P247 Added value of 3D echo in diagnosing and monitoring transcatheter valve in mac procedure in a patient with severe mitral stenosis

INTRODUCTION

Mitral annular calcification (MAC) is a chronic degenerative process involving calcification of the fibrous base of the mitral valve accounting for 12% to 26% of all mitral stenosis (MS) and eventually for significant mitral regurgitation. Calcification often extends to other parts of the mitral valve apparatus but, unlike rheumatic stenosis, does not produce commissural fusion. Surgical treatment carries a high mortality rate due to technical difficulties involving the heavily calcified annulus, advanced age and comorbidities of affected patients. In recent years, transcatheter mitral valve replacement using ballon expandable transcatheter aortic valves in severe MAC (valve-in-MAC) has been used with acceptable success rates.

PURPOSE

To describe the added value of 3D echo in the diagnostic work-up, decision making and monitoring during the interventional procedure of valve-in-MAC.

CASE PRESENTATION

Two years ago a 90-year-old female in sinus rhythm with hypertension and known coronary artery disease (CAD) was admitted with symptoms of pulmonary congestion (PC). At that time, a transthoracic 3D echocardiogram showed important MAC with a mitral valve area (MVA) estimated through 3D planimetry of 1.1 cm2, pulmonary artery pressure (PAP) of 53 mmHg, preserved biventricular function and left atrial enlargement. One year later, she was readmitted with unstable CAD and treated with percutaneous transluminal angioplasty. At that time a 3D transesophageal echocardiogram (3DTOE) showed worsening of the MVA now estimated in 0.6 cm2, a mean gradient of 19 mmHg and PAP of 88 mmHg. Albeit optimized medical therapy, her functional status worsened and less than a month later she was again readmitted in NYHA functional class III. Therefore decision making for valve-in-MAC was undertaken. Valve sizing was performed with computed tomography (CT) using the D-shape method with similar findings when compared with 3D TOE measurements. Both methods showed a favourable anatomy of the left ventricular outflow tract. Valve-in-MAC procedure was performed through transvenous transseptal access and an Edwards Sapien3-nr 29 balloon-expandable valve was deployed uneventfully, except for a residual interatrial septal defect measuring 2.2x0.8cm closed two weeks after, as she persisted with PC and pulmonary hypertension. During the procedure, 3DTOE showed a partial thrombosis involving one of the prosthesis leaflets with preserved transvalvular gradients despite anticoagulation. After that, PC resolved and PAP dropped dramatically. The patient was discharged under lifelong anticoagulation and remains asymptomatic until now.

CONCLUSION

Diagnosing and treating patients with severe MS due to MAC remains a challenge as traditional parameters and interventional procedures don’t apply for this population. Valve-in-MAC is a feasible alternative and 3DTOE may have a pivotal role in the diagnostic work-up and interventional monitoring of these cases.

Abstract P247 Figure. 3D echo timeline valve in MAC

P1467 Natural history and outcome of a patient with untreated congenital pulmonary stenosis added value of 3d echo in decision making

INTRODUCTION

congenital pulmonary valve stenosis (PVS) accounts for approximately 7% of all congenital heart defects. In less severe and untreated asymptomatic forms, it might have variable outcomes with progressive stenosis or development and worsening of pulmonary regurgitation . Atrial septal defect (ASD) might be associated in up to 20% of the cases rendering an even more unpredictable outcome and efect on right ventricular (RV) volumes and function. Cardiac magnetic ressonance is considered the gold standard method to measure RV function and volumes. Three dimensional echocardiography (3D echo) emerges as a valuable, redproducible and portable alternative not only for RV volume and function analysis but also for structural evaluation.

PURPOSE

To describe the added value of 3D echo for the diagnostic work-up, decision making and post surgical outcome in a patient with longstanding untreated PVS associated with ASD.

CASE PRESENTATION

a 56 year old asymptomatic , non syndromic man , was referred by the cardiac surgeon for a comprehensive echocardiographic evaluation (CEE) due to a previous diagnosis of PVS .The patient was aware of this diagnosis since the age of 17 and no intervention was undertaken at that time. More recently a conventional echocardiogram described a moderate PVS with RV enlargement (RVE) and no futher details regarding RV function or surgical feasibility. CEE showed RVE due to volume overload (VO) with indexed end diastolic volume (EDV) of 144ml/m2 (upper limit 76ml/m2), end sistolic volume (ESV) of 57ml/m2 (upper limit 37ml/m2) and an RV ejection fraction (RVEF) of 60% (lower limit 45%) on 3D echo. RV free wall strain (RVFWS) was -25,3% , TAPSE 32mm and fractional area change 46%, all paramenters within the normal range except for RV volumes. Anatomical analysis showed PVS with three leaflets, partial comissural fusion and retraction of the edges yelding a closure gap of at least 8mm and consequent severe regurgitation. Peak transvalvular gradient was 38mmHg and pulmonary artery was dilated measuring 6.4cm. An ostium secundum atrial septal defect (ASD) with left to right shunt measuring 15x9mm by 3D echo contributed for futher RVVO. With these information , surgical intervention was undertaken and consisted of PV replacement, excision and reconstruction of the pulmonary trunk dilation and correction of the ASD. The patient recovered well and returned three months after, for a new evaluation. At that time RV volumes reduced dramatically with EDV and ESV respectively of 44ml/m2 and 19ml/m2 RVEF of 55,7% and RWFWS of -25,6%.

CONCLUSION

untreated congenital PVS associated with ASD may have a variable outcome . Follow-up is mandatory. In the present case a CEE including more recent technologies like 3D echo and strain imaging helped in defining anatomical findings and RV function analysis thus stating the appropriatness for surgical intervention.

Abstract P1467 Figure. 3Decho pre and post surgical analysis

Endometrial carcinoma recurrence according to race and ethnicity: An NRG Oncology/Gynecologic Oncology Group 210 Study

Non-Hispanic black (NHB) women are more likely to experience an endometrial carcinoma (EC) recurrence compared to non-Hispanic white (NHW) women. The extent to which tumor characteristics, socioeconomic status (SES) and treatment contribute to this observation is not well defined. In the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study we evaluated associations between race/ethnicity and EC recurrence according to tumor characteristics with adjustment for potential confounders. Our analysis included 3,199 NHW, 532 NHB and 232 Hispanic women with EC. Recurrence was documented during follow-up. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between race/ethnicity and EC recurrence in models stratified by histologic subtype (low-grade endometrioid, high-grade endometrioid, serous, mixed cell, carcinosarcoma, clear cell) or stage (I, II, III) and adjusted for age, SES, body mass index, smoking status and treatment. In histologic subtype-stratified models, higher EC recurrence was noted in NHB women with low-grade endometrioid (HR = 1.94, 95% CI = 1.21-3.10) or carcinosarcomas (HR = 1.66, 95% CI = 0.99-2.79) compared to NHWs. In stage-stratified models, higher EC recurrence was noted among NHB women with stage I (HR = 1.48, 95% CI = 1.06-2.05) and Hispanic women with stage III disease (HR = 1.81, 95% CI = 1.11-2.95). Our observations of higher EC recurrence risk among NHB and Hispanic women, as compared to NHW women, were not explained by tumor characteristics, SES, treatment or other confounders. Other factors, such as racial differences in tumor biology or other patient factors, should be explored as contributors to racial disparities in EC recurrence.

Infertility and incident endometrial cancer risk: a pooled analysis from the epidemiology of endometrial cancer consortium (E2C2)

BACKGROUND

Nulliparity is an endometrial cancer risk factor, but whether or not this association is due to infertility is unclear. Although there are many underlying infertility causes, few studies have assessed risk relations by specific causes.

METHODS

We conducted a pooled analysis of 8153 cases and 11 713 controls from 2 cohort and 12 case-control studies. All studies provided self-reported infertility and its causes, except for one study that relied on data from national registries. Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Nulliparous women had an elevated endometrial cancer risk compared with parous women, even after adjusting for infertility (OR=1.76; 95% CI: 1.59-1.94). Women who reported infertility had an increased risk compared with those without infertility concerns, even after adjusting for nulliparity (OR=1.22; 95% CI: 1.13-1.33). Among women who reported infertility, none of the individual infertility causes were substantially related to endometrial cancer.

CONCLUSIONS

Based on mainly self-reported infertility data that used study-specific definitions of infertility, nulliparity and infertility appeared to independently contribute to endometrial cancer risk. Understanding residual endometrial cancer risk related to infertility, its causes and its treatments may benefit from large studies involving detailed data on various infertility parameters.

The etiology of uterine sarcomas: a pooled analysis of the epidemiology of endometrial cancer consortium

BACKGROUND

Uterine sarcomas are characterised by early age at diagnosis, poor prognosis, and higher incidence among Black compared with White women, but their aetiology is poorly understood. Therefore, we performed a pooled analysis of data collected in the Epidemiology of Endometrial Cancer Consortium. We also examined risk factor associations for malignant mixed mullerian tumours (MMMTs) and endometrioid endometrial carcinomas (EECs) for comparison purposes.

METHODS

We pooled data on 229 uterine sarcomas, 244 MMMTs, 7623 EEC cases, and 28,829 controls. Odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors associated with uterine sarcoma, MMMT, and EEC were estimated with polytomous logistic regression. We also examined associations between epidemiological factors and histological subtypes of uterine sarcoma.

RESULTS

Significant risk factors for uterine sarcoma included obesity (body mass index (BMI)≥30 vs BMI<25 kg m(-2) (OR: 1.73, 95% CI: 1.22-2.46), P-trend=0.008) and history of diabetes (OR: 2.33, 95% CI: 1.41-3.83). Older age at menarche was inversely associated with uterine sarcoma risk (≥15 years vs <11 years (OR: 0.70, 95% CI: 0.34-1.44), P-trend: 0.04). BMI was significantly, but less strongly related to uterine sarcomas compared with EECs (OR: 3.03, 95% CI: 2.82-3.26) or MMMTs (OR: 2.25, 95% CI: 1.60-3.15, P-heterogeneity=0.01).

CONCLUSION

In the largest aetiological study of uterine sarcomas, associations between menstrual, hormonal, and anthropometric risk factors and uterine sarcoma were similar to those identified for EEC. Further exploration of factors that might explain patterns of age- and race-specific incidence rates for uterine sarcoma are needed.

Future directions in the field of endometrial cancer research: the need to investigate the tumor microenvironment

Endometrial cancer is the most commonly diagnosed gynecologic malignancy in the United States. In 2008, approximately 40,000 cases were newly diagnosed. Although the majority of these cancers are curable by means of hysterectomy and radiotherapy, a subset of endometrial tumors exhibits an aggressive phenotype characterized by lymphovascular invasion, high histological grade, and myometrial invasion, leading to poor prognosis. The mechanisms involved in this aggressive transformation are largely unknown, however, interactions between the primary tumor mass and the surrounding stroma likely play a role in this transformation. Despite the fact that research in other common malignancies has elucidated important associations between stromal protein expression and invasion, these mechanisms have been poorly explored in the area of endometrial cancer. In fact, few investigations have been conducted in the area of tumor microenvironment for endometrial tumors. Invasion and metastasis are two primary reasons for treatment failure related to endometrial cancer. Expression of stromal-derived proteins can potentially serve as biomarkers of aggressive disease as well as biomarkers for remission monitoring. In order to study how expression of these proteins relates to the prognosis of endometrial cancer, these proteins need to be explored in large sets of existing data and/or tissue banks. In this paper, we briefly review the role of three stromal related pathways, SDF-1alpha/CXCR4, HGF/c-Met, and VEGF-A in endometrial cancer prognosis as an overview of the literature. We report that the role of SDF-1alpha/CXCR4 and HGF/c-Met in endometrial cancer prognosis remains unclear, whereas the evidence pertaining to VEGF indicates that overexpression is involved in tumor growth and metastasis. Finally, we would like to highlight the need to explore stromal proteins as a potential tool for the detection of aggressive endometrial tumors and explore some of the molecular approaches that can be utilized in the exploration of the tumor environment.

Cancer screening and cancer mortality in Nevis, West Indies

OBJECTIVE

Cancer screening is one approach that can reduce morbidity and mortality through early detection of pre-cancers; however anxiety, fear, and lack of information are important barriers to universal cancer screening in the Caribbean. Nevis is a small island located in the Eastern Caribbean. We report available data on screening prevalence and cancer mortality for four common cancers: cervical, breast, colon and prostate.

METHODS

Demographic information, screening utilization (when available) and cancer mortality statistics were obtained from the Charlestown Health Clinic and the annual reports from the Ministry of Health. Moreover physicians and key stakeholders were interviewed to assess current guidelines for cancer screening as well as to indicate areas of need.

RESULTS

Cervical cancer screening is under-utilized in Nevis. Between 2001 and 2007, the overall prevalence of Pap testing fluctuated minutely (mean: 6.87%, range: 6.06-7.41%). Systematic screening for breast, colon, and prostate cancer is not routinely performed, thus utilization rates are not available. Cancer mortality varied slightly between 2002 and 2006; prostate cancer had the highest overall crude mortality rate (30.6 deaths/100,000 persons). Physician interviews revealed that adherence to US and European cancer screening guidelines are inappropriate for their population of patients. Breast and prostate cancers are frequently diagnosed in these geographic areas before the age when cancer screening is currently recommended.

CONCLUSION

Cancer is perceived as an important health problem by physicians, key stakeholders and citizens, however cancer screening is under-utilized in Nevis. Future research should focus on generating screening guidelines that are relevant for this population, as well as methods to promote screening.