LA-NSCLC). In this study we sought to identify the risk factors for pneumonitis with CRT-ICI therapy in LA-NSCLC cases and determine its impact on survival.

MATERIALS AND METHODS

We conducted a retrospective chart review of 140 patients with LA-NSCLC who underwent curative-intent CRT-ICI with durvalumab between 2018 and 2021. Pneumonitis was diagnosed by a multidisciplinary team of clinical experts. We used multivariable cause-specific hazard models to identify risk factors associated with grade ≥2 pneumonitis. We constructed multivariable Cox proportional hazard models to investigate the impact of pneumonitis on all-cause mortality.

RESULTS

The median age of the cohort was 67 years; most patients were current or former smokers (86%). The cumulative incidence of grade ≥2 pneumonitis was 23%. Among survivors, 25/28 patients had persistent parenchymal scarring. In multivariable analyses, the mean lung dose (hazard ratio 1.14 per Gy, 95% confidence interval 1.03-1.25) and interstitial lung disease (hazard ratio 3.8, 95% confidence interval 1.3-11.0) increased the risk for pneumonitis. In adjusted models, grade ≥2 pneumonitis (hazard ratio 2.5, 95% confidence interval 1.0-6.2, P = 0.049) and high-grade (≥3) pneumonitis (hazard ratio 8.3, 95% confidence interval 3.0-23.0, P < 0.001) were associated with higher all-cause mortality.

CONCLUSIONS

Risk factors for pneumonitis in LA-NSCLC patients undergoing CRT-ICI include the mean radiation dose to the lung and pre-treatment interstitial lung disease. Although most cases are not fatal, pneumonitis in this setting is associated with markedly increased mortality.

Protocol in a Day: An Educational Institutional Workshop for Protocol Development

PURPOSE/OBJECTIVE(S)

The Protocol-in-a-Day (PIAD) workshop was developed to support junior faculty and residents with clinical trial protocol design, with the main goal of providing initial feedback during development to reduce time for review and approval from institutional oversight committees. Our objectives are to mentor and educate participants and to evaluate the time to institutional approval by oversight committees.

MATERIALS/METHODS

PIAD provided concurrent educational feedback on 6 key elements of trial design. These included: (1) regulatory aspects; (2) institutional scientific review committee (SRC) and institutional review board (IRB); (3) clinical research and data coordination (including nursing); (4) statistics; (5) correlatives including imaging, biospecimens, and health services research/patient-reported outcomes; and (6) operations. The average number of days from submission to IRB approval or study activation for PIAD protocols was compared to other protocols submitted between January 2018 - January 2022 within the Division of Radiation Oncology. Participants were also given a 15-question survey to assess their perspective of the impact of the workshop.

RESULTS

A total of 25 protocols went through the PIAD workshop between January 2018-January 2022. Of the 25 protocols, 7 (28%) were excluded from this study due to not being submitted possibly after participants benefited from education on the limitations of their design. Eighteen protocols were included in our final analyses. These protocols included phase II (n = 11), phase 1 (n = 5), and phase III (n = 2). At the time of this report, all protocols (n = 18) have received IRB approval and have been activated. Protocol elements that could impact study activation included protocols requiring investigational new drug (IND) approval (n = 8) and multicenter studies (n = 1). Analyzing the time of submission to request for activation showed a decrease in time for protocols that went through PIAD vs those that did not [PIAD protocols, 254 days vs All other protocols, 262 days]. Likewise, those who attended PIAD had a lower average time from submission to IRB Approval [ PIAD protocols, 40 days vs All other protocols, 59 days]. All participants (100%) of the PIAD workshop responded that the educational program "improved the overall quality of the study design." The most commonly cited changes were protocol language (n = 17), statistics (n = 15), consent language (n = 8), and study design (n = 8). Aspects participants identified as the most educational included mentorship from regulatory, clinical research finance, and IRB review.

CONCLUSION

PIAD from participant surveys provided high educational value in the areas of improving trial quality, language and statistical design. When analyzing the average time, from 'submission to IRB initial approval' and 'submission to activation', PIAD protocols had a shorter time for approval, and thus suggests PIAD is effective in improving the overall design of protocols.

Definitive Radiotherapy for Oligometastatic and Oligoprogressive Thyroid Cancer

PURPOSE/OBJECTIVE(S)

Local consolidative radiotherapy (LCT) for oligometastatic disease is a promising paradigm improving outcomes for various malignancies but has been underexplored for metastatic thyroid cancer. We hypothesize that LCT to distant sites with definitive RT doses can yield favorable outcomes and defer systemic therapy escalation for these patients.

MATERIALS/METHODS

We reviewed 96 thyroid cancer patients who received 175 LCT courses from 2010-2022 to 228 metastatic sites, including: thorax (45%), bone (40%), brain (6%), head/neck (5%), and abdomen (3%). Common prescriptions were 50-55Gy/4-5fxs or 56-70Gy/8-10fxs for lung; 52.5-60Gy/15fxs for mediastinum; and 18-24Gy/1fx or 27-30Gy/3fxs for bone. RECIST v1.1 and CTCAE v5.0 were used to define progression and toxicities, respectively. Outcomes were evaluated via Kaplan-Meier and associations examined via Cox proportional hazards modeling.

RESULTS

Median age was 63 years (range: 26-92), with 62 oligometastatic cases (total 1-5 sites) and 34 oligoprogressive (with 1-5 growing sites). Primary disease was controlled in all patients, with 39% receiving post-op RT and 66% prior RAI. Histologies included papillary (40%), anaplastic (25%), follicular (12%), medullary (9%), Hurthle (7%), and poorly-differentiated (7%). Median time from initial diagnosis to LCT was 3 yrs (IQR 1-8), and median follow-up from 1st LCT was 21 mos (IQR 9-51). Patients received an average 2 LCT courses (range 1-8) treating 1-4 sites. Median survival (OS) from 1st LCT was 9 yrs (95% CI = 5-14). On multivariable analysis (MVA), worse OS was associated with anaplastic histology (HR 4.6, p<.01), but longer OS was associated with prior RAI (HR 0.33, p = .02) and oligometastatic disease (HR 0.3, p = .01). For anaplastic histology, median OS was 1.2 years vs. 9.3 years for non-anaplastic; 3-yr OS was 36% vs. 88% (log-rank, p<.01). Five-year OS for oligometastatic cases was 75% vs 53% for oligoprogressive (log-rank, p = .04). Median progression free survival (PFS) from 1st LCT was 15.5 mos (95% C I = 11-20). On MVA for all LCT courses, time to any progression (TTP) was negatively associated with anaplastic histology (HR 1.7, p = .02) and 2nd or higher LCT course (HR 1.45, p = .05), but favorably associated with thoracic site (HR 0.49, p<.01). Following later LCT courses, median TTP was 11 mos vs 17 mos for initial LCT course (log-rank, p = .03). After LCT to lung/chest, TTP was 18.6 mos vs 9.5 mos for non-thoracic sites (log-rank, p<.01). Only 6% of failures occurred at previously treated lesions. Most LCT courses (67%) were without ongoing chemotherapy, while 25% entailed continuing the same regimen and 9% had planned treatment post-RT. There were 2 Grade 3 toxicities (pneumonitis and esophagitis) and no Grade 4-5 events.

CONCLUSION

With high local control rates and minimal toxicity, LCT can be a feasible strategy to defer systemic therapy escalation for oligometastatic and oligoprogressive thyroid cancer.

Long-Term Outcomes and Toxicity in Esophageal Cancer Patients after Neoadjuvant or Definitive Concurrent Chemotherapy with Proton Beam Therapy

PURPOSE/OBJECTIVE(S)

Proton-beam therapy (PT) is increasingly utilized over three dimensional-conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) photon irradiation for the treatment of various malignancies due to better toxicity reduction. We investigated the long-term outcomes and toxicity in esophageal cancer (EC) patients treated with PT as part of their neoadjuvant concurrent chemoradiation followed by surgery (nCRT) or definitive concurrent chemoradiation (dCRT) treatment regimen.

MATERIALS/METHODS

All consecutively treated, American Joint Committee on Cancer 7th edition clinical stage I-IV EC patients from 2006 to 2022 were retrospectively analyzed. Standard RT dose for most patients was 50.4 Gy/28 fractions. nCRT patients had surgery within 4 months post-RT. Kaplan-Meier method was used to determine overall survival (OS), locoregional recurrence-free survival (LRRFS) and distant metastatic-free survival (DMFS). Acute and chronic RT-related toxicities were graded with Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

There were 510 EC PT patients: 204 (40%) had nCRT and 306 (60%) had dCRT. Most lesions were located in the lower esophagus, of adenocarcinoma histology and treated with passive scatter PT. Overall median follow-up was 72 months. Median, 3- and 5-year OS for all patients were 43 months, 54.1% and 44.9%, respectively. Median LRRFS and DMFS were not reached. Esophagitis was the most common grade ≥3 (G3+) toxicity (59 patients; 28.9%, including a G4 and a G5 toxicity), followed by nausea (29 patients; 14.2%) and esophageal stricture (26 patients, 12.7%). With nCRT, median, 3- and 5-year OS were 80 months, 64.7% and 56.1%, respectively, while the median LRRFS and DMFS were not reached again. Their most common G3+ toxicity was esophagitis in 14 patients (6.9%) followed by nausea (8 patients; 3.9%). An nCRT patient developed G4 RT pneumonitis. Pathological complete response (pCR) was observed in 58 patients (28.4%). Surgery-related pulmonary, cardiac and gastrointestinal complications were reported in 38 (18.6%), 40 (19.6%) and 43 (21.1%) patients, respectively. dCRT patients had a median follow-up of 65 months, and median, 3- and 5-year OS of 32 months, 46.7% and 37.0%, respectively. Although the median LRRFS was not reached, the median DMFS was 74 months. The most observed dCRT G3+ toxicity was esophagitis (45 patients, 22.1%: including both G4 and G5 patients) and then esophageal stricture (23 patients, 11.3%). A dCRT patient developed G4 fistula.

CONCLUSION

To our knowledge, this is the largest single-institutional study on EC long-term outcomes and toxicity using PT. Our cohort reveals good outcomes and mostly mild CRT-related toxicities. Trimodality nCRT with protons demonstrates excellent outcomes relative to the CROSS trial (49.4 months) with identical pCR rate (29% in CROSS) and similar toxicity profile. nCRT with protons should be studied rigorously in the current randomized phase III trial NRG GI006.

Comorbidities and Their Impact on Treatment Tolerance and Outcome in Elderly NSCLC Patients Treated with Concurrent Chemoradiation Using Proton or Photon Followed by Immunotherapy

PURPOSE/OBJECTIVE(S)

To investigate comorbidities and their impact on treatment tolerance and survival for elderly NSCLC patients treated with concurrent chemoradiation using proton beam therapy (PBT) or intensity modulated radiation therapy (IMRT) followed by immunotherapy (IO).

MATERIALS/METHODS

This is a retrospective study in senior patients (≥ 65 years) with inoperable locally advanced- NSCLC (LA-NSCLC) who received concurrent chemoradiation (CRT) therapy followed by adjuvant IO. Comorbidities are listed in table 1 and scored according to hazard ratios (HRs) of death. Treatment tolerance and comorbidities were compared between modalities using Fisher's exact test. Association between comorbidities and treatment tolerance was analyzed using logistic regression; association between comorbidities and survival was analyzed by Cox proportional hazards regression.

RESULTS

Total 218 patients were included with median age of 72 (range 65-86) years. Fifty-three (24.3%) were PBT and 165 (75.7%) were IMRT. Majority patients were white ethnics, had stage III adenocarcinoma disease and good performance score, and received RT dose 60-66 Gy. The median follow-up time for the whole group was 23 months. A 97% of patients had ≥1, and 62% had ≥4 comorbidities. The combined comorbidity scores ranged from 0 to 25. No significant difference in comorbidities between modalities except IMRT had more patients with COPD (36% vs. 51%, p = 0.047). Rates of hospitalization and ER visit during CRT+IO were 28% and 5%, respectively. Rates of IO discontinuation and interruption were 55% and 8%, respectively. Patients received >6 months IO had significantly lower risk of death (HR: 0.25, p<0.001). No significant difference in treatment tolerance between modalities. In multivariable analysis, atrial fibrillation, pulmonary disease, and depression were the comorbidities associated with hospitalization during CRT+IO (p<0.05); dementia was the comorbidity associated with IO interruption (p = 0.042); heart failure, COPD, asthma, osteoporosis and HIV were the comorbidities associated with poor OS (p<0.05). Combined comorbidity score was associated with OS with HR of 1.13 (p<0.001) with adjustment of race, GTV and induction chemotherapy.

CONCLUSION

Comorbidities were associated with hospitalization and IO interruption during the whole course of CRT and IO therapy, with increased IO discontinuation which negatively impacted survival. Evaluating and scoring comorbidities at diagnosis could be a useful method to predict risk of death before treatment start.

Comparing 90-Day Post-Operative Mortality after Neoadjuvant Proton-Based vs. Photon-Based Chemoradiotherapy for Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Standard of treatment for locally advanced esophageal cancer consists of chemoradiotherapy (CRT) followed by surgery. Evidence suggests that proton beam therapy (PBT) results in lower toxicity and fewer post-operative complications compared to photon-based radiotherapy (RT). Mortality in the first 90 days after surgery is a rare event occurring in 2-8% of patients, with higher reported rates (of up to 17%) in older patients. This 90-day mortality (90DM) rate is an important measure of post-operative (non-oncologic) mortality as a proxy of quality of care. We hypothesize that PBT could reduce the incidence of 90DM compared to photon-based RT.

MATERIALS/METHODS

From a single-center retrospectively acquired database patients with esophageal cancer treated with neoadjuvant CRT and esophagectomy in 1998-2022 were selected. Univariable logistic regression analyses were used to study the associations of RT modality and other patient- and treatment-related characteristics with 90DM. Subsequently, 3 separate methods were applied to adjust for confounding bias. These included multivariable logistic regression, 1:1 nearest-neighbor propensity score matching (PSM), and inverse probability of treatment weighting (IPTW). Finally, stratified analyses for patient groups aged ≥67 vs. <67 years were performed.

RESULTS

A total of 894 eligible patients were included (PBT, n = 202; photon-based RT, n = 692). PBT patients had a significantly higher age, better performance score, and a higher number of comorbidities. The 90DM rate was 5 (2.5%) in the PBT group and 29 (4.2%) in the photon-based RT group (p = 0.262). Significant univariable predictors of 90DM included higher age and tumor location. After multivariable adjustment, PBT vs. photon therapy was not significantly associated with 90DM (OR 0.49, 95% CI 0.18-1.31). The 90DM rates in the PSM cohort (n = 181 vs. n = 181) were 2.8% for PBT and 3.3% for photon-based RT (p = 0.379). The 90DM rates in the IPTW cohort were 2.8% for PBT and 4.1% for photon-based RT (p = 0.427). In the full cohort, stratified analysis for age groups revealed that in patients aged ≥67 years, PBT was associated with a decreased risk of 90DM compared to photon-based RT (1.3% vs. 8.8%; p = 0.046), which was not the case in patients aged <67 years. In the PSM cohort, a comparable (but non-significant) difference was observed in favor of PBT in patients aged ≥67 years (i.e., 1.5% vs. 7.5%; p = 0.099). Within-group analyses in the original cohort demonstrated that a higher age significantly increased the risk of 90DM within the photon-based RT group (8.8% vs. 2.7% for age ≥67 vs. <67 years; p = 0.001), but not within the PBT group (1.3% vs. 3.2%; p = 0.398).

CONCLUSION

Post-operative 90DM after esophagectomy for cancer was not significantly different between PBT and photon-based neoadjuvant CRT. However, among older patients we observed a signal that PBT may reduce the risk of 90DM. Higher age increased the risk of 90DM in patients who underwent photon-based RT, but not in patients who underwent PBT.

Plasma extrachromosomal circular DNA is a pathophysiological hallmark of short-term intensive insulin therapy for type 2 diabetes

BACKGROUND

Extrachromosomal circular DNA (eccDNA) has emerged as a promising biomarker for disease diagnosis and prognosis prediction. However, its role in type 2 diabetes remains unexplored.

OBJECTIVE

To investigate the characteristics and dynamics of circulating eccDNAs in newly diagnosed type 2 diabetes mellitus (T2DM) patients undergoing short-term intensive insulin therapy (SIIT), a highly effective treatment for inducing long-term glycemic remission.

METHODS

We conducted Circle-Seq analysis on plasma samples from 35 T2DM patients at three time points: pre-SIIT, post-SIIT, and 1-year post-SIIT. Our analysis encompassed the characterization of eccDNA features, including GC content, eccDNA length distribution, genomic distribution, and the genes in eccDNAs.

RESULTS

Following SIIT, we observed an increase in plasma eccDNA load, suggesting metabolic alterations during therapy. Notably, a correlation was identified between eccDNA profiles and glycemia in T2DM, both quantitatively and genetically. Our analysis also revealed the frequent presence of metabolism-related genes within T2DM plasma eccDNAs, some of which spanned gene exons and/or fractions.

CONCLUSION

This study represents the first report of cell-free eccDNA in T2DM and underscores a compelling association between cell-free eccDNA and profound glycemic changes. These findings highlight the potential of eccDNAs as crucial players in the context of T2DM and glycemic control.

Prospective Trial of Using Imaging to Predict Pathologic Response and Clinical Outcomes in Locally Advanced Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Trimodality therapy with chemoradiation (CRT) followed by esophagectomy is the standard of care for locally advanced esophageal cancer. An unresolved question is whether pathologic complete response (pCR) can be assessed non-invasively for patients post-CRT. In this study, we assessed whether diffusion-weighted imaging (DWI) with MRI or PET can be used as predictors of pCR and other clinical outcomes after CRT.

MATERIALS/METHODS

Patients were enrolled on a single-arm institutional trial (PA13-0380) assessing the role of imaging in predicting outcomes in potentially resectable esophageal patients undergoing trimodality therapy. All patients received neoadjuvant CRT, and 29 patients had subsequent surgery. DWI MRI and PET scans were obtained at baseline, 2 weeks after the start of CRT (interim) and 4 to 6 weeks after completion of CRT (follow up). Apparent diffusion coefficients (ADCs) were calculated based on DWI images. Circulating tumor DNA was obtained for 27 patients post-radiation using CAPP-Seq. Mann-Whitney tests compared imaging changes associated with pCR. Discrimination of pCR by imaging changes was quantified by received operating characteristics. Youden's index was applied to select optimal thresholds. Kaplan-Meier analysis was performed to assess differences in overall survival (OS) and progression-free survival (PFS) by changes in DWI, PET, and ctDNA parameters.

RESULTS

Our cohort of 60 patients had a median follow up of 42.7 months, age of 65.4 yrs, and ECOG of 1 at completion of CRT. 90% were male, 58% had a history of smoking, and 85% were white. 83% had adenocarcinoma with the rest squamous cell carcinoma. Stages of the patients ranged from IIA to IIIB. All had moderately (47%) or poorly (53%) differentiated disease. All received 41.4-50.4 Gy in 1.8 Gy fractions with the majority receiving 50.4 Gy (95%). 29 patients underwent surgery after CRT of which 8 (27.6%) had pCR. Mean ΔADC from baseline to mid-treatment was most associated with pCR (AUC = 0.98, p<0.001) for patients undergoing surgery. Max ΔADC from baseline to first follow-up was most associated with OS (p = 0.002) and PFS (p<0.001) for the whole cohort. 27 patients had ctDNA analyzed after RT with the presence of ctDNA significantly associated with worse OS (HR = 0.12, p = 0.05) and PFS (HR = 0.10, p = 0.002). Combining ctDNA and max ΔADC generated a model that was more predictive of OS and PFS than either alone. We found that neither the PET parameters of TLG or SUV max at baseline or changes in these parameters from baseline to mid-treatment or first follow-up were as predictive as DWI.

CONCLUSION

We show that changes in DWI is associated with pCR, OS, and PFS in resectable esophageal cancer patients undergoing CRT. DWI was more predictive than PET and a model combining DWI and ctDNA was the most predictive of clinical outcomes. This study shows the significant promise of using DWI in potentially guiding treatment decisions in esophageal cancer patients and will require validation in a larger cohort.

Increase in precipitation and fractional vegetation cover promote synergy of ecosystem services in China’s arid regions—Northern sand-stabilization belt

Research on synergies and trade-offs between ecosystem services (ES) contributes to a better understanding of the linkages between ecosystem functions. Relevant research mainly focuses on mountain areas, while research in arid areas is obviously insufficient. In this research, we use the northern sand-stabilization belt (NSB) as an example to explore how the synergies and trade-offs between different ES vary with the gradient of precipitation and fractional vegetation cover (FVC) over the period 2000-2020. Based on five simulated ecosystem services (habitat provision, sand-stabilization service, water conservation service, soil conservation service and carbon sequestration service), the Pearson correlation coefficient method was used to analyze the various characteristics of the trade-offs and synergies among the different ES pairs along the FVC and precipitation gradients. Results showed that: Synergies between most paired ES increased significantly with increasing precipitation and FVC. However, ES have different sensitivities to environmental change, FVC promotes bit more synergy of ES pairs than precipitation. The study also found that land use/land cover may be an important driving factor for trade-offs and synergies between paired ES. The findings demonstrate that increased precipitation and FVC promote synergy of ecosystem services in arid regions of China. In the future, it can be investigated whether anthropogenic increase in FVC in arid regions can significantly contribute to the synergy of ES. In the meantime, this study could improve our understanding of arid and semi-arid (or macro-regional) ecosystems and contribute to the development of ecosystem management and conservation measures in NSB.

Radiation Therapy Decision Making Process and Operations for COVID-19 Positive Patients

Purpose/Objective(s)

A challenging clinical dilemma during the COVID-19 pandemic is management of cancer patients who test positive for COVID. Given the need to balance the risk of disease progression with the risk of transmission to other patients and staff, radiation therapy for these patients requires careful consideration and modification of standard workflows. It is also critical to develop processes to mitigate radiation treatment interruption, which can affect patient outcomes. The objective of this study was to report the clinical operations and outcomes for COVID positive patients receiving radiation therapy during the pandemic at a tertiary cancer center including 2 network locations.

Materials/Methods

During March 2020 to March 2022, the Radiation Oncology COVID committee (RO COVID) developed an integrated process to triage patients, provide treatment recommendations, and implement infection control procedures to safely deliver radiation therapy to COVID positive patients. Policies were created for each center with multidisciplinary input from infectious disease, radiation oncology, radiation therapy, and nursing. All COVID positive patients were presented to the RO COVID group and evaluated for clinical urgency, benefit with radiation, and life expectancy. If deemed necessary, a limited planned break or hypofractionated regimen was recommended to minimize staff exposure. We conducted a retrospective review of COVID positive patients with different primary malignancies treated through the COVID positive pathway.

Results

A total of 68 COVID positive patients were treated with the COVID positive pathway (HN 15, Breast 9, CNS 8, GU 8, GYN, 7, Thoracic 6, GI 5, HEME 5, PED 3, SARC 2). The median age was 57.1 years (IQR 45.8-63.4) and 47% were female. There were 39 patients (57%) who were asymptomatic and were tested for routine pre-radiation screening or due to concerns of COVID exposure. Twenty-three (34%) patients were treated with palliative intent and 8 (12%) were treated for an emergent indication (i.e., spinal cord compression, bleeding). Thirteen (19%) patients were receiving radiation treatment, had a treatment break (7-21 days), and then resumed their radiation course. All treatments were successfully completed without known nosocomial spread of COVID to staff or other patients. Among this heterogenous group of patients, 58 (85%) were alive with a median follow up of 2 months (IQR 0.5-7.5). COVID infection may have contributed to 3 out of 10 deaths (4% of total cohort). The remaining deaths were due to progression of disease or other non-COVID causes.

Conclusion

In this study, COVID positive patients were safely treated with radiation therapy through a comprehensive decision making and clinical operations pathway taking into account evolving COVID guidelines for three different variant surges. Although limited in follow up, patient outcomes are promising with few COVID-related deaths and low overall mortality rates, even with hypofractionated regimens.

Cardiovascular disease risk prediction via machine learning using mental health data

Background

Robust and accurate risk prediction models are much needed in cardiovascular disease. It is well-known that mental health is associated with the risk of developing cardiovascular disease. It is unknown whether mental health markers can enhance existing risk prediction models for cardiovascular disease.

Purpose

The main purpose of this study was to assess capability of mental health factors along with traditional risk factors to be used in cardiovascular predictive machine learning models, and to develop a combined machine learning approach using both traditional risk and psychological factors in 375,145 participants of the UK Biobank.

Methods

A comprehensive Pearson correlation analysis is carried out on UK Biobank data. Subsequently, an ensemble model containing decision tree, random forest, XGBoost, support vector machine (SVM), and deep neural network (DNN) classification approaches was built to predict cardiovascular diseases (CVD) in UK Biobank participants. The model was first trained using traditional cardiovascular risk factors, and subsequently trained using a combination of cardiovascular risk and psychological factors.

Results

The correlation analysis revealed that there is a correlation between CVD and mental health factors suggesting the potential of mental health application for machine learning models. Our ensemble machine learning model was able to predict CVD with an accuracy of 73.49% using CVD risk factors alone. However, by combining psychological factors with CVD risk factors in the training data, an improved accuracy of 95.70% was achieved. The accuracy and robustness of ensemble machine learning model outperformed any of five constituent learning algorithms alone.

Conclusions

Our results suggest that mental health assessment data along with traditional risk factors provides a powerful, safe and affordable machine learning model enrichment that can be used for state-of-the-art prediction of CVD.

Funding Acknowledgement

Type of funding sources: None.

The lipoxygenase gene OsRCI-1 is involved in the biosynthesis of herbivore-induced JAs and regulates plant defense and growth in rice

The pathway mediated by jasmonic acid (JA), biosynthesized via 13-lipoxygenases (LOX), plays a central role in both plant development and defense. In rice, there are at least fourteen 13-LOXs. Yet, only two 13-LOXs have been known to be involved in the biosynthesis of JA and plant defenses in rice. Here we cloned a chloroplast-localized 13-LOX gene from rice, OsRCI-1, whose transcripts were upregulated following infestation by brown planthopper (BPH, Nilaparvata lugens), one of the most important pests in rice. Overexpression of OsRCI-1 (oeRCI lines) increased levels of BPH-induced JA, jasmonate-isoleucine, trypsin protease inhibitors and three volatile compounds, 2-heptanone, 2-heptanol and α-thujene. BPHs showed a decreased colonization, fecundity and mass, and developed slowly on oeRCI plants compared with wild-type (WT) plants. Moreover, BPH-infested oeRCI plants were more attractive to the egg parasitoid of BPH, Anagrus nilaparvatae than equally treated WT plants. The decreased attractiveness to BPH and enhanced attractiveness to the parasitoid of oeRCI plants correlated with higher levels of BPH-induced 2-heptanone and 2-heptanol, and 2-heptanone, respectively. Compared with oeRCI plants, WT plants had higher plant height and 1000-grain weight. These results indicate that OsRCI-1 is involved in herbivore-induced JA bursts and plays a role in plant defense and growth.

Randomized Trial of Osilodrostat for the Treatment of Cushing Disease

CONTEXT

Cushing disease, a chronic hypercortisolism disorder, is associated with considerable morbidity and mortality. Normalizing cortisol production is the primary treatment goal.

OBJECTIVE

We aimed to evaluate the safety and efficacy of osilodrostat, a potent, orally available 11βhydroxylase inhibitor, compared with placebo in patients with Cushing disease.

METHODS

LINC 4 was a phase III, multicenter trial comprising an initial 12-week, randomized, double-blind, placebo-controlled (osilodrostat:placebo, 2:1) period followed by a 36-week, open-label treatment period (NCT02697734). Adult patients (aged 18-75 years) with confirmed Cushing disease and mean urinary free cortisol (mUFC) excretion ≥ 1.3 times the upper limit of normal (ULN) were eligible. The primary endpoint was the proportion of randomized patients with mUFC ≤ ULN at week 12. The key secondary endpoint was the proportion achieving mUFC ≤ ULN at week 36 (after 24 weeks' open-label osilodrostat).

RESULTS

Seventy-three patients (median age, 39 years [range, 19-67]; mean/median mUFC, 3.1 × ULN/2.5 × ULN) received randomized treatment with osilodrostat (n = 48) or placebo (n = 25). At week 12, significantly more osilodrostat (77%) than placebo (8%) patients achieved mUFC ≤ ULN (odds ratio 43.4; 95% CI 7.1, 343.2; P < 0.0001). Response was maintained at week 36, when 81% (95% CI 69.9, 89.1) of all patients achieved mUFC ≤ ULN. The most common adverse events during the placebo-controlled period (osilodrostat vs placebo) were decreased appetite (37.5% vs 16.0%), arthralgia (35.4% vs 8.0%), and nausea (31.3% vs 12.0%).

CONCLUSION

Osilodrostat rapidly normalized mUFC excretion in most patients with Cushing disease and maintained this effect throughout the study. The safety profile was favorable.

AB1043 IDENTIFICATION OF UNUSUAL TOPHI ANTERIOR TO THE THYROID CARTILAGE USING DIFFERENT IMAGING METHODS

Background

Inadequately treated gout patients could develop tophi. However, tophi could appear as atypical mass, leading to difficulty in differential diagnosis.

Objectives

The objectives of the study were to describe an unusual case with tophi anterior to the Thyroid Cartilage using different imaging methods.

Methods

Clinical information of the case was presented. Ultrasound, dual energy Computed Tomography (DECT) and CT scan were compared to describe the tophi.

Results

A 66-year-old man with a 30-year history of gout was admitted. He had received urate-lowering drugs intermittently over the past few years. Physical examination revealed multiple tophi on the hands, feet, and other auricular surfaces. Moreover, there was a subcutaneous mass above the thyroid cartilage (Figure 1A). Ultrasound revealed hyperechoic nodule anterior to the thyroid cartilage, 11*7cm in size, with uneven internal echo, no blood flow signal inside, and a close relationship between the barrier of the nodule and the thyroid cartilage (Figure 1B). DECT of the neck confirmed that the mass anterior to the thyroid cartilage were tophi (Figure 1C-D). A plain radiographic evaluation demonstrated soft-tissue swellings and para-articular erosions involving hands (Figure 1E-F). The serum creatinine and uric acid levels were elevated as follows, creatinine, 562 μmol per liter (normal range, 31.8 to 116); and uric acid, 621 μmol per liter (normal range, 90 to 420).

Figure 1.

Tophi detected by different imaging methods. A.A picture of the mass anterior to the thyroid cartilage; B. A mass anterior to the thyroid cartilage detected by ultrasound; C. The mass anterior to the thyroid cartilage detected by dual energy CT; D. The mass anterior to the thyroid cartilage detected by CT scan; E. a picture of tophi in the hands; F. a plain radiograph of tophi in the hands.

Conclusion

DECT has more advantages over ultrasound and CT for detection of atypical tophi in gout patients.

Disclosure of Interests

Yutong Jiang Grant/research support from: Scientific and Technological Planning Project of Guangzhou City [grant number 202102020150], Xinyu Wu: None declared, Zetao Liao: None declared, Jun Qi: None declared, Jieruo Gu: None declared

POS0014 EFFICACY AND SAFETY OF JAK INHIBITORS IN REFRACTORY OR INITIAL TREATMENT OF ADULT ONSET STILL’S DISEASE

Background

Inappropriate activation of pro-inflammatory cytokines such as interleukin (IL)-1, IL-6 or IL-18, is a pathogenic cornerstone in adult onset Still’s disease (AOSD). Beyond therapies targeting IL-1 and IL-6, Janus kinases (JAK) inhibitors have been suggested to be efficient in refractory AOSD patients [1].

Objectives

To assess the efficacy and safety of JAK inhibitors in the treatment of AOSD patient refractory to, or with initial treatment.

Methods

This retrospective study was based on our single center of the department of rheumatology and immunology. The data was collected from the patients’ medical records using a standardized questionnaire and analyzed at different time points. The response to JAK inhibitors was categorized as complete remission (CR), partial remission (PR) or failure (F) [2].

Results

7 patients were recruited (Table 1), including 4 refractory patients and 3 initial patients. Mean age at JAK inhibitor treatment start was 27.5 years for refractory patients and 35 years for initial patients; and mean disease duration was 66.5 months and 1 month respectively. All patients had fever and polyarthritis, 5 patents had rash. In addition, pulmonary hypertension, abnormal liver function tests, abdominal pain, and heart failure were also observed in our patients. Response to corticosteroids, conventional synthetic or biological Disease Modifying Anti-Rheumatic Drugs (DMARDs) had been considered inadequate in 4 refractory patients. Tofacitinib was added in the initial treatment for 3 patients for high disease activity. In total, baricitinib was used in 2 patients and tofacitinib in 5 patients. Steroids were concurrently used in 6 patients, MTX in three, SASP and NSAIDs in one. At a mean follow up of 3.8 months, complete remission was observed in one patient (with tofacitinib), partial remission was in 5 patients (4 patients with tofacitinib and one with baricitinib), and failure in one (patients with baricitinib). At the last visit, steroids could be decreased but not stopped in those 6 patients. Tolerance of JAK inhibitors was excellent, none infectious disease or other severe side effect were observed.

Table 1.

Characteristics of the AOSD patients

No.SexAge (year)Disease Duration (Month)Main symptomsTreatments before JAKionsetJAKiSteroids at onsetConconmitant treatmentSteroids at the end of F-UF-U(month)Outcome1M2629Fever, polyarthritisPred+MTXTofacitinib0MTX04PR2M259Fever, polyarthritis, rash, pulmonary hypertensionPred+MTXBaricitinib16MTX+Pred124F3M3812Fever, polyarthritis, rashPred+MTX+CsA+NSAIDsTofacitinib24Pred123PR4M21216Fever, polyarthritisPred+MTX+SASP+NSAIDs+TNFiBaricitinib4Pred+MTX+SASP+NSAIDs43PR5F331Fever, polyarthritis, rash, abnormal liver function testsPredTofacitinib40Pred25CR6F471Fever, polyarthritis, rash, abdominal painPredTofacitinib36Pred45PR7F251Fever, polyarthritis, rash, heart failurePredTofacitinib40Pred123PR

Pred: prednisone; MTX: Methotrexate; SASP: salicylazosulfapyridine; CsA: ciclosporin A; NSAIDs: Non-Steroidal Antiinflammatory Drugs; TNFi: Tumor necrosis factor inhibitor. CR: complete remission; PR: partial remission; F: failure.

Conclusion

JAK inhibitors treatment may be helpful for some patients with refractory AOSD, or patients with severe disease activity at initial treatment. Different treatment responses were observed in these short series of cases, which might be due to the phenotype of patients. However, the scale of patients in our study was too low to draw a conclusion. Further study and additional information are needed to evaluate more precisely the risk-benefit ratio of this treatment, and a possible difference in efficacy among the different groups of patients or JAK inhibitors.

References

[1]Aosd T, Table E. Ann Rheum Dis 2020;79:842–4.

[2]Vercruysse F, Barnetche T, Lazaro E, et al. Arthritis Res Ther 2019;21:1–11. doi:10.1186/s13075-019-1838-6.

Figure 1.

Changes in laboratory test (A) WBC; (B) CRP; (C) ESR;(D) Ferritin. M0: baseline; M1: month 1; M3: month 3; M5: month 5.

Acknowledgements

None

Disclosure of Interests

None declared

AB1520 EFFECTIVE TREATMENT OF TOCILIZUMAB IN PATIENTS WITH REFRACTORY ADULT-ONSET STILL’S DISEASE

Background

Pro-inflammatory cytokines such as interleukin 6 (IL-6) are involved in the pathogenesis of adult-onset Still’s disease (AOSD). Anti-IL-6 agents such as tocilizumab have been tried to treat AOSD successfully.

Objectives

To access the efficacy of tocilizumab in the treatment of AOSD patient refractory to,or with initial treatment.

Methods

We reviewed three cases with refractory AOSD treated with tocilizumab. All patients fulfill the Cush criteria for AOSD. All patients performed blood culture, auto-antibodies test and bone marrow test to exclude infectious diseases, other rheumatic diseases and tumors. All patients received broad-spectrum antibiotics and had no response. All patients received glucocorticoid therapy and at least one kind of anti-cytokine therapies but didn’t have full response. Then the three patients received intravenous tocilizumab treatment of 8mg/kg every 2 weeks or 4 weeks.

Results

The first patient, a 21-year-old woman, performed positron emission tomography (PET-CT) and lymphoglandula pathology in addition to routine tests. She received high dose methylprednisolone (500mg per day for 3 days and followed by 80mg per day), gamma globulin injection (20g per day for 3 days) and baricitinib 4mg per day for 12 days, but had no response to the treatment. Then she received tocilizumab of 8mg/kg every 2 weeks and stopped baricitinib. And the symptoms and blood tests improved gradually, and the methylprednisolone dose reduced to 16mg per day at the last follow-up.

The second patient is a 52-year-old man, and performed bone marrow cytology and PET-CT to excluded hematological diseases. He received methylprednisolone 80mg per day, adalimumab and tofacitinib treatment. But the patients still got recurrent fever, high ESR, CRP and serum ferritin. Then he stopped adalimumab and tofacitinib, and received tocilizumab of 8mg/kg every 2 weeks and reduced to 8mg/kg every 4 weeks because of economic factors. The patient did not develop fever and the inflammatory indexes such as ESR/CRP gradually decreased to normal range. And methylprednisolone dose reduced to 32mg nowadays.

The third patient is a 30-year-old woman and has recurrent AOSD for 15 years. She had tried glucocorticoids, methotrexate, iguratimod, baritinib and entanercept successively. Yet she still had recurrent arthritis on hand and knee, and elevated ESR/CRP/serum ferritin. Additionally she suffered femoral head necrosis because of excessive doses of glucocorticoid. The patient received tocilizumab 8mg/kg every 4 weeks, then joint symptoms and inflammatory indicators improved significantly. The methylprednisolone dose was also successfully reduced to 4mg/d.

The Figure 1 showed the main course of disease evolution.

Figure 1.

Conclusion

Tocilizumab may be an effective candidate in refractory AOSD despite no response to other treatments.

Disclosure of Interests

None declared

The effect of short-term intensive insulin therapy on inflammatory cytokines in patients with newly diagnosed type 2 diabetes

BACKGROUND

Diabetes mellitus was a chronic low-grade inflammatory disease and had increased circulating inflammatory cytokines and acute phase proteins. We aimed to identify the changes of inflammatory cytokines in newly diagnosed type 2 diabetic patients after short-term intensive insulin therapy using continuous subcutaneous insulin infusion (CSII).

METHODS

Thirty-three newly diagnosed type 2 diabetic patients were enrolled between September 2020 to December 2020. Expression of 40 inflammatory cytokines of the patients were tested with RayBiotech antibody array before and after 1 week of intensive insulin therapy of CSII. Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis was carried out to explore the signaling pathway involved in the therapy.

RESULTS

Five inflammatory cytokines were downregulated significantly after 1 week of CSII therapy. They were interleukin-6 receptor (IL-6R), regulated upon activation normal T-cell expressed and secreted (RANTES), intercellular adhesion molecule-1 (ICAM-1), tissue inhibitor of metalloproteinase-1 (TIMP-1), and platelet-derived growth factor type BB (PDGF-BB) (p < 0.05 and foldchange <0.83). Among patients with baseline glycated hemoglobin (HbA1c) < 10%, three proinflammatory cytokines were decreased significantly after therapy: IL-6R, RANTES, and ICAM-1. As for the patients with baseline HbA1c ≥ 10%, eight inflammatory cytokines were inhibited significantly after the treatment, including ICAM-1, IL-6R, RANTES, TIMP-1, TIMP-2, macrophage inflammatory protein-1 beta (MIP-1β), PDGF-BB, and tumor necrosis factor receptor type II (TNF RII). No matter which subgroup of baseline HbA1c level was considered, the decreased cytokines after CSII therapy were significantly involved in TNF signaling pathway. Nuclear factor-kappa B (NF-κB) signaling pathway was mainly enriched in patients with baseline HbA1c ≥ 10%.

CONCLUSIONS

A panel of 40 inflammatory cytokines, measured by protein microarray, were evaluated for 1 week of CSII treatment in newly diagnosed type 2 diabetic patients. After treatment, many proinflammatory cytokines decreased. In the higher baseline HbA1c subgroup, more proinflammatory cytokines improved. No matter which subgroup of HbA1c level was considered, IL-6R, RANTES, and ICAM-1, which were involved in TNF signaling pathway, decreased significantly after CSII therapy. This was the first report showing that the cytokines of IL-6R, TIMP-2, PDGF-BB, and TNF RII decreased after the CSII therapy.

Identification of Novel Compound Heterozygous Variants of the PNPLA6 Gene in Boucher-Neuhäuser Syndrome

Background: Boucher–Neuhäuser syndrome (BNS, MIM 215470) is a rare autosomal recessive syndrome caused by mutations in the PNPLA6 gene. Few BNS cases have been reported for functional validation at the RNA level. Herein, we report on the family of a 17-year-old girl with clinical characteristics of BNS, genetic validation, and a systematic review of PNPLA6 variants related to BNS.

Methods: Clinical data and blood samples were collected from the patient and their parents, and whole-exome sequencing was performed and confirmed by Sanger sequencing. RNA-sequencing (RNA-Seq) and quantitative RT-PCR (qRT-PCR) were performed, and the three-dimensional protein structures of the variants were predicted.

Results: We report a 17-year-old female with progressive night blindness since the age of four, primary amenorrhea, and non-development of secondary sexual characteristics. Her impaired vision was diagnosed as retinal pigmentary degeneration of the retina. She had congenital hypogonadotropic hypogonadism (CHH) but no cerebellar ataxia at present. Two novel compound heterozygous variants (c.2241del/p.Met748TrpfsTer65 and c.2986A>G/p.Thr996Ala) of the PNPLA6 gene (NM_006702.4) were identified by whole-exome sequencing. The former variant was carried from her healthy father and has not been reported previously. The latter was inherited from her healthy mother and was noted in a report without functional studies. The RT-PCR results showed that the mRNA expression of PNPLA6 was lower in this patient and her father than in the control group. She was diagnosed with BNS. Both variants (c.2241del and c.2986A>G) were likely pathogenic according to the ACMG criteria. The novel variants in the PNPLA6 gene related to Boucher–Neuhäuser syndrome were summarized in this article.

Conclusion: The possibility of Boucher–Neuhäuser syndrome should be considered when patients present with night blindness, impaired vision, and hypogonadotropic hypogonadism. Gene sequencing is currently the primary diagnostic method. Herein, novel compound heterozygous variants of PNPLA6 were identified in a BNS patient, and its function was verified at the RNA level. The PNPLA6 c.2241del variant is novel and potentially pathogenic, expanding the mutation spectrum in PNPLA6.

Serum GDF-15 Predicts In-Hospital Mortality and Arrhythmic Risks in Patients With Acute Myocardial Infarction

This study aims to evaluate the association of serum growth differentiation factor 15 (GDF-15) with in-hospital mortality and arrhythmic risks in patients with acute myocardial infarction (AMI). A total of 296 consecutive patients with AMI were enrolled in our hospital from Jan. 2018 to Dec. 2020. Serum GDF-15 levels were measured at baseline. The primary endpoint was in-hospital all-cause mortality, and the secondary endpoint was major adverse cardiac events (MACEs) during hospitalization, defined as a composite of cardiovascular death, heart failure, sustained ventricular arrhythmias (ventricular tachycardia or ventricular fibrillation), and bleeding. During hospitalization, patients with a higher GDF-15 level had significantly higher incidences of in-hospital mortality (7.4% vs 1.4%; P = .02) and MACEs (9.5% vs 20.9%, P < .01) than those with a lower GDF-15 level. Multivariate logistic regression analysis showed that a higher GDF-15 level was significantly associated with increased risks of in-hospital mortality (OR = 1.92, 95% CI: 1.44-2.50; P < .01) and MACEs (OR = 2.19, 95% CI: 1.56-2.77; P < .01). In conclusion, GDF-15 was associated with the risks of in-hospital mortality and MACEs, indicating that it should be a prognostic biomarker for patients with AMI.

Sea Surface Temperature Analysis for Fengyun-3C Data Using Oriented Elliptic Correlation Scales

Sea surface temperature (SST) is critical for global climate change analysis and research. In this study, we used visible and infrared scanning radiometer (VIRR) sea surface temperature (SST) data from the Fengyun-3C (FY-3C) satellite for SST analysis, and applied the Kalman filtering methods with oriented elliptic correlation scales to construct SST fields. Firstly, the model for the oriented elliptic correlation scale was established for SST analysis. Secondly, observation errors from each type of SST data source were estimated using the optimal matched datasets, and background field errors were calculated using the model of oriented elliptic correlation scale. Finally, the blended SST analysis product was obtained using the Kalman filtering method, then the SST fields using the optimum interpolation (OI) method were chosen for comparison to validate results. The quality analysis for 2016 revealed that the Kalman analysis with a root-mean-square error (RMSE) of 0.3243 °C had better performance than did the OI analysis with a RMSE of 0.3911 °C, which was closer to the OISST product RMSE of 0.2897 °C. The results demonstrated that the Kalman filtering method with dynamic observation error and background error estimation was significantly superior to the OI method in SST analysis for FY-3C SST data.

Quality of life in first episode psychosis: a cluster analytic approach

PURPOSE

Quality of life is increasingly recognised as an important outcome for young people with first episode psychosis (FEP). The first aim was to determine whether distinct homogenous subgroups of young people with FEP could be delineated based on profiles on quality of life domains (Physical Health, Psychological, Social relationships and Environmental). The second aim was to examine the discriminant validity of these subgroups with respect to demographic, functioning and clinical features of FEP.

METHOD

Quality of life, demographic characteristics, clinical characteristics, cognition and functioning were assessed in 145 people with FEP. Cluster analysis using Ward's methods and Squared Euclidean Distance with a k-means verification were employed to identify subgroups with homogenous quality of life profiles. The clusters were externally validated using multinomial logistic regressions.

RESULTS

Three distinct quality of life profiles were identified: one with good quality of life across all domains (30%), one with poor quality of life particularly in Psychological and Social relationships domains (28%), and one 'intermediate' group with comparatively low Psychological quality of life (42%). Depression, semantic verbal fluency, social inclusion and social/occupational functioning showed associations with group membership.

CONCLUSION

Our results suggest the potential of maintaining relatively good quality of life despite the experience of FEP. Future research on interventions to improve quality of life may consider the potential of addressing depression, social inclusion and social/occupational functioning.

[An optimized protocol of meniscus cell extraction for single-cell RNA sequencing]

OBJECTIVE

To optimize the protocol of meniscus cell extraction to enhance the efficiency of cell suspension preparation and maintain a high cell viability for single-cell RNA sequencing.

METHODS

We compared the efficiency of the routine cell extraction methods (short-time digestion and long-time digestion) and the optimized protocol for obtaining meniscus cell suspensions by evaluating the cell number obtained and the cell viability. Single-cell RNA sequencing datasets were analyzed to evaluate the stability of the cell suspension prepared using the optimized protocol. The reliability of the optimized protocol was assessed by comparing the single-cell RNA sequencing dataset obtained by the optimized protocol with published single-cell RNA sequencing datasets of the meniscus.

RESULTS

The optimized protocol harvested a greater number of cells (over 1×10⁵) than the routine protocols. The cell suspension prepared with the optimized protocol showed a cell viability higher than 80%, the highest among the 3 methods. Analysis of single-cell RNA sequencing datasets showed that the ratio of the mitochondrial genes was below 20% in over 80% of the cells. CD34⁺ cells, MCAM⁺ cells and COL1A1⁺ cells were identified in the datasets. Comparison with the publish datasets showed that the optimized protocol was capable of harvesting COL3A1⁺, COL1A1⁺, MYLK⁺, BMP2⁺, CD93⁺ and CDK1⁺ cells.

CONCLUSION

Single-cell suspension prepared from the meniscus can be stably obtained using the optimized protocol for single-cell RNA sequencing using the 10× Genomics platform.

Genetic Profiles and Three-year Follow-up Study of Chinese Males With Congenital Hypogonadotropic Hypogonadism

BACKGROUND

The correlation between long-term treatment outcomes with genotypes in congenital hypogonadotropic hypogonadism (CHH) males is rarely reported.

AIM

To investigate the correlations among genotypes, phenotypes, and treatment outcomes for CHH male patients.

METHODS

Whole exome sequencing was performed for 73 Chinese CHH males from one academic center. Patients self-selected one of the 4 treatments: pulsatile Gonadorelin pump (PGP), cyclical gonadotropins therapy (CGT), human menopausal gonadotropin monotherapy, or testosterone replacement treatment. Clinical assessments were performed every 3 months for 3 years.

OUTCOMES

The pathogenicity of variants was determined. Baseline clinical features, spermatogenesis outcomes were analysed.

RESULTS

62 variants were identified in 51 patients (69.9%), 17 of which were novel. Among these mutations, variants on FGFR1, PROKR2, CHD7, ANOS1 and NSMF gene were 16.1%, 16.1%, 11.3%, 8.1% and 8.1% respectively. 11 patients followed the oligogenic pattern (21.6%). All CHD7 patients had hearing impairment, or structural deformities of external/ inner ear and were diagnosed as CHARGE syndrome. 24.7% of CHH patients manifested with ear/hearing anomalies. KS patients had higher rates of cryptorchidism history and ear/hearing anomalies than normosmic CHH subjects. Male patients with PROKR2 mutations showed relatively better testicular development, less dental deformity when compared with FGFR1 mutations. About 30% normosmic patients defined by simple olfactory assessment showed olfactory nerve center (ONC) dysplasia under nasal sinus MRI examination. Among the CHH males treated with CGT or PGP, 70.2% reached spermatogenesis within 3 years of treatment.

CLINICAL IMPLICATIONS

No direct correlation was observed between certain responsible genes and spermatogenic outcomes. When CHH patients were identified with CHD7 variants, ear/hearing evaluation should be carefully performed. The precise assessment of ONC development was advised for normosmic CHH subjects.

STRENGTHS & LIMITATIONS

This study provided informative long-term treatment data of CHH male patients screened with whole exome sequencing. The limitations included small number of subgroups with multifaceted gene variants, clinical heterogeneity, uncontrolled sperm-inducing treatment method. The seventeen novel mutations worth experimental validation in the future.

CONCLUSION

The clinical severity is partially related with specific gene variants, and detailed individualized data and outcomes were provided. Ear/hearing anomalies were closely connected with CHD7 variants, and were common problems for CHH patients. Simple olfactory assessment underestimated the true olfactory deficit. L. Zhang, Y. Gao, Q. Du, et al. Genetic Profiles and Three-year Follow-up Study of Chinese Males With Congenital Hypogonadotropic Hypogonadism. J Sex Med 2021;XX:XXX-XXX.

Serum inhibin B for differentiating between congenital hypogonadotropic hypogonadism and constitutional delay of growth and puberty: a systematic review and meta-analysis

PURPOSE

The distinction between congenital hypogonadotropic hypogonadism (CHH) and constitutional delay of growth and puberty (CDGP) in patients with delayed puberty is difficult to distinguish, but important for timely treatment. The aim of this study is to perform a systematic review and meta-analysis to determine the diagnostic performance of serum inhibin B (INHB) levels for differentiating CHH and CDGP.

METHODS

PubMed, EMBASE, and Cochrane Library databases were systematically searched from the date of database inception to November 10, 2019 for studies examining the use of serum INHB to discriminate between CHH and CDGP. Pooled odds ratios (OR), sensitivity, specificity, and 95% confidence intervals (CI) were calculated. The Quality Assessment of Diagnostic Studies-2 (QUADAS-2) was used to assess the quality of the included studies. Sub-analyses were performed including that based on testicular volume (TV) and study design.

RESULTS

Seven studies, comprising of 349 patients (96 CHH and 253 CDGP), were included in the meta-analysis. For differentiating between CHH and CDGP, INHB level exhibited good diagnostic accuracy with a pooled sensitivity of 92% (95% confidence interval [CI]: 0.86-0.96, I² = 0.4%, p = 0.4343), specificity of 92% (95% CI: 0.88-0.94, I² = 68.1%, p = 0.0009), and pooled area under the receiver operating characteristic curve (AUC) of 0.9619. The cut-off values of INHB for boys were 56, 66, 80, 96, 94.7, 111, and 113 pg/ml (assay method standardized to Gen II ELISA). Sub-analyses showed that testicular volume and study design could be a source of statistically significant heterogeneity in specificity. In boys with a testicular volume of ≤3 ml, INHB performed well with a sensitivity of 92%, specificity of 98%, and AUC of 0.9956.

CONCLUSION

INHB exhibits excellent diagnostic efficiency in distinguishing CHH from CDGP, especially in boys with severe puberty deficiency (TV ≤ 3 ml).

Osilodrostat Is an Effective and Well-Tolerated Treatment for Cushing’s Disease (CD): Results From a Phase III Study With an Upfront, Randomized, Double-Blind, Placebo-Controlled Phase (LINC 4)

Background: In a prior Phase III, randomized-withdrawal study, osilodrostat, a potent oral 11β-hydroxylase inhibitor, provided rapid and sustained normalization of mean urinary free cortisol (mUFC) in most patients (pts) with CD. Now, we report efficacy and safety results from another Phase III study of osilodrostat in pts with CD that included an upfront, double-blind, randomized, placebo-controlled phase (LINC 4: NCT02697734). Methods: Adults with CD with mUFC >1.3 x ULN were randomized 2:1 to osilodrostat 2 mg bid or matching placebo for a 12-week (W) double-blind period, with dose adjustments at W2, 5 and 8 (range 1-20 mg bid) based on efficacy and tolerability; dose matching and adjustments were managed by independent endocrinologists. From W12 to W48, all pts received open-label osilodrostat, with dose adjustments permitted (range 1-30 mg bid). At W48, pts could enter an optional extension. Primary endpoint: proportion of randomized pts in each arm who received ≥1 treatment dose with mUFC ≤ULN at W12. Results: 73 pts were randomized and received osilodrostat (n=48) or matching placebo (n=25; baseline median [range] mUFC 2.5 x ULN [0.7-12.5] vs 2.2 x ULN [0.2-18.9]). 77% of osilodrostat recipients achieved mUFC ≤ULN at W12 vs 8% of placebo recipients (OR 43.4; 95% CI 7.1-343.2; P<0.0001). At W36, 81% (95% CI 69.9-89.1) of osilodrostat recipients had mUFC ≤ULN (key secondary endpoint). Median time to first controlled mUFC response was 35 days (95% CI 34‒52) for pts randomized to osilodrostat. Median duration of osilodrostat exposure at data cut-off (Feb 25, 2020) was 71.7 vs 62.3 weeks for pts randomized to osilodrostat and placebo (median [IQR] dose 4.7 [3.8-9.0] vs 6.0 mg/day [3.7-9.7]). Up to W12, 3 osilodrostat pts discontinued, 1 because of an AE (arthralgia), vs 0 with placebo. The most common (≥30%) AEs occurring by W12 were decreased appetite (38% osilodrostat vs 16% placebo), arthralgia (35% vs 8%) and nausea (31% vs 12%). AEs related to hypocortisolism and adrenal-hormone-precursor accumulation occurred in 15% vs 0% and 44% vs 36% of osilodrostat and placebo pts; most were grade 1/2 and resolved with dose reduction/interruption and/or concomitant medication. During the overall study period, the most common (≥30%) AEs occurring on osilodrostat treatment were arthralgia (45%), decreased appetite (45%), fatigue (38%), nausea (37%) and headache (33%). Improvements in cardiovascular- and metabolic-related parameters, including systolic and diastolic blood pressure and HbA_1c, were observed with osilodrostat treatment at W12 and W48.

Conclusion: Osilodrostat was superior to placebo at normalizing mUFC levels at W12 (77% vs 8%). Improvements in mUFC levels were sustained at W36. Few pts discontinued because of AEs; hypocortisolism-related AEs were infrequent and manageable. We conclude that osilodrostat is a highly effective and well-tolerated treatment for pts with CD.