How I treat endocrine-dependent metastatic breast cancer

Estrogen receptor-positive (ER+)/HER2-negative (HER2-), the so-called luminal-type breast cancer, is the most frequent subset, accounting for around 70% of all breast cancer cases. Endocrine therapy (ET) combined with cyclin-dependent kinases (CDK) 4/6 inhibitors is the standard first option in the management of advanced luminal breast cancer independently of disease extension. Classically, patients undergo multiple lines of ET ± targeted treatments until endocrine resistance occurs and palliative chemotherapy is proposed. Understanding endocrine resistance mechanisms and development of novel ET options is one of the main challenges in current clinical research. Another area of utmost interest is the improvement of post-endocrine therapeutic approaches. Among others, the development of antibody-drug conjugates (ADCs) is very promising, and some of these drugs will probably soon become a part of the therapeutic arsenal against this incurable disease. This review paper provides an overview of currently available treatment options in ER+/HER2- metastatic breast cancer and extensively discusses new approaches in late clinical development.

Immune biology of NSCLC revealed by single-cell technologies: implications for the development of biomarkers in patients treated with immunotherapy

First-line immunotherapy in non-small-cell lung cancer largely improved patients' survival. PD-L1 testing is required before immune checkpoint inhibitor initiation. However, this biomarker fails to accurately predict patients' response. On the other hand, immunotherapy exposes patients to immune-related toxicity, the mechanisms of which are still unclear. Hence, there is an unmet need to develop clinically approved predictive biomarkers to better select patients who will benefit the most from immune checkpoint inhibitors and improve risk management. Single-cell technologies provide unprecedented insight into the tumor and its microenvironment, leading to the discovery of immune cells involved in immune checkpoint inhibitor response or toxicity. In this review, we will underscore the potential of the single-cell approach to identify candidate biomarkers improving non-small-cell lung cancer patients' care.

A new cardiopulmonary exercise testing score for predicting heart failure events

Background

Cardiopulmonary exercise test (CPET) provides several variables (V) that are strong predictors of events in patients (pts) with heart failure (HF).

Purpose

Our aim was to develop and evaluate the predictive power (PP) of a CPET-based score, comparing to that of the Heart Failure Survival Score – HFSS.

Methods

Retrospective evaluation of adult pts with HF submitted to CPET in a tertiary center. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation (MTV). The PP of several CPET V's was assessed using ROC curve analysis, which was used to define optimal threshold values for each V. A multiple regression analysis was performed to identify independent prognostic predictors and to determine the regression coefficient (β) for the Vs included in the model, each expressed dichotomously using the threshold value. According to β, a weight was assigned to each V and summed to calculate the composite score. ROC curves were compared using the Hanley and McNeil test.

Results

CPET was performed in 487 HF pts, with a mean age of 56±13 years, 79% were male. 46% of pts were of ischemic etiology, with a mean LVEF of 30±8%, a mean HFSS of 8.6±1.1 and a mean BNP value of 509±668pg/ml. The mortality rate during a mean follow-up of 21 months, was 19% (93pts) with 23 pts (5%) undergoing HT. The primary endpoint was reached by 55 (11%) pts. The variables with higher predictive power were OUES (AUC 0.796), ventilatory power (AUC 0.790), the partial pressure of end-tidal CO2 at the anaerobic threshold (PETCO2L – AUC of 0.787), the pVO2 (AUC 0.767) and heart rhythm (HR) during the test (AUC – 0.640). LVEF also presented a high predictive power with AUC of 0.755. The multivariate analysis revealed that pVO2, PETCO2L, AF, and LVEF were independent prognostic predictors. According to the β of these Vs, the equation was calculated as follows: (pVO2 × 2.194) + (PETCO2L × 1.545) + (LVEF × 1.134) + (HR × 1.055; 0 if AF, 1 if sinus rhythm). The score presented a high PP with an AUC of 0.866. A cut-off of 120 had an 83.6% sensitivity and a 75% specificity for MTV, and pts with a score value of <120 had a markedly lower rate of MTV (log-rank p<0.001). When compared to HFSS, our score presented a higher PP (0.866 vs 0.774, p=0.011).

Conclusion

A multivariable score based on readily available CPET Vs provides a simple, integrated and powerful method to predict HF events.

Funding Acknowledgement

Type of funding sources: None.

Promoting physical activity among university students with a co-constructed program during Covid-19 pandemic

Introduction

Since the beginning of the COVID-19 pandemic, sanitary context and e-learning has greatly modified students’ lifestyles. An increase of sedentary behaviors, a reduction in physical activity (PA) and a stronger tendency to move towards unhealthy diet have been demonstrated. Most of the research is largely descriptive and to date, no interventional studies have been conducted to prevent the deterioration of students’ health.

Objectives

The objective of the present research aims to evaluate the effects of an intervention program on the lifestyle and psychological state of student. Its primary objective is to promote PA among students, to improve both physical condition and motivation to engage in physical activity for one’s health by promoting motivational levers. Its second objective is to reduce and/or prevent the deterioration of the health of university students.

Methods

Students from University of Nîmes were recruited and randomly assigned to one of the two following conditions: an experimental group and a control group. The experimental group participated to an 8-weeks program of PA (co-constructed by users during design-based innovative workshops) whereas the control group did not. For each group, measures of PA, sedentary time, anthropometric data, sleep, physical condition and psychological variables (anxiety, depression, motivation, body appreciation, perceived control, well-being, …) were carried out before (T1: october 2021) and after (T2: December 2021) these 8-weeks in order to evaluate the benefits from the PA program.

Results

These assessments were performed in October 2021 (T1) and December 2021 (T2).

Conclusions

Data are still being collected and will be presented in April 2022.

Disclosure

No significant relationships.

Student mental health during the first two years of the COVID- 19 pandemic

Introduction

The COVID-19 pandemic have had deleterious effects on mental health of students. Authors suggest that the psychological effects will persist long after COVID-19 has peaked, but we have no data to confirm this.

Objectives

Objective: The objective of this study is to compare clinical issues (concerns, anxiety and depression symptoms) and adjustment (coping strategies) in French university students during different phases of the COVID-19 pandemic in 2020 and 2021 (during two periods of lockdown and two periods after lockdown)

Methods

Method: Data were collected anonymously at four timepoints: during France’s first national lockdown (23 April- 8 May 2020; n_T1 = 1294); during the period after lockdown (9‑23 June 2020; n_T2 = 321); 1 year after the first lockdown, which was also a lockdown period (23 April- 8 May 2021; n_T3 = 2357); and 1 year after the first unlockdown, which was also a unlockdown period (9‑23 June 2021, n_T4 = 1174). The following variables were measured: concerns, coping strategies, anxiety and depressive symptoms.

Results

In 2021, students have significantly higher levels of anxiety and depressive symptoms than in 2020, and this is even more pronounced during the lockdown periods. For example, 44.1% had probable anxiety symptoms in the 2021 lockdown, compared to 33% in the 2020 lockdown. In the unlockdown periods, the rates are 21.7% in 2020 and 26.4% in 2021.

Conclusions

Our results suggest that university students, known to be a vulnerable population with significant mental health deterioration, have become even more vulnerable with the COVID-19 pandemic.

Disclosure

No significant relationships.

Assessment of activation duration across the right ventricular outflow tract in patients with premature ventricular contractions using noninvasive electrocardiographic mapping: a validation study

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Introduction

Previous studies have reported that wavefront propagation speed across the right ventricular outflow tract (RVOT) can distinguish premature ventricular contractions (PVCs) with a RVOT origin from PVCs with a left ventricular outflow tract (LVOT) origin.

Aim

Validate the non-invasive electrocardiographic mapping (ECGI) for assessment of RVOT activation duration (AD) during PVCs and assess its value as a predictor of the origin of the PVCs.

Methods

We studied 18 consecutive patients, 8 males, median age 55 (35-63) years that underwent ablation of frequent (> 10.000 per 24 h) idiopathic PVCs with inferior axis, that had and an ECGI performed before ablation and the RVOT mapped in PVC. The ECGI was performed with the Amycard system, and invasive mapping was performed with the Carto or Ensite system. Isochronal activation maps of the RVOT in PVC were obtained with the activation direction method (ADM) of the ECGI, and with the Carto and Ensite systems. Total RVOT AD was measured as the time interval between the earliest and the latest activated region. Agreement between the two methods was performed using a Bland-Altman plot and linear regression . The cutoff value of AD to predict PVC origin was calculated with ROC curve.

Results

PVCs originated from the RVOT in 11 (61%) patients. The median (Q1-Q3) RVOT AD measured with ECGI was 54 (39-68) ms and with invasive map 57 (36-70) ms. The agreement between both methods was good with an R2 of 0.747, p<0.0001. Figure displays the Bland-Altman plot (panel A), the linear regression plot (panel B). and two examples of the ECGI isochronal map (panel C). The AD was significantly higher in PVCs from the RVOT vs LVOT, both with ECGI and Carto, respectively 62 (58-73) vs 37 (33-40) ms, p<0.0001 and 68 (60-75) vs 34 (30-40) ms, p<0.0001. The cutoff value of 43 ms for AD measured with ECGI, predicted the origin of the PVCs with a sensitivity and specificity of 100%.

Conclusions

We found good agreement between ECGI and Carto. The AD obtained with ECGI was accurate to predict the origin of the PVCs.

Evaluation of RV-arterial coupling in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The ratio of echocardiography-derived tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP) - TAPSE/PASP ratio - is a noninvasive measure of RV-arterial coupling. TAPSE/PASP ratio is a potent independent predictor of prognosis in heart failure and pulmonary arterial hypertension, with a prognostic cutoff value of 0.36 mm/mmHg.

Objective

To assess the prognostic impact of TAPSE/PASP ratio in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 2 years for the primary endpoint of cardiac death and HT. Echocardiographically determined TAPSE/PASP ratio was used to assess RV-arterial coupling and a survival analysis was performed to evaluate the prognostic impact of the suggested cutoff of 0.36 mm/mmHg.

Results

A total of 450 Heart Failure with Reduced Ejection Fraction (HFrEF) patients with a mean age of 56 ± 12 years, of which 80% are male, and with a mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and PASP of 38 ± 11mmHg. The mean TAPSE/PASP was 0.80 ± 0.28. Fifty-four patients (12%) met the primary endpoint. Patients with RV-arterial uncoupling (TAPSE/PASP < 0.36 mm/mmHg) were more likely to have a non-ischaemic etiology for HF (66.7% vs 40%, p = 0.047), had a lower prevalence of diabetes (53.3% vs 77.9%, p = 0.041), a higher prevalence of moderate-to-severe mitral regurgitation (33.3% vs 13.0%, p = 0.035), a lower LVEF (26.2 ± 6.1 vs 29.9 ± 5.9, p = 0.038), a higher prevalence of RV dysfunction (73.3% vs 26.7%, p < 0.001) and worse cardiopulmonary fitness (pVO2: 12.7 ± 5.1 vs 15.8 ± 6.0 ml/kg/min, p = 0.047; VE/VCO2 slope: 49.5 ± 17.2 vs 37.6 ± 9.7, p < 0.001; cardiorespiratory optimal point: 36.9 ± 11.3 vs 29.0 ± 6.4, p < 0.001). More patients in the group of TAPSE/PASP < 0.36 mm/mmHg met the primary endpoint (33.3% vs 9.6%, p = 0.034) and more patients underwent urgent HT (13.3% vs 1.4%, p = 0.44). RV-arterial coupling was associated with a lower survival free of events during follow-up (log-rank p = 0.010).

Conclusion

RV-arterial coupling predicts a worse prognosis in advanced HF patients, with those below a cutoff of 0.36 mm/mmHg having lower survival. This variable may improve risk stratification in this setting. Abstract Figure.

Prognostic impact of right ventricular function in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

In patients with heart failure with reduced ejection fraction (HFrEF), the presence of coexistent right ventricular (RV) systolic dysfunction is associated with a worse functional capacity and outcome. However, the measurement of RV function is often overshadowed by its left counterpart.

Purpose

To assess the prognostic impact of RV dysfunction in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team for possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 1 year for the primary endpoint of cardiac death and HT. RV systolic dysfunction was defined by a tricuspid annular plane systolic excursion (TAPSE) < 17 mm and/ or fractional area change (FAC) < 35%. A survival analysis was performed to evaluate the prognostic impact of RV dysfunction and survival curves were compared using the log-rank test.

Results

A total of 450 HFrEF patients (mean age of 56 ± 12 years, 80% male, mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and RV FAC of 37 ± 6%), of which 30.4% had RV dysfunction. Thirty patients (6.7%) met the primary endpoint. Patients with RV dysfunction had a higher NT-proBNP value (3278.9 ± 296.7 pg/mL, p = 0.005) and a lower LVEF (26.7 ± 6.4 vs 31.4 ± 5.1, p < 0.001), as well as a worse cardiopulmonary fitness (CPET duration: 7.2 ± 3.8 vs 8.6 ± 4.1, p = 0.019; pVO2: 13.6 ± 4.9 vs 16.2 ± 6.1 ml/kg/min, p = 0.006; VE/VCO2 slope: 41.8 ± 11.9 vs 37.0 ± 10.6, p = 0.015; cardiorespiratory optimal point: 33.0 ± 8.9 vs 28.4 ± 6.2, p < 0.001). RV dysfunction was associated with a lower survival free of events during the first follow-up year (log-rank p = 0.046).

Conclusion

RV is associated with a poor survival in advanced HF patients and it may improve risk stratification in this population. Abstract Figure.

Functional mitral regurgitation in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Moderate-to-severe functional mitral regurgitation (fMR) is present in about one-third of patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF) and contributes to progression of the symptoms of HF and is and independent predictor of worse clinical outcomes.

Objective

To characterize the population of advanced HF patients with severe fMR and assess its prognostic impact.

Methods

Prospective evaluation of adult patients with advanced HFrEF were referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 1 year for the primary endpoint of cardiac death and HT. Severe fMR was defined by an EROA ≥ 20 mm2 and/or a regurgitant volume (RVol) ≥ 30 mL either taken from TTE or TOE. A survival analysis was performed to evaluate the prognostic impact of fMR and survival curves were compared using the log-rank test.

Results

A total of 450 HFrEF patients (mean age of 56 ± 12 years, 80% male, mean LVEF of 29 ± 4%) of which 14.4% had severe fMR, with a mean EROA of 29.2 ± 3.1 mm2 and a mean RVol of 43.6 ± 4.7 mL. Thirty patients (6.7%) met the primary endpoint. Patients with severe fMR were more likely to be female (69.2% vs 81.5%, p = 0.026) and to have atrial fibrillation (27.0% vs 14.1%, p = 0.028), had a higher NT-proBNP value (3625.8 ± 496.9 vs 1940 ± 212.4 pg/mL, p = 0.001), a lower LVEF (25.9 ± 6.8 vs 29.0 ± 6.7, p = 0.001), more dilated LV (LV end-diastolic diameter: 72.8 ± 13.3 vs 66.9 ± 9.0 P = 0.036), a lower HFSS value (8.1 ± 1.0 vs 8.6 ± 1.0). There was no difference regarding HF etiology, NYHA class or cardiopulmonary fitness (pVO2: 16.6 ± 5.6 vs 16.5 ± 6.3 ml/kg/min, p = 0.19; VE/VCO2 slope: 35.4 ± 9.9 vs 34.0 ± 9.7, p = 0.328). EROA was an independent predictor of the primary outcome (OR 1.23, 95% CI 1.08-1.54, p = 0.039) and patients with severe fMR had a lower survival free of events during the first follow-up year (log-rank p = 0.012).

Conclusion

Severe fMR was associated with worse clinical outcomes in advanced HF population. Abstract Figure.

Lymphovascular invasion has a significant prognostic impact in patients with early breast cancer, results from a large, national, multicenter, retrospective cohort study

Background

We determined the prognostic impact of lymphovascular invasion (LVI) in a large, national, multicenter, retrospective cohort of patients with early breast cancer (BC) according to numerous factors.

Patients and methods

We collected data on 17 322 early BC patients treated in 13 French cancer centers from 1991 to 2013. Survival functions were calculated using the Kaplan–Meier method and multivariate survival analyses were carried out using the Cox proportional hazards regression model adjusted for significant variables associated with LVI or not. Two propensity score-based matching approaches were used to balance differences in known prognostic variables associated with LVI status and to assess the impact of adjuvant chemotherapy (AC) in LVI-positive luminal A-like patients.

Results

LVI was present in 24.3% (4205) of patients. LVI was significantly and independently associated with all clinical and pathological characteristics analyzed in the entire population and according to endocrine receptor (ER) status except for the time period in binary logistic regression. According to multivariate analyses including ER status, AC, grade, and tumor subtypes, the presence of LVI was significantly associated with a negative prognostic impact on overall (OS), disease-free (DFS), and metastasis-free survival (MFS) in all patients [hazard ratio (HR) = 1.345, HR = 1.312, and HR = 1.415, respectively; P < 0.0001], which was also observed in the propensity score-based analysis in addition to the association of AC with a significant increase in both OS and DFS in LVI-positive luminal A-like patients. LVI did not have a significant impact in either patients with ER-positive grade 3 tumors or those with AC-treated luminal A-like tumors.

Conclusion

The presence of LVI has an independent negative prognostic impact on OS, DFS, and MFS in early BC patients, except in ER-positive grade 3 tumors and in those with luminal A-like tumors treated with AC. Therefore, LVI may indicate the existence of a subset of luminal A-like patients who may still benefit from adjuvant therapy.

•

In a study of 17 322 early BC patients, LVI had a significant independent negative prognostic impact on survival.

•

LVI negatively impacted survival in almost every patient category and cancer subtype, with and without AC.

•

LVI did not have a negative survival impact in patients with ER+ grade 3 or with luminal A-like tumors with chemotherapy.

•

Results suggest a possible benefit of AC in LVI-positive luminal A-like patients.

Predictive ability of cardiopulmonary exercise test parameters in heart failure patients with cardiac resynchronization therapy

Introduction

There is evidence suggesting that a peak oxygen uptake (pVO2) cut-off of 10ml/kg/min provides a more precise risk stratification in Cardiac Resynchronization Therapy (CRT) patients. Our aim was to compare the prognostic power of several cardiopulmonary exercise testing (CPET) parameters in patients with CRT and assess the discriminative ability of the guideline-recommended pVO2 cut-off values.

Methods

Prospective evaluation of consecutive heart failure (HF) patients with left ventricular ejection fraction ≤40%. The primary endpoint was a composite of cardiac death and urgent heart transplantation (HT) in the first 24 follow-up months and was analyzed by several CPET parameters for the highest area under thecurve (AUC) in the CRT group. A survival analysis was performed to evaluate the risk stratification provided by several different cut-offs.

Results

A total of 450 HF patients, of which 114 had a CRT device. These patients had a higher baseline risk profile, but there was no difference regarding the primary outcome (13.2% vs 11.6%, p=0.660). End-tidal carbon dioxide pressure at the anaerobic threshold (PETCO2AT) had the highest AUC value, which was significantly higher than that of pVO2 in the CRT group (0.951 vs 0.778, p=0.046). The currently recommended pVO2 cut-off provided accurate risk stratification in this setting (p&lt;0.001),and the suggested cut-off value of 10 ml/min/kg did not improve risk discrimination in device patients (p=0.772).

Conclusion

PETCO2AT outperforms pVO2's prognostic power for adverse events in CRT patients. The current guideline-recommended pVO2 cut-off can precisely risk-stratify this population.

Funding Acknowledgement

Type of funding sources: None.

A new approach to atrial flutter ablation using functional substrate mapping with wavefront discontinuity during sinus rhythm

Funding Acknowledgements

Type of funding sources: None.

Background

Ultra high-density (UHD) mapping allows accurate identification of local abnormal electrograms and low voltage within a small area range, allowing precise identification of reentry circuits. Areas with high isochronal density in a small area known as deceleration zones (DZ) are responsible for reentry.

Purpose

Identify the DZ and areas of low voltage in sinus rhythm (SR) and evaluate the feasibility of performing atrial flutter (AFL) ablation by targeting those zones.

Methods

We prospectively enrolled patients in SR referred for AFL ablation (either typical or atypical). An isochronal late activation mapping (ILAM) during SR with UHD catheter was performed, annotating latest deflection of local electrograms. DZ were defined as areas with &gt;3 isochrones within 1cm radius, prioritizing zones with maximal density. Atrial flutter was then induced and ILAM during flutter was performed for comparison. Voltage mapping was also assessed (0.1-0.5mV). Ablation targeted DZ in SR that displayed the higher voltage. DZ in SR were compared to DZ in AFL. Number of radiofrequency (RF) applications needed to terminate AFL were assessed. After AFL termination, complete line of the slow conduction zone was completed, and pulmonary vein isolation (PVI) was done in case of left AFL. Categorical variables are presented in absolute and relative values and median and interquartile range were used for numerical variables, as well t-student test for correlation of numerical variables.

Results

We studied 6 AFL (4 atypical, 66.7%) in 5 patients, 2 male (40%), median age 70 (64- 72). UHD ILAM in SR with 2195 points (1212-2865) and 2197 points (1356-3102) in AFL (p = 0.62).  The UHD ILAM identified a median of (QR) DZ in SR, that colocalized with AFL isthmus and DZ in AFL in 100%. DZ were not always located in low voltage areas. Aiming at the higher voltage in the DZ terminated the AFL in all cases, with a median RF time of 38 (25-58) seconds and AFL was no longer inducible. However, according to protocol, the complete line of slow conduction zone was done, with a median RF time of 1049.5 (274-1194) seconds (p = 0,009).

Conclusions

Isochronal mapping in sinus rhythm with UHD catheters can display the functional substrate for reentry in AFL, allowing a substrate guided ablation in case of non-inducible AFL. Targeting the areas of high isochronal density, is effective in terminating AFL, obviating the need for extensive ablation. Abstract Figure.

Assessment of wavefront propagation speed on the right ventricular outflow tract: deceleration zones associated with the presence of low voltage areas

Funding Acknowledgements

Type of funding sources: None.

Background and aims

Activation wavefront is rapid and uniform in normal myocardium. Fibrosis is associated with deceleration zones (DZ) and late activated zones. The presence of low voltage areas (LVAs) in the right ventricular outflow tract (RVOT) of patients with premature ventricular contractions (PVCs) from this origin has been described previously. The aim of this study was to evaluate in sinus rhythm, the RVOT endocardial activation duration (EAD) and the presence of DZs, in patients with PVCs and in controls.

Methods

Consecutive patients with frequent (&gt;10.000/24 h) idiopathic PVCs with inferior axis subjected to ablation that had an activation and voltage map of the RVOT performed in sinus rhythm. A control group of patients without PVCs that underwent ablation of supraventricular arrhythmias was also studied. Patients with structural heart disease, previous ablation or conduction disease were excluded. The RVOT EAD was measured as the time interval between the earliest and the latest activated region. Also evaluated the number of 10 ms isochrones throughout the RVOT and the maximal number of 10 ms isochrones within 1 cm, and a DZ was defined as a zone with &gt; 3 isochrones within 1 cm. Low voltage areas (LVA) were defined as areas with local electrogram amplitude &lt;1.5 mV.

Results

42 patients, 29 in the PVC group and 13 control subjects. The site of origin of the PVCs was the RVOT in 23 patients and the LVOT in 6. The characteristics of the two groups are displayed in the Table. Patients with PVCS had longer RVOT EAD, total number of isochrones and presence of DZ was also significantly higher (See table).  LVAs were more frequent in PVCs from the RVOT than from the LVOT (83% vs 33%, p = 0.033). Patients with LVA had longer EAD 60 (52-67) vs 36 (34-40) ms, p &lt; 0.0001 (Figure A) and more DZ than patients without LVA 95% vs 0%, p &lt; 0.0001 (Figure B and C).

Conclusions

The velocity of the wavefront propagation was slower and DZs were more frequently present in patients with PVCs and were associated with presence of LVAs. All sampleN= 42PVCsN = 29ControlsN = 13p-valueAge in years, median (Q1-Q3)56 (35-65)58 (38-66)53 (28-67)0.648Male gender, n (%)19 (45)14 (48)5 (39)0.401Nº points in the map, median (Q1-Q3)410 (338-589)467 (345-660)345 (333-465)0.056Activation duration in ms, median (Q1-Q3)41.8 (36-61)56 (41-66)39 (35-41)0.001Nº isochrones, median (Q1-Q3)4 (4-6)5 (4-6)4 (4-4)0.037Presence of DZs, n (%)20 (48)20 (69)0 (0)&lt;0.0001Presence of LVAs, n(%)21 (50)21 (72)0 (0)&lt;0.0001Abstract Figure.

Echocardiographic but not clinical response to CRT is an independent predictor of a better survival free from arrhythmic events

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac resynchronization therapy (CRT) is of proven benefit in heart failure patients, improving mortality and reducing hospital admissions. There is however uncertainty if the arrhythmic risk is reduced in responders.

Purpose

We aimed to assess if patients with a CRT implanted for primary prevention had less arrhythmic episodes if they responded to this therapy and if echocardiographic and clinical responses to CRT differ regarding the occurrence of ventricular arrhythmias.

Methods

We prospectively enrolled patients that underwent CRT implant for primary prevention according to ESC guidelines. Patients were classified as responders if they fulfilled one of four criteria (echocardiographic or clinical) at six months after implant: a 5% absolute improvement in LV ejection fraction (LVEF), a 15% improvement in LVEF, a 15% decrease in LV end-diastolic volume or a decrease in NYHA class. During follow-up with device interrogation, arrhythmic ventricular events (AVE) were classified as appropriate ICD therapies or sustained ventricular tachycardia either occurring in ICD monitoring zones or undetected by the device due to a slower rare, but clinically documented. All patients were further classified according to type of pacing, biventricular or LV only. Demographic characteristics of patients were also assessed.

Results

We enrolled 73 patients, 58 (79.5%) male, median age of 72 (65-77) years. Median LVEF was 28 (22-35) % (p = 0.95 between groups), ischemic etiology in 36 (46.6%, p = 1.00). The two groups with and without AVE did not differ significantly regarding clinical, echocardiographic, and electrocardiographic characteristics (table). CRT echocardiographic response criteria were met by 50 (68.5%) of patients and clinical criteria by 53 (72.6%) patients. AVE occurred in 15 (20.5%) patients. In univariate regression analysis, echocardiographic response was associated with reduced AVE (OR 0,14; p = 0,005). Clinical response to CRT was not associated with AVE (p = 0.07). LV only pacing was associated with a higher probability of AVE (OR 5.1; p = 0.038). In Cox regression multivariate analysis, response to CRT was the only independent predictor of better survival free from AVE (HR 0.28;CI 95%, p = 0.044) and LV only pacing was not associated with more episodes of ventricular arrhythmias (p = 0.17). Conclusions: Echocardiographic, but not clinical response to CRT therapy, is the only independent predictor of a higher survival free from arrhythmic events. In spite controversies regarding the arrhythmogenic role of LV pacing, this was not associated with higher ventricular arrhythmic events. Abstract Figure.

Lack of prognostic impact of sentinel node micro-metastases in endocrine receptor-positive early breast cancer: results from a large multicenter cohort☆

Background

Prognostic impact of lymph node micro-metastases (pN1mi) has been discordantly reported in the literature. The need to clarify this point for decision-making regarding adjuvant therapy, particularly for patients with endocrine receptor (ER)-positive status and HER2-negative tumors, is further reinforced by the generalization of gene expression signatures using pN status in their recommendation algorithm.

Patients and methods

We retrospectively analyzed 13 773 patients treated for ER-positive breast cancer in 13 French cancer centers from 1999 to 2014. Five categories of axillary lymph node (LN) status were defined: negative LN (pN0i−), isolated tumor cells [pN0(i+)], pN1mi, and pN1 divided into single (pN1 = 1) and multiple (pN1 > 1) macro-metastases (>2 mm). The effect of LN micro-metastases on outcomes was investigated both in the entire cohort of patients and in clinically relevant subgroups according to tumor subtypes. Propensity-score-based matching was used to balance differences in known prognostic variables associated with pN status.

Results

As determined by sentinel LN biopsy, 9427 patients were pN0 (68.4%), 546 pN0(i+) (4.0%), 1446 pN1mi (10.5%) and 2354 pN1 with macro-metastases (17.1%). With a median follow-up of 61.25 months, pN1 status, but not pN1mi, significantly impacted overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and breast-cancer-specific survival. In the subgroup of patients with known tumor subtype, pN1 = 1, as pN1 > 1, but not pN1mi, had a significant prognostic impact on OS. DFS and MFS were only impacted by pN1 > 1. Similar results were observed in the subgroup of patients with luminal A-like tumors (n = 7101). In the matched population analysis, pN1macro, but not pN1mi, had a statistically significant negative impact on MFS and OS.

Conclusion

LN micro-metastases have no detectable prognostic impact and should not be considered as a determining factor in indicating adjuvant chemotherapy. The evaluation of the risk of recurrence using second-generation signatures should be calculated considering micro-metastases as pN0.

•

LN micro-metastases have no detectable prognostic impact.

•

pN1 status, but not pN1mi, significantly impacted overall survival, disease-free survival, metastasis-free survival.

•

In the subgroup of patients with known tumor subtype, pN1=1, as pN1>1, but not pN1mi, had a significant prognostic impact on OS.

•

LN micro-metastases should not be considered as a determining factor in indicating adjuvant chemotherapy.

Predictors of atrial fibrillation occurrence in patients with hypertrophic cardiomyopathy

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of dysrhythmias, especially atrial fibrillation (AF).

Purpose

The aim of this study was to evaluate the incidence of AF in HCM patients (P) and to determine predictors of AF.

Methods

Retrospective analysis of HCM P at a single tertiary center. Baseline clinical, echocardiographic and cardiovascular magnetic resonance (CMR) characteristics were collected. On follow up AF was identified by electrocardiogram and/or 24 hours Holter monitoring.

Results

61P (59% male) were included, with a mean age of 58±2 years. 27.9% had angina (all of them CCS 2), 34.4% were in NYHA II and 14.8% in NYHA III, 8.2% had syncope and 39.3% had palpitations. A family history of sudden cardiac death (SCD) or cardiomyopathy was present in 40.4% of the cases. The mean HCM risk SCD score was 3.35±0.28%. On echocardiography left atrium (LA) diameter was 44.86±0.87mm, LA volume (LAvol) was 89.97±5.39mL (indexed LAvol 46.05±2.55mL/m2), interventricular septum (IVS) was 16.83±0.663mm, left ventricle (LV) mass was 290.94±13.897g and maximum wall thickness (MWT) was 20.59±0.596mm. 77% P had LA enlargement. 88.5%P had late gadolinium enhancement (LGE) in CMR with a median number of 5±7 segments involved. AF developed in 23P (37.7%), with a mean age of 58±3 years. Predictors of AF development were NYHA III (p=0.007), risk score (p=0.007), LA diameter (p=0.007), LAvol (p=0.005) and indexed LAvol (p=0.002), MWT (p=0.0015), LGE in more than 5 segments (p=0.029) and LGE in the inferior basal and inferior median IVS (p=0.033 and p=0.042). The only independent predictor was LAvol (p=0.0012), with an area under the curve of 0.755 and a cut off of 85.9mL being the best predictor (p=0.004). Combining LAvol &gt;85.9mL with LGE involving &gt;5 segments and LAvol &gt;85.9mL with LGE in inferior basal IVS (IBIVS) a statistically significant difference between groups was achieved (p=0.009 in the combined predictor LAvol + LGE &gt;5 segments and p=0.002 in the combined predictor LAvol + LGE in IBIVS) (figure 1 and figure 2). In a multivariable analysis including these 2 combined predictors and LAvol alone the only independent predictor was the combination of LAvol + IBIVS involvement.

Conclusion

AF is frequent in patients with HCM and develops in younger ages than in general population. NYHA III, risk score, LA diameter, LAvol, MWT, LGE &gt;5 segments and LGE in IBIVS and in IMIVS were predictors of AF, with LAvol being the independent predictor. The combination of LAvol with LGE &gt;5 segments and LAvol with LGE in IBIVS presented stronger predictor value comparing with these characteristics alone.

Funding Acknowledgement

Type of funding source: None

Insights from microRNAs into the pathophysiology of coronary and multiterritorial atherosclerosis

Introduction

The mechanisms underlying the different phenotypic presentations of atherosclerosis are still poorly understood. MicroRNAs regulate genetic expression at the post-transcriptional level and each has specific biological functions. MicroRNAs could therefore be useful for understanding the epigenetic drivers for development of isolated coronary atherosclerosis and more extensive disease (coronary and extra-coronary). We evaluated if the expression profile of circulating microRNAs was associated with coronary and multiterritorial atherosclerosis.

Methods

We prospectively recruited three groups of age- and sex-matched participants, with: 1) no coronary atherosclerosis (calcium score=0, no soft plaques in coronary angioCT scan), neither carotid or inferior limbs atherosclerosis (controls); 2) isolated obstructive coronary artery disease (CAD) (≥50% for the left main, ≥70% for other epicardial vessels) (isolated CAD group); 3) obstructive disease of the coronary, inferior limbs and carotid arterial beds (multi-territorial disease group). Obstructive atherosclerosis of carotid and inferior limbs arteries (≥50% stenosis by Doppler or angioCT imaging) was assessed in all participants. Acute atherosclerotic events or coronary revascularization within 12 months, heart failure, infections, malignancy and severe renal dysfunction were exclusion criteria. Six microRNAs with diverse mechanisms of action were selected (mir-21, miR-27b, miR-29a, miR-126, miR-146, miR-218) and measurements of their circulating levels were performed in a blinded fashion, using RT-PCR SYBR Green.

Results

Twenty four patients were included, including 8 patients in each group. Mean age was 61±9 years, and 83% were male. In patients with atherosclerosis, classical cardiovascular risk factors were globally more prevalent. The expression of miR-146 and miR-218, both of which regulate endothelial function, was significantly decreased in the isolated CAD group compared to controls (Figure; data are expressed as median [IQR]). There was a further decrease in the expression of both microRNAs in patients with multiterritorial atherosclerosis compared to patients with isolated CAD. The expression of other microRNAs did not differ. Smoking was associated with the presence of isolated CAD and multiterritorial atherosclerosis (14% vs 30% vs 56% of smokers across groups, p=0.002), and with a decreased expression of miR-218 (1.6 [0.02–83] fold vs 0.1 [0.001–0.7] fold, p=0.023).

Conclusions

The expression of the endothelial regulators miR-146 and miR-218 was decreased in patients with isolated CAD compared to controls, and even more hampered in patients with multiterritorial atherosclerosis. Higher degrees of endothelial dysfunction may therefore contribute to a more diffuse atherosclerotic presentation through miR-146 and miR-218. Atherogenesis related to smoking may be partially mediated by miR-218.

Funding Acknowledgement

Type of funding source: None

Innate immunity is linked to the severity of stable coronary artery disease through sCD40L pathway

Introduction

Soluble CD40 ligand (sCD40L) activates different cell types involved in innate immunity, including macrophages and platelets. The influence of innate immunity, particularly of sCD40L pathway, on stable coronary artery disease (SCAD) expression is not fully understood. We evaluated if sCD40L expression is related to the presence of SCAD and to its clinical and anatomical severity.

Methods

We prospectively recruited two groups of age- and sex-matched participants: 1) without coronary artery disease (CAD) (calcium score=0, no soft plaques on coronary angioCT scan) (controls); and 2) with stable obstructive CAD (≥50% for the left main, ≥70% for other epicardial vessels, on invasive coronary angiography). Acute atherosclerotic events or coronary artery bypass grafting (CABG) within 12 months, previous percutaneous coronary intervention, heart failure, infection, malignancy and severe renal dysfunction were exclusion criteria. Clinical, laboratorial and anatomical data were prospectively collected. Serum was stored at −80°C and measurements were performed in a blinded fashion, by ELISA (sCD40L Human Quantikine).

Results

Sixty-three participants were included: 14 controls and 49 patients with SCAD. In SCAD patients, classical cardiovascular risk factors were globally more prevalent and the serum levels of sCD40L (5553±3356 vs 3099±644 ng/mL, p&lt;0.001), leucocytes counts (7.6±1.8 vs 6.4±1.7x109/L, p=0.010), neutrophils counts (4.4±1.5 vs 3.5±1.5x109/L, p=0.010) and neutrophils/lymphocytes ratio (2.4±1.1 vs 1.9±0.7, p=0.019) were significantly higher, while c-reactive protein (CRP) levels did not differ, compared to controls. sCD40L levels were positively correlated with leucocytes (r=0.36) and neutrophils (r=0.28) counts (all p&lt;0.05), but not with CRP. Clinically, sCD40L levels were associated (ANOVA p&lt;0.001) and positively correlated (Pearson r=0.54, p&lt;0.001) with angina severity (Fig. 1A). Anatomically, patients with a higher number of significant coronary artery lesions presented higher sCD40L levels (Fig. 1B); sCD40L levels were positively correlated with the number of: diseased vessels (r=0.33), significant coronary artery lesions (r=0.31), and all coronary artery lesions (r=0.33) (all p&lt;0.05), without correlation with the Gensini score. Linear regression analysis considering clinical and laboratorial data revealed that sCD40L was an independent predictor of CAD severity, as assessed by the number of significant lesions (model: sCD40L β 0.28, 95% CI 0.03–0.34; hypertension β 1.1, 95% CI 0.97–3.64). Among SCAD patients, those with previous CABG (n=15) had lower sCD40L levels than patients waiting for revascularization (n=34) (3317±1680 vs 6793±3631 ng/mL, p&lt;0.001).

Conclusions

Increased expression of sCD40L was associated with the presence of SCAD, with angina severity and with CAD severity, while previous revascularization was associated with decreased sCD40L levels.

Funding Acknowledgement

Type of funding source: None

Prognostic value of the cardiorespiratory optimal point during submaximal exercise testing

Background

Peak oxygen consumption (pVO2) is a key parameter in assessing the prognosis of heart failure with reduced ejection fraction (HFrEF) patients (pts). However, it is a less reliable parameter when the cardiopulmonary exercise test (CPET) is not maximal. It is crucial to identify the submaximal exercise variables with the best prognostic power (PP), in order to improve the management of pts that cannot attain a maximal CPET.

Purpose

The aim of this study was to evaluate and compare the PP of several exercise parameters in submaximal CPET for risk stratification in pts with HFrEF.

Methods

Prospective evaluation of adult pts with HFrEF submitted to CPET in a tertiary center. A submaximal CPET was defined by a respiratory exchange ratio (RER) ≤1.10. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation. Several CPET parameters were analyzed as potential predictors of the combined endpoint and their PP (area under the curve - AUC) was compared to that of pVO2, using the Hanley and McNeil test.

Results

CPET was performed in 487 HF pts, of which 317 (66%) performed a submaximal CPET. Pts averaged 57±12 years of age, 77% were male, 45.7% had ischemic cardiomyopathy, with a mean LVEF of 30.4±7.6%, a mean heart failure survival score of 8.6±1.1. The mean pVO2 was 17.1±5.5 ml/kg/min and the mean RER 1.01±0.08. During a mean follow-up (FU) time of 11±1 months, 18 pts (6%) met the primary endpoint. Cardiorespiratory optimal point (OP - VE/VO2) had the highest AUC value (0.915, p=0.001), followed by the partial pressure of end-tidal CO2 at the anaerobic threshold - PETCO2L (0.814, p&lt;0.001). pVO2 presented an AUC of 0.730 (p=0.001). OP≥31 and PETCO2L ≤37mmHg had a sensitivity of 100 and 76.9% and a specificity of 71.1 and 67%, respectively, for the primary outcome. OP presented a significantly higher PP than pVO2 (p=0.048), whether PETCO2L didn't achieve any statistical significance (p=0.164). Pts with anOP≥31 presented a significantly lower survival free of HT during FU (log rank p=0.002).

Conclusion

OP had the highest PP for HF events of all parameters analyzed for a submaximal CPET. This parameter can help stratify the HF pts physiologically unable to reach a peak level of exercise.

Funding Acknowledgement

Type of funding source: None

Palliative care delivery according to age among metastatic breast cancer patients. ESME-MBC cohort

Background

Metastatic breast cancer (MBC) may require inpatient palliative care (IPC) but literature suggests age-related disparities in palliative care delivery. This study, based on real-world data, aimed to assess the cumulative incidence function (CIF) of IPC delivery and if age is an independent factor, taking into account the competing risk of death.

Methods

The national multicenter ESME (Epidemio-Strategy-Medical-Economical)-MBC cohort includes consecutive MBC patients treated in the 18 French Comprehensive Cancer Centers. IPC identification used ICD-10 palliative care coding. Main analysis first estimated pseudo values of 2-year and 8-year CIF of IPC. Linear regression models estimated the mean changes of pseudo-values (2 models: 2-year and 8-year CIF of IPC).

Results

Our analysis included 12375 patients, 5093 (41.2%) of whom were aged 65 or over. The median follow-up was 41.5 months (95% CI, 40.5-42.5). The CIF of IPC was 10.3% (95% CI, 10.2-10.4) and 24.8% (95% CI, 24.7-24.8) at two and eight years, respectively. At two years, among triple-negative patients, young patients (&lt;65 yo) had a higher CIF of IPC than older patients after adjusting for cancer characteristics, centre, and period (65+/&lt;65: β=-0.05; 95% CI, -0.08 to -0.01). Among other tumour subtypes, older patients received short-term IPC more frequently than young patients (65+/&lt;65: β = 0.02; 95% CI, 0.01 to 0.03). At eight years, outside large centres, IPC was delivered less frequently to older patients adjusted to cancer characteristics and period (65+/&lt;65: β=-0.03; 95% CI, -0.06 to -0.01).

Conclusions

We found a relatively low CIF of IPC and that age influenced IPC delivery. Young triple negative and older non-triple negative patients needed more short-term IPC. Older patients diagnosed outside large centres received less long-term IPC. These findings highlight the need for a wider implementation of IPC facilities and for more age-specific interventions.

Key messages

Our study highlighted particular challenge for older MBC patients diagnosed outside large French Comprehensive Cancer Centers. By identifying age at MBC diagnosis as a factor of IPC delivery, this report supports a wider implementation of IPC facilities and more age-specific interventions.

1185 Three-dimensional speckle tracking echocardiography for the global and regional assessment of myocardial deformation in breast cancer patients submitted to anthracyclines

Introduction

Serial echocardiographic assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for screening for cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle tracking echocardiography (STE) has several technical advantages, is more reproducible, and has a better correlation to magnetic resonance than 2D STE, it is still not currently used in this setting. We aimed to investigate the usefulness of 3D STE in evaluating left ventricle mechanics and its relation to CTRCD.

Methods

Prospective study of female breast cancer patients submitted to anthracycline chemotherapy who underwent one transthoracic echocardiography (ETT) before and at least one ETT during/after chemotherapy. Standard ETT parameters and 3D volumetric measurements were assessed. STE was used to estimate 2D GLS – average and 18 segments – and 3D GLS, global circumferential strain (GCS), global radial strain (GRS) and global area strain (GAS) – average and 17 segments. CTRCD was defined as an absolute decrease in 2D or 3D LVEF &gt;10% to a value &lt;54% or a relative decrease in 2D GLS &gt;15%.

Results

105 patients (mean age 53.8 ± 12.5 years, 52.4% immunotherapy, 77.2% radiotherapy, 2.8 echocardiograms/patient) were included. During a mean follow-up of 12.1 months, 24 patients (22.9%) developed CTRCD. During anthracycline therapy, there was a significant worsening of 2D LVEF (65.6 vs. 57.8), 3D LVEF (61.5 vs. 54.4), 2D GLS (-21.1 vs. -18.0), 3D GLS (-15.6 vs. -10.9), 3D GCS (-14.0 vs. -11.0), 3D GRS (42.0 vs. 28.5) and 3D GAS (-27.0 vs. -20.0) [all p &lt;0.001]. More than 73% of patients presented 3D global strain values below the limits of normal during chemotherapy. On 3D strain regional analysis, impaired contractility was observed in the anterior, inferior and septal walls. Logistic regression analysis showed that 3D GRS and 3D GCS were associated with a higher incidence of CTRCD. In the multivariate model, 3D GRS remained the only independent predictor of CTRCD. The receiver operating curve analysis showed a good calibration and discrimination of 3D GCS and 3D GRS in predicting CTRCD with areas under de curve of 0.748 and 0.719, with the optimal cut-off values being 0.342 for GCS and 0.344 for GRS. These variations were observed a median of 45 days and 22.5 days before the diagnosis of CTRCD, respectively.

Conclusion

3D strain parameters worsened during anthracycline therapy, with predominant involvement of septal, anterior and inferior walls. Variations of 3D GCS and GRS were predictive of subsequent CTRCD, and thus can be considered an earlier sign of CTRCD, with added value over the currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered in order to offer targeted monitoring and timely initiation of cardioprotective treatment.

P1527 Papillary fibroelastomas: diagnostic challenges and clinical and morphologic features

Introduction

Papillary fibroelastomas are rare benign primary cardiac tumors that more frequently involve cardiac valves. They are frequently incidentally discovered by echocardiography but may also cause symptoms.

Purpose

The aim of this study was to characterize several features of histologically confirmed fibroelastomas.

Methods

Retrospective analysis of patients with echocardiographic suspicion of fibroelastoma between 2009 and 2019 in a single tertiary center. Echocardiography was compared with histology, and echocardiographic, surgical and pathological information about confirmed fibroelastomas was collected.

Results

37 patients (P) (54.1% men) with an echocardiographic suspicion and/or histologically confirmed fibroelastoma were included, with a mean age of 58 +- 3 years (min 22, max 82). Echocardiographic report was analyzed in 34P (91.9%), with 32P (94.1%) reporting a likely fibroelastoma and 2P (5.9%) reporting a non-specified mass. 21P (56.8%) had surgery, with 12P (57.1%) having a surgical suspicion of a fibroelastoma, 2P (9.5%) of a mixoma, 1P (4.8%) of a non-specified mass and 6P (28.6%) with undefined suspicion. Of the 21P who had surgery, 66.7% (14P) had a histologically confirmed fibroelastoma, 1P (4.8%) had a mixoma, and 6P (28.6%) had other diagnoses. From the 14P with histologically confirmed fibroelastoma 64.3% had this suspicion by echocardiography and 35.7% had an echocardiogram reporting a non-specified. There was a global concordance between echocardiography and histology in 52.9%. The mean age of confirmed fibroelastoma P was 54 +-5years, and 50% were men. 7P (50%) were asymptomatic, 2 (14.3%) had a stroke, 2 (14.3%) had syncope, 1 (7.1%) had fatigue, 1 (7.1%) had palpitations and 1P had consciousness alteration. In echocardiography most P (71.4%) had only one mass but 1P had 4 different masses. The tumors had a longer axis between 6 and 25mm, with the majority (57.1%) measuring more than 10mm. 12P (85.7%) had valvular fibroelastomas, 50% of these in the aortic valve (3 in non-coronary cusp, 1 in right coronary cusp and 2 non-specified) and 50% in the mitral valve (all in sub-valvular apparatus, involving anterior leaflet, tendinous chord or papillary muscle). 1P had a left ventricular fibroelastoma (apical) and 1P had four masses in the left atrium. Macroscopically 4 lesions had a gelatinous consistency, 2 of them were membranous, 2 were elastic, 2 were friable, 1 was villainous and in 3 of them consistency was not described. The majority (57%) was white, 14% was translucent and in the rest the color was not specified. There was no described recurrence after surgery and there were no deaths registered.

Conclusion

In this population there was a reasonable concordance between echocardiography and histology, but in some cases the diagnosis was undefined or wrong. 50% of the patients were asymptomatic and the majority had valvular fibroelastomas, but a few had a different location.

P1349 POCUS by general and family physician - advancing physical examination

BACKGROUND

Alongside with the development of hand held equipment, echo is becoming more accessible to nontraditional settings. General and family medicine (GPs) are at the forefront of any health system, but the use of cardiac echo by GPs is still unexplored. PURPOSE: This study aims to evaluate the accuracy of echocardiography assessment performed as an extension of the physical exam by GPs. METHODS: Two GPs underwent standard echocardiography training for 6 months. Subsequently, patients with diabetes or arterial hypertension were submitted to an echocardiogram performed by their GPs using a pocket ultrasound. Views obtained (with and without color Doppler) were parasternal long and short axis, apical and subcostal, with measurements of the posterior wall (PW), interventricular septum (IVS), left ventricle (LV), left atrium (LA), aorta and inferior vena cava (IVC). Studies were reviewed at the workstation and measured by two experts who classified the exams according to the image quality. RESULTS: Sixty echocardiograms were analyzed (mean age of 61y, 42% females and 58% males). In 50% the image quality was considered sufficient, 42% considered good and 8% considered bad. There were statistically significant differences between the GPs and expert measurements on the sinus of Valsalva (30.3 ± 3 to 28.8 ± 3.1mm, p = 0.001), LV in systole (p &lt; 0.001, 28[24,31] for 31[29,34]mm), IVS (p = 0.001, 10.9 ± 1.7 for 10.1 ± 1.5mm), PW (p = 0.018, 8.7 ± 1.1 to 9.2 ± 1.6mm) and TAPSE (p = 0.021, 20.9 ± 2.3 to 20.1 ± 2.7mm). There were no significate differences in the measurements of the ascending aorta, LA, LV in diastole and IVC. Agreement between the GPs and the experts was moderate for the evaluation of LVH (k = 0.48). The concordance was substantial for evaluation of LV function (k = 0.66) and excellent for evaluation of pericardial effusion (k = 1) and right ventricular function (k = 1). Concordance was excellent for mitral insufficiency (k = 0.83) and substantial for aortic insufficiency (k = 0.68) and tricuspid insufficiency (k = 0.61). A case of mitral stenosis was identified by both. GPs signalized a case of mild aortic stenosis that the expert did not consider. CONCLUSION: GPs trained in echocardiography, using pocket ultrasound, can obtain cardiac images with sufficient quality for interpretation by experts in the majority of cases. In this study, differences in dimensions might be explained by interobserver variability and/or by the performance of measurements in different environments, mobile vs workstation. Overall the differences were minor and clinically meaningless.

100 Association of age-related left atrial remodeling with ischemic stroke in patients with normal sinus rhythm

OnBehalf

The ARIC Study

Background

Age-related left atrial (LA) structural/functional abnormalities in elderly patients with normal sinus rhythm and preserved ejection fraction may precede the development of overt atrial fibrillation, and also may be related to stroke.

Purpose

To evaluate the association of 3-dimensional echocardiographic (3DE) atrial contractility parameters with subclinical cerebral infarcts (SCIs), as assessed by brain MRI, and clinically diagnosed stroke

Methods

We studied 407 participants (mean age 76 ± 5 years, 40.5% male) from the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS) without AF and who underwent a brain MRI and a 3DE examination in 2011-13. We defined 3 groups: those with no cerebral infarcts on brain MRI (NCIs, N = 315); those with MRI-diagnosed SCIs (N = 58); and those with clinically diagnosed stroke (N = 34).

Results

While still within the normal range, LA indexed volume significantly increased across the 3 groups (P-trend = 0.01).This was accompanied by an increase in the LA global longitudinal strain (GLS), an echocardiographic index of LA reservoir function (P-trend = 0.004). E/e’ divided by LA GLS—index of atrial stiffness—worsened across groups (P-trend = 0.005) and was independently associated with SCIs and Stroke, pooled together, [OR per 1 %-1, 1.97; 95% CI (1.24, 3.11), P = 0.004], and Stroke [OR per 1 %-1, 2.30; 95% CI (1.23, 4.30), P = 0.009]. LA GLS was marginally associated with an increased odd of SCIs [OR per 1 %, 1.07; 95% CI (1.01, 1.13), P = 0.014].

Conclusions

Among elderly participants with normal sinus rhythm and preserved ejection fraction in a large cohort study, markers of LA function and stiffness are associated with increased odds of subclinical infarcts and stroke. These data suggest that even subtle LA dysfunction, which may contribute to LA stasis, may predispose to subclinical cerebral infarcts and stroke.

First Measurement of Near-Threshold J/ψ Exclusive Photoproduction off the Proton

We report on the measurement of the γp→J/ψp cross section from E_{γ}=11.8  GeV down to the threshold at 8.2 GeV using a tagged photon beam with the GlueX experiment. We find that the total cross section falls toward the threshold less steeply than expected from two-gluon exchange models. The differential cross section dσ/dt has an exponential slope of 1.67±0.39  GeV^{-2} at 10.7 GeV average energy. The LHCb pentaquark candidates P_{c}^{+} can be produced in the s channel of this reaction. We see no evidence for them and set model-dependent upper limits on their branching fractions B(P_{c}^{+}→J/ψp) and cross sections σ(γp→P_{c}^{+})×B(P_{c}^{+}→J/ψp).

Abstract P2-06-04: Enhancing abiraterone acetate efficacy in androgen receptor-positive triple negative breast cancer: Chk1 as a potential target

Purpose: Our aim was to identify predictive factors of abiraterone acetate (AA) efficacy and putative new druggable targets in androgen receptor (AR)-positive triple-negative breast cancer (TNBC) treated in the UCBG 2012-1 trial.

Material and methods: We defined AA response as either complete or partial response, or stable disease at 6 months. Using Ampliseq, we sequenced 91 general and breast cancerassociated genes from the tumor DNA samples. We analyzed transcriptomes from the extracted RNA samples on a Nanostring platform and performed immunohistochemistry (IHC) on tumor samples using tissue microarrays. We assessed AA and CHK1 inhibitors (GDC-0575 and AZD7762) efficacies, either alone or in combination, on cell lines grown in vitro and in vivo.

Results: Classical IHC apocrine markers, including AR, FOXA1, GGT1 and GCDFP15, allowed identifying AA responders and non-responders. All responders have clear apocrine features. Transcriptome analysis revealed that 31 genes were differentially expressed in the two subgroups, 9 of them being linked to proliferation and DNA damage repair. One of the most significant differences was the overexpression in non-responders of CHEK1, a gene encoding Chk1, a protein kinase that can be blocked by specific inhibitors. In vitro, AA and Chk1 inhibitor combination showed additive or slightly synergistic effect on cell viability, cell cycle, apoptosis and accumulation of DNA damages. In vivo, orthotopic xenograft experiments confirmed the efficacy of this combination therapy.

Conclusions: This study suggests that apocrine features can be helpful in the identification of AA-responders. We identified Chk1 as a putative drug target in AR-positive TNBCs.

Citation Format: Grellety T, Callens C, Richard E, Pulido M, Goncalves A, Gestraud P, MacGrogan G, Bonnefoi H, Cardinaud B. Enhancing abiraterone acetate efficacy in androgen receptor-positive triple negative breast cancer: Chk1 as a potential target [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 P2-06-04.

Abstract GS3-07: Clinical utility of circulating tumor cell count as a tool to chose between first line hormone therapy and chemotherapy for ER+ HER2- metastatic breast cancer: Results of the phase III STIC CTC trial

Background: In ER+ HER2- metastatic breast cancer (MBC) patients, the clinical choice between 1st line hormone therapy (HT, the recommended option) or chemotherapy (CT) is based on the absence of “visceral crisis” or adverse prognostic factors, with no proven/objective criteria. In that context, STIC CTC (NCT01710605) was set up as a strategy trial to test whether circulating tumor cells (CTC) count could help customize the choice between 1st line HT or CT.

Methods: For this multicenter phase 3 non-inferiority trial, the main inclusion criteria were: ER+ HER2- MBC with no prior therapy, PS≤2, no contra-indication to HT or CT and informed consent. The a priori treatment choice (HT or CT) and CTC count (CellSearch®) were obtained in all patients prior to randomization. Patients were randomized 1:1 between clinically-driven choice (CTC count not disclosed, HT or CT administered as decided a priori), or a CTC-driven choice (HT if &lt;5 CTC/7.5ml, CT if ≥5 CTC/7.5ml). The primary objective was treatment efficacy (PFS hazard ratio), non-inferiority being established if the upper bound of the PFS HR 2-sided 90%CI is ≤1.25; secondary objectives included subgroup analyses (CTC status, patient characteristics) and OS.

Results: 761 MBC patients were randomized between 02/2012 and 08/2016. Baseline characteristics: 7.8% of patients had a PS=2, 24.1% had a de novo metastatic disease; 63.3% received prior adjuvant HT and 49.9% prior adjuvant CT; 31.3% had ≥3 metastatic sites. A priori treatments (HT or CT) and CTC count (&lt; or ≥5 CTC/7.5ml) were well balanced between the two arms. After randomization, in the clinically-driven arm, N=267 (72.4%) patients received HT and N=102 (27.6%) CT (as decided a priori). In the CTC-driven arm: (1) the a priori choice of HT was confirmed by a low CTC count in N=181 (67.5%) of patients, while N=87 (32.5%) were switched to CT due to a high CTC count; (2) the a priori choice of CT was confirmed by high CTC count in only N=48 (48%) patients, while N=52 (52%) were switched to HT. The primary endpoint was met, PFS being not inferior in the CTC-driven arm (HR=0.98, 90%CI=[0.84–1.13]). Analyses focusing on discordant subgroups showed that for patients with a priori choice of HT but with high CTC count (leading to a switch to CT in the CTC-arm), PFS was significantly longer in the CTC-driven arm than in the standard arm (HR=0.67, 95%CI=[0.49–0.92]; p=0.01), with a non-significant trend toward longer OS (HR=0.68, 95%CI=[0.44–1.07]; p=0.09). Inversely, for patients with a priori choice of CT but with low CTC count (i.e. de-escalation to HT in the CTC arm), PFS was not statistically different between the two arms.

Conclusion: This trial demonstrates the clinical utility of CTC count as an objective decision tool when considering 1st line therapy in ER+ HER2- MBC. In most patients, CTC count did confirm the a priori clinical choice; however, trial results show that in discrepant cases, CTC count may be trusted for either escalating (i.e. considering CT in patients if high CTC count) or de-escalating (i.e. considering HT in patients if low CTC count) 1st line therapy.

Funding: French National Cancer Institute; Menarini Silicon Biosystems.

Citation Format: Bidard F-C, Jacot W, Dureau S, Brain E, Bachelot T, Bourgeois H, Goncalves A, Ladoire S, Naman H, Dalenc F, Gligorov J, Espie M, Levy C, Ferrero J-M, Loirat D, Cottu P, Dieras V, Simondi C, Berger F, Alix-Panabieres C, Pierga J-Y. Clinical utility of circulating tumor cell count as a tool to chose between first line hormone therapy and chemotherapy for ER+ HER2- metastatic breast cancer: Results of the phase III STIC CTC trial [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 GS3-07.

Abstract PD2-03: Circulating tumor DNA (ctDNA) and circulating tumor cells (CTC) predictive value in HER2 negative metastatic breast cancer patients treated with first line weekly paclitaxel and bevacizumab: Results of a prospective cohort from the French Breast Cancer InterGroup Unicancer (UCBG): COMET study

Background: Increased levels of CTC and a persistent elevated level after just one cycle of chemotherapy are very strong and independent markers of worse progression-free survival (PFS) and overall survival (OS) in patients (pts) with metastatic breast cancer (MBC) (Bidard et al, Lancet Oncol 2014). ctDNA can be used to detect mutation associated with resistance to treatment. It has also been shown that dynamic changes in ctDNA levels closely reflect changes in tumor burden. We prospectively monitored CTC and ctDNA early variations during first line chemotherapy for MBC.

Patients & methods: The French cohort COMET is a prospective study including first line HER2 negative patients (pts) receiving weekly paclitaxel and bevacizumab according to EMA approved combination. The aim of this cohort is to evaluate clinical, biological and radiological parameters associated with pts outcome (CTC, serum markers, ctDNA, pharmacogenomic polymorphisms, metabolomic parameters, visceral fat, serum estradiol level and quality of life). We present here the first planned analysis on pts evaluated for CTC (CellSearch) and ctDNA using targeted sequencing (Roche SeqCap technology) of a panel of 46 genes and 8 promoters, using unique molecular identifiers to increase ctDNA detection sensitivity. Blood samples were obtained at baseline (BL) and before the second cycle of chemotherapy (C2).

Results: From 09/2012 to 5/2014, 218 pts were included in this substudy. Median age was 55 years and 22% of pts had triple negative BC. At BL, 70% of pts had ≥1 detectable CTC per 7.5 ml of blood (median 4 CTC, range 1- 30,000) and 37% at C2. With a threshold of ≥5 CTC, 47% of pts were positive at BL and 22% at C2. For ctDNA, out of the first 141 pts analyzed, 105 had at least one somatic mutation detected in plasma (74%). The average number of mutations per pt was 2.7 and most commonly mutated genes were TP53 and PIK3CA. ESR1 was found mutated in 9% of all cases and restricted to the ER+ subgroup. Median Allelic Frequency was 10% (range 0.6-83%). Only 33% of pts had detectable ctDNA at C2. At BL, CTC and ctDNA levels were correlated (r=0.46, p&lt;0.0001). Despite no complete overlap, 11% of pts had no CTC nor ctDNA detected. Median follow-up was 53 months and median OS was 32 months. Increased level of CTC and ctDNA were significantly associated with decreased PFS and OS. At C2, ≥5 CTC or still detectable ctDNA were strong markers of reduced OS: HR 4.6 (CI95 3.1-7) and HR 3.2 (CI95 1.8 – 5.5), respectively (both p&lt; 0.0001). At multivariate analysis for PFS, detectable ctDNA at C2 and triple negative status were the only significant prognostic factors. None of serum marker level at BL or their early variations had prognostic value.

Conclusion: This is the largest prospective cohort assessing the respective prognostic values of early CTC and ctDNA changes in homogenously treated first line MBC patients. Analysis of mutations profile variations and comparison with primary tumor and metastasis biopsies are ongoing and may reveal early mechanisms of resistance.

Citation Format: Pierga J-Y, Silveira A, Lorgis V, Tanguy M-L, Tredan O, Dubot C, Jacot W, Goncalves A, Debled M, Levy C, Ferrero J-M, Jouannaud C, Luporsi E, Mouret-Reynier M-A, Dalenc F, Lemonnier J, Berger F, Proudon C, Bidard F-C. Circulating tumor DNA (ctDNA) and circulating tumor cells (CTC) predictive value in HER2 negative metastatic breast cancer patients treated with first line weekly paclitaxel and bevacizumab: Results of a prospective cohort from the French Breast Cancer InterGroup Unicancer (UCBG): COMET 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 PD2-03.

Abstract P6-21-01: Xentuzumab (BI 836845), an insulin-like growth factor (IGF)-neutralizing antibody (Ab), combined with exemestane and everolimus in hormone receptor-positive (HR+) locally advanced/metastatic breast cancer (LA/mBC): Randomized phase 2 results

Background:

Xentuzumab (Xen), an IGF-1/-2-neutralizing Ab, binds IGF-1 and IGF-2, inhibits their growth-promoting signaling, and suppresses AKT activation by everolimus (Ev). This Phase 1b/2 trial evaluates Xen in combination with Ev and exemestane (Ex) in HR+/HER2− LA/mBC.

Methods:

The two-arm, open-label, randomized Phase 2 part enrolled female patients (pts) with HR+/HER2− LA/mBC not amenable to curative therapy and refractory to nonsteroidal aromatase inhibitors. Pts were randomized (1:1) to: oral Ev (10 mg/d) + Ex (25 mg/d); or Xen (1000 mg/wk iv) + Ev (10 mg/d) + Ex (25 mg/d). Randomization was stratified by visceral metastases (VM; Y vs N). Treatment continued in 28-day cycles until progression, intolerable adverse events (AEs) or other reasons for discontinuation. Primary endpoint was progression-free survival (PFS), with an interim futility analysis incorporated in the study design.

Results:

Following the results of the interim analysis, the Data Monitoring Committee (DMC) advised early termination of the trial and discontinuation of Xen treatment. Thus, Xen treatment exposure time and time-to-event data for the Xen+Ev+Ex arm are limited. Of the 139 women treated (Xen+Ev+Ex 70; Ev+Ex 69), 77% had VM. Median PFS was not significantly different between arms (Xen+Ev+Ex vs Ev+Ex, 7.3 vs 5.6 months; HR [95% CI] 0.97 [0.57–1.65]; p=0.91). In a pre-specified subgroup of pts without VM, Xen+Ev+Ex showed favorable PFS vs Ev+Ex (HR 0.21 [0.05–0.98]; Pint=0.0141). Pint values &lt;0.05 were also observed for ad hoc subgroups: measurable disease at baseline; bone-only metastases. Rates of total AEs/grade ≥3 AEs/drug-related AEs were similar between arms (Xen+Ev+Ex, 100/60/96%; Ev+Ex, 99/58/96%). The most common AEs overall were diarrhea (44 vs 33%), mucosal inflammation (39 vs 32%), rash (34 vs 33%) and stomatitis (34 vs 38%); most were grade 1/2. 6% of pts in the Xen+Ev+Ex arm discontinued Xen due to AEs. Ev/Ex discontinuations (Xen+Ev+Ex vs Ev+Ex) occurred in 13/6% vs 23/6%; 1 pt each in the Xen+Ev+Ex arm died from pneumonitis and liver injury and 1 pt each in the Ev+Ex arm died from Burkitt's lymphoma, acute kidney injury and metastases to the peritoneum.

Conclusion:

In the overall population, PFS did not improve with the addition of Xen to Ev+Ex and the trial was therefore discontinued early. Nevertheless, a favorable signal was observed in the pre-specified subgroup of pts without VM when treated with Xen+Ev+Ex, which warrants additional investigation. The safety profile was comparable between arms.

Citation Format: Crown J, Sablin M-P, Cortés J, Bergh J, Im S-A, Lu Y-S, Martínez N, Neven P, Lee KS, Morales S, Pérez-Fidalgo JA, Adamson D, Goncalves A, Prat A, Jerusalem G, Schlieker L, Espadero R-M, Bogenrieder T, Chin-Lun Huang D, Schmid P. Xentuzumab (BI 836845), an insulin-like growth factor (IGF)-neutralizing antibody (Ab), combined with exemestane and everolimus in hormone receptor-positive (HR+) locally advanced/metastatic breast cancer (LA/mBC): Randomized phase 2 results [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 P6-21-01.