FAIRLANE, a double-blind placebo-controlled randomized phase II trial of neoadjuvant ipatasertib plus paclitaxel for early triple-negative breast cancer

BACKGROUND

This hypothesis-generating trial evaluated neoadjuvant ipatasertib-paclitaxel for early triple-negative breast cancer (TNBC).

PATIENTS AND METHODS

In this randomized phase II trial, patients with early TNBC (T ≥ 1.5 cm, N0-2) were randomized 1 : 1 to receive weekly paclitaxel 80 mg/m2 with ipatasertib 400 mg or placebo (days 1-21 every 28 days) for 12 weeks before surgery. Co-primary end points were pathologic complete response (pCR) rate (ypT0/TisN0) in the intention-to-treat (ITT) and immunohistochemistry phosphatase and tensin homolog (PTEN)-low populations. Secondary end points included pCR rate in patients with PIK3CA/AKT1/PTEN-altered tumors and pre-surgery response rates by magnetic resonance imaging (MRI).

RESULTS

pCR rates with ipatasertib versus placebo were 17% versus 13%, respectively, in the ITT population (N = 151), 16% versus 13% in the immunohistochemistry PTEN-low population (N = 35), and 18% versus 12% in the PIK3CA/AKT1/PTEN-altered subgroup (N = 62). Rates of overall and complete response (CR) by MRI favored ipatasertib in all three populations (CR rate 39% versus 9% in the PIK3CA/AKT1/PTEN-altered subgroup). Ipatasertib was associated with more grade ≥3 adverse events (32% versus 16% with placebo), especially diarrhea (17% versus 1%). Higher cycle 1 day 8 (C1D8) immune score was significantly associated with better response only in placebo-treated patients. All ipatasertib-treated patients with low immune scores and a CR had PIK3CA/AKT1/PTEN-altered tumors.

CONCLUSIONS

Adding ipatasertib to 12 weeks of paclitaxel for early TNBC did not clinically or statistically significantly increase pCR rate, although overall response rate by MRI was numerically higher with ipatasertib. The antitumor effect of ipatasertib was most pronounced in biomarker-selected patients. Safety was consistent with prior experience of ipatasertib-paclitaxel. A T-cell-rich environment at C1D8 had a stronger association with improved outcomes in paclitaxel-treated patients than seen for baseline tumor-infiltrating lymphocytes. This dependency may be overcome with the addition of AKT inhibition, especially in patients with PIK3CA/AKT1/PTEN-altered tumors.

CLINICALTRIALS.GOV

NCT02301988.

eLearning Technologies on the follow-up of Young People with Chronic Diseases

Introduction Non-communicable diseases are increasing worldwide due mainly to rapidly changing lifestyles and socio-economic status affecting the well-being and the lives of young people along their whole life. Hence, there is a need to provide adequate and useful measures to support patients living with those diseases in order to foster youth emotional and physical health and improve their daily life.

Objectives The aim of this presentation is to demonstrate the use of eLearning content to empower families, communities and young patients in dealing with the daily routine of chronic diseases.

Methodology Based on a human centred design, 176 youngsters with asthma, obesity, and diabetes aged between 3-16 years old were assessed to gather information about perceived needs and preferences in relation to disease management. Ineffective communication, lack of knowledge/skills, poor adherence to treatment and low acceptance of the disease were the main aspects highlighted. Based on those results, participants were fully involved participating in the iterative development of eLearning package to face these needs, gathering specific information about its content, design and usability.

Results The project has generated eLearning modules, using Articulate technologies, providing practical information and learning content in three languages, in partnership with health research centres, hospitals and patient associations in Portugal, Spain and France. There are lots of packages: obesity, respiratory diseases and diabetes. In each of these, the content is provided using gamification strategies and role models. eLearning is one of the components of the follow up process, being complemented by a mobile application with an interactive support chat and fun games.

Conclusion ELearning tools, along with other online tools, contribute to generate a more positive perspective on the control of the disease and to support families and patients to get reliable information and connect with medical assistance.

P1136Is there a negative impact of permanent pacemaker implantation in long-term outcomes after transcatheter aortic valve implantation?

Introduction

Transcatheter aortic valve implantation (TAVI) is an established treatment in patients (P) with aortic stenosis. Despite the continuous developments of this procedure, high-grade conduction disturbances requiring permanent pacemaker (PPM) implantation is still a major and common complication of TAVI. Furthermore, long-term chronic right ventricular pacing has been associated with negative effects on ventricular function and heart failure (HF).

Aim

  to evaluate the long-term impact of PPM after TAVI focusing on mortality and HF hospitalization.

Methods

 We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2018 at our institution. All P had pre-procedural clinical evaluation, including ECG, cardiac computed tomographic angiography and transthoracic echocardiography. P with previous PPM were excluded.

Results

 265P (57% male, mean age 81.4 years, 20% with left ventricular ejection fraction <40%) were analysed. Mean STS score and mean Euroscore II were 6.33% and 7.07%, respectively. Mean transvalvular gradient was 52.78 mmHg and mean aortic valve area 0.67 cm2. Forty-seven P (17%) underwent PPM implantation during the first 30 days after TAVI. P requiring PPM had higher prevalence of diabetes mellitus, chronic renal disease, atrial fibrillation and right bundle branch block. During a mean follow-up of 20.3 months, post-TAVI PPM was associated with similar mortality rate (29.8% vs. 25.6%, HR 1.28, 95% CI 0.72-2.29, p = 0.42) and similar cardiovascular mortality (9.8% vs. 6.4%, HR 0.72, 95% CI 0.21-2.4, p = 0.59) compared to P without PPM. There were no significant differences in HF hospitalization (4.9% vs. 2.4%, p = 0.47). Kaplan-Meier curves of total mortality and cardiovascular mortality according to the need for PPM post-TAVI were similar. 

Conclusions

 In P submitted to TAVI, PPM implantation is a relatively common finding, not associated with higher risk of total mortality, cardiovascular mortality or HF hospitalization in a long-term follow-up.

Biological effects and bioaccumulation of gold in gilthead seabream (Sparus aurata) - Nano versus ionic form

The question of whether gold (Au) is more toxic as nanoparticles or in its ionic form remains unclear and controversial. The present work aimed to clarify the effects of 96 h exposure to 4, 80 and 1600 μg·L^-1 of 7 nm gold nanoparticles (AuNPs) - (citrate coated (cAuNPs) or polyvinylpyrrolidone coated (PVP-AuNPs)) - and ionic Au (iAu) on gilthead seabream (Sparus aurata). Effects at different levels of biological organization (behaviour, neurotransmission, biotransformation, oxidative stress/damage and genotoxicity) were assessed. cAuNPs induced oxidative stress and damage (lipid peroxidation increase), even at 4 μg·L^-1, and reduced the ability of S. aurata to swim against a water flow at 1600 μg·L^-1. Exposure to cAuNPs induced more adverse effects than exposure to PVP-AuNPs. All tested concentrations of Au (nano or ionic form) induced DNA breaks and cytogenetic damage in erythrocytes of S. aurata. Generally, iAu induced significantly more effects in fish than the nano form, probably associated with the significantly higher accumulation in the fish tissues. No fish mortality was observed following exposure to AuNPs, but mortality was observed in the group exposed to 1600 μg·L^-1 of iAu.

Do microplastics affect the zoanthid Zoanthus sociatus?

Microplastics (1 μm-5 mm), a ubiquitous and persistent marine pollutant, pose a severe threat to coral reefs when recently associated with physiological distress and increased diseases on corals. Studies conducted so far have only reported effects on scleractinian species. Knowledge about its effects on other corals (e.g. Order Zoantharia) remains uncovered, and responses at biochemical levels remain poorly documented. This study aimed to assess the potential effects induced by the presence of microplastics (1 and 10 mg L^-1 low-density polyethylene, LDPE MP, or polyvinyl chloride, PVC MP) in the tropical and subtropical cosmopolitan species Zoanthus sociatus (order Zoantharia. Anthozoa: Hexacorallia), at organism level (survival and behaviour), endosymbionts (photosynthetic efficiency) and the cellular level (oxidative stress, detoxification capacity and energy metabolism). In a short-term exposure (96 h), this species was more sensitive to PVC MP. The presence of this polymer at a concentration of 10 mg L^-1 caused a ten-fold higher adhesion to the coral epidermis, increased photosynthetic efficiency, lipid peroxidation, and antioxidant defences; without, however, inducing energetic costs. Although the observed physiological and biochemical effects did not compromise Z. sociatus survival in the short term, it does not rule out potential long-term (cumulative) effects that could endanger this and other physiologically similar species that underlie coral reefs.

Effects of gold nanoparticles in gilthead seabream-A proteomic approach

Despite the widespread use of nanoparticles (NPs), there are still major gaps of knowledge regarding the impact of nanomaterials in the environment and aquatic animals. The present work aimed to study the effects of 7 and 40 nm gold nanoparticles (AuNPs) - citrate and polyvinylpyrrolidone (PVP) coated - on the liver proteome of the estuarine/marine fish gilthead seabream (Sparus aurata). After 96 h, exposure to AuNP elicited alterations on the abundance of 26 proteins, when compared to the control group. AuNPs differentially affected several metabolic pathways in S. aurata liver cells. Among the affected proteins were those related to cytoskeleton and cell structure, gluconeogenesis, amino acids metabolism and several processes related to protein activity (protein synthesis, catabolism, folding and transport). The increased abundance of proteins associated with energy metabolism (ATP synthase subunit beta), stress response (94 kDa glucose-regulated protein) and cytoskeleton structure (actins and tubulins) may represent the first signs of cellular oxidative stress induced by AuNPs. Although higher gold accumulation was found in the liver of S. aurata exposed to 7 nm PVP-AuNPs, the 7 nm cAuNPs were more bioactive, inducing more effects in liver proteome. Gold accumulated more in the spleen than in the other assessed tissues of S. aurata exposed to AuNPs, highlighting its potential role on the elimination of these NPs.

Mental flexibility and problem solving in adult patients who present non-suicidal self-injury

Introduction

Non-Suicidal Self-Injury (NSSI) is considered a dysfunctional way of dealing with problem situations.

Objective

This study aimed to investigate the problem solving capacity in adults with NSSI compared to controls.

Methods

Thirty-three patients who sought treatment for NSSI (NSSI group) were compared with 33 individuals without psychiatric disorder (control group). We also investigated Axis I disorders, executive functions and problem solving capacity.

Results

In both groups, the majority were women (77.25%) with a mean age of 30 years, and the beginning of NSSI behavior of 16 years. The most common NSSI behaviour was skin cutting, and the most common reason given for engaging in that behaviour was “to stop negative feelings”. The most common psychiatric comorbidities were major depressive disorder (60.6%). Compared to controls, the group with NSSI showed lower results in relation to problem solving capacity (P = 0.000) and mental flexibility (P = 0.007). Deficits in problem solving capacity may be a reflection of low mental flexibility of adults with NSSI. This may be a risk factor for the beginning of NSSI and the persistence of it in adulthood.

Conclusion

Early identification and treatment focused on problem solving capacity during the adolescence may prevent the chronicity of NSSI.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

9 Pregnancy loss in Holstein lactating recipient cows diagnosed pregnant by pregnancy-associated glycoprotein test in blood

The objective of this study was to evaluate the pregnancy loss (PL) between Day 30 (P30) and Day 80 (P80) of pregnancy in lactating Holstein recipients that received an invivo- (flush) or invitro-produced (IVF) embryo. The recipient cows were located at Maddox Dairy in Riverdale, CA, USA, a Holstein herd that milks 3500 cows with a 305-day mature-equivalent milk production of 12 800 kg. First-lactation cows were enrolled in a Presynch-Ovsynch oestrus-synchronization program and scheduled to be artificially bred for the first time at 80 days after calving or to receive an embryo 7 or 8 days after the expected heat (recipients). The data from 590 pregnancies (1045 embryo transfers) from embryos transferred between January 2018 and March 2019 was analysed. Only grade 1 embryos (from morula to hatched blastocyst stage) produced invivo or invitro from Holstein donor heifers, lactating or dry cows, were transferred fresh (invivo or invitro) or frozen-thawed (invivo), and pregnancy rates are shown in Table 1. The ruminant trophoblast produces pregnancy-associated glycoproteins (PAG) that can be detected by enzyme-linked immunoassay (ELISA) in the blood of pregnant cattle as early as 28 days after insemination. Various dairy herds in the USA have been using this test to supplement or replace the use of transrectal ultrasonography for early pregnancy diagnosis. Blood was sampled on P30 after expected heat day (23 days after embryo transfer) from the recipient cows and sent to IDEXX for the PAG Bovine Pregnancy Test, which was reconfirmed on P80 of pregnancy by transrectal ultrasonography. Pregnancy loss was considered to have occurred when a cow was pregnant on P30 but not pregnant on P80. The variable PL was analysed by binary logistic regression in the MINITAB program, and the model included effects of donor status (heifer vs. milk vs. dry) and embryo type. The total PL was 12.2% (72/590) and the details are shown in Table 1. No effect of donor status (P=0.80) was detected. However, there was effect of embryo type (P=0.004). The IVF embryos had a PL of 18.0% compared with 9.5% for the invivo-produced embryos. Further research should be performed to study heifer embryos PL, because currently more embryos are being produced from very young donor cows and sires due to intensive use of genomic testing. In conclusion, there is a higher PL in lactating dairy recipients receiving IVF fresh embryos compared with fresh or frozen invivo-produced embryos. Table 1.Embryo transfer (ET) pregnancy rates (PR, P30) in first-lactation Holstein cows (top) and pregnancy loss (PL) from Day 30 (P30) to 80 (P80) in first-lactation recipient Holstein cows (bottom) Item Heifer donor Lactating donor Dry donor Total ET P30 PR% ET P30 PR% ET P30 PR% ET P30 PR% Invivo - fresh 6 3 50.0 43 25 58.1 329 206 62.6 378 234 61.9 Invivo - frozen 75 38 50.7 221 129 58.4 296 167 56.4 IVF - fresh 123 61 49.6 91 42 46.2 157 86 54.8 371 189 50.9 Total 129 64 49.6 209 105 50.2 707 421 59.5 1045 590 56.5 P30 P80 PL% P30 P80 PL% P30 P80 PL% P30 P80 PL% Invivo - fresh 3 3 0.0 25 24 4.0 206 186 9.7 234 213 9.0 Invivo - frozen 38 35 7.9 129 115 10.9 167 150 10.2 IVF - fresh 61 48 21.3 42 35 16.7 86 72 16.3 189 155 18.0 Total 64 51 20.3 105 94 10.5 421 373 11.4 590 518 12.2

P672 Predictors of ventricular arrythmias and mortality after implantation of primary prevention antitachycardia devices

Background

Patients (pts) with reduced left ventricular (LV) systolic function have high risk of sudden cardiac death and benefit from implantable cardioverter-defibrillators (ICDs/CRT-Ds). However, the risk for arrhythmic events and device therapies is extremely heterogeneous in this population, so more accurate tools for risk stratification are required.

Purpose

To assess predictors of mortality and arrhythmic events in pts receiving primary prevention ICDs/ CRTs.

Methods

Retrospective analysis of 150 pts submitted to primary prevention ICD/ CRT-D implantation with remote monitoring between 2014-2018. Demographic, clinical and echocardiographic data from implantation and follow-up period were retrieved. Arrhythmic events and device therapies were retrieved from remote monitoring and clinic visits. Univariate analysis was performed followed by a multivariate Cox analysis to evaluate predictors of events. p < 0.05 were considered significant.

Results

150 pts, 80.7% male, with a mean age of 64.30 ± 12.9 years (Y) and a mean follow-up (FU) time of 38 ± 15 months. 66% of pts implanted an ICD. 52.0% of pts presented with an ischemic cardiomyopathy and 41.3% had atrial fibrillation. 35.3% had chronic kidney disease (GFR < 60mL/min) and 24.0% were diabetic. Mean BNP value of 449.6 ± 631.3pg/mL and mean peak VO2 of 15.3mL/kg/min. Mean LV ejection fraction (LVEF) during FU of 35.9 ± 12.1% and a mean average global longitudinal strain (GLS) of -8.7 ± 5.5%. 63pts (42.0%) suffered a ventricular arrhythmia, mostly non-sustained ventricular tachycardia, of which 47.6% received appropriate therapies. Mortality rate of 13.3% during follow-up (20 pts). Baseline diabetes (p = 0.040) and post-procedural pulmonary artery systolic pressure (PASP) (p = 0.002) were independent predictors of overall mortality in the follow-up. Male gender (p = 0.041), baseline diabetes (p = 0.011) and atrial fibrillation (p = 0.038) were associated with ventricular events. In patients with CRT-D, a percentage of biventricular pacing superior to 95% was found to be protective against ventricular arrhythmias. Interestingly despite being associated with a higher overall mortality (p = 0.028), a reduced LVEF wasn’t related to the arrhythmic burden of our population, neither the GLS nor the LV mechanical dispersion were predictors of ventricular arrhythmias.

Conclusion

Baseline diabetes and PASP were independent predictors of mortality in our population of ICD/CRT-D pts implanted in primary prevention setting. An increased percentage of biventricular pacing was associated to improved clinical outcomes in patients receiving cardiac resynchronization therapy. Identification of predictors of events in this population can help individualize its management.

P1260 Chagas disease, a new challenge to the old continent

Case Report

A 53-year-old female patient from the North Region of Brazil with a past medical history of Chagas Disease (CD) with esophageal involvement and permanent atrial fibrillation (AF) presented to the Emergency Department (ED) due to complaints of retrosternal discomfort and dizziness. The patient reported multiple recent syncopal episodes and had performed a recent 24-hour Holter monitoring revealing AF with predominantly slow ventricular rate and frequent ventricular premature beats. Her sister had recently been diagnosed with obstructive hypertrophic cardiomyopathy. During the ED stay, the patient developed a syncopal monomorphic ventricular tachycardia, requiring synchronized electrical cardioversion. Post cardioversion EKG revealed a sinus rhythm with a right bundle branch block, left anterior fascicular block and 1st degree AV block. The patient was admitted in the Cardiology Department for further investigation. Transthoracic echocardiogram revealed a dilated left ventricle with a reduced systolic function (LVEF of 38%, GLS of -7.1%), with an aneurysm of the basal inferior and posterior walls and a markedly dilated left atrium (68mL/m2). Cardiac magnetic resonance imaging showed a marked dilation of both atriums and ventricles, with biventricular systolic dysfunction, hypertrabeculation of the left ventricular wall and the presence of diffuse intramural and subepicardic fibrosis. These features were compatible with chagasic cardiomyopathy. Due to biventricular systolic dysfunction, the documentation of AV conduction disturbance, the natural history of the disease and the need for antiarrhythmic therapy, the patient underwent cardiac resynchronization therapy–defibrillator implantation. 1 week after the procedure, the patient experienced an arrhythmic storm with a total of 6 CRT-D shocks. Amiodarone was initiated and beta-blocker was titulated to the maximum tolerated dose, with no recurrence of ventricular tachycardia. On the 3 month follow-up visit the patient denied symptoms of congestive heart failure. Device interrogation revealed a high percentage of biventricular pacing and no arrhythmic events.

Conclusion

This case describes the most remarkable and characteristic features of chagasic cardiomyopathy. It is almost always progressive and is associated with a worse outcome comparing with other cardiomyopathies. The prevalence of CD is growing in traditionally nonendemic areas and its timely recognition is fundamental.

P1262 If anything can go wrong, it will: management of a pericardial effusion in a young patient

Case Report

A 25 year-old male patient with an unremarkable past medical history presented to the Emergency Department due to a hemodynamically stable wide complex tachycardia at 260bpm with no response to adenosine, which was successfully treated with synchronized electrical cardioversion. Post cardioversion EKG revealed a pre excitation pattern and the transthoracic echocardiogram showed a large pericardial effusion with diastolic right atrial collapse. The patient was admitted in the Cardiology Department for emergent pericardiocentesis and further investigation. A total of 800 mL of bloody pericardial fluid was removed, compatible with an exudate, but fluid culture and cytology were inconclusive. Due to a rapid reaccumulation of pericardial fluid, the patient underwent a pericardial window, after which he developed an intractable pleuritic thoracalgia, refractory to the combination of ibuprofen, colchicine and oral steroid, despite the resolution of the pericardial effusion. He was also submitted to an electrophysiologic study with successful ablation of a right sided accessory pathway. Analysis of the pericardial fluid and biopsy were inconclusive once again, including a low level of adenosine deaminase and negative acid-fast bacilli test and nucleic acid amplification test for Mycobacterium tuberculosis. The patient was afebrile and denied any constitutional symptoms or relevant epidemiological context. The remainder etiological study was unremarkable, with the exception of fluctuating antibody titers for adenovirus, Borrelia burgdorferi and Mycoplasma pneumoniae, which were interpreted as a result of cross-reactivity. Nevertheless, a course of 21 days of doxycycline was tried without any significant improvement. Thoracic-abdominal-pelvic CT and PET scan were normal. Direct inoculation in guinea pig led to positive results for Mycobacterium tuberculosis and antituberculous therapy was started. Despite pathogen directed antibiotic treatment, there was no clinical improvement and the pericardial effusion gradually relapsed, evolving to cardiac tamponade requiring emergent drainage. Histologic examination of pericardial fragments finally revealed massive infiltration by an undifferentiated malignant tumor compatible with a malignant epithelioid hemangioendothelioma. Due to the patient’s poor performance status and rapidly deteriorating clinical course, it was decided not to start chemotherapy. The patient eventually died, 6 months after his admission to the ED and 2 weeks after the neoplasm’s diagnosis.

Conclusion

In regions with a high Tuberculosis incidence, there should be a high degree of suspicion for tuberculous pericarditis, especially in cases of recurrent pericardial effusion. Immunosuppressed individuals, such as oncologic patients, are at an increased risk for tuberculosis. The management of relapsing pericardial effusion remains a diagnostic challenge as described in this clinical case.

227 Is the antral follicle count on a random day of the oestrous cycle correlated with superovulatory responses in Santa Inês ewes?

Antral follicle count (AFC) performed after an oestrus synchronization protocol has been studied as a tool to select ewes with high potential for invivo embryo production (Pinto et al. 2018 Theriogenology 113, 146-152). However, it would be interesting to know whether AFC assessed on a random day of the oestrous cycle correlates with the superovulatory response. The present study was conducted to evaluate the correlation between AFC at the beginning of progesterone (P4)-based oestrus synchronization protocol used as basis of superovulatory treatment and the number of corpora lutea (CL) 12h before recovery of embryos in Santa Inês ewes. The study was conducted during September and October in northeast Brazil (03°40′26″S and 40°14′20″W) using 8 adult Santa Inês ewes. On a random day of oestrous cycle (Day 0) all ewes received an intravaginal device (CIDR) of progesterone (0.3g, Eazi-breed, Zoetis), which remained for 9 days. On Day 7, the pFSH (133mg, Folltropin V, Vetoquinol) treatment began, with 6 decreasing doses (25, 25, 15, 15, 10, and 10%) injected IM at 12-h intervals. On Day 9, 2 equal doses of D-cloprostenol were injected at a 12-h interval (37.5µg, Prolise, Agener União). All ewes showed oestrus and were mated by fertile rams. Flunixin meglumine (24.9 mg; Banamine, MSD Animal Health) was administered IM on Days 12, 13, and 15. On Day 16, non-surgical embryo recovery (NSER) was performed after cervical dilation using D-cloprostenol and oestradiol benzoate at 16h and oxytocin 20min before. Transrectal B-mode ultrasound evaluations (Z5 Vet, Mindray), frequency 7.5MHz, were performed on Day 0 and 7 and 12h before NSER to evaluate the ovarian population present. Pearson correlation analysis (P<0.05) was performed using Bioestat 5.3 software. The number of AFC per ewe at the beginning of the protocol and on Day 7 were 9.9±2.7 and 11±3.2, respectively. The numbers of CL, recovered embryos, and viable embryos were 14.0±3.5, 8.2±10.9, and 6.0±11.0, respectively. There was no correlation of AFC on a random day of oestrous cycle with the number of AFC on Day 7 (P=0.42), number of corpora lutea (P=0.44), number of recovered embryos (P=0.18), or number of viable embryos (P=0.11) in superovulated ewes. In conclusion, we did not find significant correlations between AFC on a random day of oestrous cycle and the superovulatory/embryos response in Santa Inês ewes. Financial support for this study was provided by Embrapa (02.13.06.026.00.02 and 02.13.06.026.00.04) and FAPEMIG (PPM 00201-17).

11 Invivo-derived embryo pregnancy rates at Maddox Dairy from 2008 to 2018

Maddox Dairy, located in Riverdale, CA, USA, is a Holstein herd that milks 3500 cows with a 305-day mature-equivalent milk production of 12 800 kg, and they have been producing high genetic animals by embryo transfer (ET) since the early 1980s. Invivo-derived embryos from Holstein donors were transferred fresh (grade 1 or 2) or frozen (grade 1), at morula (4), early blastocyst (5), or blastocyst (6) stage, to virgin heifers (VH, natural oestrus, 13-15 months old) or lactating cows (LC, Presynch-Ovsynch, 86 days in milk, first or second lactation) 6 to 9 days after oestrus. Pregnancy diagnosis was done by transrectal ultrasonography at 32-46 days in VH and by the IDEXX PAG test at 30 days in LC. June, July, August, September, and October were called critical months (first service AI conception rate drops below 44%) and compared with the other months. The data from 32 503 ETs between January 2008 and December 2018 are summarised on Table 1. Pregnancy rates (PR) are lower for LC recipients than for VH. Embryo transfers performed 7 or 8 days after oestrus had higher PR in both types of recipients and embryos, but Day 6 and 9 oestrus are also used with fair results. The season does not seem to affect PR. There is not enough difference in the combination of stage and days from oestrus for invivo-derived embryos. These numbers do not belong to a planned experiment. Several management changes during the years were made, which make it very difficult to apply statistical methods to analyse the data correctly. They are used as a tool to make decisions in an attempt to improve future results. Table 1.Pregnancy rate (PR) of virgin heifers (top) and lactating cows (bottom)-fresh (SH) and frozen (OZ) invivo-derived embryo transfer1 Heat-months SH-ST4 SH-ST5 SH-ST6 SH-All OZ-ST4 OZ-ST5 OZ-ST6 OZ-All PR% n PR% n PR% n PR% n PR% n PR% n PR% n PR% n Heifers 6 d-CM 62 934 66 243 68 69 63 1246 56 473 58 219 62 42 57 734 6 d-OM 62 1623 67 489 69 211 64 2323 56 600 55 296 48 137 55 1033 6 d-T 62 2557 67 732 69 280 63 3569 56 1073 57 515 51 179 56 1767 7 d-CM 64 1506 68 495 67 221 65 2222 60 822 62 340 63 156 61 1318 7 d-OM 66 2723 68 1021 69 510 67 4254 57 1120 59 581 57 231 58 1932 7 d-T 66 4229 68 1516 69 731 67 6476 58 1942 60 921 60 387 59 3250 8 d-CM 65 1348 64 518 67 322 65 2188 59 595 64 258 63 108 61 961 8 d-OM 66 2166 68 886 70 510 67 3562 61 770 60 364 51 130 60 1264 8 d-T 66 3514 67 1404 69 832 66 5750 60 1365 62 622 56 238 60 2225 9 d-CM 60 109 56 43 70 20 60 172 60 5 33 6 50 4 47 15 9 d-OM 58 129 63 57 60 40 60 226 63 16 50 18 75 4 58 38 9 d-T 59 238 60 100 63 60 60 398 62 21 46 24 63 8 55 53 All-CM 64 3897 66 1299 67 632 65 5828 58 1895 61 823 63 310 60 3028 All-OM 65 6641 67 2453 69 1271 66 10 365 58 2506 58 1259 53 502 58 4267 All-T 65 10 538 67 3752 69 1903 66 16 193 58 4401 60 2082 57 812 59 7295 Lactating cows 6 d-CM 54 265 48 86 50 12 53 363 38 141 31 77 50 10 36 228 6 d-OM 49 463 52 203 45 56 50 723 46 101 48 54 59 27 48 182 6 d-T 51 728 51 289 46 68 51 1086 41 242 38 131 57 37 42 410 7 d-CM 54 755 59 274 56 103 55 1137 43 928 48 450 43 192 45 1570 7 d-OM 55 914 66 367 54 109 58 1393 46 1052 45 564 47 353 46 1969 7 d-T 55 1669 63 641 55 212 57 2530 45 1980 46 1014 46 545 45 3539 8 d-CM 63 252 68 82 76 33 65 368 48 219 56 80 42 33 50 332 8 d-OM 61 257 64 161 53 47 61 466 50 191 53 77 56 16 51 284 8 d-T 62 509 65 243 63 80 63 834 49 410 55 157 47 49 50 616 All-CM 56 1272 58 442 60 148 57 1868 44 1288 47 607 43 235 45 2130 All-OM 55 1634 62 731 51 212 56 2582 47 1344 46 695 48 396 47 2435 All-T 55 2906 60 1173 55 360 57 4450 45 2632 47 1302 46 631 46 4565 1ST=stage; CM=critical months (June, July, August, September, and October); OM=other months.

10 Pregnancy rates following artificial insemination or embryo transfer in lactating Holstein cows

Excessive heat affects the fertility of high production lactating cows, and reduced pregnancy rates (PR) are observed during summer and early fall. Embryo production programs are used to produce more calves from high genetic merit animals, but could it also increase fertility by bypassing all the negative variables affecting the embryo development before Day 7 (oocyte development, ovulation, fertilization, early embryo development)? The data from AIs and embryo transfers (ET) between June 2017 and May 2019 were analysed. June, July, August, September, and October were called critical months (first-service AI conception rate dropped below 44%). The cows were located at Maddox Dairy in Riverdale, CA, USA, a Holstein herd that milks 3500 cows with a 305-day mature-equivalent milk production of 12 800 kg. First- and second-lactation cows were enrolled in a Presynch-Ovsynch oestrus-synchronization program and scheduled for the first AI at 86 days after calving or to receive an embryo 7 or 8 days after the expected heat. The embryos were produced invivo or invitro from Holstein donors and were transferred fresh or frozen. Blood was sampled on Day 30 after expected heat day (23 days after embryo transfer), and pregnancy was detected by the IDEXX PAG Bovine Pregnancy Test. Table 1 summarises the results, where ET PR% is the number of pregnant cows divided by the number of cows that received and embryo. All the cows synchronized for AI were bred, but only cows with the presence of a corpus luteum (CL) on ET day received an embryo. The presence of a CL was not detected in 28.7% (471/1642) of the cows (32.2% in the critical months and 25.7% in the others). Unfortunately, we could not detect the presence of a CL by ultrasonography every time we transferred embryos, so the nonovulation rate might be overestimated. The cows without a CL were considered open and used to calculate the adjusted PR (AdjPR%). Embryo transfer PR is superior to that of AI, especially during the critical months. Fresh invivo embryos have the most impact. When the cows without CLs are considered open, the difference between AI and ET is still evident for fresh invivo embryos. Besides producing animals with higher genetic merit, depending on the type of embryo used, ET can increase fertility in lactating Holstein cows, especially during the critical months. The other benefit of using ET is that cows that do not ovulate are synchronized right away, which is not the case for AI cows. Table 1.AI×embryo transfer in lactating Holstein cows1 from June 2017 to May 20192 Item Critical months (June to October) Other months (November to May) All year %PR n Adj PR% n %PR n Adj PR% n %PR n Adj PR% n Artificial insemination 41.2% 896 41.2% 896 47.7% 1767 47.7% 1767 45.5% 2663 2663 Fresh invivo embryo 62.7% 373 47.5% 493 69.5% 262 55.3% 329 65.5% 635 50.6% 822 Frozen invivo embryo 59.3% 221 44.8% 292 59.4% 256 47.3% 322 59.3% 477 46.1% 614 IVF fresh embryo 47.9% 167 36.2% 221 54.0% 363 43.0% 456 52.1% 530 40.8% 677 Total embryos 58.5% 761 44.2% 1006 60.2% 881 47.9% 1107 59.4% 1642 46.1% 2113 1Lactating Holstein cows, first and second lactation, first service, Presynch-Ovsynch, 85 DIM. 2PR%=the number of pregnant cows divided by the number of cows that received and embryo; AdjPR%=adjusted pregnancy rate.

P175 Cardiac device infection: to extract or not to extract, that is the question

Introduction

The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients.

Case report

We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock.

Conclusion

Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.

Microbiological quality of raw berries and their products: A focus on foodborne pathogens

Berry samples (n = 316; strawberries, raspberries, blackberries and blueberries) obtained from a fruit processing plant were examined regarding bacteriological quality and their potential public health risk. Three types of berry products were analysed including raw material, product from the mixing step and final product. Escherichia coli, Salmonella spp., Listeria monocytogenes, Bacillus cereus, sulphite-reducing clostridia spores and coagulase-positive staphylococci were the parameters investigated. Salmonella enterica serovar Braenderup and L. monocytogenes were isolated from one fruit sample of raw material each. Two samples harboured E. coli between 0.7 and 0.9 log cfu g-1, not exceeding the hygienic criteria. Coagulase-positive staphylococci were not detected in the studied samples; however, coagulase-negative staphylococci (CNS) were isolated from a small proportion of samples mainly raspberries. Presumptive B. cereus were isolated from a relatively large proportion of the samples, raspberries and blackberries being the most contaminated fruits. The absence of pathogenic microorganisms in the final product as well as the low prevalence of presumptive B. cereus and CNS indicates proper implementation of good manufacturing and hygiene practices (GMPs/GHPs) by the food industry. Nevertheless, the results indicate that the raw material examined may contain pathogenic bacteria and thereby represent a risk to consumers regarding the manifestation of foodborne diseases.

The impact of the winery's wastewater treatment system on the winery water footprint

In the Mediterranean region, water scarcity has already prompted concern in the wine sector due to the strong impact it has on vineyard productivity and wine quality. Water footprint is an indicator that takes account of all the water involved in the creation of a product and may help producers to identify hotspots, and reduce water consumption and the corresponding production costs. In recent years several studies have been reported on wine water footprint determination, but mostly focused on the viticulture phase or assuming no grey water footprint at the winery since it has a treatment system. In the framework of the WineWaterFootprint project a medium-size winery was monitored, with direct measurements, regarding determination of the blue and grey components of water footprint. The determined winery water footprint ranged from 9.6 to 12.7 L of water per wine bottle of 0.75 L, the wastewater produced being responsible for about 98%, which means that the grey component cannot be disregarded. The developed scenarios show that a potential reduction of 87% in winery water footprint can be obtained with almost no investment. The challenge of reducing the grey footprint is not in technology development, but rather in the proper maintenance and monitoring of treatment systems.

P3800Defibrillation for right ventricular dysfunction - An echocardiographic method for therapy selection

Introduction

Cardiac resynchronization therapy (CRT) is recommended for heart failure (HF) patients with left ventricular ejection fraction (LVEF) <35% and QRS>130 mseg. We aim to identify if baseline transthoracic echocardiographic (TTE) data can predict the need for defibrillation therapies in a primary prevention HF population referred for CRT implant.

Methods

We analyzed 119 consecutive HF patients in primary prevention referred for CRT implantation between 2004 and 2016. All patients underwent TTE before implantation. During a mean follow-up time of 58.4±33.9 months, all patients were evaluated with device interrogation every 6 months. In order to determine which parameters can predict sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) occurrence, a multivariate analysis was performed including previous medical history, baseline laboratorial, electro and echocardiographic data.

Results

We included 86.6% (n=106) males, mean age at implant 65.5±9.7 years. A CRT-defibrillator (CRT-D) was implanted in 82 (64.2%) patients and a VT or VF was documented in 16 patients (13.4%). Baseline characteristics are presented in the table. After multivariate analysis, baseline right ventricular dysfunction (defined as TAPSE≤18mm) was an independent predictor for VT or VF occurrence (OR=4.83, 95CI 1.67–6.25, p=0.002).

Baseline characteristics VT/VF (n=16) No VT/VF (n=103) P-value Age (years, mean ± SD) 62,4±7,9 66,2±9,5 0,135 Female gender (n, %) 2 (12,5) 14 (15,1) 0,572 Ischemic cardiomyopathy (n, %) 7 (43,8) 21 (22,6) 0,073 NYHA III + IV (n, %) 13 (81,3) 76 (73,8) 0,984 QRS width (mseg, mean ± SD) 168,5±19,5 177,6±22,2 0,142 Atrial fibrillation (n, %) 5 (31,3) 17 (18,3) 0,089 LVEF (%, mean ± SD) 24,6±4,8 26,3±6,3 0,302 TAPSE (mm, mean ± SD) 14,9±4,9 17,9±4,3 0,034 PASP (mmHg, mean ± SD) 48,5±9,4 43,5±14,6 0,419 Mitral regurgitation (moderate or greater, n, %) 5 (31,3) 24 (28,9) 0,077 iVol (mL/m2, mean ± SD) 134,2±36,6 128,7±44,1 0,690 CRT-D implantation (n, %) 16 (100,0) 60 (64,5) 0,002

Conclusion

In a real-world HF population, right ventricular dysfunction defined by echocardiography was an independent predictor for VT or VF occurrence. This may help more accurate patient selection for CRT-D implantation.

P4408Cardiovascular response in diabetic patients submitted to treadmill electrocardiographic exercise stress test

Introduction

Diabetes mellitus (DM) is an entity commonly associated with neuropathy, a factor that may have repercussions on the cardiovascular system, specifically in its capacity to respond to stimuli.

Objectives

To evaluate the cardiovascular response to exercise in diabetic patients, comparing it with a control group.

Methods

Patients who underwent treadmill eletrocardiographic exercise stress test (EST) between January 2016 and November 2018 without the influence of negative chronotropic medication were included.

Results

A total of 187 patients were identified, having a mean age of 57±13 years, of whom 120 (64%) were of the male gender. Eighty-four (45%) were diabetic. The group of diabetic patients had a higher prevalence of arterial hypertension, however the number of classes of antihypertensive drugs was not significantly different between diabetic and non-diabetic patients. There were no significant differences in the remaining demographic variables. Patients with DM presented lower maximal heart rates (HR) (141±14 vs 148±19 beats/minute, p=0.015), lower HT reserve (59±16 vs 67±21 beats/minute, p=0.005), as well as a lower rate of HR fall in the recovery period (13±5 vs 16±5 beats/minute2, p<0.001). Total EST time was also lower in diabetic patients (median 7.0 IQR=3 vs 7.3 IQR=3.5 minutes, p=0.044). Additionally, the number of years since the time of diagnosis of DM was inversely correlated with the degree of increase in systolic blood pressure (SBP) with exercise (r=−0.22, p=0.045), and the pre-test SBP (median 135 IQR=24 vs 130 IQR=20 mmHg, p=0.048) and post-test SBP (median 150 IQR=20 vs 140 IQR=25 mmHg, p=0.007) were higher in patients with DM.

Discussion

In this study it was found that patients with DM present an impaired chronotropic response, both in exercise and recovery periods, and it was observed that the capacity to increase SBP is inversely correlated to the duration of DM. These data may reflect the neuropathic involvement in DM and its influence in the cardiovascular response to exercise.

P6579Genetic profile and predictors of positive genetic test in Brugada syndrome

Introduction

Brugada syndrome (BS) is a channelopathy with autosomal dominant transmission, incomplete penetrance and variable expression. There are 18 different gene mutations described in association with this syndrome, however 70% of patients remain without identifiable genetic cause. Genetic testing is appropriated for patients with clinical diagnosis but it is also a very important tool in familiar screening.

Aim

We aim to characterize genetic profile of patients with clinical diagnosis of BS and identify differences between patients with and without causative mutation.

Methods

We included patients followed by the arrhythmology department of our hospital with diagnosis of BS and that have performed genetic test (or patients who were identified through familiar screening and with negative genetic test in the index case). Patients identified through familiar screening with positive genetic test but no spontaneous electrocardiographic pattern, still awaiting pharmacologic provocative test at the time of enrolment – no clinical diagnosis - were excluded. Genetic test was considered positive when we found a pathogenic or probably pathogenic mutation. Mutations in PKP, SLMAP, CACNA, CACNB, SCN10A and CLASP genes considered of uncertain clinical relevance were not included as positive genetic test. We analysed differences between subset of patients with and without causative mutation regarding clinical and electrocardiographic variables. We performed multivariate analysis to find predictors of positive genetic test.

Results

From our 173 patients, 140 met the inclusion criteria and none exclusion criteria so they were enrolled. Patients were 61% male with mean age of 50±15 years old. Mean follow-up was 26±28 months; 24,4% of index cases were positive for causative mutation, 6,8% patients with pathogenic mutation in SCN5A gene and 17,6% with probably pathogenic mutation in SCN5A.

We haven't found significant differences between the 2 groups (negative and positive genetic test) in any clinical variable included. Regarding electrocardiographic variables, patients in whom a mutation was identified had longer PR interval (192±36 vs 170±28, p=0.001), longer QRS (121±19 VS 111±18 p=0.017), particularly when QRS>110ms (p=0,002), and longer QT (398±25 VS 370±45 p=0.015) In multivariate analysis, PR interval (p=0.032) and QRS>110ms (p=0,041) were independent predictors for positive genetic test.

Conclusion

In our BS population, there were no clinical differences between patients with and without causative mutation, also concerning events rate. Patients with positive genetic test have significantly longer PR interval and QRS>110ms than in patients with genetic test negative. Those results can be interpreted in relation to sodium channel disfunction in patients with SCN5A mutation.

BEECH: a dose-finding run-in followed by a randomised phase II study assessing the efficacy of AKT inhibitor capivasertib (AZD5363) combined with paclitaxel in patients with estrogen receptor-positive advanced or metastatic breast cancer, and in a PIK3CA mutant sub-population

BACKGROUND

BEECH investigated the efficacy of capivasertib (AZD5363), an oral inhibitor of AKT isoforms 1-3, in combination with the first-line weekly paclitaxel for advanced or metastatic estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer, and in a phosphoinositide 3-kinase, catalytic, alpha polypeptide mutation sub-population (PIK3CA+).

PATIENTS AND METHODS

BEECH consisted of an open-label, phase Ib safety run-in (part A) in 38 patients with advanced breast cancer, and a randomised, placebo-controlled, double-blind, phase II expansion (part B) in 110 women with ER+/HER2- metastatic breast cancer. In part A, patients received paclitaxel 90 mg/m2 (days 1, 8 and 15 of a 28-day cycle) with capivasertib taken twice daily (b.i.d.) at two intermittent ascending dosing schedules. In part B, patients were randomly assigned, stratified by PIK3CA mutation status, to receive paclitaxel with either capivasertib or placebo. The primary end point for part A was safety to recommend a dose and schedule for part B; primary end points for part B were progression-free survival (PFS) in the overall and PIK3CA+ sub-population.

RESULTS

Capivasertib was well tolerated, with a 400 mg b.i.d. 4 days on/3 days off treatment schedule selected in part A. In part B, median PFS in the overall population was 10.9 months with capivasertib versus 8.4 months with placebo [hazard ratio (HR) 0.80; P = 0.308]. In the PIK3CA+ sub-population, median PFS was 10.9 months with capivasertib versus 10.8 months with placebo (HR 1.11; P = 0.760). Based on the Common Terminology Criteria for Adverse Event v4.0, the most common grade ≥3 adverse events in the capivasertib group were diarrhoea, hyperglycaemia, neutropoenia and maculopapular rash. Dose intensity of paclitaxel was similar in both groups.

CONCLUSIONS

Capivasertib had no apparent impact on the tolerability and dose intensity of paclitaxel. Adding capivasertib to weekly paclitaxel did not prolong PFS in the overall population or PIK3CA+ sub-population of ER+/HER2- advanced/metastatic breast cancer patients.ClinicalTrials.gov: NCT01625286.

Unha cirúrgica de biopolímero de cana de açúcar para preservação do leito ungueal após avulsão

Objetivo: Desenvolver uma unha cirúrgica de BPCA com o propósito de produzir uma cobertura para o leito unguealimediatamente exposto após avulsão da lâmina ungueal. Método: A unha cirúrgica de BPCA foi produzida a partir dogel de BPCA, que tem propriedades viscoelásticas e é estável em concentrações de 0,6% e 0,8%. Resultados: A comprovada biocompatibilidade e a baixa toxicidade do polissacarídeo celulósico permitem idealizar a sua utilização comoum dispositivo médico, servindo como barreira mecânica, proteção do leito ungueal e remodelação da lâmina ungueal.As características físico-químicas do polissacarídeo permitem a produção de um modelo ungueal autoaderente e resistente, servindo temporariamente como substituto da lâmina ungueal. Além disso, o custo da unha cirúrgica de BPCA éacessível. Conclusão: A unha cirúrgica de BPCA parece ser uma alternativa promissora para manutenção e cicatrizaçãodo leito ungueal.Palavras-chave: Doenças da Unha; Biopolímeros; Saccharum; Curativos Oclusivos; Cicatrização.   ABSTRACTObjective: Develop a surgical nail of BPCA with the purpose of producing a cover for the nail bed immediately exposedafter avulsion of the nail plate. Method: The surgical nail of BPCA was produced from the BPCA gel, which has viscoelastic properties and is stable at concentrations of 0.6% and 0.8%. Results: The biocompatibility and low toxicity of thecellulosic polysaccharide allow to idealize its use as a medical device, serving as a mechanical barrier, protection of thenail bed and remodeling of the nail plate. The physico-chemical characteristics of the polysaccharide allow the production of a self-adhesive and resistant nail model, serving temporarily as a substitute for the nail plate. In addition, the costof the surgical nail of BPCA is affordable. Conclusion: The surgical nail of BPCA appears to be a promising alternativefor maintenance and healing of the nail bed.Keywords: Nail Diseases; Biopolymers; Saccharum; Occlusive Dressings; Wound Healing.

A predictive model of pathologic response based on tumor cellularity and tumor-infiltrating lymphocytes (CelTIL) in HER2-positive breast cancer treated with chemo-free dual HER2 blockade

Background

The presence of stromal tumor-infiltrating lymphocytes (TILs) is associated with increased pathologic complete response (pCR) and improved outcomes in HER2-positive early-breast cancer (BC) treated with anti-HER2-based chemotherapy. In the absence of chemotherapy, the association of TILs with pCR following anti-HER2 therapy-only is largely unknown.

Patients and methods

The PAMELA neoadjuvant trial treated 151 women with HER2-positive BC with lapatinib and trastuzumab [and hormonal therapy if hormone receptor (HR)-positive] for 18 weeks. Percentage of TILs and tumor cellularity were determined at baseline (N = 148) and at day 15 (D15) of treatment (N = 134). Associations of TILs and tumor cellularity with pCR in the breast were evaluated. A combined score based on tumor cellularity and TILs (CelTIL) measured at D15 was derived in PAMELA, and validated in D15 samples from 65 patients with HER2-positive disease recruited in the LPT109096 neoadjuvant trial, where anti-HER2 therapy-only was administer for 2 weeks, then standard chemotherapy was added for 24 weeks.

Results

In PAMELA, baseline and D15 TILs were significantly associated with pCR in univariate analysis. In multivariable analysis, D15 TILs, but not baseline TILs, were significantly associated with pCR. At D15, TILs and tumor cellularity were found independently associated with pCR. A combined score (CelTIL) taking into account both variables was derived. CelTIL at D15 as a continuous variable was significantly associated with pCR, and patients with CelTIL-low and CelTIL-high scores had a pCR rate of 0% and 33%, respectively. In LPT109096, CelTIL at D15 was found associated with pCR both as a continuous variable and as group categories using a pre-defined cut-off (75.0% versus 33.3%).

Conclusions

On-treatment TILs, but not baseline TILs, are independently associated with response following anti-HER2 therapy-only. A combined score of TILs and tumor cellularity measured at D15 provides independent predictive information upon completion of neoadjuvant anti-HER2-based therapy.

Clinical trial number

NCT01973660.

Genotoxicity of gold nanoparticles in the gilthead seabream (Sparus aurata) after single exposure and combined with the pharmaceutical gemfibrozil

Due to their diverse applications, gold nanoparticles (AuNPs) are expected to increase of in the environment, although few studies are available on their mode of action in aquatic organisms. The genotoxicity of AuNPs, alone or combined with the human pharmaceutical gemfibrozil (GEM), an environmental contaminant frequently detected in aquatic systems, including in marine ecosystems, was examined using gilthead seabream erythrocytes as a model system. Fish were exposed for 96 h to 4, 80 and 1600 μg L^-1 of 40 nm AuNPs with two coatings - citrate or polyvinylpyrrolidone; GEM (150 μg L^-1); and a combination of AuNPs and GEM (80 μg L^-1 AuNPs + 150 μg L^-1 GEM). AuNPs induced DNA damage and increased nuclear abnormalities levels, with coating showing an important role in the toxicity of AuNPs to fish. The combined exposures of AuNPs and GEM produced an antagonistic response, with observed toxic effects in the mixtures being lower than the predicted. The results raise concern about the safety of AuNPs and demonstrate interactions between them and other contaminants.

Abstract P2-08-19: Exploratory biomarker analyses of FAIRLANE, a double-blind placebo (PBO)-controlled randomized phase II trial of neoadjuvant ipatasertib (IPAT) + paclitaxel (PAC) for early triple-negative breast cancer (TNBC)

Background: The oral AKT inhibitor IPAT is being evaluated in cancers with a high prevalence of PI3K/AKT pathway activation. In the PBO-controlled randomized phase II FAIRLANE trial (NCT02301988), adding IPAT to PAC as neoadjuvant therapy for TNBC led to a numerical increase in pathologic complete response (pCR) in unselected patients (17.1% vs 13.3%), with a greater treatment effect in patients with PIK3CA/AKT1/PTEN-altered tumors (17.9% vs 11.8%). The addition of IPAT also led to an increase in complete response (CR) by MRI (27.6% vs 13.3%) that was enhanced in patients with PIK3CA/AKT1/PTEN-altered tumors (39.3% vs 8.8%) [Oliveira, AACR 2018]. We report an exploratory analysis performed to provide better understanding of potential biomarkers for response.

Methods: Pretreatment tumor samples were evaluated for genomic alterations using the FoundationOne® (Foundation Medicine) assay (n=144) and gene expression by RNA-Seq (n=92). Samples were classified into TNBC subtypes based on the method developed by Lehmann and Pietenpol [Lehmann, J Clin Invest 2011]. Tumor-infiltrating lymphocytes (TILs) were quantified using the Salgado method [Salgado, Ann Oncol 2015] (n=135).

Results: Of 62 patients (43%) with PIK3CA/AKT1/PTEN-altered tumors, 21 had an activating mutation in PIK3CA or AKT1 and 47 had an alteration in PTEN (6 [3 in each arm] had both PIK3CA mutation and PTEN alteration). Although only 3 patients with PIK3CA/AKT1-mutant tumors achieved a pCR, there was an increased rate of MRI CR with the addition of IPAT to PAC [Table]. In patients with PTEN alterations, both pCR rate and MRI CR rate were increased with IPAT. In patients treated with PBO + PAC, all 4 pCR patients evaluable by RNA-Seq were of the immunomodulatory (IM) subtype. However, in the IPAT + PAC arm, pCRs were also seen in patients with basal-like 1 (BL-1), mesenchymal (M), and mesenchymal stem-like (MSL) subtypes. Consistent with this observation, in the PBO + PAC arm, samples from patients achieving a pCR had significantly higher levels of stromal TILs than those from patients who did not have a pCR, while no difference was observed in the IPAT + PAC arm.

Response, n (%)PIK3CA/AKT mutation (n=21)PTEN alteration (n=47) IPAT + PAC (n=11)PBO + PAC (n=10)IPAT + PAC (n=21)PBO + PAC (n=26)pCR1 (9%)2 (20%)4 (19%)3 (12%)CR by MRI5 (45%)1 (10%)8 (38%)2 (8%)

Conclusions: This retrospective exploratory biomarker analysis of the phase II FAIRLANE trial of neoadjuvant IPAT for TNBC provides insight into the potential heterogeneity of response and resistance to taxane therapy. The results also hint that response to PAC alone is dependent on baseline immune infiltration and that this dependency might be relieved with the addition of AKT inhibition.

Citation Format: Wongchenko MJ, Oliveira M, Saura C, Nuciforo P, Calvo I, Andersen J, Passos Coelho JI, Gil Gil M, Bermejo B, Patt DA, Ciruelos E, Singel SM, Maslyar DJ, Xu N, de la Peña L, Baselga J, Gendreau S, Isakoff SJ. Exploratory biomarker analyses of FAIRLANE, a double-blind placebo (PBO)-controlled randomized phase II trial of neoadjuvant ipatasertib (IPAT) + paclitaxel (PAC) for early triple-negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-19.

Abstract P6-17-07: Gene signatures and subtype changes during HER2 dual blockade in PAM50 HER2-enriched HER2-positive breast cancer

Background: HER2-positive (HER2+) breast cancer (BC) is composed of 4 molecular subtypes: Luminal A and B, HER2-enriched (HER2-E) and Basal-like. Among them, the HER2-E is highly sensitive to anti-HER2 treatment. However, ˜60% of HER2-E tumors do not achieve a pathological complete response (pCR) following neoadjuvant dual HER2 blockade without chemotherapy. Here, we aimed to better understand the molecular changes of the HER2-E subtype during anti-HER2 treatment.

Methods: Gene expression was evaluated in 101 patients with HER2-E tumors from the PAMELA neoadjuvant phase II trial (Lancet Oncol 2017). Briefly, women with HER2+ BC were treated with lapatinib and trastuzumab (and hormonal therapy if hormone receptor [HR]-positive) for 18 weeks. The median time between the last dose of treatment and surgery was 35 days (range=213; interquartile range=16). Expression of the PAM50 genes and 6 PAM50 signatures (Luminal A, Luminal B, HER2-E, Basal-like, normal-like and the PAM50 proliferation score) were determined using the nCounter platform at baseline (n=101), after 2 weeks of treatment (n=96) and in residual tumors (non-pCR) at surgery (n=57). Same analyses were done in 2 HER2+/HER2-E cell line models (BT474 [HR+] and SKBR3 [HR-]) following in vitro treatment with trastuzumab in combination with lapatinib. Biological changes between 2 time-points were determined by paired t-tests with a false discovery rate (FDR) &lt;5%.

Results: After 2 weeks of treatment, 85.7% and 94.6% of the 56 genes/signatures were found differentially expressed (FDR&lt;5%) in HER2-E/HR+ (n=35) and HER2-E/HR- (n=61) tumors, respectively. The two gene lists were highly correlated (correlation coefficient=0.93). Overall, a significant relative increase in Luminal A and normal-like signature scores, and a relative decrease in proliferation, HER2-E and Luminal B signature scores, were observed between baseline and week 2. Interestingly, a PAM50 subtype switch to Luminal A was observed in 31.6% and 4.8% of HER2-E/HR+ and HER2-E/HR- tumors. In BT474 and SKBR3, all genes/signatures were also found differentially expressed (FDR&lt;5%) following 72h of dual HER2 blockade. The in vitro findings recapitulated the in vivo findings in 80-86% of the genes/signatures. Similar to tumors, a switch to a Luminal A subtype following dual HER2 blockade was observed in BT474 but not in SKBR3. Finally, 92.9% of the 56 genes/signatures were found differentially expressed (FDR&lt;5%) in residual tumors at surgery compared to week 2. Contrary to the findings in the first 2 weeks of treatment, a general rebound effect in gene expression was observed between week 2 and surgery. Similarly, a rebound effect was observed in 60% of the genes/signatures in BT474 after removing anti-HER2 therapy for 72h, leading to a subtype switch from Luminal A back to HER2-E.

Conclusions: Dual HER2 blockade in the HER2-E subtype induces large biological changes that lead to a more low-proliferative Luminal A phenotype both in tumors and in vitro models, especially in HER2-E/HR+ disease. These phenotypic changes are reversible upon stopping anti-HER2 treatment. This finding supports the use of maintenance anti-HER2 treatment +/- endocrine therapy (if HR+) in advanced HER2+ BC.

Citation Format: Brasó-Maristany F, Griguolo G, Llombart-Cussac A, Pascual T, Paré L, Bermejo B, Oliveira M, Morales S, Martinez N, Vidal M, Pernas S, Lopez R, Muñoz M, Galvan P, Garau I, Manso L, Alarcón J, Martínez E, Villagrasa P, Cortés J, Prat A. Gene signatures and subtype changes during HER2 dual blockade in PAM50 HER2-enriched HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-07.

Abstract P6-18-02: Primary and secondary results of the first nationwide molecular screening program in Spain for patients with advanced breast cancer (AGATA SOLTI-1301 study)

Background: Metastatic breast cancer is the second leading cause of death among women globally. A better understanding of tumor biology, and the availability of high-throughput technologies, have enabled the emergence of precision medicine bringing new expectations and giving rise to molecular screening programs (MSP). SOLTI, as a collaborative Spanish network, designed AGATA, the first multi-institutional MSP ever implemented in this country. Here, we report both the primary and some of the secondary results of the pilot study.

Methods: A total of 10 sites within SOLTI network in Spain participated. DNA-sequencing of 56 cancer related genes was performed using FFPE tumor samples (primary or metastatic). Each clinical case was reviewed by a multidisciplinary advisory board (MAB), which recommended, in a prospective manner, potential experimental treatments, mainly in the context of clinical trials. The primary objective was to determine the success rate of matching a DNA alteration to an experimental drug or drug class. Secondary objectives included a comprehensive molecular characterization of tumor samples by PAM50 subtyping and quantification of protein expression levels by MASS-SPEC (70 proteins panel).

Results: 305 patients (pts) were screened from September 2014 to July 2017 and 260 (85.3%) were finally evaluated by the MAB. Pts characteristics were: mean age 54 years (29-80), ER+/HER2- (n=192; 74%), HER2+ (n=30; 11.5%) and TNBC (n=38; 14.5%). 163 primary tumors and 97 metastatic samples were profiled. Regarding the primary objective, 116 pts (45%) presented at least one mutation (range 1-6) that could be matched to a drug or drug class. Of these, 13 pts (11.2%) received therapy matched to their molecular profile according to the MAB recommendation and their follow-up is still on-going. No mutation was detected in 97 (37%) pts (WT), and 47 patients (18.1%) presented a mutation but no match was possible. The most common mutations were PIK3CA (34%), TP53 (22%), AKT1 (5%), ESR1 (3%) and ERBB2 (3%). Intrinsic subtype distribution in 177 samples was as follows: 34% Luminal A (n=60); 21% Luminal B (n=36); 13% HER2E (n=22); 19% Basal-like (n=34) and 13% Normal-like (n=23). Compared to primary tumors (n=110), the proportion of HER2-enriched disease in metastatic tumors (n=63) was significantly higher (6% vs 20%; p=0.005). Protein expression analysis was performed in 146 samples (94 primary and 57 metastasis). In 19 cases (13%), the outlier expression of some targetable proteins (FGFR1 [n=4, 2.7%], IGF1R [n=4, 2.7%], EGFR [n=1, 0.7%], CEACAM5 [n=6, 4.1%], IDO1 [n=2, 1.37%], TROP2 [n=2, 1.37%]) were identified. Of note, HER2 overexpression (&gt;740 amol/μg) was observed in 4 HER2- cases. Finally, among WT tumors, 21% presented a potential drug-matched protein target.

Conclusions: Nationwide molecular screening in Spain is feasible. Nearly half of patients had tumors with mutation(s), mostly PIK3CA, that could be matched to a potential drug or drug class. PAM50 profile might be helpful to navigate towards a therapeutic decision making, although the MAB could not make any targeted-driven recommendation yet with this data. More clinical evidence is needed to use MASS-SPEC as a diagnostic tool.

Citation Format: Pernas S, Villagrasa P, Nuciforo PG, Vivancos A, Scaltriti M, Rodón J, Burgués O, Canes J, Dueñas M, Cecchi F, Vidal M, Lluch A, Perelló A, Llombart A, Dorca J, Montaño A, Oliveira M, Ribas G, Rapado I, Paré L, Prat A, Ciruelos E. Primary and secondary results of the first nationwide molecular screening program in Spain for patients with advanced breast cancer (AGATA SOLTI-1301 study) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-02.

Abstract P6-17-08: Dynamics of tumor-infiltrating lymphocytes (TILs) during neoadjuvant dual HER2 blockade in HER2-positive (HER2+) breast cancer in the absence of chemotherapy

Background: TILs in HER2+ breast cancer (BC) predict 1) prognosis in early setting, 2) complete pathological response (pCR) following neoadjuvant antiHER2-based therapy and 3) response to trastuzumab and pembrolizumab in the metastatic setting. However, less is known regarding changes in TILs during antiHER2-based treatment.

Methods: Stromal TILs where evaluated centrally using H/E slides in tumor samples from the PAMELA (NCT01973660) neoadjuvant phase II trial. Briefly, 151 women with HER2+ BC were treated with lapatinib and trastuzumab, and hormonal therapy if HR positive, for 18 weeks. TIL levels were determined at baseline (n=148), after 2 weeks of treatment (n=134) and at surgery (n=137). Expression of 560 genes, including immune-related genes (e.g. CD8A, CD4, PD1 and PDL1) was measured at the same timepoints (baseline n=151, 2-weeks n=144, surgery n=144) using the nCounter platform. Intrinsic subtyping at baseline was determined using the PAM50 gene expression predictor. Changes in TILs between 2 time-points were determined by paired t-tests. Correlation of TILs with gene expression was assessed by quantitative SAM analysis using a False Discovery Rate &lt;1%. All statistical tests were two-sided and considered significant when p&lt;0.05. All statistical analyses were carried out using the R software.

Results: Compared to baseline, a significant increase in TILs was observed at week 2 in HR- (p&lt;0.001) and HER2-enriched (HER2-E) tumors (p=0.001), but not in HR+ (p=0.133) and non-HER2-E tumors (p=0.067). Within HR- and HER2-E tumors, increase in TILs at week 2 from baseline was observed regardless of pathological response at surgery (pCR and HR- [p=0.008]; RD and HR- [p=0.037]; pCR and HER2-E [p=0.010]; RD and HER2-E [p=0.056]). Compared to week 2, a significant decrease in TILs at surgery was observed in HR- (p=0.002) and HER2-E (p=0.003) tumors, but not in HR+ (p=0.616) and non-HER2-E tumors (p=0.578). Within HR- and HER2-E tumors, a significant decrease in TILs between week 2 and surgery was observed in tumors achieving pCR (p=0.004 and p=0.005), while, in tumors not achieving pCR, no significant tendency was observed (26.4% and 33.0% of tumors showed an increase and a decrease of TILs between week 2 and surgery). Nonetheless, the vast majority of residual tumors (non-pCR) at surgery had TILs above ≥5%: 34.3% 5-10%, 21.0% 10-20%, 15.2% 20-40% and 11.4% ≥40%. Finally, TILs scoring was found highly enriched (FDR&lt;1%) for immune-related genes tracking activated CD8 T-cells (i.e. CD8A, CD3G, LAG3 and PD1). Expression of these immune genes consistently correlated with TIL levels across the 3 time-points.

Conclusions: In early HER2+ BC, a general increase in TILs is observed following 2 weeks of dual HER2 blockade. This observation is mostly observed in HR- and HER2-E subtype, but regardless of pathological response at surgery. After 2 weeks of treatment, TILs consistently decrease in patients achieving a pCR, whereas two main patterns of TILs expression are observed in patients with residual disease at surgery. Nonetheless, most residual tumors at surgery are inflamed (i.e. TILs ≥5%) and might be good candidates for clinical trials evaluating adjuvant immune checkpoint inhibitors.

Citation Format: Griguolo G, Holgado E, Cortés J, Fasani R, Pascual T, Paré L, Bermejo B, Oliveira M, Morales S, Martinez N, Vidal M, Pernas S, Lopez R, Muñoz M, Galvan P, Garau I, Manso L, Alarcón J, Martínez E, Villagrasa P, LLombart-Cussac A, Prat A, Nuciforo P. Dynamics of tumor-infiltrating lymphocytes (TILs) during neoadjuvant dual HER2 blockade in HER2-positive (HER2+) breast cancer in the absence of chemotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-08.

Abstract OT3-02-05: CORALLEEN: A phase 2 clinical trial of chemotherapy or letrozole plus ribociclib as neoadjuvant treatment for postmenopausal patients with luminal B/HER2-negative breast cancer

Background: Dysregulation of cyclin D-CDK4/6-Rb pathway is associated with endocrine resistance in hormone receptor–positive (HR+) breast cancer. Recently, a CDK4/6 inhibitor has shown unprecedented efficacy in metastatic disease, leading to its regulatory approval. Several others are currently in clinical development for the management of HR+ breast cancer in the early and advanced settings. However, it is vital to gain insights into the molecular and biological effects of this class of agents and could identify patients who can benefit the most, delaying or avoiding the use of chemotherapy.The neoadjuvant setting provides an ideal scenario to carry out these investigations. Hence, we propose to conduct an exploratory study to evaluate the biological effects and the efficacy of ribociclib in patients with primary luminal B tumors. We hypothesize that the combination of ribociclib plus letrozole may offer clinical benefit in the preoperative setting. Methods: This is a parallel, multicenter, two-arm, randomized exploratory study in postmenopausal women with primary operable HR+/HER2-negative Luminal B breast cancer designed to evaluate the clinical benefit of ribociclib plus letrozole. Eligibility includes stage I-III operable breast cancer, Luminal B by PAM50, ECOG 0-1. They will be randomized 1:1 to receive either six 28-days cycles of ribociclib (600mg; 3-weeks-on/1-week-off) plus daily letrozole (2.5mg) or chemotherapy: four cycles of AC (doxorubicin 60 mg/m2, cyclophosphamide 600 mg/m2 every 21 days) followed by weekly paclitaxel during 12 weeks. Baseline, Day 15 on-treatment, and surgical specimens will be collected for molecular characterization and evaluation of response (decrease in Ki67, change to ROR low disease) The primary endpoint is the rate of Residual Cancer Burden (RCB) per MD Anderson Cancer Center procedures. A rate of RCB 0 and 1 score at surgery, with a rank between 20% to 25% with 47 evaluable patients by group of treatment will offer a precision between 11.5% and 12.4%, respectively (95%CI). Ninety-four patients will be enrolled in 21 sites across Spain. The trial was activated in July 2017. As of June 2018, 78 patients have been recruited.

Citation Format: Gavila J, Saura C, Oliveira M, Ciruelos E, Gonzalez X, de la Peña L, Bermejo de las Heras B, Muñoz M, Fernandez P, Villagrasa P, Ortega V, Lopez R, Celiz P, Pascual T, Prat A. CORALLEEN: A phase 2 clinical trial of chemotherapy or letrozole plus ribociclib as neoadjuvant treatment for postmenopausal patients with luminal B/HER2-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-02-05.

Choroid thickness profile in patients with lupus nephritis

BACKGROUND

Choroidopathy is a rare manifestation of systemic lupus erythematosus (SLE). This entity is associated with active phases of severe SLE and it is frequently accompanied by acute kidney failure, central nervous system involvement and coagulopathy.

PURPOSE

To evaluate the choroid thickness of patients with lupus nephritis (LN) without choroidopathy, and to compare this with that of age-matched SLE patients without LN and healthy control subjects.

STUDY DESIGN

Cross-sectional case control study.

MATERIAL AND METHODS

Fifteen women with LN in remission phase (study group), 15 women with SLE in remission without LN (SLE control group), and 15 healthy women (healthy control group), without ocular diseases or significant refractive error, were recruited. Full ophthalmological examination and a macular optical coherence tomography in enhanced depth imaging mode were performed. The choroid thickness was measured at nine macular points and six lines of mean choroidal thickness were determined. A comparative analysis between the three groups was performed using the one-way ANOVA test and the paired t-test. The choroid thickness of patients under corticotherapy was also compared to that of patients without corticotherapy. Additionally, the correlation between choroid thickness and disease duration was evaluated using the Pearson analysis.

RESULTS

The mean macular choroidal thickness was 295.73 ± 67.62 μm in the study group, 233.34 ± 41.01 µm in the SLE control group, and 240.98 ± 37.93 μm in the control group ( p = 0.00006 and p = 0.0003, respectively). Additionally, the choroid thickness was significantly thicker than in the SLE and healthy control groups at the foveal ( p = 0.004 and p < 0.000), nasal ( p < 0.000 and p = 0.001), superior ( p = 0.002 and p < 0.000) and inferior ( p < 0.000 and p = 0.001) mean lines. The choroidal thickness in this group was not associated with the duration of the disease. The subgroup of patients with LN under corticotherapy did not reveal a significantly different choroidal thickness.

CONCLUSION

This study suggests a relationship between LN and choroidal changes, which may represent an increased risk for choroidopathy in these patients. Choroid thickening was not related with the duration of the disease. This thickening may be correlated with histopathological changes similar to those occurring in kidney glomeruli.

Effects and bioaccumulation of gold nanoparticles in the gilthead seabream (Sparus aurata) - Single and combined exposures with gemfibrozil

Gold nanoparticles (AuNPs) are found in a wide range of applications and therefore expected to present increasing levels in the environment. There is however limited knowledge concerning the potential toxicity of AuNPs as well as their combined effects with other pollutants. Hence, the present study aimed to investigate the effects of AuNPs alone and combined with the pharmaceutical gemfibrozil (GEM) on different biological responses (behaviour, neurotransmission, biotransformation and oxidative stress) in one of the most consumed fish in southern Europe, the seabream Sparus aurata. Fish were exposed for 96 h to waterborne 40 nm AuNPs with two coatings - citrate and polyvinylpyrrolidone (PVP), alone or combined with GEM. Antioxidant defences were induced in liver and gills upon both AuNPs exposure. Decreased swimming performance (1600 μg.L^-1) and oxidative damage in gills (4 and 80 μg.L^-1) were observed following exposure to polyvinylpyrrolidone coated gold nanoparticles (PVP-AuNPs). Generally, accumulation of gold in fish tissues and deleterious effects in S. aurata were higher for PVP-AuNPs than for cAuNPs exposures. Although AuNPs and GEM combined effects in gills were generally low, in liver, they were higher than the predicted. The accumulation and effects of AuNPs showed to be dependent on the size, coating, surface charge and aggregation/agglomeration state of nanoparticles. Additionally, it was tissue' specific and dependent on the presence of other contaminants. Although, gold intake by humans is expected to not exceed the estimated tolerable daily intake, it is highly recommended to keep it on track due to the increasing use of AuNPs.