Unresectable stage III non-small cell lung cancer: Insights from a Portuguese expert panel

INTRODUCTION

The management of unresectable stage III non-small cell lung cancer (NSCLC) is clinically challenging and there is no current consensus on optimal strategies. Herein, a panel of Portuguese experts aims to present practical recommendations for the global management of unresectable stage III NSCLC patients.

METHODS

A group of Portuguese lung cancer experts debated aspects related to the diagnosis, staging and treatment of unresectable stage III NSCLC in light of current evidence. Recent breakthroughs in immunotherapy as part of a standard therapeutic approach were also discussed. This review exposes the major conclusions obtained.

RESULTS

Practical recommendations for the management of unresectable stage III NSCLC were proposed, aiming to improve the pathways of diagnosis and treatment in the Portuguese healthcare system. Clinical heterogeneity of patients with stage III NSCLC hinders the development of single standardised algorithm where all fit.

CONCLUSIONS

A timely diagnosis and a proper staging contribute to the best management of each patient, optimizing treatment tolerance and effectiveness. The expert panel considered chemoradiotherapy as the preferable approach when surgery is not possible. Management of adverse events and immunotherapy as a consolidation therapy are also essential steps for a successful strategy.

Omecamtiv mecarbil for the management of heart failure: a meta-analysis of randomized controlled trials

Background

Omecamtiv mecarbil (OM) is a selective cardiac myosin activator that promotes contractility in patients with Heart Failure with Reduced Ejection Fraction (HFrEF). We aimed to study the clinical outcomes of OM in this population.

Methods

PubMed, Cochrane CENTRAL Registry of Controlled Trials, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) that compared OM with placebo for the management of HFrEF. Efficacy and safety data were summarized with odds ratios (OR) and a 95% confidence interval (CI) using a fixed-effect model predicting low heterogeneity between studies.

Results

Four RCTs were included, totalizing 9,364 patients, 4,779 treated with OM and 4,585 with placebo. Mean age ranged from 63–66 years, 15–22% female, ejection fraction 26–29%, ischemic etiology 53–66%. Length of follow up ranged from 1 to 21 months. There was no difference in the outcomes all cause death (OR 0.99, 95% CI 0.9–1.1, p=0.91), cardiovascular death (OR 1.01, 95% CI 0.91–1.12, p=0.87) and heart failure events or hospitalizations (OR 0.96, 95% CI 0.87–1.05, p=0.35), Figure.

Conclusion

In a meta-analysis of 4 RCTs, OM showed no difference compared with placebo in the risk of all-cause death, cardiovascular death, or heart failure events among patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Predictors of lung entrapment in malignant pleural effusion

INTRODUCTION

Malignant pleural effusion (MPE) is a common complication in advanced stages of malignancy and is associated with poor prognosis. Non-expandable lung (NEL) often occurs and its presence influences the MPE approach. Our main objective was to assess risk factors for malignant NEL.

METHODS

Patients diagnosed with pathologically confirmed MPE between January 2012 and December 2018 in our institution were retrospectively analyzed. Demographic and clinical data of patients were reviewed and compared according to the presence or absence of NEL. A univariate and multivariate binary logistic regression analysis were used to determine predictors of the development of NEL.

RESULTS

Of 365 patients included, 68 (18.6%) had NEL. After multivariate analysis, we found that loculated MPE (OR 8.63, 95%CI 4.30-17.33, p<0.001), complete hemithorax opacification (OR 2.81, 95%CI 1.17-6.76, p<0.021), lung cancer (OR 2.09, 95%CI 1.01-4.31, p=0.047) and higher effusion-serum LDH ratio (OR 1.09, 95%CI 1.00-1.17, p=0.039) were independent predictors of malignant NEL. There were no significant differences compared with expandable lung group regarding time from primary malignancy diagnosis to MPE diagnosis (3.0, IQR 0.0-75.8 vs 2.0, IQR 0.0-75.5 weeks, p=0.942) or MPE symptoms onset to MPE diagnosis (4.0, IQR 1.0-9.0 vs 3.0, IQR 1.0-9.0 weeks, p=0.497). Patients with NEL had a higher number of therapeutic pleural drainages (3.0, IQR 2.0-6.0 vs 2.0, IQR 1.0-3.0; p<0.001) and longer hospital stay (32.5, IQR 15.5-46.3 vs 21.0, IQR 11.0-36.0, p=0.007), measured in hospitalization days until the end of life, than patients with expandable lung. The rate of recurrence of pleural effusion was not significantly different between groups (p=0.291). Overall survival (OS) was 3.0 (95%CI, 2.3-3.7) months, regardless of lung expandability (p=0.923).

CONCLUSION

Loculated MPE, complete hemithorax opacification, lung cancer and a higher effusion-serum LDH ratio were found to be independent predictors for NEL. These patients underwent thoracocenteses more frequently and had longer hospitalization days, although without significant impact in the OS.

Influence of edaphic conditions and persistent organic pollutants on earthworms in an infiltration basin

In recent decades, stormwater management has developed to allow stormwater to infiltrate directly into the soils instead of being collected and routed to sewer systems. However, during infiltration, stormwater creates a sediment deposit at the soil surface as the result of high loads of suspended particles (including pollutants), leading to the settlement of sedimentary layers prone to colonization by plants and earthworms. This study aims to investigate the earthworm communities of a peculiar infiltration basin and investigate the influence of edaphic conditions (water content, organic matter content, pH, height of sediment) and of persistent organic pollutants (POPs: PCBs, PCDDs and PCDFs) on these earthworms. Attention was paid to their age (juveniles or adults) and their functional group (epigeic, endogeic, anecic). We found that the earthworm abundance was mostly driven by edaphic conditions, with only a slight impact of POPs, with a significant negative impact of PCBDLno for juveniles and endogeic, and PCDDs for epigeic. On the contrary, the height of the sediment and the water content are beneficial for their presence and reproduction. Furthermore, POPs contents are also linked to physicochemical parameters of the sediment. Bioaccumulation was clearly revealed in the studied site but does not differ between juveniles and adults, except for PCDDs. Conversely, BAF values seemed to vary between functional groups, except for PCBDL non-ortho. It strongly varies with the family types (PCBs versus PCCD/Fs) and between congeners within the same family, with specific strong bioaccumulation for a few congeners.

Predictors of immune-related adverse events and outcomes in patients with NSCLC treated with immune-checkpoint inhibitors

OBJECTIVE

To identify predictors of immune-related adverse events (IRAEs) in patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs). Assess associations between outcomes and the development of IRAEs.

METHODS

Retrospective analysis of patients with NSCLC treated with ICIs between 2016 and 2020 in the Pulmonology Department of our hospital. Patients with and without IRAEs were compared. A logistic regression analysis was performed to determine predictors of IRAEs. Progression-free survival (PFS) and overall survival (OS) curves were calculated using the Kaplan-Meier method, and the long-rank test was used to assess survival differences between groups. Univariate and multivariate Cox proportional-hazards regression models were used to identify factors associated with PFS and OS. The value considered statistically significant was p≤0.05.

RESULTS

A total of 184 patients (77.7% men, mean age 66.9±9.5 years) treated with ICIs were analyzed. During follow-up, 49 (26.6%) patients developed IRAEs and 149 (81.0%) died. According to the multivariate logistic regression analysis, treatment with statins (OR:3.15; p = 0.007), previous systemic corticosteroid therapy (OR:3.99; p = 0.001), disease controlled as response to ICI (OR:5.93; p < 0.001) and higher hemoglobin values (OR:1.28; p = 0.040) were independent predictors for the development of IRAEs. Patients who developed IRAEs had significantly longer medians of PFS (41.0 vs 9.0 weeks, p < 0.001) and OS (89.0 vs 28.0 weeks; p < 0.001).

CONCLUSIONS

Patients treated with statins, pre-ICI systemic corticosteroids, higher baseline hemoglobin value and controlled disease as initial response to ICI had a higher risk of developing IRAEs. The development of IRAEs was associated with better outcomes.

Gynaecological cytology in women under the age of 30—the impact of P16/KI67 dual-staining cytology

Background

The HPV detection test is not recommended as a primary screening of cervical lesions, before the age of 30, because the high rate of HPV infections with a high rate of spontaneous resolution in this age group. This study aims to evaluate the performance of p16/Ki67 dual staining in detecting high-grade squamous cervical lesions in these women.

Methods

Cervical-vaginal samples from 67 women HPV positives under the age of 30 and cervical biopsies of 41 of these women. Results of p16/Ki67 dual staining, cytology and histology were analysed. In 53 of the women, 159 results of p16/Ki67 dual staining, HPV test and cytology, obtained in 3 follow-up medical visit, were compared.

Results

The p16/ki67 dual staining was positive in 23.9% and negative in 76.1% of all 67 women. All women with high squamous intraepithelial lesion cytology, 39.1% with low squamous intraepithelial lesion cytology, 17.4% with negative for intraepithelial lesion cytology and 10% with atypical squamous cells cytology, were p16/Ki-67 dual staining positives. In the 41 women with histological diagnosis, p16/ki67 dual staining showed a sensitivity of 87.5% and a specificity of 96% to detect HSIL. When comparing, the tests differ significantly (P &lt; 0.001), p16/ki67 dual staining was positive in 24% of positive cytology and in 19.5% of positive HPV tests.

Conclusions

Our results demonstrate that p16/Ki67 dual stain has good sensitivity and specificity to detect HSIL and can be useful on women under the age of 30, avoiding excessive diagnosis and reducing colposcopy referrals. Further studies are required in a large number of women.

Central venous catheter infection in Canadian home parenteral nutrition patients: a 5-year multicenter retrospective study

HIGHLIGHTS

A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates.

OBJECTIVES

CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs.

METHODS

Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments.

RESULTS

Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days.

CONCLUSION

We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.

Nanorectenna spectrally-selective plasmonic hot electron response to visible-light lasers

Active metasurfaces with novel visible and infrared (vis/IR) functionalities represent an exciting, growing area of research. Rectification of vis/IR frequencies would produce needed direct current (DC) with no inherent frequency limitation (e.g. no semiconducting bandgap). However, controlling the materials and functionality of (nano)rectennas for rectifying 100 s of THz to the visible regime is a daunting challenge, because of the small features and simultaneously the need to scale up to large sizes in a scalable platform. An active metasurface of a planar array of nanoscale antennas on top of rectifying vertical diodes is a 'nanorectenna array' or 'microrectenna array' that rectifies very high frequencies in the infrared, or even higher frequencies up to the visible regime. We employ a novel strategy for forming optical nanorectenna arrays using scalable patterning of Au nanowires, demonstrate strong evidence for spectral-selective high-frequency rectification, characteristic of optical antennas. We discover a previously unreported out-of-equilibrium electron energy distribution, i.e. hot electrons arising from plasmonic resonance absorption in an optical antenna characterized by an effective temperature, and how this effect can significantly impact the observed rectification.

The role of interventional bronchoscopy in the management of post-intubation tracheal stenosis: A 20-year experience

PURPOSE

Benign tracheal stenosis management is still controversial, and there is no international consensus on the best treatment option. Thus, we aimed to look into the history of PITS and the different strategies used in its treatment. The importance of bronchoscopic treatment was also defined, and its effectiveness and safety were assessed.

METHODS

Retrospective study of patients diagnosed with PITS, who were referred to the Bronchology Department between January 1996 and December 2016.

RESULTS

Of 115 patients enrolled (mean age 48.5±17.6 years, 53% males), 66.1% had complex stenosis. The most common causes of intubation were respiratory (29.9%), neurological (26.8%) and surgical (19.6%). Complex stenosis was caused by longer intubation, and was more frequent among previously tracheostomized patients. The most common location was the upper third of trachea (60.9%). Most cases were initially treated by interventional bronchoscopy, and although serial dilations were effective in some complex PITS, a higher proportion of simple stenosis was successfully managed with this treatment option. Long-term recurrence after serial dilation was observed in 25.0% of cases. Stent placement was required (19.1%) only for complex PITS. Stent-related complications were frequent (61.9%) and linked to the stenting time (p<0.001). Overall, there were no procedure-related complications. Surgical intervention was also performed (30.0%), always with complex PITS. Post-surgical recurrences were observed in 24.2% of cases.

CONCLUSIONS

Interventional bronchoscopy is an efficient and safe modality in PITS management. Further studies are needed for better classification and improved knowledge of PITS pathogenesis, and to achieve international consensus of definition to guide clinicians in their practice.

101 Effects of Active Immunization Against GnRH in Oocyte Donors with Cystic Ovarian Disease

Cows intensively used as oocyte donors for in vitro embryo production (IVEP) are usually kept nonpregnant for prolonged intervals, exposed to successive hormonal treatments, and frequently become overweight. These are all risk factors for the development of endocrine unbalance and, consequently, cystic ovarian disease (COD). The aim of this study was to evaluate the effect of active immunization against gonadotropin-releasing hormone (GnRH) on (1) ovarian follicular population, and (2) development potential of oocytes used for IVEP. Nelore (Bos indicus) cows (n = 14), previously diagnosed with chronic COD (Faria et al. 2017 Anim. Reprod., in press), weighing 620.0 ± 12.8 kg and with body condition score of 4.1 ± 0.2, were assigned to control (n = 6) or treatment (n = 8) group. Cows in the treatment group received 2 SC injections of 1.0 mL of anti-GnRH vaccine (Bopriva, Zoetis, Brazil), 28 days apart (weeks 0 and 4), whereas cows in the control group received placebo on the same schedule. Transrectal ultrasonography was performed weekly from week 0 to evaluate the number and distribution of follicles among size classes, endometrial thickness, and clinical presence of mucometra. Immunization was considered effective (E-IM) when no follicles ≥5.0 mm were observed on the ovaries during a given examination. Cows having E-IM were then used as oocyte donors for IVEP. Cumulus-oocyte complexes (COC) were collected in 5 consecutive ovum pick-up weekly sessions. As a control for IVEP, oocytes from a slaughterhouse were used, with similar procedures performed on the same days and using the same semen batch. The MIXED procedure of SAS (SAS Institute Inc., Cary, NC, USA) with repeated-measures statement was used to evaluate the effects of treatment, time, and interactions on ovarian endpoints; and the GLM procedure was used to analyse embryo production data. Results are shown as mean ± SEM. There were time and time × treatment effects on ovarian parameters. Treated cows had a decrease (P < 0.05) in the average diameter of the largest follicle and in the number of follicles ≥8 mm, and an increase (P < 0.05) in follicular population after week 6. Nonetheless, individual response to treatment was variable: only 50% of the cows (4 of 8) were E-IM at week 8, whereas 25% (2 of 8) still had COD (largest follicle ≥18.0 mm) at this timepoint. Overall, a negative correlation was detected between follicular population and the diameter of the largest follicle (r = –0.60, P < 0.0001) or the number of follicles ≥8 mm (r = –0.47, P < 0.0001). There was no effect (P > 0.05) of treatment on endometrial thickness or mucometra score. Cows with E-IM produced 22.2 ± 3.6 total and 12.9 ± 2.3 viable COC. Cleavage rate did not differ between E-IM and control (slaughterhouse) oocytes (70.8 ± 7.0 v. 75.1 ± 3.0%, respectively; P > 0.05); however, blastocyst rate was greater in the E-IM group compared with controls (39.7 ± 5.5 v. 20.5 ± 4.7%, respectively; P < 0.02). In summary, our results suggest that active immunization against GnRH leads to variable results in the distribution of the follicular population in cows with COD, but it does not negatively affect IVEP efficiency. This research was supported by Zoetis, CNPq, and CAPES.

Thyroid storm and myxoedema: two reversible causes of acute heart failure

Cardiovascular signs and symptoms can prevail in both hypothyroidism and hyperthyroidism. Case 1: 30-year-old female with acute right heart failure as first manifestation of Graves' disease. It illustrates some of its cardiovascular complications, particularly pulmonary hypertension, tricuspid regurgitation, atrial fibrillation, mitral valve prolapse and mitral regurgitation. Case 2: 83-year-old-man with a severe primary hypothyroidism/myxoedema crisis presented to emergency department with extreme bradyarrhythmia with hemodynamic impact and heart failure signs, which led to implantation of definitive pacemaker. Thyroid disorders are treatable entities and most cardiovascular changes are reversible. Early diagnosis is mandatory and can avoid severe complications and, eventually, invasive therapeutics interventions. Pulmonary hypertension and acute heart failure, especially in young adults, should be screened for underlying hyperthyroidism.

Search for Neutrinoless Double-Beta Decay of (130)Te with CUORE-0

We report the results of a search for neutrinoless double-beta decay in a 9.8 kg yr exposure of (130)Te using a bolometric detector array, CUORE-0. The characteristic detector energy resolution and background level in the region of interest are 5.1±0.3  keV FWHM and 0.058±0.004(stat)±0.002(syst)counts/(keV kg yr), respectively. The median 90% C.L. lower-limit half-life sensitivity of the experiment is 2.9×10(24)  yr and surpasses the sensitivity of previous searches. We find no evidence for neutrinoless double-beta decay of (130)Te and place a Bayesian lower bound on the decay half-life, T(1/2)(0ν)>2.7×10(24)  yr at 90% C.L. Combining CUORE-0 data with the 19.75 kg yr exposure of (130)Te from the Cuoricino experiment we obtain T(1/2)(0ν)>4.0×10(24)  yr at 90% C.L. (Bayesian), the most stringent limit to date on this half-life. Using a range of nuclear matrix element estimates we interpret this as a limit on the effective Majorana neutrino mass, m(ββ)<270-760  meV.

The value of rapid on-site evaluation during EBUS-TBNA

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to increase endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) accuracy in the diagnosis of mediastinal lesions and lung cancer staging. However, studies have reported controversial results. The purpose of our study was to evaluate the influence of ROSE on sample adequacy and diagnostic accuracy of EBUS-TBNA.

METHODS

Prospective observational study that enrolled 81 patients who underwent EBUS-TBNA for investigation of hilo-mediastinal lesions or lung cancer staging. The first 41 patients underwent EBUS-TBNA with ROSE (ROSE group) and the last 40 patients without ROSE (non-ROSE group). Sample adequacy and diagnostic accuracy of EBUS-TBNA in both groups were compared.

RESULTS

Adequate samples were obtained in 93% of the patients in the ROSE group and 80% in non-ROSE group (p=0.10). The diagnostic accuracy of EBUS-TBNA was 91% in ROSE group and 83% in non-ROSE group (p=0.08). Analyzing the EBUS-TBNA purpose, in the subgroup of patients who underwent EBUS-TBNA for investigation of hilo-mediastinal lesions, these differences between ROSE and non-ROSE group were higher compared to lung cancer staging, 93% of patients with adequate samples in the ROSE group vs. 75% in the non-ROSE group (p=0.06) and 87% of diagnostic accuracy in ROSE group vs. 77% in non-ROSE group (p=0.10).

CONCLUSIONS

Despite the lack of statistical significance, ROSE appears to be particularly useful in the diagnostic work-up of hilo-mediastinal lesions, increasing the diagnostic yield of EBUS-TBNA.

Clinical challenges of persistent pulmonary air-leaks--case report

Air leaks are a common problem after pulmonary resection and can be a source of significant morbidity and mortality. The authors describe the case of a 68-year-old male patient who presented with a persistent air-leak after pulmonary resection. Watchful waiting, surgical procedures, as well as medical therapy like pleurodesis and implantation of endobronchial one-way valves on the bronchial segments identified using systematic occlusion of the bronchial segments, were all tried unsuccessfully. During that time the patient remained hospitalized with a chest tube. The instillation of methylene blue through the chest tube was used to identify the segments leading to the persistent air-leak; this enabled successful endobronchial valve placement which sufficiently reduced the size of the air-leak so that the chest tube could be removed. Nonsurgical approaches seem promising and, for some patients may be the only treatment option after all conventional treatments have failed or are considered too high risk.

Regulation of cll by interleukin-10 - role of antisense IL-10

The role of IL-10 on the in vitro growth of B cells from patients with B-chronic lymphocytic leukemia (CLL) was investigated. Previous work on a murine model of CLL demonstrated that the malignant B-l cells produce significantly higher levels of IL-10 mRNA than normal B-1 or B cells and antisense oligodeoxynucleotides specific for IL-10 mRNA inhibited their growth. In the present study, peripheral blood cells from CLL patients were found to be varied in the amount of IL-10 mRNA present. Several CLL samples underwent apoptosis in response to culturing in the presence of antisense IL-10. There was a correlation between the levels of IL-IO mRNA and the sensitivity to growth inhibition by antisense IL-10. This may indicate that, antisense IL-10 inhibits cell growth in a sub-population of CLL in which IL-10 is an autocrine cytokine.

Halting the fuse discharge propagation using optical fiber microwires

We report and analyze the halting of the fuse effect propagation in optical fiber microwires. The increase of the mode field diameter in the tapered region decreases the optical intensity resulting in the extinction of the fuse effect. This fiber element presents a low insertion loss and can be introduced in the optical network in order to protect the active equipment from the damage caused by the fuse effect.

Integrated PET/CT in non small cell lung cancer staging--clinical and pathological agreement

INTRODUCTION

Integrated PET/CT has become a fundamental tool in the preoperative assessment of non small lung cancer (NSCLC) providing useful anatomical and metabolic information to characterize tumoral lesions and to detect unsuspected metastatic disease.

AIM

To compare the agreement between clinical and pathological staging before and after the use of PET/CT.

MATERIAL AND METHODS

Retrospective study of patients with NSCLC who underwent potentially curative surgery throughout 10.5 years. Cohen's kappa coefficient was used to evaluate staging agreement.

RESULTS

One hundred and fifty patients were evaluated, 78% males, with a mean age of 65 (±9.6) years. Thirteen percent were submitted to neoadjuvant chemotherapy. PET/CT was performed in 41%. Global agreement between clinical and pathological staging was 51% (kappa=0.3639). There was a statistically significant difference between the staging results in patients who underwent PET/CT, when compared to the subgroup who did not (p=0.003). For those with PET/CT false negatives occurred in less 39%, false positives in more 12% and clinical and pathological staging coincided in more 27%. The overall results reflected an improvement in the agreement between clinical and pathological staging in the PET/CT subgroup (67%, kappa=0.5737 vs 40%, kappa=0.2292). PET/CT accuracy was enhanced when patients re-staged after neoadjuvant therapy were excluded and a substantial staging agreement was obtained for those who had the exam only for staging purposes (73%, kappa=0.6323).

CONCLUSION

Inclusion of PET/CT in NSCLC preoperative assessment improved the accuracy of the clinical staging, with a good level of agreement with pathological staging.