Type 2 diabetes and heart failure: Characteristics and prognosis in preserved, mid-range and reduced ventricular function

OBJECTIVE

To study the characteristics and prognostic implications of type 2 diabetes in different heart failure entities from a nationwide perspective.

METHODS

This observational study comprised 30,696 heart failure patients prospectively included in the Swedish Heart Failure Registry (SwedeHF) 2003-2011 from specialist care, with mortality information available until December 2014. Patients were categorized into three heart failure entities by their left ventricular ejection fraction (heart failure with preserved ejection fraction: ⩾50%, heart failure with mid-range ejection fraction: 40%-49% and heart failure with reduced ejection fraction: <40%). All-cause mortality stratified by type 2 diabetes and heart failure entity was studied by Cox regression.

RESULTS

Among the patients, 22% had heart failure with preserved ejection fraction, 21% had heart failure with mid-range ejection fraction and 57% had heart failure with reduced ejection fraction. The proportion of type 2 diabetes was similar, ≈25% in each heart failure entity. Patients with type 2 diabetes and heart failure with preserved ejection fraction were older, more often female and burdened with hypertension and renal impairment compared with heart failure with mid-range ejection fraction and heart failure with reduced ejection fraction patients among whom ischaemic heart disease was more common. Type 2 diabetes remained an independent mortality predictor across all heart failure entities after multivariable adjustment, somewhat stronger in heart failure with left ventricular ejection fraction below 50% (hazard ratio, 95% confidence interval; heart failure with preserved ejection fraction: 1.32 [1.22-1.43], heart failure with mid-range ejection fraction: 1.51 [1.39-1.65], heart failure with reduced ejection fraction: 1.46 [1.39-1.54]; p-value for interaction, p = 0.0049).

CONCLUSION

Type 2 diabetes is an independent mortality predictor across all heart failure entities increasing mortality risk by 30%-50%. In type 2 diabetes, the heart failure with mid-range ejection fraction entity resembles heart failure with reduced ejection fraction in clinical characteristics, risk factor pattern and prognosis.

Effectiveness of different outreach strategies to identify individuals at high risk of diabetes in a heterogeneous population: a study in the Swedish municipality of Södertälje

BACKGROUND

Identifying type 2 diabetes mellitus (T2DM) is a prerequisite for the institution of preventive measures to reduce future micro and macrovascular complications. Approximately 50% of people with T2DM are undiagnosed, challenging the assumption that a traditional primary healthcare setting is the most efficient way to reach people at risk of T2DM. A setting of this kind may be even more suboptimal when it comes to reaching immigrants, who often appear to have inferior access to healthcare and/or are less likely to attend routine health checks at primary healthcare centres.

OBJECTIVES

The objective of this study was to identify the best strategy to reach individuals at high risk of T2DM and thereby cardiovascular disease in a heterogeneous population.

METHODS

All 18-65-year-old inhabitants in the Swedish municipality of Södertälje ( n∼51,000) without known T2DM and cardiovascular disease were encouraged to complete the Finnish Diabetes Risk Score (FINDRISC: score > 15 indicating a high and > 20 a very high risk of future T2DM and cardiovascular disease) through the following communication channels: primary care centres, workplaces, Syrian orthodox churches, pharmacies, crowded public places, mass media, social media and mail. Data collection lasted for six weeks.

RESULTS

The highest response rate was obtained through workplaces (27%) and the largest proportion of respondents at high/very high risk through the Syrian orthodox churches (18%). The proportion reached through primary care centres was 4%, of whom 5% were at elevated risk. The cost of identifying a person at elevated risk through the Syrian orthodox church was €104 compared with €8 through workplaces and €112 through primary care centres.

CONCLUSIONS

The choice of communication channels was important to reach high/very high-risk individuals for T2DM and for screening costs. In this immigrant-dense community, primary care centres were inferior to strategies using workplaces and churches in terms of both the proportion of identified at-risk individuals and costs.

Elevated levels of insulin-like growth factor-binding protein 1 predict outcome after acute myocardial infarction: A long-term follow-up of the glucose tolerance in patients with acute myocardial infarction (GAMI) cohort

OBJECTIVE

To investigate the long-term prognostic value of insulin-like growth factor-binding protein 1 in patients with acute myocardial infarction.

METHODS

Patients ( n = 180) with admission glucose < 11 mmol/L without previously known diabetes admitted for an acute myocardial infarction in 1998-2000 were followed for mortality and cardiovascular events (first of cardiovascular mortality/acute myocardial infarction/stroke/severe heart failure) until the end of 2011 (median 11.6 years). Fasting levels of insulin-like growth factor-binding protein 1 at day 2 were related to outcome in Cox proportional hazard regression analyses.

RESULTS

Median age was 64 years, 69% were male and median insulin-like growth factor-binding protein 1 was 20 µg/L. Total mortality was 34% ( n = 61) and 44% ( n = 80) experienced a cardiovascular event during a median follow-up time of 11.6 years. After age adjustment, insulin-like growth factor-binding protein 1 was associated with all-cause (1.40; 1.02-1.93, p = 0.039) and cancer mortality (2.09; 1.15-3.79, p = 0.015) but not with cardiovascular death ( p = 0.29) or cardiovascular events ( p = 0.57). After adjustments also for previous myocardial infarction, previous heart failure and body mass index, insulin-like growth factor-binding protein 1 was still associated with all-cause mortality (1.38; 1.01-1.89, p = 0.046).

CONCLUSION

In patients with acute myocardial infarction without previously known diabetes, high insulin-like growth factor-binding protein 1 was associated with long-term all-cause and cancer mortality but not with cardiovascular events.

The Accuracy of Point-of-Care Equipment for Glucose Measurement in Screening for Dysglycemia in Patients with Coronary Artery Disease

BACKGROUND

Point-of-care equipment for measuring glucose saves time and costs for both patients and professionals and minimizes preanalytic errors when screening for or managing dysglycemia, that is, impaired glucose tolerance and type 2 diabetes. The accuracy of such devices has, however, been questioned compared with analyses at an accredited hospital laboratory.

OBJECTIVE

To investigate the agreement between glucose measurements made by the point-of-care HemoCue^® Glucose 201 RT System (HemoCue, Ängelholm, Sweden) and local hospital laboratories.

MATERIAL

Patients with established coronary artery disease (CAD) recruited in Sweden and the United Kingdom within the auspices of the European Action on Secondary and primary Prevention by Intervention to Reduce Events (EUROASPIRE) V survey (n = 87; 18-80 years) with or without previously known dysglycemia were investigated. Plasma glucose values collected in the fasting state (n = 85) and 60 (n = 57) and 120 (n = 72) min after a glucose load were analyzed both using HemoCue monitors and local hospital laboratories. The two measurement techniques were compared using a bias plot according to Bland-Altman, the surveillance error grid, and Spearman correlation test.

RESULTS

The bias plot method showed small differences between the HemoCue and local hospital laboratory methods, the HemoCue and central hospital laboratory, and the local hospital laboratories and the central hospital laboratory. In the surveillance error grid, 98.6% of the values were in the deep green zone, indicating no risk and the remaining values (1.4%) were within the light green zone, indicating "slight lower risk."

CONCLUSION

The HemoCue point-of-care system is accurate for dysglycemia screening in patients with CAD.

Adiponectin, Free Fatty Acids, and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Acute Coronary Syndrome

OBJECTIVE

In observational cohorts, adiponectin is inversely associated and free fatty acids (FFAs) are directly associated with incident coronary heart disease (CHD). Adiponectin tends to be reduced and FFAs elevated in type 2 diabetes. We investigated relationships of adiponectin and FFA and major adverse cardiovascular events (MACEs) and death in patients with acute coronary syndrome (ACS) and type 2 diabetes using data from the AleCardio (Effect of Aleglitazar on Cardiovascular Outcomes After Acute Coronary Syndrome in Patients With Type 2 Diabetes Mellitus) trial, which compared the PPAR-α/γ agonist aleglitazar with placebo.

RESEARCH DESIGN AND METHODS

Using Cox regression adjusted for demographic, laboratory, and treatment variables, we determined associations of baseline adiponectin and FFAs, or the change in adiponectin and FFAs from baseline, with MACEs (cardiovascular death, myocardial infarction, or stroke) and death.

RESULTS

A twofold higher baseline adiponectin (n = 6,998) was directly associated with risk of MACEs (hazard ratio [HR] 1.17 [95% CI 1.08-1.27]) and death (HR 1.53 [95% CI 1.35-1.73]). A doubling of adiponectin from baseline to month 3 (n = 6,325) was also associated with risk of death (HR 1.20 [95% CI 1.03-1.41]). Baseline FFAs (n = 7,038), but not change in FFAs from baseline (n = 6,365), were directly associated with greater risk of MACEs and death. There were no interactions with study treatment.

CONCLUSIONS

In contrast to prior observational data for incident CHD, adiponectin is prospectively associated with MACEs and death in patients with type 2 diabetes and ACS, and an increase in adiponectin from baseline is directly related to death. These findings raise the possibility that adiponectin has different effects in patients with type 2 diabetes and ACS than in populations without prevalent cardiovascular disease. Consistent with prior data, FFAs are directly associated with adverse outcomes.

Anaemia and iron deficiency in heart failure: epidemiological gaps, diagnostic challenges and therapeutic barriers in sub-Saharan Africa

Anaemia and iron deficiency (ID) are common and of prognostic importance in heart failure (HF). In both conditions the epidemiology, diagnosis and therapies have been extensively studied in high-income countries but are still largely unexplored in sub-Saharan Africa (SSA). The lack of adequate and robust epidemiological data in SSA makes it difficult to recognise the significance of anaemia and ID in HF. From a clinical perspective, less attention is paid by clinicians to screening for anaemia in HF, and as far as interventions are concerned, there are no clinical trials in SSA that provide guidance on the appropriate interventional approach. Therefore studies are needed to provide more insight into the burden and peculiarities of and intervention for anaemia and ID in HF in SSA, where the pathophysiology might be different from that in high-income countries. There is increasing appreciation that targeting ID may serve as a useful additional treatment strategy for patients with chronic HF in high-income countries. However, there is limited information on the diagnosis of and therapy for ID in HF in SSA, where infections and malnutrition are more likely to influence the situation. This article reviews the present epidemiological gap in knowledge about anaemia and ID in HF, as well as the diagnostic and therapeutic challenges in SSA.

Haemostatic Factors and Inhibitors and Coronary Artery Bypass Grafting: Preoperative Alterations and Relations to Graft Occlusion

Graft closure remains a major problem after coronary artery bypass surgery. While a number of graft characteristics influencing the risk of occlusion have been defined, the role of haemostatic factors and inhibitors has not been studied in detail. The present study examined the time course of changes in blood coagulation and fibrinolytic function after coronary artery bypass grafting in 20 consecutive patients. Pre- and postoperative determinations of haemostatic factors and inhibitors were also related to the presence of graft occlusion assessed by angiography at three months after surgery. A broad panel of haemostatic tests was used preoperatively, on the first, third and eight postoperative days, and at three months after surgery. A particular emphasis was placed on fibrinogen, factor VII activity, von Willebrand factor (vWF), plasminogen activator inhibitor-1 (PAI-1) activity, anticoagulant proteins C and S, thrombin-antithrombin complex and D-dimer. A marked activation of the coagulation cascade was noted postoperatively along with enhanced degradation of cross-linked fibrin. The degree of activation of blood coagulation and fibrinolysis differed widely between individuals and appeared to relate only partly to the acute phase reaction produced by the surgical trauma. Preoperative values of haemostatic factors and inhibitors showed fairly weak associations with the levels of postoperative determinations. Basal tPA and factor VIII levels, fibrinogen and TAT concentrations on the third and eighth postoperative day, and factor VII amidolytic activity on the third postoperative day differed (p <0.05) between patients with and without occluded grafts at reangiography. Accordingly, combined pre- and postoperative assessment of haemostatic function may contribute to the identification of individuals at risk for early graft closure after coronary artery bypass grafting.

Homeostasis Model Assessment of Insulin Resistance and Survival in Patients With Diabetes and Acute Coronary Syndrome

OBJECTIVE

Insulin resistance has been linked to development and progression of atherosclerosis and is present in most patients with type 2 diabetes. Whether the degree of insulin resistance predicts adverse outcomes in patients with type 2 diabetes and acute coronary syndrome (ACS) is uncertain.

DESIGN

The Effect of Aleglitazar on Cardiovascular Outcomes after Acute Coronary Syndrome in Patients with Type 2 Diabetes Mellitus trial compared the peroxisome proliferator-activated receptor-α/γ agonist aleglitazar with placebo in patients with type 2 diabetes and recent ACS. In participants not treated with insulin, we determined whether baseline homeostasis model assessment of insulin resistance (HOMA-IR; n = 4303) or the change in HOMA-IR on assigned study treatment (n = 3568) was related to the risk of death or major adverse cardiovascular events (cardiovascular death, myocardial infarction, and stroke) in unadjusted and adjusted models. Because an inverse association of HOMA-IR with N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been described, we specifically examined effects of adjustment for the latter.

RESULTS

In unadjusted analysis, twofold higher baseline HOMA-IR was associated with lower risk of death [hazard ratio (HR): 0.79, 95% CI: 0.68 to 0.91, P = 0.002]. Adjustment for 24 standard demographic and clinical variables had minimal effect on this association. However, after further adjustment for NT-proBNP, the association of HOMA-IR with death was no longer present (adjusted HR: 0.99, 95% CI: 0.83 to 1.19, P = 0.94). Baseline HOMA-IR was not associated with major adverse cardiovascular events, nor was the change in HOMA-IR on study treatment associated with death or major adverse cardiovascular events.

CONCLUSIONS

After accounting for levels of NT-proBNP, insulin resistance assessed by HOMA-IR is not related to the risk of death or major adverse cardiovascular events in patients with type 2 diabetes and ACS.

Severe Periodontitis Is Associated with Myocardial Infarction in Females

The aim of the present study was to test the hypothesis that there is a sex difference in the association between periodontitis (PD) and a first myocardial infarction (MI). The analysis in the case-control study was based on 785 patients (147 females and 638 males) with a first MI and 792 matched controls (147 females and 645 males), screened for cardiovascular risk factors and subjected to a panoramic dental X-ray. Periodontal status was defined by alveolar bone loss and diagnosed as no PD (≥80% remaining alveolar bone), mild to moderate PD (66% to 79%), or severe PD (<66%). Logistic regression was used when analyzing PD as a risk factor for MI, adjusting for age, smoking, diabetes, education, and marital status. The mean age was 64 ± 7 y for females and 62 ± 8 y for males. Severe PD was more common in female patients than female controls (14 vs. 4%, P = 0.005), with an increased risk for severe PD among female patients with a first MI (odds ratio [OR] = 3.92, 95% confidence interval [CI] =1.53 to 10.00, P = 0.005), which remained (OR = 3.72, 95% CI = 1.24 to 11.16, P = 0.005) after adjustments. Male patients had more severe PD (7% vs. 4%; P = 0.005) than male controls and an increased risk for severe PD (OR = 1.88, 95% CI = 1.14 to 3.11, P = 0.005), but this association did not remain following adjustment (OR = 1.67, 95% CI = 0.97 to 2.84, NS). Severe PD was associated with MI in both females and males. After adjustments for relevant confounders, this association did, however, remain only in females. These data underline the importance of considering poor dental health when evaluating cardiovascular risk, especially in females.

Abstract P3-02-02: Concordance between immunohistochemical and gene-expression based subtyping of early breast cancer using core needle biopsies and surgical specimens - experices from SCAN-B

Introduction: Preoperative chemotherapy in early breast cancer increases the rate of breast preservation and provides prognostic information. Treatment decisions in these cases rely on biomarker assessments and subtyping from tissue acquired through core needle biopsies. Tumor heterogeneity and representativity are pit-falls when limited tissue is available. Biomarker expression may change considerably as a result of preoperative chemotherapy, and in a subset of cases a complete pathological response at time of surgery may even preclude any further assessment. Therefore, the reliability and reproducibility of biomarkers in base-line core biopsies are of utmost importance for patients treated with preoperative chemotherapy.

Material and Methods: In an ongoing population-based study of early breast cancer, the SCAN-B (NCT02306096), patients were identified for whom an ultra-sound guided core needle biopsy was analyzed for biomarkers during primary clinical work-up and the patient was offered primary surgery as initial treatment. Clinical biomarker profiles including immunohistochemical (IHC) determinations of ER, PgR, HER2 and Ki67 were translated to subtypes according to modified St Gallen criteria (2013) and compared with paired samples from surgical specimens. In addition, tumor specimens for biomolecule extraction and RNA sequencing were collected fresh in RNAlater.

Results: IHC data was available from 51 paired samples. The subtype distribution in core needle biopsies was DCIS in 1 case (2 %), LCIS in 1 case (2 %) Luminal A-like in 16 cases (31 %), Luminal B-like (HER2 negative) in 26 cases (51 %), Luminal B-HER2-like (HER2 positive) in 4 cases (8 %), HER2-positive (non-luminal) in 1 case (2 %) and triple negative (ductal) breast cancer in 2 cases (4 %). The subtype distribution in surgical specimens was DCIS in 0 case (0 %), LCIS in 1 case (2 %) Luminal A-like in 18 cases (35 %), Luminal B-like (HER2negative) in 23 cases (45 %), Luminal B--like (HER2 positive) in 6 cases (12 %), HER2-positive (non-luminal) in 1 case (2 %) and triple negative (ductal) breast cancer in 2 cases (4 %). Notably, 5/16 cases classified as Luminal A-like in the core needle biopsy were reclassified as Luminal B-like (HER2-negative) in the surgical specimen, whereas 9/26 cases classified as Luminal B-like (HER2-negative) in the core needle biopsy were reclassified as either Luminal A-like (7 cases) or Luminal B-like (HER2 positive) (2 cases) in the surgical specimen. In all instances, except one, transition between Luminal A-like and Luminal B-like was due to recorded Ki67 expression. One case that was classified as a DCIS in the core needle was reclassified as Luminal B-like (HER2 negative) at time of surgery.

Discussion: In this limited material, discordance between evaluations regarding Luminal A-like and Luminal B-like was considerable. Especially the misclassification of primary HER2-positive breast cancer needs further evaluation. These findings may be caused by tumor heterogeneity, and highlight the risk of both over- and under-treatment upon biomarker assessment from core needle biopsies. Data from gene expression based subtype classifications will be presented during the meeting.

Citation Format: Morgan G, Larsson C, Tahin B, Vallon-Christersson J, Häkkinen J, Ehinger A, Malmberg M, Hegardt C, Borg Å, Rydén L, Saal LH, Hedenfalk I, Loman N. Concordance between immunohistochemical and gene-expression based subtyping of early breast cancer using core needle biopsies and surgical specimens - experices from SCAN-B [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-02-02.

Abstract P1-07-05: AIB1 is a new putative prognostic biomarker in the luminal A and B-like (HER2-negative) classification of invasive lobular carcinoma

Background: Estrogen receptor (ER) positive HER2-negative breast cancer comprises 75–80% of all breast cancer. This fraction is even higher (&gt;90%) in invasive lobular carcinoma (ILC). According to the St Gallen surrogate definitions of the intrinsic subtypes, Ki67 and progesterone receptor (PgR) are used to classify these tumors as luminal A- and luminal B-like (HER2-negative). These guidelines are based on information derived from patient materials with mixed histological types, where the vast majority of the patients have invasive ductal carcinoma. The `luminal-like classification´ together with histological grade, tumor size and lymph node status is widely used in the clinic for prognostication. The aim of the present study was to investigate if the same markers are applicable for ILC, and furthermore, if additional biomarkers involved in the endocrine signaling system, e.g. Amplified in breast cancer 1 (AIB1) and the putative G protein-coupled estrogen receptor (GPER), might provide complementary prognostic information.

Patients: Two hundred and thirty-three (N = 233) well-characterized patients with primary ILC, diagnosed between 1980 and 1991 were included. Forty-two percent of the patients received adjuvant endocrine treatment and 2 % received adjuvant chemotherapy. All biomarkers were analyzed immunohistochemically on tissue microarray, whereas histological grade was evaluated on whole sections according to Elston and Ellis (NHG). The primary endpoint was breast cancer mortality (BCM).

Results: In univariable analyses with 10-year follow-up, Ki67 (high vs. low), NHG (3 vs. 1+2) and AIB1 (high vs. low) were significantly associated to BCM (Hazard Ratio: 4.7, 95% CI: 2.1–10.4, p &lt;0.001; HR: 3.1, 95% CI: 1.5–6.4, p = 0.003; HR: 3.2, 95% CI: 1.4–7.2, p = 0.005 respectively), whereas PgR (&lt;1% vs ≥1%) and GPER (linear 0-4) were not (p = 0.25; p = 0.31 respectively). Essentially the same effect was seen after multivariable adjustment for lymph node status (+ vs. -), tumor size (&gt;20 mm vs. &lt;20 mm), adjuvant treatment and age (continuous). Subgrouping the tumors into luminal A- and B-like (HER2-negative) according to St Gallen surrogate definitions did not show significant prognostic differences between the two groups (p = 0.12). Patients with &lt;20 mm, lymph node negative breast cancer and favorable tumor characteristics (low Ki67, NHG 1+2, and low AIB1) had a 10-year BCM of 4.2% (95% CI: 1.4–12%). This group constituted 34% of the patients included in the present study.

Conclusions: In contrast to other previous studies, where breast cancers of mixed histological types were included, PgR was not significantly associated to prognosis in the ER-positive HER2-negative subgroup in the present study, consisting only of ILC. The prognostic role of PgR and the clinical usefulness of the luminal A and B-like (HER2-negative) classification (using only Ki67 and PgR) in ILC is still to be further investigated. The prognostic importance of Ki67 and NHG in this subgroup was, however, confirmed also in ILC, and AIB1 might be a new putative prognostic factor. By combining Ki67, NHG, and AIB1, together with lymph node status and tumor size, a group of patients with an excellent prognosis could be identified.

Citation Format: Narbe U, Forsare C, Bendahl P-O, Lövgren K, Alkner S, Sjöström M, Rydén L, Leeb-Lundberg F, Ingvar C, Fernö M. AIB1 is a new putative prognostic biomarker in the luminal A and B-like (HER2-negative) classification of invasive lobular carcinoma [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-05.

Abstract P3-08-13: Serum thymidine kinase activity is an independent prognostic factor for progression-free and overall survival in women with metastatic breast cancer

Introduction:

Although prognosis and treatment of metastatic breast cancer (MBC) have improved over the last years, there is still an unmet clinical need for more precise prognostic and treatment monitoring tools. Liquid-based markers are preferred since they reflect real-time tumor progression and are not dependent on repeated invasive tissue biopsies. Thymidine kinase 1 (TK1) is an enzyme involved in nucleotide metabolism and has a fundamental role in the DNA synthesis. It can be used as a marker of cell proliferation rate and the TK1 activity has demonstrated correlations to prognosis and usefulness for treatment monitoring in different malignancies. The aim of this study was to determine serum TK1 activity (sTK1) levels measured with the DiviTum assay (Biovica, Sweden), in women with MBC scheduled for 1st line systemic therapy and to evaluate its potential for prediction of outcome and treatment monitoring.

Methods:

142 women with MBC scheduled for 1st line systemic treatment and included in a prospective monitoring trial (CTC-MBC, NCT01322893) were evaluated for sTK1 at baseline (BL) and during treatment at 1, 3 and 6 months. 132 patients had at least one follow-up sample. sTK1 activity levels were measured and correlations to important clinicopathological variables and prognosis (PFS and OS) at BL and during treatment were evaluated.

Results:

The median sTK1 level at BL was 391 u/L (range 10-35520 u/L). When comparing patients with high (above median) versus low (below median) sTK1 levels at BL, high sTK1 levels were found to be associated to worse performance status (p=0.001) and high number of metastatic sites (p=0.03). There was also a statistically significant association between high sTK1 levels and high Ki67 expression in biopsies from metastatic lesions (p=0.038). In univariable analyses high sTK1 levels correlated to worse PFS and OS (HRPFS-BL 2.32, p&lt;0.001; HROS-BL 2.54, p&lt;0.001) at BL. In multivariable analysis adjusted for clinically used prognostic factors, sTK1 was an independent prognostic factor for PFS and OS (HRPFS-BL 2.4, p&lt;0.001; HROS-BL 2.0, p=0.01). During treatment, sTK1 was significantly associated with OS from each of the four time points and onwards (BL, 1, 3, 6 months) (HROS-1m 1.93, p=0.01; HROS-3m 2.35, p=0.02; HROS-6m 2.78, p=0.002) in univariable analysis. High sTK1 levels were also associated with impaired PFS (HRPFS-1m 1.48, p=0.06; HRPFS-3m 1.52, p=0.07; HRPFS-6m 2.03, p=0.009) and these associations were significant at BL and 6 months.

Discussion:

sTK1 activity level is an independent prognostic factor for PFS and OS in patients with MBC scheduled for 1st line systemic therapy. During treatment, sTK1 is prognostic for OS evaluated from all time-points up to 6 months. The sTK1 effects observed for PFS are slightly weaker, but still propose potential usefulness for treatment monitoring. Further, sTK1 levels correlate to Ki67 expression in metastatic lesions suggesting that it can be useful as a liquid-based real-time proliferation marker. In conclusion, these results are clinically relevant for prognostication and treatment monitoring in patients with MBC. Future studies of sTK1 are justified to further elucidate in what settings this marker is most useful.

Citation Format: Larsson A-M, Jansson S, Bendahl P-O, Baker S, Bergqvist M, Aaltonen K, Rydén L. Serum thymidine kinase activity is an independent prognostic factor for progression-free and overall survival in women with metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-13.

Abstract PD2-08: Predictors of axillary nodal metastasis based on gene expression and clinicopathological characteristics: Data from a population-based prospective study, the Sweden Cancerome Analysis Network – Breast (SCAN-B)

Background

Gene expression patterns show promise in estimating prognosis and directing adjuvant therapy, but its significance in guiding axillary treatment is sparsely evaluated. We aimed to identify predictors for nodal status based on gene expression patterns alongside clinicopathological characteristics, and to validate the performances as well as the prognostic importance of the predictors in a population-based context.

Material and Methods

The study assigned consecutive patients with primary breast cancer enrolled in the SCAN-B study (ClinicalTrials.gov ID: NCT02306096)in South Sweden between September 2010-March 2015. Exclusion criteria were: prior breast cancer, neoadjuvant therapy or unknown nodal status after surgical staging. Data on age, tumour size, multifocality, vascular invasion, NHG and ER/PR/HER2 status were retrieved. 3026 patients were successfully profiled by RNA sequencing (RNA-seq) forming the study analysis cohort. Patients enrolled during 2011 (n=1206) were excluded from predictor training/test sets and kept as an independent validation set. Seven machine-based learning algorithms were evaluated for all samples and for each of the molecular subtypes based on routine analysis: ER+/HER2-, HER2+ and TNBC. Primary outcome was discrimination (AUC) for N0/N+ based on either clinicopathological parameters, RNA-seq data or mixed data. Secondary outcome was to evaluate the prognostic value of the predictors. Kaplan-Meier estimates were used to portray univariate survival data in subgroups stratified by nodal status.

Results

The Swedish National Quality Registry for Breast Cancer revealed 5235 patients eligible for study inclusion, of which 89% were enrolled in the SCAN-B study. Distribution of clinicopathological characteristics for the 3026 RNA-sequenced patients reflected features in the catchment region, and were similar for the training/test sets (n = 1820) as well as the validation set (n = 1206). Mean AUCs from 10 iterative assessments in the training/test sets identified Generalized Boosted Regression Models having the highest performance. AUCs for clinicopathological predictors in the validation set were 0.73, 0.75, 0.71 and 0.66 for all samples, ER+/HER2-, HER2+ and TNBC, respectively. Corresponding AUCs for gene expression predictors were 0.66, 0.66, 0.62 and 0.57, respectively, while the best predictive performances were achieved with mixed predictors, revealing AUCs 0.75, 0.75, 0.78 and 0.68, respectively. Preliminary results indicated prognostic value of the predictors; patients with stated N0 but predicted N+ by the models had worse survival rates. On the contrary, a trend towards better survival was observed for those with stated N+ but predicted N0 by the models.

Conclusions

Subgroup-specific predictors for nodal status based on gene expression data alongside traditional clinicopathological characteristics were developed, and independently validated regarding performance and prognostic value, in a population-based breast cancer cohort. Integrating gene expression data in the preoperative setting may improve decision-making on the required extent of axillary surgery and systemic therapy needed.

Citation Format: Dihge L, Staaf J, Vallon-Christersson J, Hegardt C, Häkkinen J, Borg Å, Rydén L. Predictors of axillary nodal metastasis based on gene expression and clinicopathological characteristics: Data from a population-based prospective study, the Sweden Cancerome Analysis Network – Breast (SCAN-B) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-08.

Abstract P2-02-09: Breast cancer subtype distribution and circulating tumor DNA in response to neoadjuvant chemotherapy: Experiences from a preoperative cohort within SCAN-B

Introduction: Preoperative chemotherapy in early breast cancer increases the rate of breast preservation and provides prognostic information. In the case of residual disease, a change in subtypes may be observed. Sensitive and reproducible biomarkers predicting treatment response early during the treatment course are needed in order to better exploit the potential benefit of an individualized preoperative treatment.

Material and Methods: In an ongoing prospective study within the population-based SCAN-B project (NCT02306096), patients undergoing preoperative chemotherapy for early or locally recurrent breast cancer have been treated with iv Epirubicin and Cyclophosphamide q3w x 3 in sequence with either Docetaxel q3w x 3 or Paclitaxel q1w x 9 with a preoperative intent. HER2-positive cases also received HER2-directed treatment. At baseline, patients were staged using sentinel node biopsy for clinically node-negative patients and CT scan for cytologically confirmed node-positive cases. A clinical core needle biopsy as well as tissue from the surgical specimen was collected for determination of conventional biomarkers including ER, PgR, HER2 and Ki67. Tumor biopsies for biomolecule-extraction and RNA-sequencing were taken using ultrasound guidance and collected fresh in RNAlater at baseline, after 2 treatment cycles, as well as at surgery. Blood plasma samples were collected at baseline, after one-, three-, and six- 3w treatment cycles, and post-surgery. Using RNA-sequencing data, somatic mutations were identified in the tumor biopsies and personalized analyses for circulating tumor DNA (ctDNA) were performed. A pathological complete remission (pCR) was defined as the complete disappearance of invasive breast cancer in the breast and axilla at time of definitive surgery. Subtyping was performed using modified St Gallen criteria (2013).

Results: Thus far, 45 patients aged 24-74 years have been included, of which 34 (76 %) were clinical stage 2 and 11 (24%) were stage 3. The subtype distribution at baseline was five Luminal A-like (11 %), 21 Luminal B-like (HER2 negative) (47 %), 8 HER2-positive (18 %) and 11 Triple-negative (ductal) (24 %). The rates of pCR in 38 operated cases to date were 0/3 Luminal A-like, 3/19 Luminal B-like (HER2 negative), 2/8 HER2-positive, and 4/7 Triple-negative (overall 24 % pCR rate). One patient did not undergo surgery due to clinically progressive disease. In 25 cases with evaluable residual disease at surgery, there was a shift in the subtype in 13 (52 %), the majority of which represented a transition from Luminal B to Luminal A. No Triple-negative cases underwent a change in subtype during treatment. Results of the ctDNA analyses will be presented at the meeting.

Discussion: We have established an infrastructure allowing for an extensive evaluation of preoperative chemotherapy in early breast cancer. The goal is to develop methods to refine response-guided treatment in early breast cancer using molecular responses in the tumor as well as in the blood circulation. The patients continue to be prospectively monitored with iterative ctDNA analyses during follow-up.

Citation Format: Loman N, Chen Y, Aaltonen K, Brueffer C, George AM, Zander L, Vallon-Christersson J, Häkkinen J, Förnvik D, Rigo R, Ehinger A, Malmberg M, Larsson C, Hegardt C, Borg Å, Rydén L, Saal LH. Breast cancer subtype distribution and circulating tumor DNA in response to neoadjuvant chemotherapy: Experiences from a preoperative cohort within SCAN-B [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-02-09.

Abstract P2-01-03: Improved prognostic information by serial monitoring of CTC enumeration and CTC-clusters from baseline to six months in patients with metastatic breast cancer scheduled for 1st line systemic therapy

Background: Detection and enumeration of circulating tumor cells (CTCs) allows real time monitoring of disease evolvement. In women with metastatic breast cancer (MBC), a CTC count of ≥5 CTCs is associated with decreased progression-free survival (PFS) and overall survival (OS). Serial sampling after therapy initiation has indicated that longitudinal CTC enumeration adds prognostic information, but data from long time sampling is sparse. The aim of this study was to evaluate if prospective longitudinal detection of CTC count and CTC clusters in women with newly diagnosed MBC can improve prognostication and monitoring of patients in the clinical setting.

Methods: Longitudinal blood samples were collected at baseline (BL) and after 1, 3 and 6 months in 156 women with MBC scheduled for 1st line systemic therapy. CTC enumeration and cluster detection were performed by the CellSearch® system in a prospective monitoring trial (NCT01322893). 115 patients had evaluable samples at all time-points. Primary endpoint was PFS and secondary endpoint was OS at BL in relation to CTC count and as landmark analyses during treatment. In addition, change in CTC count during therapy was compared to progressive disease (PD) versus non-PD. Structured clinical and radiological evaluation for PD was performed every 3rd month.

Results: Seventy-nine (52%) of 152 evaluable patients had ≥5 CTC and 14/79 patients had CTC-clusters (33 clustered CTC) at BL. Median follow-up time was 25 (7-69) months. Patients with ≥5 CTCs had inferior PFS and OS in uni-(data not shown) and multivariable analysis (HRPFS 1.91 (1.26-2.91), P=0.003) (HROS 3.57 (2.02-6.31), P&lt;0.001) at BL. Presence of clusters at BL was prognostic for OS (HROS 2.37 (1.25-4.51), P=0.008). Longitudinal landmark analysis of number of CTCs and presence of CTC clusters showed a time-dependent increase in HR during treatment for CTCs and CTC-clusters and predicted worse PFS and OS at all time-points. Stratifying patients based on CTC count and presence of clusters revealed four risk groups (0, 1-4, ≥5 CTC, ≥5 CTC + clusters) where patients with clusters had inferior PFS and OS at all time points. Change in CTC count from BL to 1 and 3 months, and from 3 to 6 months was significantly related to evaluation at 3 and 6 months (PD vs non-PD, P=0.013 (3 months), P=0.016 (6 months)) and change in CTC count from BL to 1, 3 and 6 months was also significantly predictive of both PFS and OS. Notably, survival was significantly inferior for patients with persistent CTC ≥5 during treatment.

Discussion: CTC is an independent prognostic factor for MBC patients scheduled for 1st line systemic therapy. By longitudinal monitoring during treatment, the prognostic information by presence of ≥5 CTC and clusters increases over time and supports long time monitoring of patients. Importantly, detection of CTC-clusters identifies a subgroup of patients with dismal prognosis at all time-points indicating that CTC-clusters renders important clinical information. Change in CTC count during systemic therapy is related to outcome of evaluation and prognosis at all time-points.

Citation Format: Larsson A-M, Jansson S, Bendahl P-O, Baker S, Graffman C, Lundgren C, Loman N, Aaltonen KE, Rydén L. Improved prognostic information by serial monitoring of CTC enumeration and CTC-clusters from baseline to six months in patients with metastatic breast cancer scheduled for 1st line systemic therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-01-03.

Undetected dysglycaemia common in primary care patients treated for hypertension and/or dyslipidaemia: on the need for a screening strategy in clinical practice. A report from EUROASPIRE IV a registry from the EuroObservational Research Programme of the European Society of Cardiology

Background

Dysglycaemia defined as type 2 diabetes (T2DM) and impaired glucose tolerance (IGT), increases the risk of cardiovascular disease (CVD). The negative impact is more apparent in the presence of hypertension and/or dyslipidaemia. Thus, it seems reasonable to screen for dysglycaemia in patients treated for hypertension and/or dyslipidaemia. A simple screening algorithm would enhance the adoption of such strategy in clinical practice.

Objectives

To test the hypotheses (1) that dysglycaemia is common in patients with hypertension and/or dyslipidaemia and (2) that initial screening with the Finnish Diabetes Risk Score (FINDRISC) will decrease the need for laboratory based tests.

Methods

2395 patients (age 18–80 years) without (i) a history of CVD or TDM2, (ii) prescribed blood pressure and/or lipid lowering drugs answered the FINDRISC questionnaire and had an oral glucose tolerance test (OGTT) and HbA1c measured.

Results

According to the OGTT 934 (39%) had previously undetected dysglycaemia (T2DM 19%, IGT 20%). Of patients, who according to FINDRISC had a low, moderate or slightly elevated risk 20, 34 and 41% and of those in the high and very high-risk category 49 and 71% had IGT or T2DM respectively. The OGTT identified 92% of patients with T2DM, FPG + HbA1c 90%, FPG 80%, 2hPG 29% and HbA1c 22%.

Conclusions

(1) The prevalence of dysglycaemia was high in patients treated for hypertension and/or dyslipidaemia. (2) Due to the high proportion of dysglycaemia in patients with low to moderate FINDRISC risk scores its initial use did not decrease the need for subsequent glucose tests. (3) FPG was the best test for detecting T2DM. Its isolated use is limited by the inability to disclose IGT. A pragmatic strategy, decreasing the demand for an OGTT, would be to screen all patients with FPG followed by OGTT in patients with IFG.

Design and baseline characteristics of participants in the Researching cardiovascular Events with a Weekly INcretin in Diabetes (REWIND) trial on the cardiovascular effects of dulaglutide

The aim was to determine the effects of dulaglutide, a synthetic once-weekly, injectable human glucagon-like peptide 1 analogue that lowers blood glucose, body weight, appetite and blood pressure, on cardiovascular outcomes. People with type 2 diabetes, aged ≥50 years, with glycated haemoglobin (HbA1c) ≤9.5%, and either a previous cardiovascular event, evidence of cardiovascular disease or ≥2 cardiovascular risk factors were randomly allocated to a weekly subcutaneous injection of either dulaglutide (1.5 mg) or placebo and followed within the ongoing Researching cardiovascular Events with a Weekly INcretin in Diabetes (REWIND) trial every 3 to 6 months. The primary cardiovascular outcome is the first occurrence of the composite of cardiovascular death or non-fatal myocardial infarction or non-fatal stroke. Secondary outcomes include each component of the primary composite cardiovascular outcome, a composite clinical microvascular outcome comprising retinal or renal disease, hospitalization for unstable angina, heart failure requiring hospitalization or an urgent heart failure visit, and all-cause mortality. Follow-up will continue until the accrual of 1200 confirmed primary outcomes. Recruitment of 9901 participants (mean age 66 years, 46% women) occurred in 370 sites located in 24 countries over a period of 2 years. The mean duration of diabetes was 10 years, mean baseline HbA1c was 7.3%, and 31% had prior cardiovascular disease. The REWIND trial's international scope, high proportion of women, high proportion of people without prior cardiovascular disease and inclusion of participants whose mean baseline HbA1c was 7.3% suggests that its cardiovascular and safety findings will be directly relevant to the typical middle-aged patient seen in general practice throughout the world.

Coagulation Factor V (Arg506 → Gln) Mutation and Early Saphenous Vein Graft Occlusion after Coronary Artery Bypass Grafting

The factor V (Arg506→Gln) mutation confers an increased risk of deep vein thrombosis, whereas its role in saphenous vein graft closure after coronary artery bypass grafting (CABG) remains unclear. This study examined the anticoagulant response to activated protein C (APC ratio) in relation to the surgical trauma and the significance of the factor V Leiden mutation in determining postoperative thrombin generation and fibrin formation and the risk of early vein graft occlusion. A total of 108 men undergoing elective CABG for exertional angina pectoris (mean age 61.1 ± 8.7 years) were examined. The patency of saphenous vein grafts was studied at routine reangiography three months after CABG.

Of 100 patients who underwent reangiography, 23 had one or more occluded vein grafts at reangiography. Heterozygosity for the factor V (Arg506→Gln) mutation tended to be associated with early saphenous vein graft occlusion (5/11 carriers vs. 18/89 non-carriers with graft occlusion, व2 = 3.52, p = 0.06), whereas pre- and postoperative APC ratios did not. Pre- and postoperative determinations of prothrombin fragment 1+2, thrombin-antithrombin complexes and soluble fibrin levels did not differ between patients with and without the mutation.

Early saphenous vein graft occlusion after CABG could tentatively be added to deep vein thrombosis as a vascular complication that can be attributed to the factor V (Arg506→Gln) mutation.

Correction to: Updates on cardiovascular outcome trials in diabetes

Following publication of the original article [1], the authors submitted a corrected version of Table 4 (see below).

Effects of acarbose on cardiovascular and diabetes outcomes in patients with coronary heart disease and impaired glucose tolerance (ACE): a randomised, double-blind, placebo-controlled trial

BACKGROUND

The effect of the α-glucosidase inhibitor acarbose on cardiovascular outcomes in patients with coronary heart disease and impaired glucose tolerance is unknown. We aimed to assess whether acarbose could reduce the frequency of cardiovascular events in Chinese patients with established coronary heart disease and impaired glucose tolerance, and whether the incidence of type 2 diabetes could be reduced.

METHODS

The Acarbose Cardiovascular Evaluation (ACE) trial was a randomised, double-blind, placebo-controlled, phase 4 trial, with patients recruited from 176 hospital outpatient clinics in China. Chinese patients with coronary heart disease and impaired glucose tolerance were randomly assigned (1:1), in blocks by site, by a centralised computer system to receive oral acarbose (50 mg three times a day) or matched placebo, which was added to standardised cardiovascular secondary prevention therapy. All study staff and patients were masked to treatment group allocation. The primary outcome was a five-point composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, hospital admission for unstable angina, and hospital admission for heart failure, analysed in the intention-to-treat population (all participants randomly assigned to treatment who provided written informed consent). The secondary outcomes were a three-point composite outcome (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke), death from any cause, cardiovascular death, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, hospital admission for unstable angina, hospital admission for heart failure, development of diabetes, and development of impaired renal function. The safety population comprised all patients who received at least one dose of study medication. This trial is registered with ClinicalTrials.gov, number NCT00829660, and the International Standard Randomised Controlled Trial Number registry, number ISRCTN91899513.

FINDINGS

Between March 20, 2009, and Oct 23, 2015, 6522 patients were randomly assigned and included in the intention-to-treat population, 3272 assigned to acarbose and 3250 to placebo. Patients were followed up for a median of 5·0 years (IQR 3·4-6·0) in both groups. The primary five-point composite outcome occurred in 470 (14%; 3·33 per 100 person-years) of 3272 acarbose group participants and in 479 (15%; 3·41 per 100 person-years) of 3250 placebo group participants (hazard ratio 0·98; 95% CI 0·86-1·11, p=0·73). No significant differences were seen between treatment groups for the secondary three-point composite outcome, death from any cause, cardiovascular death, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, hospital admission for unstable angina, hospital admission for heart failure, or impaired renal function. Diabetes developed less frequently in the acarbose group (436 [13%] of 3272; 3·17 per 100 person-years) compared with the placebo group (513 [16%] of 3250; 3·84 per 100 person-years; rate ratio 0·82, 95% CI 0·71-0·94, p=0·005). Gastrointestinal disorders were the most common adverse event associated with drug discontinuation or dose changes (215 [7%] of 3263 patients in the acarbose group vs 150 [5%] of 3241 in the placebo group [p=0·0007]; safety population). Numbers of non-cardiovascular deaths (71 [2%] of 3272 vs 56 [2%] of 3250, p=0·19) and cancer deaths (ten [<1%] of 3272 vs 12 [<1%] of 3250, p=0·08) did not differ between groups.

INTERPRETATION

In Chinese patients with coronary heart disease and impaired glucose tolerance, acarbose did not reduce the risk of major adverse cardiovascular events, but did reduce the incidence of diabetes.

FUNDING

Bayer AG.

Updates on cardiovascular outcome trials in diabetes

In 2008 the Food and Drug Administration introduced a guidance for industry that requires the investigation of cardiovascular outcomes of glucose-lowering medications. Since then, an increasing number of cardiovascular outcome trials have been completed in diabetes patients with high cardiovascular risk for members of the SGLT-2 and DPP4 inhibitors and GLP-1 receptor agonist classes. The trials confirmed cardiovascular safety for all tested anti-hyperglycaemic drugs and, in addition empagliflozin, semaglutide and liraglutide could even reduce cardiovascular risk. The present review summarizes the results of the DEVOTE, CANVAS, EXSCEL and ACE trials that tested cardiovascular safety of Insulin degludec, canagliflozin, once-weekly exenatide and acarbose and were published in 2017. We provide context on these results by comparing them with earlier trials of glucose-lowering drugs and give an outlook on what to expect in coming years.

The Prognostic Value of Fasting Plasma Glucose, Two-Hour Postload Glucose, and HbA1c in Patients With Coronary Artery Disease: A Report From EUROASPIRE IV: A Survey From the European Society of Cardiology

OBJECTIVE

Three tests are recommended for identifying dysglycemia: fasting glucose (FPG), 2-h postload glucose (2h-PG) from an oral glucose tolerance test (OGTT), and glycated hemoglobin A1c (HbA1c). This study explored the prognostic value of these screening tests in patients with coronary artery disease (CAD).

RESEARCH DESIGN AND METHODS

FPG, 2h-PG, and HbA1c were used to screen 4,004 CAD patients without a history of diabetes (age 18-80 years) for dysglycemia. The prognostic value of these tests was studied after 2 years of follow-up. The primary end point included cardiovascular mortality, nonfatal myocardial infarction, stroke, or hospitalization for heart failure and a secondary end point of incident diabetes.

RESULTS

Complete information including all three glycemic parameters was available in 3,775 patients (94.3%), of whom 246 (6.5%) experienced the primary end point. Neither FPG nor HbA1c predicted the primary outcome, whereas the 2h-PG, dichotomized as <7.8 vs. ≥7.8 mmol/L, was a significant predictor (hazard ratio 1.38, 95% CI 1.07-1.78; P = 0.01). During follow-up, diabetes developed in 78 of the 2,609 patients (3.0%) without diabetes at baseline. An FPG between 6.1 and 6.9 mmol/L did not predict incident diabetes, whereas HbA1c 5.7-6.5% and 2h-PG 7.8-11.0 mmol/L were both significant independent predictors.

CONCLUSIONS

The 2h-PG, in contrast to FPG and HbA1c, provides significant prognostic information regarding cardiovascular events in patients with CAD. Furthermore, elevated 2h-PG and HbA1c are significant prognostic indicators of an increased risk of incident diabetes.

Nomograms for preoperative prediction of axillary nodal status in breast cancer

Background

Axillary staging in patients with breast cancer and clinically node‐negative disease is performed by sentinel node biopsy (SLNB). The aim of this study was to integrate feasible preoperative variables into nomograms to guide clinicians in stratifying treatment options into no axillary staging for patients with non‐metastatic disease (N0), SLNB for those with one or two metastases, and axillary lymph node dissection (ALND) for patients with three or more metastases.

Methods

Patients presenting to Skåne University Hospital, Lund, with breast cancer were included in a prospectively maintained registry between January 2009 and December 2012. Those with a preoperative diagnosis of nodal metastases were excluded. Patients with data on hormone receptor status, human epidermal growth factor receptor 2 and Ki‐67 expression were included to allow grouping into surrogate molecular subtypes. Based on logistic regression analyses, nomograms summarizing the strength of the associations between the predictors and each nodal status endpoint were developed. Predictive performance was assessed using the area under the receiver operating characteristic (ROC) curve. Bootstrap resampling was performed for internal validation.

Results

Of the 692 patients eligible for analysis, 248 were diagnosed with node‐positive disease. Molecular subtype, age, mode of detection, tumour size, multifocality and vascular invasion were identified as predictors of any nodal disease. Nomograms that included these predictors demonstrated good predictive abilities, and comparable performances in the internal validation; the area under the ROC curve was 0·74 for N0versus any lymph node metastasis, 0·70 for one or two involved nodes versusN0, and 0·81 for at least three nodes versus two or fewer metastatic nodes.

Conclusion

The nomograms presented facilitate preoperative decision‐making regarding the extent of axillary surgery.

Defines need for staging?

Saliva and plasma levels of cardiac-related biomarkers in post-myocardial infarction patients

AIM

To relate cardiac biomarkers, such as cystatin C and growth differentiation factor-15 (GDF-15) in saliva to myocardial infarction (MI) and to periodontal status, and to investigate the relation between salivary and plasma cardiac biomarkers.

MATERIALS AND METHODS

Two hundred patients with MI admitted to coronary care units and 200 matched controls without MI were included. Dental examination and collection of blood and saliva samples was performed 6-10 weeks after the MI for patients and in close proximity thereafter for controls. Analysing methods: ARCHITECT i4000SR, Immulite 2000 XPi or ELISA.

RESULTS

The mean age was 62 ± 8 years and 84% were male. Total probing pocket depth, fibrinogen, white blood cell counts and HbA1c were higher in patients than controls. GDF-15 levels correlated with most of the included clinical variables in both study groups. No correlation was found between plasma and saliva levels of cystatin C or GDF-15.

CONCLUSION

Salivary cystatin C and GDF-15 could not differentiate between MI patients and controls.