Non-small cell lung cancer cells with uncommon EGFR exon 19delins variants respond poorly to third-generation EGFR inhibitors.

BACKGROUND: This study compared the clinical efficacy of first-, second-, and third-generation tyrosine kinase inhibitors (TKIs) in previously untreated non-small cell lung cancer (NSCLC) patients harboring uncommon epidermal growth factor receptor (EGFR) exon 19delins variants. METHODS: We retrospectively analyzed the clinical outcomes of NSCLC patients with EGFR exon 19delins mutations who were treated with third- and first-generation EGFR TKIs. In vitro and in vivo studies were conducted to verify the sensitivity of these mutations to distinct generations of TKIs. Molecular simulation was used to investigate the structural characteristics of the EGFR mutant molecules. RESULTS: In a multicenter cohort of 1,526 patients, 37 (2.4 %) had uncommon EGFR 19delins mutations. Twenty-four patients were treated with first-generation EGFR TKIs, and third-generation TKIs were administered to ten patients as frontline therapy. Patients carrying EGFR exon 19delins mutations who were given third-generation TKIs exhibited comparatively shorter progression-free survival (PFS) and overall survival (OS) in relation to those who received first-generation EGFR inhibitors; median PFS: 6.9 months vs. 19.1 months (p < 0.001), Median OS: 19.1 months vs. 32.6 months (p < 0.001). In vivo and in vitro studies revealed that uncommon EGFR 19delins variants exhibit limited sensitivity to third-generation EGFR inhibitors in contrast to first- and second-generation EGFR inhibitors. The molecular binding affinity of third-generation EGFR TKIs toward uncommon EGFR 19delins mutations was less than that of first- and second-generation EGFR inhibitors. CONCLUSIONS: Uncommon EGFR 19delins variants respond poorly to third-generation EGFR inhibitors in NSCLC. Uncommon EGFR 19delins mutations may serve as an unfavorable predictive factor for the efficacy of third-generation EGFR TKI therapy, offering potential guidance for future clinical decision-making.

Suppurative Temporomandibular Arthritis Caused by Chronic Suppurative Otitis Media: A Case Report.

The clinical diagnosis and treatment, including information such as age, history, clinical symptoms, signs, audiology, imaging examination, mode of operation, and postoperative follow-up, of a patient with suppurative temporomandibular arthritis caused by chronic suppurative otitis media were analyzed. As conservative drug treatment and drainage surgery were ineffective, the patient was treated with microscopic open radical mastoidectomy, tympanoplasty, the plasty of the cavity of auricular concha, facial nerve decompression, coarctation of the mastoid cavity combined with otoendoscpic resection of the lower temporomandibular lesions, and standard anti-inflammatory treatment after surgery. The patient appeared to be cured at the 3-month follow-up. The ear canal was dry, without any preauricular swelling, purulent ear discharge, otalgia, limitation of mouth opening, or other symptoms. A clear diagnosis by defining the scope of the lesions, analysis of the transmission route of the lesions, and standard conservative treatment, local drainage, and surgical resection, if necessary, are recommended for patients with suppurative temporomandibular arthritis.

Potential benefit of osismertinib plus bevacizumab in leptomeningeal metastasis with EGFR mutant non-small-cell lung cancer.

BACKGROUND: EGFR-mutant non-small cell lung cancer (NSCLC) is prone to leptomeningeal metastasis (LM) after Tyrosine kinase inhibitors (TKIs) treatment. Our previous study suggested that osimertinib plus bevacizumab was safe and effective in LM from EGFR-mutant NSCLC. This study aimed to compare the efficacy of osimertinib plus bevacizumab with osimertinib in EGFR-mutant NSCLC patients with LM. METHODS: We retrospectively reviewed the data from 27 LM patients with EGFR-mutant NSCLC who received osimertinib with or without bevacizumab at the Second Affiliated Hospital of Nanchang University. Next, we investigated the antitumor efficacy of osimertinib plus bevacizumab in an LM xenograft model using the H1975 (EGFR exon20 T790M and exon21 L858R) cell line. We examined the ability of osimertinib plus bevacizumab compared with osimertinib to penetrate the blood-brain barrier (BBB) and explored the potential mechanism. RESULTS: Our retrospective study observed the improved survival of LM patients in osimertinib plus bevacizumab group. The median overall survival (OS) of the patients who received osimertinib and bevacizumab (n = 16) compared with osimertinib group (n = 11) was 18.0 months versus 13.7 months (log-rank test, p = 0.046, HR = 2.867, 95% CI 1.007-8.162). The median intracranial Progression-free Survival (iPFS) was 10.6 months versus 5.5 months (log-rank test, p = 0.037, HR = 3.401, 95% CI 1.079-10.720). In the LM xenograft model with H1975 cells, the combined treatment significantly increased the effective intracranial concentration of osimertinib, modulated the level of E-cadherin and downregulated the levels of EGFR and downstream signaling pathways including p-AKT and reduced tumor microvessel density (TMD), indicated that combined osimertinib with bevacizumab may exhibit a synergistic effect in EGFR-mutant LM model possibly by modulating the level of E-cadherin. CONCLUSIONS: Our findings indicate the potential benefit of osimertinib plus bevacizumab in LM with EGFR-mutant NSCLC, and more larger sample size research are still needed.

Characteristics and outcomes of primary pleural angiosarcoma: A retrospective study of 43 published cases.

ABSTRACT: Primary pleural angiosarcoma (PPA) is an extremely rare malignancy for which there is no consensus on treatment. The clinical course of PPA is usually quickly fatal, regardless of the treatment used.We summarized and evaluated a relatively large population of published PPA cases to assess prognostic factors, diagnostic approaches, treatment methods and clinical outcomes. Using the CNKI, Embase, and PubMed databases, literature published in English and Chinese from 1988 through 2020 was searched using the terms "primary pleural angiosarcoma," "pleural angiosarcoma," and "pleuropulmonary angiosarcoma."A total of 43 patients with PPA were identified in retrospective case series and case reports. The median age at diagnosis was 64 years (range 24-87 years), and the median overall survival was 4 months (range 0.1-180 months). Approximately 80% of patients died from PPA within 10 months of diagnosis, and the 2-year survival rate was approximately 4.4%. In univariate analyses, the presence of pleural effusion and hemothorax were significant predictors of decreased survival, with hazard ratios (HRs) of 2.7 (P = .04) and 3.3 (P = .006), respectively. Sixteen patients received no therapy, and their prognosis was worse than patients who did receive therapy (P = .019). Radiation therapy improved survival more than no radiation therapy (P = .007). Patients appeared to derive clinical benefit from chemotherapy (P = .048). However, tumor resection did not seem to provide a survival benefit (P = .051). In multivariate analysis, tumor resection, and radiation were independent, statistically significant, positive predictors of better survival, with HRs of 0.3 (P = .017) and 0.1 (P = .006), respectively. The presence of hemothorax was an independent predictor of worse prognosis (P = .006).Primary angiosarcoma of the pleura is a rare, poorly understood malignancy with a poor prognosis; hence, the clinical spectrum of PPA is not completely defined. By multivariate analysis, this retrospective study showed a survival benefit of tumor resection or radiation therapy, and the presence of hemothorax was a significant prognostic factor for poor outcomes.

Thoracic stereotactic body radiation therapy plus first-line tyrosine kinase inhibitors for patients with epidermal growth factor receptor-mutant polymetastatic non-small-cell lung cancer: A propensity-matched retrospective study.

ABSTRACT: The role of thoracic stereotactic body radiation therapy (SBRT) in addition to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in EGFR-mutant polymetastatic non-small-cell lung cancer (NSCLC) has not been well established. This retrospective study aimed to evaluate the efficacy and safety of EGFR-TKIs with thoracic SBRT for the treatment of this patient group.Polymetastatic NSCLC was defined as having >5 metastatic lesions. Patients with polymetastatic NSCLC harboring positive EGFR mutations after initial TKI therapy for at least 8 weeks were eligible for SBRT between August 2016and August 2019. Eligible patients were treated with thoracic SBRT, and TKIs were administered for the duration of SBRT and continued after SBRT until they were considered ineffective. The control group was treated with TKI monotherapy. Propensity score matching (ratio of 1:4) was used to account for differences in baseline characteristics. Progression-free survival (PFS), overall survival, and treatment safety were evaluated.In total, 136 patients were included in the study population. Among them, 120 patients received TKIs alone, and 16 patients received TKIs with thoracic SBRT. The baseline characteristics did not significantly differ between the two cohorts after propensity score matching. The median PFS was 17.8 months in the thoracic SBRT group and 10.8 months in the control group (P = .033). In the multivariate analysis, a Cox regression model showed that thoracic SBRT was an independent statistically significant positive predictor of improved survival, with a hazard ratio of 0.54 (P = .046). We recorded no severe toxic effects or grade 4 to 5 toxicities.Real-world data demonstrate that thoracic SBRT significantly extends PFS in EGFR-mutant polymetastatic NSCLC patients with tolerable toxicity. Given these results, randomized studies are warranted.

Primary pleural epithelioid angiosarcoma treated successfully with anti-PD-1 therapy: A rare case report.

RATIONALE: Primary pleural angiosarcoma (PPA) is an extremely rare malignancy for which there is no consensus on treatment. The clinical course of PPA is usually quickly fatal, regardless of the treatment used. PATIENT CONCERNS: We describe the rare case of a 52-year-old man who presented initially with hemoptysis and received emergency surgery for the primary. DIAGNOSES: He received a confirmed diagnosis of primary pleural angiosarcoma (PPA) by postoperative pathology and was subsequently treated with radiotherapy and chemotherapy, but had failed and was intolerant to chemotherapy. INTERVENTIONS: The patient had 5% tumor PD-L1 positivity with 22C3 pharmDx and received pembrolizumab (200 mg every 21 days) for 13 cycles. OUTCOMES: The disease remained well controlled according to the RECIST 1.1. criteria. He is currently under observation and waiting to start the next cycle of immunotherapy. LESSON: Our case report suggests that the use of anti-PD-1 therapy does show efficacy in the treatment of PPA and may provide a viable treatment option for patients.

EGFR (p. G719A+L747V)/EML4-ALK Co-alterations in Lung Adenocarcinoma with Leptomeningeal Metastasis Responding to Afatinib Treatment: A Case Report.

Leptomeningeal metastasis (LM) is a disastrous complication of advanced lung adenocarcinoma (LAC) associated with poor prognosis and rapid deterioration of performance status. The prevalence of epidermal growth factor receptor (EGFR)/anaplastic lymphoma kinase (ALK) co-alterations in patients with LAC was low. Herein, we report a patient with alterations in both EGFR (p. G719A+L747V) and echinoderm microtubule-associated protein-like ALK (EML4-ALK) fusion and LM who was treated with afatinib. The patient's clinical symptoms improved, and imaging examination revealed reduced intracranial and extracranial lesions. The progression-free survival (PFS) using afatinib for LM was 25 months, and no severe adverse events occurred.

Osimertinib combined with bevacizumab for leptomeningeal metastasis from EGFR-mutation non-small cell lung cancer: A phase II single-arm prospective clinical trial.

BACKGROUND: Leptomeningeal metastasis (LM) is associated with poor prognosis in non-small cell lung cancer (NSCLC). The aim of this study was to investigate the efficacy and safety of osimertinib combined with bevacizumab for LM from epidermal growth factor receptor mutation (EGFRm) NSCLC. METHODS: We conducted a phase II single-arm prospective clinical trial of EGFRm NSCLC with LM treated with osimertinib combined with bevacizumab. LM response assessment was based on the modified RANO LM radiological criteria; CNS and extra-CNS response was evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. The primary end points included LM progression-free survival (PFS) and objective response rate (ORR); the secondary end points included safety and LM overall survival (OS). RESULTS: A total of 14 patients were included in the study, with a median age of 61 years, and they were predominantly female (64%). EGFR mutations were reported in exons 19 del (n = 7) and 21 L858R (n = 7). When LM was diagnosed, 12 (85.7%) patients had clinical symptoms, 71.4% (10/14) of patients were diagnosed with LM by cytology, and five (35.7%) patients had a performance status (PS) score > 2. The median LM PFS was 9.3 months (95% CI: 8.2-10.4), and the LM ORR was 50%. The safety findings in the present study were consistent with the known profile of osimertinib with bevacizumab; the median LM OS was 12.6 months, and the one-year survival rate was 35.7%. CONCLUSIONS: Osimertinib combined with bevacizumab is an appropriate treatment option for patients with LM from EGFRm NSCLC. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: To date, there is no prospective clinical study on the treatment of osimertinib combined with bevacizumab in EGFRm NSCLC with LM. WHAT THIS STUDY ADDS: The median LM PFS was 9.3 months (95% CI: 8.2-10.4), and the LM ORR was 50%, the median LM OS was 12.6 months, and the one-year survival rate was 35.7%. Osimertinib combined with bevacizumab is an appropriate treatment option for patients with LM from EGFRm NSCLC.

[Management of Drug Therapy for Leptomeningeal Metastasis of Sensitive Driver Gene Positive Non-small Cell Lung Cancer].

Leptomeningeal metastasis (LM) is one of the serious complications of advanced non-small cell lung cancer (NSCLC), although the incidence is not high, the clinical symptoms are severe and the prognosis is poor. LM is prone to occur in patients with positive driver gene than negative. At present, the treatment of LM mainly includes molecular targeted therapy, systemic chemotherapy, whole brain radiotherapy, intrathecal chemotherapy and immunotherapy. Although there are many treatments, the efficacy of LM is still unsatisfactory. This article reviews the drug therapy of sensitive driver gene positive NSCLC LM.

L-carnitine's role in KAATSU training- induced neuromuscular fatigue.

KAATSU training at greatly reduced intensities has been proven to result in substantial increases in both muscle hypertrophy and strength. Nevertheless, this revolutionary training method (combined with the restriction of venous blood flow from the working muscle) may cause underlying hypoxia and neurotransmitter dysfunction, which are linked to neuromuscular fatigue. Hence, an exploration of KAATSU training-induced hypoxic and neurodegenerative events is of utmost importance before promoting this training mode, although KAATSU has been shown to result in numerous positive training adaptations. Furthermore, based on substantial evidence, L-carnitine supplementation exerts neuroprotective effects by attenuating hypoxic stress and neurotransmitter dysfunction. However, studies directly examining the effects of KAATSU exercise on both hypoxia and neurotransmitter dysfunction, which would aggravate the detrimental effects of neuromuscular fatigue, are lacking. In addition, an expansion of the applications of L-carnitine to a smaller-molecule field for treating KAATSU training-evoked neuromuscular fatigue requires further clarification. Therefore, this review aims to present the current evidence for the effectiveness of exogenous L-carnitine at reducing the amount of hypoxic damage and its neuroprotective effects mediated by increasing cerebral acetylcholine levels. Simply, L-carnitine administration may be an important contributor to the mechanisms curtailing KAATSU training-induced neuromuscular fatigue.

Learning in the Machine: Random Backpropagation and the Deep Learning Channel.

Random backpropagation (RBP) is a variant of the backpropagation algorithm for training neural networks, where the transpose of the forward matrices are replaced by fixed random matrices in the calculation of the weight updates. It is remarkable both because of its effectiveness, in spite of using random matrices to communicate error information, and because it completely removes the taxing requirement of maintaining symmetric weights in a physical neural system. To better understand random backpropagation, we first connect it to the notions of local learning and learning channels. Through this connection, we derive several alternatives to RBP, including skipped RBP (SRPB), adaptive RBP (ARBP), sparse RBP, and their combinations (e.g. ASRBP) and analyze their computational complexity. We then study their behavior through simulations using the MNIST and CIFAR-10 bechnmark datasets. These simulations show that most of these variants work robustly, almost as well as backpropagation, and that multiplication by the derivatives of the activation functions is important. As a follow-up, we study also the low-end of the number of bits required to communicate error information over the learning channel. We then provide partial intuitive explanations for some of the remarkable properties of RBP and its variations. Finally, we prove several mathematical results, including the convergence to fixed points of linear chains of arbitrary length, the convergence to fixed points of linear autoencoders with decorrelated data, the long-term existence of solutions for linear systems with a single hidden layer and convergence in special cases, and the convergence to fixed points of non-linear chains, when the derivative of the activation functions is included.

Learning in the machine: The symmetries of the deep learning channel.

In a physical neural system, learning rules must be local both in space and time. In order for learning to occur, non-local information must be communicated to the deep synapses through a communication channel, the deep learning channel. We identify several possible architectures for this learning channel (Bidirectional, Conjoined, Twin, Distinct) and six symmetry challenges: (1) symmetry of architectures; (2) symmetry of weights; (3) symmetry of neurons; (4) symmetry of derivatives; (5) symmetry of processing; and (6) symmetry of learning rules. Random backpropagation (RBP) addresses the second and third symmetry, and some of its variations, such as skipped RBP (SRBP) address the first and the fourth symmetry. Here we address the last two desirable symmetries showing through simulations that they can be achieved and that the learning channel is particularly robust to symmetry variations. Specifically, random backpropagation and its variations can be performed with the same non-linear neurons used in the main input-output forward channel, and the connections in the learning channel can be adapted using the same algorithm used in the forward channel, removing the need for any specialized hardware in the learning channel. Finally, we provide mathematical results in simple cases showing that the learning equations in the forward and backward channels converge to fixed points, for almost any initial conditions. In symmetric architectures, if the weights in both channels are small at initialization, adaptation in both channels leads to weights that are essentially symmetric during and after learning. Biological connections are discussed.

Icaritin, a novel plant-derived osteoinductive agent, enhances the osteogenic differentiation of human bone marrow- and human adipose tissue-derived mesenchymal stem cells.

For the treatment of diseases affecting bones using bone regenerative medicine, there is an urgent need to develop safe, inexpensive drugs that can strongly induce bone formation. In the present study, we systematically investigated the effects of icaritin, a metabolic product of icariin, on the osteogenic differentiation of human bone marrow­derived mesenchymal stem cells (hBMSCs) and human adipose tissue­derived stem cells (hADSCs) in vitro. After treatment with icaritin at concentrations of 10­8-10­5 M, hBMSCs and hADSCs were examined for alkaline phosphatase activity, osteocalcin (OC) secretion, matrix mineralization and expression levels of bone­related mRNA and proteins. Data showed that icaritin at concentrations 10­7-10­5 M significantly increased alkaline phosphatase activity, OC secretion at different time points, and calcium deposition at day 21. In addition, icaritin upregulated the mRNA expression of genes for bone morphogenetic proteins (BMP­2, ­4 and ­7), bone transcription factors (Runx2 and Dlx5) and bone matrix proteins (ALP, OC and Col­1). Moreover, icaritin increased the protein levels of BMPs, Runx2 and OC, as detected by western blot analysis. These findings suggest that icaritin enhances the osteogenic differentiation of hBMSCS and hADSCs. Icaritin exerts its potent osteogenic effect possibly by directly stimulating the production of BMPs. Although the osteogenic activity of icaritin in vitro was inferior to that of rhBMP­2, icaritin displayed better results than icariin. Moreover, the low cost, simple extraction procedure, and an abundance of icaritin make it appealing as a bone regenerative medicine.

Complex-valued autoencoders.

Autoencoders are unsupervised machine learning circuits, with typically one hidden layer, whose learning goal is to minimize an average distortion measure between inputs and outputs. Linear autoencoders correspond to the special case where only linear transformations between visible and hidden variables are used. While linear autoencoders can be defined over any field, only real-valued linear autoencoders have been studied so far. Here we study complex-valued linear autoencoders where the components of the training vectors and adjustable matrices are defined over the complex field with the L(2) norm. We provide simpler and more general proofs that unify the real-valued and complex-valued cases, showing that in both cases the landscape of the error function is invariant under certain groups of transformations. The landscape has no local minima, a family of global minima associated with Principal Component Analysis, and many families of saddle points associated with orthogonal projections onto sub-space spanned by sub-optimal subsets of eigenvectors of the covariance matrix. The theory yields several iterative, convergent, learning algorithms, a clear understanding of the generalization properties of the trained autoencoders, and can equally be applied to the hetero-associative case when external targets are provided. Partial results on deep architecture as well as the differential geometry of autoencoders are also presented. The general framework described here is useful to classify autoencoders and identify general properties that ought to be investigated for each class, illuminating some of the connections between autoencoders, unsupervised learning, clustering, Hebbian learning, and information theory.

[Role of DNA-associated autoantibodies to cell membrane in the diagnosis of juvenile systemic lupus erythematosus].

OBJECTIVE: To establish a method of indirect immunofluorescence (IIF) to measure DNA (mDNA)-associated autoantibodies to cell membrane, and to evaluate diagnostic value of the anti-mDNA antibodies in patients with juvenile systemic lupus erythematosus (SLE) in comparison with anti-dsDNA antibody. METHODS: Forty-four children with SLE were enrolled in this study. As a control group, 30 children with other rheumatic diseases were also enrolled. Anti-mDNA and anti-dsDNA antibodies were measured by IIF. Anti-smooth muscle (Sm) antibodies were measured by immuno-double diffusion (ID) and IIF. RESULTS: Out of 44 juvenile SLE patients, 34 (77.27%) were seropositive for anti-mDNA, which was significantly higher than that of patients with other rheumatic diseases (20.00%, P<0.05). The sensitivity and specificity of anti-mDNA for juvenile SLE diagnosis were 77.27% and 80.00%, respectively. The positive predictive value and negative predictive value were 85.00% and 70.59%, respectively. The positive rate of anti-mDNA in SLE lacking of anti-dsDNA and anti-Sm antibodies were 68.00% (17/25) and 79.49% (31/39), respectively. CONCLUSION: The detection of anti-mDNA antibodies is useful for diagnosis of juvenile SLE, especially in patients who are negative for anti-dsDNA antibodies and anti-Sm antibodies.