Screening for atrial fibrillation to prevent stroke in elderly individuals with or without preexisting cardiovascular disease

Background

Previous research has showed that various cardiovascular diseases (CVD) are associated with increased risks of atrial fibrillation (AF) and stroke. However, data on the interaction between CVD and AF screening efficacy are lacking.

Purpose

To evaluate the influence of preexisting CVD on the effects of AF screening with long-term continuous monitoring.

Methods

The LOOP Study (Atrial Fibrillation detected by Continuous ECG Monitoring using Implantable Loop Recorder to prevent Stroke in High-risk Individuals) randomized AF-naïve individuals aged ≥70 years and with additional stroke risk factors to either long-term screening with implantable loop recorder (ILR) and subsequent anticoagulation initiation upon detection of AF episodes ≥6 minutes, or usual care (the control group). In the current study, all participants from the LOOP Study were divided into two risk groups according to the presence of CVD (defined as ischemic heart disease, heart failure, previous stroke, valvular heart disease, or peripheral artery disease). The relative risks of outcomes in groupwise comparisons, as indicated by hazard ratio (HR), were assessed in the cause-specific Cox proportional-hazards model with death as competing risk.

Results

Of 6004 participants included, 1997 (33.3%) had ≥1 CVD at baseline. Compared with no CVD, the presence of CVD was associated with increased risks of AF diagnosis in the ILR group (adjusted HR 1.32 [1.09–1.59]) and of stroke or systemic arterial embolism in the entire study cohort (adjusted HR 1.34 [1.06–1.69]). For ILR screening versus usual care, there was no decrease in stroke or systemic arterial embolism among participants with preexisting CVD (adjusted HR 1.13 [0.76–1.68]), whereas a significant risk reduction was obtained by screening among those without CVD (adjusted HR 0.64 [0.44–0.93]). The interaction was significant (adjusted p-value for interaction 0.041).

Conclusions

In an elderly, high-risk population, ILR screening did not prevent stroke significantly in individuals with preexisting CVD, but it was associated with an approximately 40% risk reduction among those without CVD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The LOOP Study was funded by Innovation Fund Denmark [grant number 12-1352259], The Research Foundation for the Capital Region of Denmark, The Danish Heart Foundation [grant number 11-04-R83-A3363-22625], Aalborg University Talent Management Program, Arvid Nilssons Fond, Skibsreder Per Henriksen, R og Hustrus Fond, the European Union's Horizon 2020 program [grant number 847770], Læge Sophus Carl Emil Friis og hustru Olga Doris Friis' Legat, and an unrestricted grant from Medtronic.

Cardiac resynchronisation therapy and implantable cardioverter-defibrillator in non-ischaemic systolic heart failure: extended follow-up of the DANISH trial

Background

In the Danish Study to Assess the Efficacy of Implantable Cardioverter-Defibrillators [ICDs] in Patients with Non-ischaemic Systolic Heart Failure on Mortality (DANISH) trial, ICD implantation did not provide an overall survival benefit in patients with non-ischaemic systolic heart failure. A high proportion of patients in the DANISH trial received a cardiac resynchronisation therapy (CRT) device, which improves the prognosis in patients with heart failure. Therefore, it is of interest to examine whether the effect of ICD implantation in patients with non-ischaemic systolic heart failure is modified by CRT.

Purpose

Adding 4 years of additional follow-up to the DANISH trial, we examined the effect of ICD implantation according to status with respect to CRT implantation at baseline.

Methods

In the DANISH trial, 556 patients with non-ischaemic systolic heart failure were randomised to receive an ICD and 560 to receive usual clinical care (control). Patients fulfilling indications for a CRT device received a CRT-defibrillator (if randomised to ICD arm) or CRT-pacemaker (if randomised to control arm). In the ICD group, 322 patients (57.9%) received a CRT device; in the control group, 323 patients (57.7%) received a CRT device. In this extended follow-up study, patients were followed until May 18, 2020. The primary outcome was death from any cause; secondary outcomes were cardiovascular death and sudden cardiovascular death.

Results

During a median follow-up of 9.5 years, the ICD group did not have significantly lower all-cause mortality compared with the control group (hazard ratio [HR] 0.89 [95% CI, 0.74–1.08]). The results were independent of whether the patient received a CRT device at randomisation (patients with a CRT device: HR 0.92 [95% CI, 0.72–1.18]; patients without a CRT device: HR 0.86 [95% CI, 0.64–1.14]; P for interaction, 0.72). Similarly, ICD implantation did not reduce rates of cardiovascular death overall (HR 0.87 [95% CI, 0.70–1.09]), and this association was not modified by CRT (patients with a CRT device: HR 0.89 [95% CI, 0.66–1.19]; patients without a CRT device: HR 0.85 [95% CI, 0.60–1.20]; P for interaction, 0.86). The ICD group had significantly lower rates of sudden cardiovascular death in the overall population (HR, 0.60 [95% CI, 0.40–0.92]), and this association was not modified by CRT (patients with a CRT device: HR 0.69 [95% CI, 0.40–1.21]; patients without a CRT device: HR 0.51 [95% CI, 0.26–0.97]; P for interaction, 0.47). See Figure 1 for all results.

Conclusions

In this extended follow-up study of the DANISH trial, the effect of ICD implantation in patients with non-ischaemic systolic heart failure was not modified by CRT.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The DANISH trial was supported by unrestricted grants from Medtronic, St Jude Medical, Tryg Fonden, and the Danish Heart Foundation. No further funding was obtained for this follow-up study.

Accidental diagnosis of bradyarrhythmia in patients monitored for atrial fibrillation

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The study was supported by The Innovation Fund Denmark [12-135225], The Research Foundation for the Capital Region of Denmark [no grant number], The Danish Heart Foundation [11-04-R83-A3363-22625], Aalborg University Talent Management Programme [no grant number], Arvid Nilssons Fond [no grant number], Skibsreder Per Henriksen, R. og Hustrus Fond [no grant number], Medtronic [no grant number], and the AFFECT-EU consortium which has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 847770.

Background

The interest in heart rhythm monitoring and technologies to detect arrhythmia is increasing. The prevalence and prognostic significance of subclinical bradyarrhythmias is unknown.

Objectives

To assess the accidental diagnosis of bradyarrhythmia and its subsequent treatment and prognostic impact in persons screened for atrial fibrillation compared to unscreened persons.

Methods

We utilized a randomized trial of ≥70-year-olds with cardiovascular risk factors recruited outside the hospital setting to receive implantable loop recorder screening for atrial fibrillation (ILR group) vs. usual care (Control group). Time-to-event analyses were performed for bradyarrhythmia, pacemaker implantation, syncope, and sudden cardiovascular death.

Results

A total of 6004 participants were randomized (mean age 75 years, 47% women, 91% with hypertension, 20% with prior syncope), 4503 to Control and 1501 to ILR. The median follow-up period was 64.5 [59.3, 69.8] months. A total of 675 deaths occurred with an overall rate of 2.16 (2.00-2.33) per 100 person-years, and 67 sudden cardiovascular deaths occurred with a rate of 0.21 (0.15-0.28) for the Control group and 0.23 (0.14-0.37) for the ILR group (hazard ratio (HR) 1.11 (0.64-1.90), p=0.71)).

The overall rate of incident bradyarrhythmia was 1.63 (1.49-1.79) per 100 person-years, and bradyarrhythmia was diagnosed in 172 (3.82%) and 312 (20.8%) participants in the Control and ILR group, respectively (HR 6.21 (5.15-7.48), p<0.0001) (Figure 1). The most common bradyarrhythmia was sinus node dysfunction (SND) which was diagnosed in 68 participants in the Control group (1.51%) and 214 in the ILR group (14.26%). In the Control group, 57.35% of diagnoses of sinus node dysfunction resulted in pacemaker implantation, compared to 12.15% in the ILR group where the majority was treated conservatively (Figure 2). The second-most common type of bradyarrhythmia was high-grade atrioventricular block (AVB) which was diagnosed in 86 participants in the Control group (1.91%) and 54 in the ILR group (3.60%). In both groups, the majority of high-grade AVB was treated with pacemaker, although 29.63% in the ILR group were treated conservatively. Risk factors for bradyarrhythmia included higher age, male sex, and prior syncope.

Overall, a pacemaker was implanted in 132 (2.93%) and 66 (4.40%) participants (HR 1.53 (1.14-2.06), p<0.0001), syncope occurred in 120 (2.66%) and 33 (2.20%) participants (HR 0.83 (0.56-1.22), p=0.34), and sudden cardiovascular death occurred in 49 (1.09%) and 18 (1.20%) participants (HR 1.11 (0.64-1.90), p=0.71) in the Control and ILR group, respectively.

Conclusions

Bradyarrhythmias are highly common in ≥70-year-olds with cardiovascular risk factors. Compared to Control, ILR monitoring led to a six-fold increase in diagnosis of bradyarrhythmia and a significant increase in pacemaker implantations, but no change in the risk of syncope or sudden death.

Systolic blood pressure and effects of screening for atrial fibrillation with long-term continuous monitoring

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The LOOP Study was supported by Innovation Fund Denmark [grant number 12-1352259], The Research Foundation for the Capital Region of Denmark, The Danish Heart Foundation [grant number 11-04-R83-A3363-22625], Aalborg University Talent Management Program, Arvid Nilssons Fond, Skibsreder Per Henriksen, R og Hustrus Fond, the European Union’s Horizon 2020 program [grant number 847770 to the AFFECT-EU consortium], Læge Sophus Carl Emil Friis og hustru Olga Doris Friis’ Legat, and an unrestricted grant from Medtronic.

Background

The recently published LOOP Study was a randomized controlled clinical trial to evaluate systematic atrial fibrillation (AF) screening with long-term continuous monitoring in an elderly population at risk and found no significant reduction in stroke. However, the screening effects seemed to differ across levels of systolic blood pressure (SBP). It is well-known that hypertension constitutes a prominent risk factor for clinical AF and stroke alike, but data on the impacts of SBP on subclinical AF and hereby AF screening efficacy are lacking.

Purpose

With this post hoc analysis of the LOOP Study, we aimed to provide insights into the interaction between SBP and benefits of systematic AF screening.

Methods

The LOOP Study randomized individuals aged 70-90 years with ≥1 stroke risk factor (hypertension, diabetes, heart failure, or previous stroke) and without prior AF to either monitoring with implantable loop recorder (ILR) and initiation of oral anticoagulation upon detection of new-onset AF episodes lasting ≥6 minutes, or usual care (control group). In total, 5997 participants with available SBP measurements at enrolment were included in the present analysis. The interaction between SBP and ILR screening efficacy on stroke or systemic arterial embolism (SAE), as indicated by hazard ratio (HR) for ILR versus control, was assessed with polynomial moving-average regression. The lowest SBP threshold with significant screening benefits was further determined and used to examine clinical outcomes and the occurrence of AF with respect to dichotomized SBP. Additionally, penalized spline models were employed to assess AF occurrence by SBP as a continuous variable.

Results

HR of stroke/SAE for ILR versus control decreased with increasing SBP and the lowest threshold for significant screening benefits was at SBP ≥150 mmHg. ILR screening of participants with SBP ≥150 mmHg yielded a 45% risk reduction of stroke/SAE (HR 0.55 [0.37-0.82]). Within the ILR group, SBP ≥150 mmHg was associated with an increased risk of AF episodes ≥24 hours as compared to lower SBP (HR 1.57 [1.01-2.45]), but not with the overall occurrence of AF (HR 1.14 [0.95-1.36]). No significant association between SBP and AF occurrence in the ILR group was reported in penalized spline models either (p-value: 0.73).

Conclusions

The benefits of ILR screening for AF on stroke/SAE increased with increasing blood pressure. SBP ≥150 mmHg was associated with a 1.5-fold increased risk of AF episodes ≥24 hours, along with an almost 50% risk reduction of stroke/SAE by ILR screening.

Left atrial remodeling and cerebrovascular disease assessed by magnetic resonance imaging in patients undergoing continuous heart rhythm monitoring

Background

Atrial remodeling and atrial fibrillation (AF) have both been associated with cerebrovascular lesions. We wished to investigate the possible direct association between atrial remodeling and cerebrovascular disease including white matter lesions and lacunar infarcts in patients with and without atrial fibrillation (AF) as documented by implantable loop recorder (ILR).

Methods

Cardiac and cerebral MRI scans were acquired in a cross-sectional study including participants ≥70 years of age with stroke risk factors (history of hypertension, diabetes mellitus, congestive heart failure and/or previous stroke) but without known AF. Cerebrovascular disease was visually rated using the Fazekas scale and number of lacunar strokes. Left atrial (LA) (see figure) and ventricular volumes and function were analyzed, and associations between atrial remodeling and cerebrovascular disease were assessed with logistic regression models. Multivariable models were adjusted for sex, age, diabetes, hypertension, heart failure and history of stroke/transient ischemic attack. The analyses were stratified according to sinus rhythm or any AF during three months of continuous ILR monitoring to account for subclinical AF.

Results

Of 200 participants investigated, 87% had a Fazekas score≥1 and 45% had ≥1 lacunar infarct. Within three months of ILR implantation, AF was detected in 28 (14%) participants, while 172 (86%) had sinus rhythm only. Results are summarized in table. For participants with sinus rhythm, lower LA passive emptying fraction was associated with Fazekas score after multivariable adjustment, while LA total emptying fraction was borderline significant, and increased LA maximum and minimum volumes were associated with lacunar infarcts. There were no significant associations in patients with AF.

Sensitivity analyses showed similar results with longer screening periods for AF.

Conclusions

In patients free from AF as documented by ILR monitoring, we found an independent association between LA passive emptying and Fazekas score, and between atrial volumes and lacunar infarcts. This supports that atrial remodeling alone without AF is associated with an increased risk of cerebrovascular lesions.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Innovation Fund, DenmarkThe Research Foundation for the Capital Region of Denmark

PL03.4.A Factors associated with health-related quality of life (HRQoL) deterioration in glioma patients during the progression-free survival period

BACKGROUND

Maintenance of functioning and wellbeing during the progression-free survival (PFS) period is important for glioma patients. This study aimed to determine whether health-related quality of life (HRQoL) can be maintained during progression-free time, and factors associated with HRQoL deterioration in this period.

MATERIAL AND METHODS

We included longitudinal HRQoL data from previously published clinical trials in glioma. The percentage of patients with stable HRQoL until progression was determined per scale and at the individual patient level (i.e. considering all scales simultaneously). We assessed time to a clinically relevant deterioration in HRQoL, expressed in deterioration-free survival and time-to-deterioration (the first including progression as an event). We also determined the association between sociodemographic and clinical factors and HRQoL deterioration in the progression-free period.

RESULTS

5539 patients with at least baseline HRQoL scores had a median time from randomization to progression of 7.6 months. Between 9%-29% of the patients deteriorated before disease progression on the evaluated HRQoL scales. When considering all scales simultaneously, 47% of patients deteriorated on ≥1 scale. Median deterioration-free survival period ranged between 3.8–5.4 months, and median time-to-deterioration between 8.2–11.9 months. For most scales, only poor performance status was independently associated with clinically relevant HRQoL deterioration in the progression-free period.

CONCLUSION

HRQoL was maintained in only 53% of patients in their progression-free period, and treatment was not independently associated with this deterioration in HRQoL. Routine monitoring of the patients’ functioning and well-being during the entire disease course is therefore important, so that interventions can be initiated when problems are signalled.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Left atrial late gadolinium enhancement is associated with atrial fibrillation as detected by continuous monitoring

Background

Left atrial late gadolinium enhancement (LA LGE) measured with cardiac magnetic resonance (CMR) imaging is emerging as a marker of atrial fibrosis and has been associated with worse outcomes in AF ablation procedures. However, the prognostic value of LA LGE for incident AF remains unknown.

Methods

CMR including measurement of left ventricular (LV) and LA volumes and function, as well as LV extracellular volume fraction and LA LGE, was acquired in 68 patients aged at least 70 years with risk factors for stroke. All included patients received and implantable loop recorder and were continuously monitored for previously unknown AF. Incident AF was adjudicated by senior cardiologists.

Results

Patients were monitored for AF with implantable loop recorder during a median of 41 [36; 43] months. AF episodes lasting ≥6 minutes were detected in 32 patients (47%) and 16 patients (24%) experienced AF episodes lasting ≥5.5-hour. In Cox regression analyses adjusted for sex, age and comorbidities, we found that LA volumes and function and LA LGE were independently associated with incident AF. For LA LGE, the hazard ratio for time to AF episodes lasting ≥6 minutes and ≥5.5 hours were 1.40 (1.03, 1.89) per 10 cm2 increase (p=0.03) and 1.63 (1.11, 2.40) per 10 cm2 increase (p=0.01), respectively. LA LGE was significantly associated with high burden of AF. The addition of LA LGE to a multivariable risk prediction model for incident AF significantly increased the predictive value.

Conclusions

Extent of LA fibrosis measured by LA LGE was significantly associated with incident AF detected by implantable loop recorder.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Innovation Fund Denmark, The Research Foundation for the Capital Region of Denmark [no grant number]

Indicators of active disease and steroid dependency in patients with inflammatory bowel diseases not treated with biologics in a German real-world-setting

BACKGROUND AND AIMS

While a minority of inflammatory bowel disease (IBD) patients receives biologics in Germany, little is known about therapeutic needs of patients receiving non-biologic therapies. This study aimed to identify indicators of active disease/steroid dependency in patients with moderate to severe Crohn's disease (CD) and ulcerative colitis (UC) treated with conventional therapies and to describe health care resource use (HCRU)/cost.

METHODS

CD/UC patients treated with immunosuppressants (IS) and/or systemic or locally acting oral corticosteroids (CS) were identified in German claims data (2013-2017) and followed for 12 months post-therapy start. Indicators of active disease/steroid dependency during follow-up period were (i) ≥ 2 prescriptions of CS (sensitivity ≥ 4) or (ii) ≥ 1 IBD-related surgery or (iii) > 7 days IBD-related hospitalization(s).

RESULTS

Of 9871 included IBD patients (5170 CD, 4701 UC), 25.7%/19.9% (CD/UC) received ≥ 2 prescriptions of CS (sensitivity, 17.4%/15.7%) (i), 3.2% experienced IBD-related surgeries (ii), and 2.5% > 7 days of hospitalizations (iii). Altogether, 44.4% had indicators of active disease/steroid dependency (sensitivity, 23.9%). Among patients with active disease/steroid dependency, 78.0% received CS monotherapy at baseline. Of these, 89.6% received a CS monotherapy in the follow-up period, too. Proportionally, fewer patients with CS monotherapy (57.4%) than IS therapy (91.0%) visited a specialist. HCRU/cost per patient year was significantly higher in patients with than without active disease/steroid dependency.

CONCLUSIONS

A substantial percentage of biologic-naïve IBD patients suffers from active disease/steroid dependency. The majority receives a monotherapy with systemic CS. Referral to gastroenterologists for treatment optimization is recommended, also because active disease/steroid dependency is associated with increased HCRU/cost.

PAX8-GLIS3 gene fusion is a pathognomonic genetic alteration of hyalinizing trabecular tumors of the thyroid

The hyalinizing trabecular adenoma/tumor is a rare and poorly characterized follicular-derived thyroid neoplasm recently shown to harbor recurrent PAX8-GLIS1 or PAX8-GLIS3 gene fusions. Here we sought to define the repertoire of genetic alterations of hyalinizing trabecular tumors, and whether PAX8-GLIS3 fusions are pathognomonic for hyalinizing trabecular tumors. A discovery series of eight hyalinizing trabecular tumors was subjected to RNA-sequencing (n = 8), whole-exome sequencing (n = 3) or targeted massively parallel sequencing (n = 5). No recurrent somatic mutations or copy number alterations were identified in hyalinizing trabecular tumor, whereas RNA-sequencing revealed the presence of a recurrent genetic rearrangement involving PAX8 (2q14.1) and GLIS3 (9p24.2) genes in all cases. In this in-frame fusion gene, which comprised exons 1-2 of PAX8 and exons 3-11 of GLIS3, GLIS3 is likely placed under the regulation of PAX8. Reverse transcription RT-PCR and/or fluorescence in situ hybridization analyses of a validation series of 26 hyalinizing trabecular tumors revealed that the PAX8-GLIS3 gene fusion was present in all hyalinizing trabecular tumors (100%). No GLIS1 rearrangements were identified. Conversely, no PAX8-GLIS3 gene fusions were detected in a cohort of 237 control thyroid neoplasms, including 15 trabecular thyroid lesions highly resembling hyalinizing trabecular tumor from a morphological standpoint, as well as trabecular/solid follicular adenomas, solid/trabecular variants of papillary carcinoma, and Hurthle cell adenomas or carcinomas. Our data provide evidence to suggest that the PAX8-GLIS3 fusion is pathognomonic for hyalinizing trabecular tumors, and that the presence of the PAX8-GLIS3 fusion in thyroid neoplasms may be used as an ancillary marker for the diagnosis of hyalinizing trabecular tumor, thereby avoiding overtreatment in case of misdiagnoses with apparently similar malignant tumors.

OS7.3 Health-related quality of life (HRQoL) evaluation in the REGOMA trial: a randomized, phase II clinical trial analyzing regorafenib activity in relapsed glioblastoma patients

BACKGROUND

REGOMA trial showed that regorafenib (REG) significantly improved OS and PFS in patients (pts) with relapsed GBM with respect to lomustine (LOM). REG showed a different toxicity profile compared to LOM. Here, we report final results of the HRQoL assessment, a secondary end point.

MATERIAL AND METHODS

HRQoL was measured using the European Organization for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30) and brain module (QLQ-BN20) administered before any MRI assessments, every 8 weeks (+/- 2 weeks) until disease progression. To evaluate treatment impact on HRQoL, questionnaires at progression were excluded. Mixed-effect linear models were fitted for each of the HRQOL domain to examine the change over progression-free time within and between arms. The models included the time of questionnaire assessment, the treatment group and their interaction, as fixed effects, and a compound symmetry covariance structure for the random effects. Differences of at least 10 points were classified as a clinically meaningful change. To correct for multiple comparisons and to avoid type I error, the level of significance was set at P=0.01 (2-sided).

RESULTS

Of 119 randomized pts, 117 partecipated in the HRQoL evaluation, and 114 had a baseline assessment (n=56 REG; n=58 LOM). No statistically significant differences were observed in any generic or cancer specific domain during treatment in the REG and LOM arms, or between the two arms, except for the appetite loss scale which was significantly worse in PTS treated with REG (Global mean 14.7 (SD=28.6) vs 7.6 (SD=16.0); p=0.0081). The rate of pts with a clinically meaningful worsening for appetite loss was not statistically different between the two arms (9 out of 24 and 0 out of 13 in the REG and LOM arm, respectively;p=0.02).

CONCLUSION

In the REGOMA trial, HRQoL did not change during regorafenib treatment. Pts treated with regorafenib and lomustine reported no significant difference in HRQoL.

Cisplatin plus Vindesine versus Cisplatin plus VP16 versus Doxorubicin plus Cytoxan in Non-Small-Cell Carcinoma of the Lung. A Randomized Study

From March 1981 to January 1984, 116 patienst with advanced non-small-cell carcinoma of the lung (NSCCL) were randomly assigned to 3 combinations as follows: CDDP + DVA, CDDP + VP16 and DXR + CTX. 94 patients were evaluable for response, 106 for toxicity and survival. Of 31 patients, 15 (48%; 3 CRs and 12 PRs) responded to CDDP + DVA; of 33 patients, 12 (36%, 2 CRs and 10 PRs) responded to CDDP + VP16; of 30 patients, 3 (10%) obtained a PR with DXR+CTX (CDDP+DVA vs DXR + CTX, P < 0.005; CDDP + VP16 vs DXR + CTX, P < 0.05; CDDP + DVA vs CDDP + VP16, P = NS). The median duration of response was 22 weeks in the CDDP-DVA group, 17 weeks in the CDDP-VP16 group, and 16 weeks in the DXR+CTX group. No significant difference in survival was observed among the 3 groups (median: 43, 47, 41 weeks, respectively). Hematologic and neurologic toxicities were significantly higher in the DVA-containing regimen. Despite the lack of improvement of overall survival with the CDDP-containing combinations over the DXR + CTX control group, the good response rate makes them suitable to be used in combined therapeutic strategies.

Abstract OT1-03-03: Phase II, open label, randomized, biomarker study of immune-mediated mechanism of action of neoadjuvant subcutaneous trastuzumab in patients with operable or locally advanced/Inflammatory HER2-positive breast cancer. ImmunHER trial on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC)

Background: Tumor-infiltrating lymphocytes (TILs) have been reported to be associated with increased therapeutic efficacy of trastuzumab in the (neo)adjuvant setting for HER2-positive breast cancer (BC). Subcutaneous (SC) trastuzumab has been observed to act at different immunologic levels than IV trastuzumab. Therefore, by modifying the modality of administration of trastuzumab, it could be possible to interfere with different pathways of the immune system and exert a favorable immunomodulation in HER2-positive BC.

Trial design: In this non-comparative, phase II, neoadjuvant, randomized study, patients will be treated with FEC chemotherapy (fluorouracil 500 mg/m2; epirubicin 75 mg/m2; cyclophosphamide 500 mg/m2) q21 for 3 cycles. Then, they will be randomly assigned in a 1:1 ratio to receive: docetaxel (75 mg/m2) plus pertuzumab (840 mg loading dose, then 420 mg) plus IV trastuzumab (8 mg/kg loading dose, then 6 mg/kg) q21 for 4 cycles (Group A) or, docetaxel plus pertuzumab plus SC trastuzumab (fixed dose of 600 mg) q21 for 4 cycles (Group B). After surgery, study patients will receive trastuzumab q21 x 14 cycles using the same formulation (SC or IV) of the preoperative phase.

Eligibility criteria: Patients must have previously untreated, T2-4d primary HER2-positive BC with no metastatic disease. Other inclusion criteria are: age 18 or older; ECOG performance status 0-1; availability of tumor tissue from diagnostic biopsy; normal left ventricular ejection fraction; normal organ and marrow function.

Specific aims: The main objective of this trial is to evaluate variations of host immune response parameters to either trastuzumab SC or trastuzumab IV given in combination with pertuzumab and chemotherapy as neoadjuvant treatment of patients with HER2-positive BC. Tumor samples obtained at diagnosis and at definitive surgery will be centrally analyzed for TILs. Blood samples will be also collected during study treatment for tumor-specific lymphocyte cell activity (TLA) analysis. Feasibility, efficacy, safety and health-related quality of life will be also evaluated.

Statistical methods: The primary endpoint is post-surgery pathologic TIL rate on residual disease. The threshold for classifying subjects with high TILs, or not, is defined as equal to 15%, according to the median TIL rate observed in primary HER2-positive tumors. Because this is a phase II study with 2 non-comparative arms, Simon's optimal 2-stage design will be used for each of the 2 study groups. For each arm we assume: p1 = 0.4, expected rate of subjects with high TILs on residual disease, p0 = 0.1, lowest limit of the subject rate (alpha= 0.05; beta= 0.20).

Present accrual and target accrual: A total of 60 patients (first stage: 16 patients) will be enrolled from multiple institutions. From November 29, 2016 to June 11, 2017, 34 patients have been recruited.

Contact information:Dr. Antonino Musolino, MD, MSc, PhD; Medical Oncology Unit, University Hospital of Parma; Tel: +390521702316; Fax: +390521995448; e-mail: amusolino@ao.pr.it. Clinical Trials.gov: NCT03144947.

Citation Format: Musolino A, Gori S, Cavanna L, Graiff C, Frassoldati A, Bria E, Bisagni G, Zambelli A, Partesotti G, Brandes A, Bonetti A, Moscetti L, Zamagni C, Rocca A, Generali D, Montemurro F, Gianni L, Tognetto M, Maglietta G, Todeschini R. Phase II, open label, randomized, biomarker study of immune-mediated mechanism of action of neoadjuvant subcutaneous trastuzumab in patients with operable or locally advanced/Inflammatory HER2-positive breast cancer. ImmunHER trial on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC) [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 OT1-03-03.

Abstract PD4-13: Estrogen receptor-negative breast adenomyoepitheliomas are driven by co-occurring HRAS hotspot and PI3K pathway gene mutations: A genetic and functional analysis

Introduction:Adenomyoepithelioma (AME) of the breast is a rare biphasic tumor, characterized by epithelial and myoepithelial differentiation. Although AMEs have an indolent clinical course, a subset may progress to carcinoma and metastasize. We sought to define the mutational landscape of AMEs and investigate the functional impact of recurrent pathogenic mutations identified in these tumors.

Methods: Thirty-one AMEs were subjected to whole-exome sequencing (WES, n=8) or massively parallel sequencing targeting all coding regions of 410 key cancer genes and intronic and regulatory regions of selected genes (n=23). Somatic genetic alterations were defined using state-of-the-art bioinformatics algorithms. In an additional set of 12 AMEs, Sanger sequencing analysis of HRAS, PIK3CA and AKT1 was performed. Non-tumorigenic estrogen receptor (ER)-negative mammary epithelial cells (i.e. MCF10A, MCF10A with a PIK3CA H1047R mutation knock-in and MCF12A) were utilized for functional studies using both conventional monolayer and three-dimensional (3D) culture assays.

Results: 27 (63%) and 16 (37%) AMEs were ER-positive and ER-negative, respectively. ER-negativity was significantly associated with histologic features predictive of a more aggressive behavior, with a higher number of mutations and copy number alterations, and with a distinct mutational profile as compared to ER-positive AMEs. Of the 27 ER-positive AMEs, 12 cases (44%) harbored PIK3CA hotspot mutations, and 5 PIK3CA wild-type cases displayed E17K AKT1 hotspot mutations. By contrast, of the 16 ER-negative AMEs, 9 (56%), 9 (56%) and 3 (19%) harbored HRAS, PIK3CA (mostly E545K and H1047R hotspots) and PIK3R1 mutations, respectively. Strikingly, all HRAS mutations were restricted to ER-negative AMEs, affected the hotspot codon Q61 (Q61R/K), and all but one co-occurred with PIK3CA or PIK3R1 mutations. In addition, HRAS Q61 hotspot mutations were significantly associated with necrosis (p=0.01) and high mitotic rates (p=0.03). CDKN2A homozygous deletions were also detected only in ER-negative AMEs (19%) and found to be significantly associated with progression to carcinoma (p=0.001). Forced expression of HRAS Q61R in MCF10A and MCF12A cells resulted in i) increased proliferation and transformation, ii) an irregular growth pattern in 3D organotypic cell cultures, iii) partial loss of the epithelial phenotype, and iv) acquisition of myoepithelial differentiation, which was more overt in PIK3CA-mutant MCF10A cells. HRAS Q61Rinduced hyperactivation of the PI3K pathway, but both PI3K and MAPK pathways likely contributed to the RAS-mediated proliferation, which was completely arrested by combined AKT and MEK inhibition.

Conclusion: AMEs are phenotypically and genetically heterogeneous. Whilst pathogenic mutations in PI3K pathway-related genes occur across the spectrum of lesions, HRAS Q61 hotspot mutations are restricted to ER-negative AMEs. Our genomic and functional analyses indicate that HRAS Q61 mutations are driver events in the pathogenesis of ER-negative AMEs and, in conjunction with mutant PIK3CA, may lead to the acquisition of myoepithelial differentiation in breast epithelial cells.

Citation Format: Geyer FC, Li A, Papanastasiou AD, Smith A, Selenica P, Burke KA, Edelweiss M, Wen H-C, Piscuoglio S, Schultheis AM, Martelotto LG, Pareja F, Kumar R, Brandes A, Lozada J, Macedo GS, Muenst S, Terracciano LM, Jungbluth A, Foschini MP, Wen HY, Brogi E, Palazzo J, Rubin BP, Ng CKY, Norton L, Varga Z, Ellis IO, Rakha E, Chandarlapatty S, Weigelt B, Reis-Filho JS. Estrogen receptor-negative breast adenomyoepitheliomas are driven by co-occurring HRAS hotspot and PI3K pathway gene mutations: A genetic and functional analysis [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 PD4-13.

Polarization influence on reflectance measurements in the spatial frequency domain

In this work, we quantify the influence of crossed polarizers on reflectance measurements in the spatial frequency domain. The use of crossed polarizers is a very common approach for suppression of specular surface reflections. However, measurements are typically evaluated using a non-polarized scalar theory. The consequences of this discrepancy are the focus of our study, and we also quantify the related errors of the derived optical properties. We used polarized Monte Carlo simulations for forward calculation of the reflectance from different samples. The samples' scatterers are assumed to be spherical, allowing for the calculation of the scattering functions by Mie theory. From the forward calculations, the reduced scattering coefficient [Formula: see text] and the absorption coefficient μa were derived by means of a scalar theory, as commonly used. Here, we use the analytical solution of the scalar radiative transfer equation. With this evaluation approach, which does not consider polarization, we found large errors in [Formula: see text] and μa in the range of 25% and above. Furthermore, we investigated the applicability of the use of a reference measurement to reduce these errors as suggested in literature. We found that this method is not able to generally improve the accuracy of measurements in the spatial frequency domain. Our general recommendation is to apply a polarized theory when using crossed polarizers.

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND

As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years.

METHODS

Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients.

RESULTS

Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446).

CONCLUSIONS

The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

The distribution of cDNA sequences on field bean chromosomes

Total polyadenylated RNA was isolated from different organs of the field bean by oligo-dT latex particles. Complementary DNA (cDNA) was reverse transcribed from the mRNAs and used as a probe for fluorescent in situ hybridization to metaphase chromosomes. Hybridization signals covered the whole chromosome complement except for late-replicating Giemsa-banded heterochromatin regions, which are composed mainly (or exclusively) of tandemly arranged repetitive sequences.

Randomized phase II trial of erlotinib (E) versus temozolomide (TMZ) or BCNU in recurrent glioblastoma multiforme (GBM): EORTC 26034

2005

Background: In 40–50% of GBM epidermal growth factor receptor (EGFR) is amplified, and often constitutively activated (EGFRvIII mutant). EGFR is therefore a potential therapeutic target. Previous studies suggested activity of EGFR tyrosine-kinase inhibitors in recurrent GBM, particularly in specific molecular subsets. This study explored erlotinib (E) activity in recurrent GBM. Methods: Randomized phase II trial. Eligibility criteria: histologically proven GBM, recurrent >3 months after radiotherapy, Karnofsky performance status (KPS) =70, no prior chemotherapy for recurrent disease, tissue sample for EGFR studies. Patients (pts) received E 150mg/day (300mg/day if on enzyme inducing anti-epileptic drugs [EIAEDs]), or control (TMZ 150–200mg/m2, day 1–5 q4wk or BCNU 60–80mg/m2 i.v., day 1–3 q8wk). If no significant toxicity, E was escalated to 200mg (500mg in patients on EIAEDs). The primary endpoint was 6 months’ PFS in =10/50 pts on E (20%); P0 was set at 15%, and P1 at 30%. Response was assessed with Macdonald’s criteria. EGFR amplification (FISH) and expression of EGFR, EGFRvIII and PTEN (immunohistochemistry [IHC]) were assessed. Results: 110 patients were randomized (54 E, 56 control: 27 TMZ; 29 BCNU). Median age 55 years; median KPS 90. All but 1 patient started treatment; median number of cycles was 2 for E, 4 for TMZ and 1 for BCNU. Grade 3/4 toxicities likely related to E: dermatological (5); hemorrhage (1). Grade 3/4 toxicities for control were mainly hematological (3 TMZ, 13 BCNU). Three pts discontinued E due to toxicity. Six-month PFS was 12% for E, 24% for control. Six and 12-month survival were 61% and 24% for E, and 63% and 26% for control. Two responses were seen on control; the best response on E was SD (n=6). Patients with EGFRvIII mutations (13 in E arm, 8 in control arm) had shorter PFS (p=0.007) and OS (p=0.004) regardless of treatment. Response to E was not correlated with EGFR expression, EGFR amplification or EGFRvIII mutation. Conclusions: This randomized, controlled phase II study did not find sufficient activity for erlotinib in the general population of recurrent GBM. The presence of EGFRvIII mutations was not predictive for response.

No significant financial relationships to disclose.

Depression assessed over 1-year survival in patients with myocardial infarction

OBJECTIVE

To estimate the prevalence of ICD-10 depression using a self-reported questionnaire and to examine if depression is associated with increased 1-year mortality in patients with myocardial infarction (MI).

METHOD

In total, 763 MI-patients completed the Major Depression Inventory at discharge. Information from hospital notes was collected and patients were followed 1 year for re-admission and mortality through national registries.

RESULTS

Seventy-three patients (9.6%) were depressed at discharge. Depression was not a significant independent predictor of mortality; however, there was a significant trend for increasing mortality with increasing severity of the depressive state (P = 0.028). All mortality among depressed patients was in patients with non-Q-wave infarction.

CONCLUSION

Ten per cent of MI-patients fulfilled diagnostic criteria for depression at discharge. There was a significant trend for increasing mortality with increasing severity of the depressive episode. All mortality among depressed patients was seen in patients with non-Q-wave infarction. These findings indicate future studies in selected subgroups of MI-patients.