Neoadjuvant palbociclib plus either giredestrant or anastrozole in oestrogen receptor-positive, HER2-negative, early breast cancer (coopERA Breast Cancer): an open-label, randomised, controlled, phase 2 study

BACKGROUND

The development of more potent selective oestrogen receptor antagonists and degraders (SERDs) that can be orally administered could help to address the limitations of current endocrine therapies. We report the primary and final analyses of the coopERA Breast Cancer study, designed to test whether giredestrant, a highly potent, non-steroidal, oral SERD, would show a stronger anti-proliferative effect than anastrozole after 2 weeks for oestrogen receptor-positive, HER2-negative, untreated early breast cancer.

METHODS

In this open-label, randomised, controlled, phase 2 study, postmenopausal women were eligible if they were aged 18 years or older; had clinical T stage (cT)1c to cT4a-c (≥1·5 cm within cT1c) oestrogen receptor-positive, HER2-negative, untreated early breast cancer; an Eastern Cooperative Oncology Group performance status of 0-1; and baseline Ki67 score of at least 5%. The study was conducted at 59 hospital or clinic sites in 11 countries globally. Participants were randomly assigned (1:1) to giredestrant 30 mg oral daily or anastrozole 1 mg oral daily on days 1-14 (window-of-opportunity phase) via an interactive web-based system with permuted-block randomisation with block size of four. Randomisation was stratified by cT stage, baseline Ki67 score, and progesterone receptor status. A 16-week neoadjuvant phase comprised the same regimen plus palbociclib 125 mg oral daily on days 1-21 of a 28-day cycle, for four cycles. The primary endpoint was geometric mean relative Ki67 score change from baseline to week 2 in patients with complete central Ki67 scores at baseline and week 2 (window-of-opportunity phase). Safety was assessed in all patients who received at least one dose of study drug. The study is registered with ClinicalTrials.gov (NCT04436744) and is complete.

FINDINGS

Between Sept 4, 2020, and June 22, 2021, 221 patients were enrolled and randomly assigned to the giredestrant plus palbociclib group (n=112; median age 62·0 years [IQR 57·0-68·5]) or anastrozole plus palbociclib group (n=109; median age 62·0 [57·0-67·0] years). 15 (7%) of 221 patients were Asian, three (1%) were Black or African American, 194 (88%) were White, and nine (4%) were unknown races. At data cutoff for the primary analysis (July 19, 2021), the geometric mean relative reduction of Ki67 from baseline to week 2 was -75% (95% CI -80 to -70) with giredestrant and -67% (-73 to -59) with anastrozole (p=0·043), meeting the primary endpoint. At the final analysis (data cutoff Nov 24, 2021), the most common grade 3-4 adverse events were neutropenia (29 [26%] of 112 in the giredestrant plus palbociclib group vs 29 [27%] of 109 in the anastrozole plus palbociclib group) and decreased neutrophil count (17 [15%] vs 16 [15%]). Serious adverse events occurred in five (4%) patients in the giredestrant plus palbociclib group and in two (2%) patients in the anastrozole plus palbociclib group. There were no treatment-related deaths. One patient died due to an adverse event in the giredestrant plus palbociclib group (myocardial infarction).

INTERPRETATION

Giredestrant offers encouraging anti-proliferative and anti-tumour activity and was well tolerated, both as a single agent and in combination with palbociclib. Results justify further investigation in ongoing trials.

FUNDING

F Hoffmann-La Roche.

Neoadjuvant giredestrant (GDC-9545) plus palbociclib (P) versus anastrozole (A) plus P in postmenopausal women with estrogen receptor–positive, HER2-negative, untreated early breast cancer (ER+/HER2– eBC): Final analysis of the randomized, open-label, international phase 2 coopERA BC study

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Background: Endocrine therapy (ET) is the therapeutic mainstay for ER+ BC. Giredestrant is a highly potent, nonsteroidal, oral, selective ER antagonist and degrader (SERD) which has demonstrated robust ER occupancy, is well tolerated, and has previously shown encouraging antitumor activity as monotherapy and in combination with P in metastatic BC. coopERA BC (NCT04436744) evaluated giredestrant in eBC and met its primary endpoint, highlighting superior Ki67 suppression with single-agent giredestrant vs A at Week 2. Giredestrant was well tolerated. Here, we report the final analysis. Methods: Eligible patients (pts) with measurable ER+/HER2– untreated eBC and baseline Ki67 score ≥5% (202 planned) were randomized 1:1 to receive, on Days 1–14 of a neoadjuvant window-of-opportunity phase, 30 mg oral daily (PO QD) giredestrant or 1 mg PO QD A followed by a 16-week neoadjuvant phase of QD giredestrant or A for four 28-day cycles with 125 mg PO P on Days 1–21. Randomization was stratified by tumor size, baseline Ki67 score, and progesterone receptor status. Endpoints assessed here included Ki67 suppression from baseline to surgery, complete cell cycle arrest (CCCA; Ki67 ≤2.7%) at surgery, objective response rate (ORR), and safety. Results: At final analysis (cutoff: Nov 24, 2021), 112 and 109 pts were randomized to the giredestrant and A arms, respectively (median age: 62 years each; stage I/IIa disease: 60% vs 54%). Consistent with the primary analysis, greater suppression of Ki67 was observed at surgery with giredestrant + P (–81% [95% confidence interval (CI): –86%, –75%]) vs A + P (–74% [95% CI: –80%, –67%]). Similarly, greater CCCA was achieved at surgery with giredestrant + P (20%) vs A + P (14%). ORR was similar between the two arms (giredestrant + P: 50% [95% CI: 40%, 60%]; A + P: 49% [95% CI: 39%, 59%]). ET-related adverse events (AEs) were non-serious and occurred at similar rates between the two arms. Related Grade ≥3 AE rates were also similar at 6% each. Interruption/withdrawal of ET due to AEs was low and similar for both arms. Conclusions: In this final analysis of coopERA BC, the greater suppression of Ki67 with giredestrant vs A observed at Week 2 in the primary analysis was maintained at surgery, and safety data remained consistent with the known safety profile of giredestrant. coopERA BC is the first randomized study to show superior antiproliferative activity of an oral SERD (giredestrant) over an aromatase inhibitor (A) in ER+/HER2– eBC; studies are ongoing to further assess giredestrant’s clinical benefit. Clinical trial information: NCT04436744.

Abstract PD13-06: Neoadjuvant giredestrant (GDC-9545) + palbociclib versus anastrozole + palbociclib in postmenopausal women with estrogen receptor-positive, HER2-negative, untreated early breast cancer: Primary analysis of the randomized, open-label, phase II coopERA breast cancer study

Background Endocrine therapy, the therapeutic mainstay for estrogen receptor-positive breast cancer, targets estrogen receptor activity and/or estrogen synthesis. CDK4/6 inhibitors cause cell cycle arrest and significantly decrease expression of the proliferation biomarker Ki67 when used in conjunction with aromatase inhibitors such as anastrozole. Giredestrant, a highly potent, nonsteroidal, oral, selective estrogen receptor antagonist and degrader, achieves robust estrogen receptor occupancy, is well tolerated, and has encouraging antitumor activity as a monotherapy and in combination with the CDK4/6 inhibitor palbociclib in metastatic breast cancer. coopERA Breast Cancer (NCT04436744) is a phase II study investigating 2 weeks of giredestrant versus anastrozole in a window-of-opportunity phase, followed by 4 months of giredestrant plus palbociclib versus anastrozole plus palbociclib in a neoadjuvant phase in postmenopausal women with estrogen receptor-positive, HER2-negative, untreated early breast cancer. We will report the results of the primary analysis. Methods Eligible patients who had measurable cT1c (≥1.5 cm)-cT4a-c estrogen receptor-positive, HER2-negative, untreated early breast cancer and baseline Ki67 score ≥5% were randomized 1:1 to 1 mg oral, daily anastrozole or 30 mg oral, daily giredestrant on Days 1-14 (window-of-opportunity phase lasting 14 days) followed by daily dosing for four 28-day cycles in combination with 125 mg oral palbociclib on Days 1-21 (neoadjuvant phase lasting 16 weeks) before surgery. Patients were stratified according to T status, Ki67 score, and progesterone receptor status. The primary efficacy endpoint was centrally assessed geometric mean relative Ki67 score change from baseline to Week 2 during the window-of-opportunity phase, which is reflective of the ability of endocrine therapies to suppress tumor-cell proliferation, and is a surrogate marker for clinical outcomes. The secondary efficacy endpoint is complete cell cycle arrest rate (CCCA), defined as Ki67 score ≤2.7%, at Week 2. Safety was also assessed. Results Results of a previous interim analysis (including 83 of the planned 202 patients) demonstrated a greater relative reduction of Ki67 at 2 weeks with giredestrant (reduction from baseline to Week 2 geometric mean = 80%; 95% CI = -85%, -72%) compared with anastrozole (reduction from baseline to Week 2 geometric mean = 67%; 95% CI = -75%, -56%; P = 0.0222). Similarly, consistent Ki67 suppression was observed in patients with baseline Ki67 ≥20% (83% reduction with giredestrant versus 71% reduction with anastrozole) or <20% (65% versus 24% reductions). At Week 2, 25% of tumors exhibited CCCA with giredestrant versus 5.1% with anastrozole (a 20% difference; 95% CI = -37%, -3%). Safety results were consistent with the known safety profile for giredestrant. Fewer patients experienced adverse events (AEs) related to giredestrant (28%) than to anastrozole (38%), and no grade ≥3 AEs or serious adverse events were assessed as related to giredestrant. We will present the results of the primary analysis, which will include data from all enrolled patients, and will report the primary and secondary efficacy endpoints (including patients with Ki67 >20%), and updated safety. Conclusions The study will proceed to the primary analysis. We expect to see encouraging results based on the favorable interim analysis data that demonstrated the superior activity of giredestrant, an oral selective estrogen receptor antagonist and degrader, compared with anastrozole.

Citation Format: Sara A Hurvitz, Vanesa Quiroga, Yeon Hee Park, Aditya Bardia, Vanesa López-Valverde, Jutta Steinseifer, Tharu M Fernando, Gonzalo Spera, Cloris Xue, Peter A Fasching. Neoadjuvant giredestrant (GDC-9545) + palbociclib versus anastrozole + palbociclib in postmenopausal women with estrogen receptor-positive, HER2-negative, untreated early breast cancer: Primary analysis of the randomized, open-label, phase II coopERA breast cancer study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD13-06.

Evaluation of the intra- and inter-method agreement of brain MRI segmentation software packages: A comparison between SPM12 and FreeSurfer v6.0

PURPOSE

The lack of inter-method agreement can produce inconsistent results in neuroimaging studies. We evaluated the intra-method repeatability and the inter-method reproducibility of two widely-used automatic segmentation methods for brain MRI: the FreeSurfer (FS) and the Statistical Parametric Mapping (SPM) software packages.

METHODS

We segmented the gray matter (GM), the white matter (WM) and subcortical structures in test-retest MRI data of healthy volunteers from Kirby-21 and OASIS datasets. We used Pearson's correlation (r), Bland-Altman plot and Dice index to study intra-method repeatability and inter-method reproducibility. In order to test whether different processing methods affect the results of a neuroimaging-based group study, we carried out a statistical comparison between male and female volume measures.

RESULTS

A high correlation was found between test-retest volume measures for both SPM (r in the 0.98-0.99 range) and FS (r in the 0.95-0.99 range). A non-null bias between test-retest FS volumes was detected for GM and WM in the OASIS dataset. The inter-method reproducibility analysis measured volume correlation values in the 0.72-0.98 range and the overlap between the segmented structures assessed by the Dice index was in the 0.76-0.83 range. SPM systematically provided significantly greater GM volumes and lower WM and subcortical volumes with respect to FS. In the male vs. female brain volume comparisons, inconsistencies arose for the OASIS dataset, where the gender-related differences appear subtler with respect to the Kirby dataset.

CONCLUSIONS

The inter-method reproducibility should be evaluated before interpreting the results of neuroimaging studies.

Neoadjuvant Trastuzumab Emtansine and Pertuzumab in Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: Three-Year Outcomes From the Phase III KRISTINE Study

PURPOSE

The KRISTINE study compared neoadjuvant trastuzumab emtansine plus pertuzumab (T-DM1+P) with docetaxel, carboplatin, trastuzumab plus P (TCH+P) for the treatment human epidermal growth factor receptor 2–positive stage II to III breast cancer. T-DM1+P led to a lower pathologic complete response rate (44.4% v 55.7%; P = .016), but fewer grade 3 or greater and serious adverse events (AEs). Here, we present 3-year outcomes from KRISTINE.

METHODS

Patients were randomly assigned to neoadjuvant T-DM1+P or TCH+P every 3 weeks for six cycles. Patients who received T-DM1+P continued adjuvant T-DM1+P, and patients who received TCH+P received adjuvant trastuzumab plus pertuzumab. Secondary end points included event-free survival (EFS), overall survival, patient-reported outcomes (measured from random assignment), and invasive disease-free survival (IDFS; measured from surgery).

RESULTS

Of patients, 444 were randomly assigned (T-DM1+P, n = 223; TCH+P, n = 221). Median follow-up was 37 months. Risk of an EFS event was higher with TDM-1+P (hazard ratio [HR], 2.61 [95% CI, 1.36 to 4.98]) with more locoregional progression events before surgery (15 [6.7%] v 0). Risk of an IDFS event after surgery was similar between arms (HR, 1.11 [95% CI, 0.52 to 2.40]). Pathologic complete response was associated with a reduced risk of an IDFS event (HR, 0.24 [95% CI, 0.09 to 0.60]) regardless of treatment arm. Overall, grade 3 or greater AEs (31.8% v 67.7%) were less common with T-DM1+P. During adjuvant treatment, grade 3 or greater AEs (24.5% v 9.9%) and AEs leading to treatment discontinuation (18.4% v 3.8%) were more common with T-DM1+P. Patient-reported outcomes favored T-DM1+P during neoadjuvant treatment and were similar to trastuzumab plus pertuzumab during adjuvant treatment.

CONCLUSION

Compared with TCH+P, T-DM1+P resulted in a higher risk of an EFS event owing to locoregional progression events before surgery, a similar risk of an IDFS event, fewer grade 3 or greater AEs during neoadjuvant treatment, and more AEs leading to treatment discontinuation during adjuvant treatment.

Neoadjuvant trastuzumab (H), pertuzumab (P), and chemotherapy versus trastuzumab emtansine (T-DM1) and P in human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC): Final outcome results from the phase III KRISTINE study

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Background: KRISTINE compared neoadjuvant chemotherapy plus dual HER2- blockade (HP) with T-DM1 plus P (T-DM1+P), a targeted regimen that omits standard chemotherapy. T-DM1+P resulted in a lower pathologic complete response (pCR) rate, but a more favorable safety profile. Here we present the final outcomes from KRISTINE. Methods: KRISTINE (NCT02131064) was a randomized study of T-DM1+P versus docetaxel, carboplatin, and H plus P (TCHP). Patients with HER2-positive stage II–III BC received 6 cycles of neoadjuvant T-DM1+P or TCHP q3w. Patients receiving T-DM1+P continued adjuvant T-DM1+P; patients receiving TCHP received adjuvant HP, for 12 cycles in each arm. Patients in the T-DM1+P arm without pCR were encouraged to receive standard adjuvant chemotherapy before adjuvant T-DM1+P. Secondary endpoints, analyzed with descriptive statistics, included event-free survival (EFS; all events pre- and post-surgery), invasive disease-free survival (IDFS; invasive events post-surgery), overall survival and safety. Results: At median follow-up of 37 months, EFS favored TCHP (HR = 2.61 [95% CI: 1.36–4.98]), due to more locoregional progression events in the T-DM1+P arm before surgery (6.7% vs 0; Table). pCR was associated with reduced risk of an IDFS event (HR = 0.24 [95% CI: 0.09– 0.60]) regardless of treatment arm. There were 5 deaths (2.3%) in the TCHP arm and 6 (2.7%) in the T-DM1+P arm. There were more grade ≥3 AEs with TCHP but a higher rate of AEs leading to treatment discontinuation with T-DM1+P. Conclusions: EFS numerically favors TCHP due to locoregional progression events with T-DM1+P prior to surgery. T-DM1+P was associated with fewer grade ≥3 AEs but increased treatment discontinuation. Clinical trial information: NCT02131064. [Table: see text]

NATALEE: Phase III study of ribociclib (RIBO) + endocrine therapy (ET) as adjuvant treatment in hormone receptor–positive (HR+), human epidermal growth factor receptor 2–negative (HER2–) early breast cancer (EBC)

TPS597

Background: RIBO is a selective inhibitor of CDK4/6 with demonstrated efficacy and is well tolerated when combined with ET in pre-/peri- and postmenopausal women with HR+, HER2– advanced breast cancer. Given these findings and considering the role of CDK4/6–Rb–E2F pathway dysregulation in ET resistance, there is a rationale for evaluating whether RIBO + ET prevents, or delays acquired resistance to ET in the adjuvant setting, to improve invasive disease-free survival (iDFS). Methods: The phase 3 multicenter, randomized, open-label NATALEE trial will evaluate the efficacy and safety of RIBO + ET as adjuvant treatment in patients with HR+, HER2– EBC. Eligible women (any menopausal status) and men aged ≥ 18 years will be randomized to RIBO 400 mg/day (3 weeks on/1 week off) + ET or ET alone. In both arms, ET will comprise daily continuous letrozole 2.5 mg/day or anastrozole 1 mg/day; men and premenopausal women will also receive goserelin 3.6 mg once every 28 days. Treatment with RIBO will last 36 months whereas treatment with ET (in both arms) will last 60 months. Patients must have had American Joint Committee on Cancer (8th ed.) Anatomic Stage II (either N0 with grade 2-3 and/or Ki67 ≥ 20% or N1) or III EBC, with an initial diagnosis ≤ 18 months prior to randomization, and completed chemotherapy and radiotherapy (if indicated). Patients receiving standard (neo)adjuvant ET are eligible only if this treatment was initiated within 12 months of randomization. Key exclusion criteria include previous CDK4/6 inhibitor treatment and clinically significant, uncontrolled heart disease and/or cardiac repolarization abnormality. The primary endpoint is iDFS using STEEP (Standardized Definitions for Efficacy End Points) criteria as assessed by the investigator; secondary endpoints include recurrence-free survival, distant DFS, overall survival, patient-reported outcomes, and RIBO pharmacokinetics. Safety and tolerability will also be evaluated. Estimated enrollment is 4000 patients from 425 sites in 21 countries. Recruitment is ongoing. Clinical trial information: NCT03701334.

Abstract PD3-12: Central nervous system as first site of relapse in patients with HER2 positive early breast cancer treated in the BCIRG-006 trial

Introduction: Central Nervous System (CNS) metastases as first site of relapse is seen in 2-3% of patients with HER2+ early breast cancer (EBC) during or after treatment with adjuvant trastuzumab. Data about long-term follow-up outcomes in this population is scarce. Methodology: BCIRG-006 was designed to assess the efficacy and safety of two trastuzumab-based regimens compared to a standard (non-trastuzumab) regimen in the adjuvant treatment of HER2+ EBC. 3,222 patients were randomized to standard AC-T or two trastuzumab-based regimens (AC-TH or TCH). Ten year follow-up outcomes were previously presented; we have used this data to assess the frequency and course of CNS relapses as first site of distant recurrence. DFS and OS in these patients were estimated and compared using the Kaplan-Meier method and Log-Rank test respectively. Univariate and multivariate analyses for DFS were conducted considering patient's age, nodal status, tumor size and estrogen receptor (ER) status in the primary tumor. Results: Of the 3,222 patients randomized, 575 (17.8%) experienced a distant relapse and in 17.5% of these (n=101) CNS was the first site of recurrence. With a median follow-up of 10.3 years, the frequency of CNS relapses did not differ when comparing the trastuzumab containing arms with the control arm (OR 0.86, 95% CI: 0.56-1.33; p= 0.519). No difference was observed either between AC-TH and TCH (OR 1.14, 95% CI: 0.67-1.94; p= 0.704). There were no differences in DFS (HR 1.21, 95% CI: 0.74-1.99; p= 0.621) nor in OS (HR 0.74, 95% CI: 0.43-1.27; p= 0.377) between AC-T, AC-TH and TCH arms. Positive axillary nodes (≥4 nodes) and ER negative status at baseline remained independent risk factors for CNS relapse after univariate and multivariate analysis (HR 0.60, 95% CI: 0.8-0.95; p= 0.007 for nodal status and HR 0.56, 95% CI: 0.37-0.85; p= 0.029 for ER status). Conclusion: Among the pivotal adjuvant trastuzumab trials, BCIRG-006 is the one with the longest median FUP in which data about CNS relapses has been presented. CNS relapse in patients in this trial was an infrequent event. Its frequency and outcomes were similar across the three treatment arms. Patients with ER negative and/or ≥ 4 positive nodes are at higher risk of CNS relapse irrespective of trastuzumab therapy and may be the patient population where research efforts should be focused.

BC outcomes in patients with CNS metastases per treatment arm in the BCIRG-006 trial AC-T N=1073 n(%)AC-TH N=1074 n(%)TCH N=1075 n(%)p valueFrequency of CNS relapse37 (3.44%)30 (2.79%)34 (3.16%)0.519 ^Median DFS (months; 95% CI)23.8 (13.3-30.4)19.9 (16.6-25.1)19.9 (15.0-27.2)0.621 ⫲Median OS (months; 95% CI)42.5 (28.3-62.7)53.2 (31.2-103.6)30.3 (23.4-39.0)0.377 ⫲

^ comparing control vs. trastuzumab-containing arm using Fisher's Exact test.

⫲ comparing control vs. trastuzumab-containing arms using Log Rank test.

Citation Format: Chan A, Spera G, Machado A, Fung H, Bee V, Fresco R, Slamon DJ. Central nervous system as first site of relapse in patients with HER2 positive early breast cancer treated in the BCIRG-006 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 PD3-12.

Abstract P2-03-07: Backwards translation: Exploring beta-adrenoreceptors (ßAR) in triple negative breast cancer (TNBC), a novel and druggable pathway

Introduction: several retrospective studies suggest that ßAR blocking drugs (BB) are associated with improved survival in patients with a wide range of cancers. Recently, we retrospectively showed an association between BB intake and improved progression free survival in patients with HER2 negative advanced breast cancer (BC), particularly striking in triple-negative disease (TNBC) (Reference). Based on this finding we decided to conduct an in silico study in which we have interrogated ßARs in a publicly available BC sample database and the Translational Oncology Research Lab (TORL) translational platform with a genomic, transcriptomic and proteomic approach. Methodology: genomic and transcriptomic data sets for ßAR 1, 2 and 3 were retrieved from cBioPortal considering all BC samples available with this information in The Cancer Genome Atlas (TCGA). Transcriptomic and proteomic data sets from 48 BC cell lines obtained from TORL were queried for ßARs as well and used with validation and exploratory intent. Mutations, amplifications and deletions were queried in DNA; gene expression profiles were interrogated using RNAseq data together with protein expression by RPPA. Average expression, log ratio and fold change in mRNA and Reverse Phase Protein Array (RPPA) quantitative assessments for corresponding proteins were noted. BC cell lines with top 10 mRNA and protein levels of ßAR 1, 2 and 3 were identified. Results: CBioPortal DNA data shows ß AR1 amplified in 1-10% and deleted in 0,4%; ß-AR2 amplified in 1-3% and deleted in 0,1%; ß-AR3 amplified in 15-20% and deleted in 2% of the BC samples. CBioPortal mRNA data shows ß-AR1 is upregulated in 2.7% (mostly Progesterone Receptor negative BC); ßAR2 is upregulated in 4% (mostly TNBC); ßAR3 is upregulated in 4% (mostly HER2 negative BC) in BC samples. TORL cell line panel shows that ßARs are heterogeneously expressed between the BC cell lines (fold change range: ßAR 1 2.015-3.636; ßAR2 2.545-8.248; ßAR3 1.809-2.444). Within the 10 BC cell lines with highest ßAR1 and ßAR2 expression, 7(COLO-824, HCC1937, BT-549, BT-20, HCC1599, HCC1143, HCC1806) and 6 (184A1, MDA-MB-231, 184B5, HCC1806, MCF-10A and MDA-MB-468) of them respectively correspond to the basal BC subtype. RPPA identifies caveolin 1, PAI 1, EGFR and Bax as the proteins with the higher co-expression with ßAR1 and ßAR2. Conclusions: DNA alterations are infrequent in ßARs in BC samples. Transcriptional mRNA data from BC samples shows ßARs mostly expressed in non-luminal BC subtypes, being ßAR 2 the one with highest expression. In silico data results from BC cell line panel show ßAR 1 and ßAR 2 are highly expressed in basal BC subtype. The above data suggest that ßAR, and ßAR 2 in particular could be a relevant target to explore in in vivo BC models.

Table 1:mRNA and RPPA in BC cell linesCell lineAverage mRNALog RatioFold ChangeCaveolin 1PAI1EGFR184A1313173.048.244.183.411.72SUM-190223292.811.03-1.37-0.570.09MDA-MB-231151002.997.993.853.251.57184B5130121.973.933.902.361.82HCC1806124112.375.193.750.491.67MCF-10A119122.194.583.892.670.08ZR-75-3093001.893.72-1.51-0.61-0.25JIMT-163541.593.013.082.010.81MDA-MB-41562391.242.370.96-0.39-0.13MDA-MB-46862801.342.541.06-0.251.72

Citation Format: Spera G, Von Euw E, Fresco R, Slamon DJ. Backwards translation: Exploring beta-adrenoreceptors (ßAR) in triple negative breast cancer (TNBC), a novel and druggable pathway [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 P2-03-07.

Intensive Imaging Surveillance of Survivors of Breast Cancer May Increase Risk of Radiation-induced Malignancy

BACKGROUND

Current clinical guidelines recommend mammography as the only imaging method for surveillance in asymptomatic survivors of early breast cancer (EBC). However, non-recommended tests are commonly used. We estimated the imaging radiation-induced malignancies (IRIM) risks in survivors of EBC undergoing different imaging surveillance models.

MATERIALS AND METHODS

We built 5 theoretical models of imaging surveillance, from annual mammography only (model 1) to increasingly imaging-intensive approaches, including computed tomography (CT) scan, positron emission tomography-CT, bone scan, and multigated acquisition scan (models 2 through 5). Using the National Cancer Institute's Radiation Risk Assessment Tool, we compared the excess lifetime attributable cancer risk (LAR) for hypothetical survivors of EBC starting surveillance at the ages of 30, 60, or 75 years and ending at 81 years.

RESULTS

For all age groups analyzed, there is a statistically significant increase in LAR when comparing model 1 with more intensive models. As an example, in a patient beginning surveillance at the age of 60 years, there is a 28.5-fold increase in the IRIM risk when comparing mammography only versus a schedule with mammography plus CT scan of chest-abdomen and bone scan. We found no differences when comparing models 2 through 5. LAR is higher when surveillance starts at a younger age, although the age effect was only statistically significant in model 1.

CONCLUSION

Non-recommended imaging during EBC surveillance can be associated with a significant increase in LAR. In addition to the lack of survival benefit, additional tests may have significant IRIM risks and should be avoided.

Abstract P3-17-01: Geographic variation in adverse event reporting patterns in breast cancer clinical trials

Introduction: Adverse event (AE) reporting in clinical trials (CT) informs the safety of investigational products. Once approved, safety information in the monograph and prescribing information mainly derive from CT data. Some studies have shown geographic variations in the AE reporting patterns in multinational CT; none of them assessed this variation in cancer CT. We conducted a study to analyze the geographic AE reporting patterns in two breast cancer (BC) CT conducted by Translational Research in Oncology (TRIO).

Objective: To perform a quantitative and qualitative comparison of non-serious AE (NSAE) and serious AE (SAE) reporting patterns between several geographic regions, in breast cancer CT conducted by TRIO.

Methodology: We retrospectively analyzed aggregated NSAE/SAE data (as reported by investigators) from all patients randomized in two completed phase 3, multinational CT of anticancer therapies in advanced BC. Participating countries were grouped in 7 regions according to their geographic location (East Asia, Eastern Europe, Latin America and Caribbean, Middle East and Africa, Non-Eastern Europe, North America, Oceania). Regions were kept masked and numbered from 1 thru 7. AE data were extracted from the clinical data bases. For each region we calculated the mean number of NSAE and SAE per patient (pt), the mean number of NSAE and SAE per cycle/per pt, and the percentage (%) of pt experiencing selected AE (fatigue, febrile neutropenia and emesis). Comparisons between regions were done using unequal variance t-test and Fisher´s exact test.

Results: 1,863 patients from 35 countries and 310 sites were included. Mean number of pt per region was 331. We found significant variation in the number of NSAE/SAE reported across several regions. Two regions (1 and 6) reported the highest mean number of AE while region 4 the lowest rates. The mean number of NSAE reported in region 4 is approximately 3-fold lower than regions 1 and 6 (mean NSAE 22.8 [region 1] vs. 7.9 [region 4]; p <.0001; mean NSAE cycle/pt 9.7 [region 1] vs. 3.2 [region 4]; p <.0001). Region 4 reported 8-fold lower rates of SAE than region 1 (mean number SAE 0.1 vs. 0.8, p<.0001) (Table 1). % of pt experiencing AE fatigue, febrile neutropenia and nausea/vomiting also varied significantly across regions, especially between regions 1 and 4 (Table 2).

NSAE and SAE reporting in selected regions (regions 1 and 4) Region 1 (mean)Region 4 (mean)p-valueNSAE per pt22.87.9<.0001SAE per pt0.80.1<.0001NSAE per cycle/per pt9.73.2<.0001SAE per cycle/per pt0.10.03<.0001

Beta blockers and improved progression-free survival in patients with advanced HER2 negative breast cancer: a retrospective analysis of the ROSE/TRIO-012 study

BACKGROUND

Recent retrospective studies suggest that beta-adrenergic blocking drugs (BB) are associated with improved outcomes in patients with a range of cancers. Although limited and discordant data suggest that BB may increase overall survival (OS) in localized breast cancer (BC), there is no information on the effects of BB in women with advanced BC.

PATIENTS AND METHODS

To explore the association between BB use and BC outcomes, we retrospectively reviewed ROSE/TRIO-012, a double-blinded, multinational phase III trial that randomized 1144 patients with HER2-negative advanced BC to first-line docetaxel in combination with ramucirumab or placebo. We compared progression-free survival (PFS), OS, overall response rate, and clinical benefit rate in patients who received BB to those who did not.

RESULTS

153/1144 (13%) patients received BB; 62% prior to enrolment and 38% began after enrolment. Median PFS in BB treated patients was longer than in patients who did not receive them (10.3 versus 8.3 months; HR 0.81; 95% CI 0.66-0.99; P = 0.038). Patients treated with BB only after enrolment had even higher median PFS (15.5 versus 8.3 months, P < 0.001). In the TNBC subset, median PFS was 13.0 months with BB, compared to 5.2 months without BB (HR 0.52; 95% CI 0.34-0.79; P = 0.002). The benefit of BB intake in PFS was independent of treatment-emergent hypertension (P = 0.476) but associated with treatment arm (P = 0.037). The test for interactions between BB and treatment arm was not significant (P = 0.276). No differences were seen in OS, overall response rate, or clinical benefit rate. A validation dataset analysis had consistent but less substantial improved outcomes for women with node positive operable breast cancer receiving BB in the BCIRG-005 trial.

CONCLUSIONS

In this exploratory analysis, BB intake was associated with significant improvement in PFS, particularly in patients with TNBC and patients not previously exposed to BB.

CLINICAL TRIAL NUMBER

NCT00703326.

5α-Reductases and Their Inhibitors

5α reductase is a key enzyme in androgen metabolism. Altered enzyme function and/or regulation is responsible for numerous human pathologies such as benign prostatic hyperplasia, acne, hirsutism and male pattern baldness. In order to block androgen action through inhibition of this enzyme, numerous compounds have been synthesized during the past two decades. Among them, 4-azasteroids and in particular finasteride have been extensively studied and used in the treatment of human diseases.

Abstract P6-01-01: Impact of imaging surveillance on the risk of radiation induced malignancies in breast cancer survivors

Introduction: After curative treatment of breast cancer (BC), relevant clinical guidelines recommend against the use of imaging procedures other than yearly mammography for surveillance, based on the lack of survival benefit for intensive surveillance strategies. Nevertheless, use of non-recommended imaging tests occurs frequently in this context. Most BC surveillance studies have focused on the potential benefit of detection of early relapse, on financial burden, and risk of false positives with different follow-up regimens. No study has analyzed the risk of imaging radiation induced malignancies (IRIM) in BC survivors exposed to repeated body imaging during surveillance. We previously reported on the IRIM risk in the BC clinical trials setting (Fresco R. The Oncologist 2015). In this current study we report on this risk during surveillance in clinical practice in BC survivors.

Objective: To estimate IRIM risk in patients curatively treated for BC undergoing imaging tests during surveillance.

Methodology: We defined 6 surveillance strategies with differing imaging requirements, from a non imaging-intensive one (yearly mammography only) to intensive ones (mammography + CT, Bone scan, PET-CT and/or MUGA) (Table 1). For each strategy we calculated the imaging dose and excess lifetime attributable cancer risk (LAR) for a 60 year-old BC survivor, using NCI's Radiation Risk Assessment Tool (RadRat).

Results: Total effective imaging radiation dose received by a 60 year-old BC survivor during surveillance was 8.4 miliSieverts (mSv) when only yearly mammography is performed to 199.9 mSv when CT, MUGA and bone scan are added. Mean IRIM LAR ranges from 37.2/100,000 with the first strategy to 1,330/100,000 with the latter. Performing MUGA scans increased IRIM risk 31% compared to not performing it. The addition of any additional radiating imaging procedure to yearly mammography significantly increases LAR.

Imaging effective dose and LAR in different surveillance strategiesFollow-up strategyImaging effective dose (mSv)Excess lifetime attributable cancer risk: mean (90% uncertainty range) (/100,000)Yearly mammography only8.437.2 (21.4-60.3)Yearly mammography + Chest/abdomen CT q6mo for 3y, then annually for 2y128.4857.0 (503.0-1,350.0)Yearly mammography + Chest/abdomen CT q6mo for 3y, then annually for 2y + Bone scan q12mo for 5y159.91,060.0 (603.0-1,640.0)Yearly mammography + Chest/abdomen CT q6mo for 3y, then annually for 2y + MUGA q6mo for 2y168.41,130.0 (642.0-1,800.0)Yearly mammography + Chest/abdomen CT q6mo for 3y, then annually for 2y + MUGA q6mo for 2y + Bone scan q12mo for 5y199.91,330.0 (792.0-2,080.0)Yearly mammography + PET-CT q6mo for 3y, then annually for 2y184.41,310.0 (802.0-1,990.0)

Conclusions: A number of incremental second cancers could be derived from imaging performed during BC surveillance after curative treatment. Addition of non-recommended imaging for relapse detection increases IRIM risk compared to performing only mammography. This, in addition to the lack of proven benefit in BC endpoints, emphasizes the need to follow recommendations for surveillance clinical guidelines, and forgo imaging studies other than annual mammography to detect relapses. Substituting MUGA with echocardiogram for cardiac assessment could also reduce IRIM risk.

Citation Format: Spera G, Gonzalez V, Meyer C, Fung H, Mackey JR, Fresco R. Impact of imaging surveillance on the risk of radiation induced malignancies in breast cancer survivors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-01-01.

Imaging Radiation Doses and Associated Risks and Benefits in Subjects Participating in Breast Cancer Clinical Trials

BACKGROUND

Medical imaging is commonly required in breast cancer (BC) clinical trials to assess the efficacy and/or safety of study interventions. Despite the lack of definitive epidemiological data linking imaging radiation with cancer development in adults, concerns exist about the risks of imaging radiation-induced malignancies (IRIMs) in subjects exposed to repetitive imaging. We estimated the imaging radiation dose and IRIM risk in subjects participating in BC trials.

MATERIALS AND METHODS

The imaging protocol requirements in 10 phase III trials in the adjuvant and advanced settings were assessed to estimate the effective radiation dose received by a typical and fully compliant subject in each trial. For each study, the excess lifetime attributable cancer risk (LAR) was calculated using the National Cancer Institute's Radiation Risk Assessment Tool, version 3.7.1. Dose and risk calculations were performed for both imaging intensive and nonintensive approaches to reflect the variability in imaging performed within the studies.

RESULTS

The total effective imaging radiation dose was 0.4-262.2 mSv in adjuvant trials and 26-241.3 mSv in metastatic studies. The dose variability resulted from differing protocol requirements and imaging intensity approaches, with computed tomography, multigated acquisition scans, and bone scans as the major contributors. The mean LAR was 1.87-2,410/100,000 in adjuvant trials (IRIM: 0.0002%-2.41% of randomized subjects) and 6.9-67.3/100,000 in metastatic studies (IRIM: 0.007%-0.067% of subjects).

CONCLUSION

IRIMs are infrequent events. In adjuvant trials, aligning the protocol requirements with the clinical guidelines' surveillance recommendations and substituting radiating procedures with equivalent nonradiating ones would reduce IRIM risk. No significant risk has been observed in metastatic trials, and potential concerns on IRIMs are not justified.

IMPLICATIONS FOR PRACTICE

Medical imaging is key in breast cancer (BC) clinical trials. Most of these procedures expose patients to ionizing radiation, and the risk of second cancer development after imaging has prompted recent concerns and controversy. Using accepted calculation models, the number of malignancies were estimated that were potentially attributable to the imaging procedures performed during a patient's participation in BC clinical trials. The results show that for patients participating in metastatic trials, the risk of imaging radiation-induced malignancies is negligible. In adjuvant trials, some second cancers due to imaging could be expected, and measures can be taken to reduce their risk.

Efficacy and safety of two different testosterone undecanoate formulations in hypogonadal men with metabolic syndrome

AIM

To investigate efficacy and safety of two different preparations of testosterone undecanoate (TU) in 52 hypogonadal men [mean age 57 yr and mean testosterone (T) < 320 ng/dl] with metabolic syndrome (MS).

SUBJECTS AND METHODS

Randomized, double-blind, double-dummy study with three parallel treatment arms [oral TU; transdermal placebo gel (P); im TU] administration for 12 months (mo). Each subject was randomized (1:1:3) to receive either oral TU (2 capsules of 40 mg/twice per day at breakfast and dinner, equalling a total dose of 160 mg/day; no.=10) for 6 mo and continued with im TU for further 6 mo, or P (3-4 g/day; no.=10) and im TU (1000 mg/12 weeks from week 6; no.=32) for 12 mo.

RESULTS

After 6 mo, im TU increased T and free- T levels (p<0.0001), and improved metabolic parameters [reduction in Homeostasis Model Assessment (HOMA) index, p<0.0001; waist circumference and fat mass, p<0.001, respectively], in International Index of Erectile Function-5 and Aging Males' Symptoms scores (p<0.01, respectively). After 12 months, im TU produced further increases in T and free- T levels (p<0.0001) and metabolic parameters (reduction in HOMA-index, p<0.0001; waist circumference p<0.0001; fat mass, p<0.001). No major adverse event due to T treatment occurred.

CONCLUSIONS

Clinical efficacy of T replacement therapy in hypogonadal men with MS is reached when its plasmatic levels approach into the medium-high range of normality (>5 ng/ml), although subjective threshold values may be different. Administration of im TU was more effective than oral TU to reach the target for T levels and to improve MS parameters. TU was safe over 12 months and discontinuation rates were similar to placebo.

Is obesity protective for osteoporosis? Evaluation of bone mineral density in individuals with high body mass index

BACKGROUND

Obese individuals often present comorbidities while they appear protected against the development of osteoporosis. However, few and contradictory data are now available on skeletal modifications in obese patients. The aim of this study was to characterise bone mineral density (BMD) in overweight (BMI > 25 < 29.9) and obese (BMI > 30) patients.

METHODS

We selected 398 patients (291 women, 107 men, age 44.1 + 14.2 years, BMI 35.8 + 5.9 kg/m(2)) who underwent clinical examination, blood tests and examination of body composition. Subjects with chronic conditions or taking medications interfering with bone metabolism, hormonal and nutritional status and recent weight loss were excluded.

RESULTS

Interestingly, 37% (n = 146) of this population showed a significantly lower than expected lumbar BMD: 33% (n = 98) of women showed a T-score -1.84 +/- 0.71, and 45% (n = 48) of men showed a T-score -1.88 +/- 0.64. When the population was divided into subgroups based on different BMI, it was noted that overweight (BMI > 25 < 29.9) was neutral or protective for BMD, whereas obesity (BMI > 30) was associated with a low bone mass, compatible with a diagnosis of osteoporosis. No differences were observed in hormones and lipid profiles among subgroups.

CONCLUSIONS

Our results indicate that a subpopulation of obese patients has a significant low lumbar BMD than expected for age. Thus, a careful characterisation of skeletal metabolism might be useful in all obese individuals to avoid fragility fractures later in life.

Family history of breast cancer (BC) and biological and clinicopathologic features in Uruguayan BC patients

e11622

Background: Hereditary BC can have a distinct phenotype and behavior in comparison to sporadic BC. The aim of the present study was to investigate if there is any difference in the age at diagnosis, disease extension and biological profile in BC patients (pts) with or without a significant family history of BC. Methods: We retrospectively reviewed clinical charts of BC pts, stage 0- III who had surgery between March 2006 and March 2008. We included pts with known estrogen receptor (ER), progesterone receptor (PR) and HER2 status. The family history was obtained from the clinical charts and confirmed by a telephone interview with a standardized questionnaire. A significant family history of BC was defined by the presence of one of the following criteria: (1) 3 or more BC cases among close relatives, at least one diagnosed before 50 years (2) 2 BC cases among close relatives, at least one diagnosed before 50 years and one of the following: bilateral BC, ovarian cancer diagnosed in the family, male BC, father´s inheritance, Ashkenazi Jewish ancestry Results: 435 pts were identified, with available data on ER/PR and HER2 status in 197 pts. Family history was evaluated in 136 pts (69%) and was classified as significant in 18 (13.2%). Between pts with and without a significant family history of BC cancer there were no difference in the proportion of pts < 50 years old at diagnosis (0.36 vs. 0.39), T3/T4 tumours (0.08 vs. 0.11), axillary node positivity (0.55 vs 0.66), ER/PR+ (0.77 vs. 0.72), HER2 + (0.11 vs. 0.11) and triple negative tumors (0.19 vs 0.17). Conclusions: our data does not show any difference in the main prognostic and predictive factors between operable BC pts with and without a significant family history of BC. These findings are concordant with previous published data about a greater prevalence of BRCA2 mutations in Uruguayan families.

No significant financial relationships to disclose.

Plasma adrenomedullin and endothelin-1 levels are reduced and Raynaud's phenomenon improved by daily tadalafil administration in male patients with systemic sclerosis

The aim of our study is to evaluate in Systemic Sclerosis (SSc) male patients the tadalafil effects on Raynaud's phenomenon and on AM and ET-1 plasma levels. In an open-label study 20 consecutive male patients with SSc were enrolled and received 10 mg of tadalafil daily for 12 weeks. The primary endpoint was the subjective reduction of frequency and duration of Raynaud's attacks measured with a 10-point Raynaud's Condition Score; the secondary aim was to modify Adrenomedullin (AM) and Endothelin-1 (ET-1) plasma levels. After the treatment Raynaud's phenomenon was improved by once-daily tadalafil (decrease of mean number of Raynaud's attacks and of Raynaud's Condition Score) and plasma AM and ET-1 levels decreased. The results of our study lead us to postulate the beneficial effect of adding long term inhibition of Phosphodiesterase type 5 to Systemic Sclerosis' therapy.

Randomized phase II clinical trial of chemo-immunotherapy in advanced nonsmall cell lung cancer

The purpose of this study was to compare chemotherapy-naive patients with stage IV nonsmall cell lung cancer patients treated with chemotherapy or chemoimmunotherapy. We tested doxetacel plus cisplatinum as chemotherapy protocol. An immunomodulatory adjuvant system was added as chemoimmunotherapy to the previously mentioned protocol. This system contains three well-known and complementary conditioners of protective immune-responses: cyclophosphamide low-dose, granulocyte macrophage-colony stimulant factor and magnesium silicate granuloma. Eighty-eight patients were randomly assigned to receive every 3-weeks one of the treatments under comparison. Patients received four cycles of treatment unless disease progression or unacceptable toxicity was documented. The maximum follow-up was one year. In each arm, tumor response (rate,duration), median survival time, 1-year overall survival, safety, and immunity modifications were assessed. Immunity was evaluated by submitting peripheral blood mononuclear cells to laboratory tests for nonspecific immunity: a) phytohemaglutinin-induced lymphocyte proliferation, b) prevalence of T-Regulatory (CD4+CD25+) cells and for specific immunity: a) lymphocyte proliferation induced by tumor-associated antigens (TAA) contained in a previously described autologous thermostable hemoderivative. The difference (chemotherapy vs. chemoimmunotherapy) in response rate induced by the two treatments (39.0% and 35.0%) was not statistically significant. However, the response duration (22 and 31 weeks), the median survival time (32 and 44 weeks) and 1-year survival (33.3% and 39.1%) were statistically higher with chemoimmunotherapy. No difference in toxicity between both arms was demonstrated. A switch in the laboratory immunity profile, nonspecific and specific, was associated with the chemoimmunotherapy treatment: increase of proliferative lymphocyte response, decrease of tolerogenic T-regulatory cells and eliciting TAA-sensitization.

Efficacy of tadalafil once daily in men with diabetes mellitus and erectile dysfunction

AIMS

Erectile dysfunction (ED) is a common comorbidity in men with diabetes mellitus. Tadalafil 10 or 20 mg taken on demand is efficacious and safe for men with diabetes and ED. Recently, continuous treatment with tadalafil has been proposed, addressing ED management as any other chronic condition. This study examined whether once-daily tadalafil 2.5 and 5 mg is efficacious for men with diabetes and ED.

METHODS

This randomized, double-blind, placebo-controlled, multicentre, 12-week study enrolled 298 men with diabetes and ED to once-daily treatment with placebo, tadalafil 2.5 mg or tadalafil 5 mg. Primary efficacy measures were International Index of Erectile Function Erectile Function (IIEF EF) Domain score, and patient success rates for vaginal penetration and completion of intercourse. Patient satisfaction, endothelial function biomarkers, and safety were also assessed.

RESULTS

Patients receiving either dose of tadalafil had clinically and statistically significant improvements in IIEF EF and statistically significant improvements in mean success rates for vaginal penetration, completion of intercourse, and overall treatment satisfaction (P < or = 0.005 tadalafil vs. placebo, all measures). Endothelial dysfunction biomarkers were unchanged. The most common adverse events were headache, back pain and dyspepsia.

CONCLUSIONS

In this first study of men with diabetes and ED, once-daily tadalafil 2.5 and 5 mg was efficacious and well tolerated, suggesting this may be an alternative to on-demand treatment for some men, eliminating the need to plan sex within a limited timeframe.

Control of downy mildew on grapes in organic viticulture

Few active substances with fungicide activity can be used in organic farming, above all copper and sulphur. The copper is the only substance that can be used against downy mildew; however, since it causes problems of environmental impact, incompatible with organic farming's objective of environmentally friendly farming, the Commission of the European Communities has fixed a ceiling on use expressed in terms of kilograms of copper per hectare per year (Regulation EC n. 473/2002). In order to identify natural products that are able to carry out an anti-downy mildew activity, and to evaluate the effectiveness of low rate copper formulations that can reduce the quantities of copper compound, four-year experimental trials were carried out in organic vineyards. The trials have been carried out according to the Guidelines EPPO/OEPP PP 1/31 (3). Among the low rate copper formulations, copper hydroxide and copper sulphate have been tested. Among the natural substances alternative to copper formulations we have tested: phytostimulant, homeopathic products, acid clay-based products (bentotamnio), resistance promoters (chitosan and lignosulfonate), plant extracts (orange extract, propolis and equisetum) and potassium bicarbonate. All natural substances, with the exception of plant extracts and potassium bicarbonate, were tested in association with low rate copper formulations. In the trials it has been possible to test the effectiveness of different formulations in condition of high, medium and low pressure of Plasmopara viticola (Berk. et Curt.) Berl. et De Toni. Both the copper compounds and the natural products were able to guarantee a satisfactory protection in condition of low and medium pressure of downy mildew. The trial carried out in 2004 was characterized by high pressure of P. viticola; under this condition only the copper formulations produced a satisfactory protection against downy mildew. However, in 2004, we tested only two products alternative to copper compounds. Further studies are needed to verify if the formulations alternative to copper, that gave good results in condition of low and medium pressure of P. viticola, are able to guarantee a satisfactory protection even in condition of high pressure of downy mildew. We would like to highlight that in the four-years of trials the copper formulations tested always guaranteed a metallic copper quantity under 6 kg/ha that is the maximum limit of use/year imposed by Regulation EC n. 473/2002.

Optimization of plant protection products treatments against Plasmopara viticola

Plant protection in conventional farming, and even more so in organic farming, requires careful and prudent action agro-environmental monitoring and epidemic risk assessment. Often, however, the plant protection products are distributed in a non-targeted way, even when reduced incidence of pests do not require any treatment. In order to optimize the treatments against downy mildew, multi-annual field trials, both in conventional and organic vineyards, have been carried out. In all farms were considered 3 thesis: 1 untreated control thesis (Test), in order to follow the coarse of infection, 1 standard farm reference thesis (St), where the treatments were carried out according to the usual farm procedures and 1 experimental thesis (X). Guideline EPPO/OEPP PP 1/31 (3) have been carried out. We monitored different environmental parameters capable to influence Plasmopora viticola (Berk. and Curt.) Berl. and De Toni development. In fact by a network of RTUs (Remote Terminal Units) distributed all over the vineyards transmitting every 15 minutes via radio or via GPRS to a centralized Data Base 12 environmental parameters: time, data, precipitation, soil temperature, solar radiation, wind direction, wind speed, atmospheric relative humidity, atmospheric temperature, leaf wetness, soil humidity to cm 20 and soil humidity to cm 40. In different phenological growth stages we carried out careful disease assessments on leaves and bunches to evaluate the onset and development of P. viticola. We have studied the downy mildew infections through monitoring the environmental parameters, knowledge of P. viticola biological cycle, the evaluation of cultivar sensibility, the agricultural production method and the area characteristics, to try to optimize the anti- downy mildew treatments. The achieved results have underlined the possibility to obtain a satisfactory protection against P. viticola by correct placing of treatments. In experimental thesis (X) the number of treatments was generally lower than the number made on the thesis standard (ST), with efficacy comparable if not better. This result is most evident in conventional farms where surveillance is less accurate because is can also use plant protection products with a curative action. The trial showed the possibility of obtaining real cost containment management and a lower environmental impact associated with reduced fungicidal treatments.

Chronic administration of Sildenafil improves markers of endothelial function in men with Type 2 diabetes

OBJECTIVE

Diabetic patients have a reduced endothelial response to phosphodiesterase-5 inhibitors. The aim of this study was to determine the effects of chronic therapy with sildenafil on endothelial function in patients with Type 2 diabetes mellitus (DM2).

METHODS

In a double-blind, placebo-controlled parallel design, 20 patients without erectile dysfunction randomly received a loading dose of sildenafil (100 mg) for 3 days, followed by either sildenafil 25 mg three times a day (t.d.s.) for 4 weeks or sildenafil 25 mg t.d.s. for 4 days followed by placebo t.d.s. for 3 weeks.

RESULTS

After 1 week, flow-mediated dilatation (FMD) improved significantly (> 50% compared with baseline) in patients allocated to both sildenafil arms (62 and 64%, respectively). In patients allocated to chronic sildenafil, a progressive increase in percentage of patients with FMD improvement was noted (78, 86 and 94% at 2, 3 and 4 weeks, respectively) while a progressive decrease in the placebo group occurred (45, 18 and 6% at 2, 3 and 4 weeks, respectively). At the end of the study, a significant improvement in FMD compared with baseline was noted after chronic sildenafil (FMD from 6.8 +/- 0.5 to 12.5 +/- 0.7%, P = 0.01 vs. baseline). A decrease in endothelin-1 levels and an increase in nitrite/nitrate levels were found after chronic sildenafil; significant changes from baseline in C-reactive protein, interleukin 6, intercellular adhesion molecule and vascular adhesion molecule levels were also found.

CONCLUSIONS

In DM2 patients, daily sildenafil administration improves endothelial function and reduces markers of vascular inflammation, suggesting that the diabetes-induced impairment of endothelial function may be improved by prolonged phosphodiesterase-5 inhibition.

[Occupational risk stress in shift workers]

Aim of our study was to assess the stress risk at work in a group of nurses. 197 workers (nurses, auxiliary, physiotherapists, midwives and technicians of laboratory) were enrolled divided in two sets respectively of 100 people (subset A) with daily and nightly shifts and 97 (subset B) only daily workers. The mean age was 43.29 years (DS +/- 8.13) in subset A and 46.85 years (DS +/- 7.48) in subset B. For the survey S-90, a questionnaire composed by 90 items faces to frame some of the possible factors of risk has been used and the relative effects on health's state induced by the occupational stress were analyzed. The results show a possible greater risk of daily sleepiness in workers with nightly job. The majority of hypertension workers in subgroup B could depend more on the elevated mean age of this sample. Although a greater perception of the psychological load has been found, statistically meaningful association between the insurgence of gastrointestinal symptoms and shift was not showed.

Validating the Body Uneasiness Test (BUT) in obese patients

OBJECTIVE

To investigate the psychometric properties of the Body Uneasiness Test (BUT) in a large sample of subjects with obesity seeking treatment. BUT is a 71-item self-report questionnaire in two parts: BUT-A which measures weight phobia, body image concerns, avoidance, compulsive self-monitoring, detachment and estrangement feelings towards one's own body (depersonalization); and BUT-B, which looks at specific worries about particular body parts or functions.

METHODS

We recruited a clinical sample of 1,812 adult subjects (age range 18-65 years, females 1,411, males 401) with obesity (Body Mass Index, BMI > or = 30 kg/m2) and a normal weight (BMI value between 18.5 and 25 kg/m2) non-clinical sample of 457 adult subjects (females 248, males 209) with an Eating Attitudes Test-26 (EAT-26) score under the cut-off point 20 (scores > or = 20 indicate possible cases of eating disorders).

RESULTS

The exploratory and confirmatory analyses confirmed a structural five-factor model for BUT-A and an eight-factor model for BUT-B. Internal consistency was satisfactory. Concurrent validity with Binge Eating Scale (BES) and Three-Factor Eating Questionnaire (TFEQ) was evaluated. The authors calculated mean values for BUT scores in adult (18-65 years) patients with obesity, and evaluated the influence of gender, age and BMI. Females obtained statistically significant higher scores than males in all age groups and in all classes of obesity; patients with obesity, compared with normal weight subjects, generally obtained statistically significant higher scores, but few differences could be attributed to the influence of BMI.

CONCLUSION

The BUT can be a valuable multidimensional tool for the clinical assessment of body uneasiness in obesity; the scores of its sub-scales do not show a linear correlation with BMI values.

Rationalization of pesticide treatments against powdery mildew of grape

The powdery mildew represents one of the diseases which affect the grape, it is diffused in all agricultural regions with variable intensity and epidemic course in operation of many microclimatic factors. The powdery mildew of grape is caused from Uncinala necator (Schw.) Burr. (nowadays named Erysiphe necator Schwein.); it is controlled with systemic therapy and contact chemicaL products. In some vineyards located in Latium (central Italy), different field trials have been carried out purposely to rationalize the treatments against E. necator. We have studied the powdery mildew infections through monitoring a set of environmental parameters, the evaluation of cultivar sensibility, the agricultural production method and the area characteristics. We have analysed the following environmental parameters monitoring every 15 minutes: precipitation, soil temperature, solar radiation, wind direction, wind speed, atmospheric relative humidity, atmospheric temperature, leaf wetness, soil humidity to cm 20 and soil humidity to cm 40. Besides, we have used Artificial Intelligence analysis techniques to try to forecast U. necator infections. Guideline EPPO/OEPP PP 1/4 (4) has been used. The trials were conducted in conventional and organic farms. In 2 conventional farms and in organic farm we have considered 1 untreated control thesis, in order to follow the course of infection, 1 standard farm reference thesis (standard), where the treatments were carried out according to the usual farm procedures and 1 thesis where the treatments were carried out according to examining the environmental data. In another conventional vineyard, we have considered only 1 untreated control thesis and 1 standard farm reference thesis (standard) to study disease trend. The achieved results have underlined the possibility (through the knowledge of data pedoclimatic and cultural) to position the treatments against the powdery mildew so that to reduce their number. The lower number of treatments that could follow as a result of environmental data to analyse could bring a series of evident economic and ecologic advantages for the farms.

More years of field trials against Plasmopara viticola in organic viticolture

The organic viticulture assumes a decisive role in the national agricultural sector. More impelling problems in the management of organic vineyards are represented from the plants pathology defence and particularly of Plasmopara viticola containment. Copper represents one of the few usable fungicides in the organic farming and the only effective against downy mildew. With Regulation EC n. 473/2002, fixed maximum quantity usable of copper compounds, owing to the environment problems due to the copper accumulation in the soil. To reduce quantity of metal copper or replace it with natural products, are conducted field trials with copper compounds at a low rate or alternative to copper products. Besides, we are estimating possibility to reduce the operations against P. viticola optimizing fungicidal treatments. Field trials in the organic farms located near Rome, have been carried out. Guidelines EPPO/OEPP PP 1/31 (3) have been carried out. The results of the trials have showed that, using cupric products with low metallic content, to reduce copper quantities used, always allowed to respect the limits established by Regulation EC. The alternative products that were investigated have not guaranteed, instead, an adequate protection in high pressure of grapevine downy mildew. It was possible to reduce treatments against P. viticola through control of different environmental parameters. The trials confirm that the copper is indispensable for plant protection in organic farming as it is not possible to replace it with natural extracts substances. We can reduce, instead, the copper quantities used trough the use of new products with low quantity metal copper or through the evaluation of climatic and pedologic data that allow to rationalize the fungicidal treatments.

A two years study results in the use of artificial neural networks to forecast Plasmopara viticola infection in viticulture

This paper describes the further results of the study that has been described in session 5 of the 58th International Symposium on Crop Protection (Ghent 2006). Since then our attention has been focused on verifying the previous communication results working on a two years basis data set belonging to a specific farm. The choice of using data from a single farm derives from the considerations that have been explained in the previous study in which it was clear that an efficient forecasting Artificial Neural Network (ANN) model can be created only in restricted (or at least comparable) pedoclimatic areas. On the basis of the matured experience, at the moment we have realized an ANN which, being trained on 2005 year data, elaborating the following year data is capable of correctly predicting the real Plasmopara viticola (Berk. et Curt.) Berl. et De Toni outbreak, never giving false negative signals (no alarm in presence of infection on the field) and, finally, giving few other alarms which are totally comparable with the ones given by the most common statistical instrument used in this field trials. We confirm the advantages of this approach in terms of: (a) Management and optimization improvement of agricultural activities. (b) Reduction of plant protection products use. (c) Quality improvement of the final product for a real lowering of plant protection products use. (d) Reduction of environmental impact. (e) A more efficient management of the climate changes.

Relationship between chronic tadalafil administration and improvement of endothelial function in men with erectile dysfunction: a pilot study

Men with erectile dysfunction (ED) frequently have a disproportionate burden of comorbid vascular disorders including atherosclerotic disease. We investigated whether scheduled tadalafil is better than on-demand (OD) in improving endothelium-dependent vasodilatation of cavernous arteries in men with ED and whether this effect is also exerted on markers of endothelial function. We did an open-label, randomized, crossover study including 20 male outclinic patients aged 18 years or older (mean age 54 years) who had at least a 3-month history of ED of any severity or etiology. Tadalafil (20 mg) on alternate days (ADs) or OD was administered for 4 weeks. Primary end points were variations of basal inflow (peak systolic velocity (PSV)) and flow-mediated dilatation (FMD) of cavernous arteries compared with baseline at penile Duplex ultrasound. Secondary end points were variations of Q13-SIEDY scores regarding morning erections and of markers of endothelial function, that is, vascular cell adhesion molecule (VCAM), intercellular cell adhesion molecule, endothelin-1 (ET-1), insulin and C-reactive protein (CRP). PSVs and FMD were higher after AD treatment when compared with OD and baseline, respectively (P=0.0001), and improvements were maintained from 2 weeks after discontinuation (P<0.005). Patients receiving tadalafil AD experienced a significant improvement of morning erections as compared to AD treatment (P<0.0001); ET1, VCAM and CRP showed a robust decrease after chronic vs OD regimes (P<0.05), with concomitant increase in insulin levels (P<0.05), without any variation in blood pressure and other laboratory parameters. Chronic but not OD tadalafil improves endothelial function with sustained effects from its discontinuation. Chronic treatment also produces a dramatic increase in morning erections, which determines better oxygenation to the penis, thus providing a rationale for vascular rehabilitation.

D.M.R. ("Double Reasoned Maturing"): innovative technique of agronomic ecologic control of grey mould on grapevine. trials and various considerations

A study was carried out in order to identify agronomic ecologic solutions in the indirect grey mould control on grapevine. These specific trials started since 1990 and, after years of validation, now they are applied by the entrepreneur to the business practice in the different pedological and climatic area and on different cultivars and forms of growing. The technique of "Doppia Maturazione Ragionata" (D.M.R.) ("Doubles Reasoned Maturing") consists of far "completing" the maturing of the grape for wilting on the plant through the reasoned cut of the heads to fruit e/o of shoots. The application of D.M.R., besides determining valid and important technical and qualitative (organoleptic, economic and social quality) improvements on the product, is particularly effective in the indirect grey mould control on grapevine. Such technique, in fact, allows us to vintage the grape during the business demands and not when imposed by Botrytis cinerea; it has been possible, in some cases, to vintage in December and over, without problems of B. cinerea. The trials have shown the technical, economic, social sustainability of D.M.R. application. This paper reports all trials that have brought, by now from years, to apply in the practice DMR (Double Reasoned Maturing).

"Minimum pruning", "minimal pruning" and "physiological pruning" as new techniques in grey mould agronomic eco-compatible (natural) control. Researches and considerations

The aim of this work was to find agronomic eco-compatible ("natural") control solutions against grey mould of grapevine too. Our researches about "minimum pruning", "minimal pruning" and "physiological pruning" started in 1980, and in 1983 with specific relation to grey mould on vines of Merlot, Cabernet sauvignon and Chardonnay previously set in vegetative and productive growth balance. These researches were conducted to verify the affordability of innovative winter pruning techniques like "minimum pruning", "minimal pruning" and the so called 'physiological pruning", in the natural agronomic eco-compatible grey mould control. As a result we found that the new techniques contribute to limit the incidence of grey mould; especially "physiological pruning" followed by "minimal pruning" and 'minimum pruning". The best results were observed on Chardonnay, followed by Merlot and Cabernet sauvignon.

Artificial intelligence approach with the use of artificial neural networks for the creation of a forecasting model of Plasmopara viticola infection

Most of the forecasting models of Plasmopara viticola infections are based upon empiric correlations between meteorological/environmental data and pathogen outbreak. These models generally overestimate the risk of infections and induce to treat the vineyard even if it should be not necessary. In rare cases they underrate the risk of infection leaving the pathogen to breakout. Starting from these considerations we have decided to approach the problem from another point of view utilizing Artificial Intelligence techniques for data elaboration and analysis. Meanwhile the same data have been studied with a more classic approach with statistical tools to verify the impact of a large data collection on the standard data analysis methods. A network of RTUs (Remote Terminal Units) distributed all over the Italian national territory transmits 12 environmental parameters every 15 minutes via radio or via GPRS to a centralized Data Base. Other pedologic data is collected directly from the field and sent via Internet to the centralized data base utilizing Personal Digital Assistants (PDAs) running a specific software. Data is stored after having been preprocessed, to guarantee the quality of the information. The subsequent analysis has been realized mostly with Artificial Neural Networks (ANNs). Collecting and analizing data in this way will probably bring us to the possibility of preventing Plasmospara viticola infection starting from the environmental conditions in this very complex context. The aim of this work is to forecast the infection avoiding the ineffective use of the plant protection products in agriculture. Applying different analysis models we will try to find the best ANN capable of forecasting with an high level of affordability.

Subsurface drip irrigation with micro-encapsulated trifluralin. Trifluralin residues in soils and cultivations

In full field and greenhouse agriculture, the subsurface water distribution with underground driplines--subsurface drip irrigation--is advantageous to obtain a better production and a simplification of cultivation practices. This technique can have a major applicative interest on condition that the roots' intrusion inside the driplines irrigators is eliminated or reduced. To reach this goal, a study has been made on vegetable greenhouse cultivations, and on subsurface drip irrigation with underground driplines protected against roots' intrusion with a product containing micro-encapsulated polyethylene Trifuralin (trifluralin). Underground pipes with driplines (without trifluralin) have constituted the confrontation thesis. The trifluralin residues have been determined through GC-ECD, according to different cultivation phases for two entire production cycles: with 30% of leaf covering, at the moment of flowering and maturation, during production and at the harvest ending, on soil, leaves and maturation, during the production and, at the harvest ending, on fruits.

Diagnosing Erectile Dysfunction: The penile dynamic colour duplex ultrasound revisited

A number of disease processes of the penis including Peyronie's disease, priapism, penile fractures and tumors are clearly visualized with ultrasound. Diagnostic evaluation of erectile dysfunction (ED) by penile dynamic colour-duplex Doppler ultrasonography (D-CDDU) is actually considered a second level approach to ED patients because of the fact that intracavernous injections test IV with prostaglandin-E(1) may provide important information about the patients' erectile capacity. However, no direct vascular imaging and a high percentage of false negative diagnoses of vasculogenic ED are its major pitfalls and subsequent treatment decisions remain quite limited. The occurrence of ED and its sentinel relationship to cardiovascular disease has prompted more accurate vascular screening in all patients even in the absence of cardiovascular risk factors. The sonographic evaluation of the intima-media thickness of the carotid arteries may sometimes represent an early manifestation of diffuse atherosclerotic disease and endothelial damage. This latter finding is often the cause of failure to oral agents, i.e. phosphodiesterase inhibitors, because of inability of the dysfunctional endothelium to release nitric oxide. D-CDDU represents an accurate tool to investigate cavernous artery inflow and venous leakage when compared with more invasive diagnostic techniques i.e. selective arteriography and dynamic infusion cavernosometry along with cavernosography.

A novel diagnostic tool for detecting functional patency of the small bowel: the Given patency capsule

BACKGROUND AND STUDY AIMS

The current visualization of small-bowel strictures using traditional radiological methods is associated with high radiation doses and false-negative results. These methods do not always reveal small-bowel patency for solids. The aim is to assess the safety of the Given patency system and its ability to detect intestinal strictures in patients with strictures that are known or suspected radiologically.

MATERIALS AND METHODS

The Given patency capsule is composed of lactose, remains intact in the gastrointestinal tract for 40-100 hours post ingestion, and disintegrates thereafter. A total of 34 patients with small-bowel stricture were prospectively enrolled; 30 had a previous diagnosis of Crohn's disease, three had adhesion syndrome and in one ischemic enteritis was suspected. Of the patients, 15 (44.1 %) had previously undergone surgery. Following ingestion, the capsule was monitored for integrity and transit time, using a specially designed Given scanner and also radiologically. Seventeen patients had been enrolled with the intent of using the patency capsule as a preliminary test in patients with small-bowel strictures before undergoing video capsule endoscopy.

RESULTS

30 patients (88.2 %) retrieved the capsule in the stool; it was intact in 20 (median transit time 22 hours), and disintegrated in 10 patients (median transit time 53 hours). Six patients complained of abdominal pain which disappeared within 24 hours. The scanner successfully indicated the presence of the capsule in 94 % of cases. Ten patients underwent video capsule endoscopy following the patency capsule examination; in all of these the video capsule passed through the small-bowel stricture.

CONCLUSIONS

This feasibility study has shown that the Given patency capsule is a safe, effective, and convenient tool for assessment of functional patency of the small bowel. It can indicate functional patency even in cases where traditional radiology indicates stricture.

Gastrointestinal surgical emergencies in patients treated for hemathological malignancies

BACKGROUND

Upper and lower gastrointestinal symptoms are major and serious complications in patients who undergo chemotherapy for hematological malignancies. Their most frequent causes are acute intestinal graft-versus-host disease (GVHD) after bone marrow transplant, infections, toxicity or preexisting gastrointestinal diseases. Mortality can reach 30-60% of cases.

PATIENTS AND METHODS

We report 15 cases operated on for abdominal emergencies: 3 severe gastrointestinal bleeding and 12 acute abdomen.

RESULTS

We performed 10 bowel resections, one cholecystectomy, one splenectomy, two laparotomy with pancreatic debridement and peritoneal lavage, and one suture of perforated peptic ulcer. Operative mortality was 33.3% (5/15). Deaths have been reported only in the group of patients with acute abdomen. In all cases death was correlated to generalized sepsis related to immunosuppression.

CONCLUSIONS

We believe that an aggressive approach, consisting of close monitoring and early laparotomy combined with vigorous supportive therapy, should be used when dealing with suspected gastrointestinal complications in patients with hematological malignancies.

Results of emergency surgery in patients with Moschowitz's disease refractory to hematological treatment: is splenectomy always advisable?

BACKGROUND

Patients with thrombotic thrombocytopenic purpura (TTP), Moschowitz's disease, run a high risk of perioperative bleeding and need intensive hematologic support. In some patients, TTP is associated with cancer but the surgical role in these patients is still unclear. To illustrate the surgical problems and outcome we present the case histories of three patients with TTP observed in our emergency department.

MATERIALS AND METHODS

Two patients had TTP secondary to cancer and one patient with primary TTP (no evidence of neoplasia) had emergency operation for gastric hemorrhage, occlusion and TTP unresponsive to plasmapheresis.

RESULTS

The first two patients who had not radical resection of cancer and no splenectomy, died for TTP complications. The third patient who underwent emergency splenectomy, had an uneventful postoperative course and TTP completely regressed.

CONCLUSIONS

These case reports suggest that patients with TTP should be screened to rule out cancer. In patients with acute cancer-related complications emergency surgery should aim to resect the cancer. An associated splenectomy may increase the effectiveness of postoperative hematologic therapy.

The pituitary-testicular axis in microgravity: analogies with the aging male syndrome

Extraterrestrial exploration has gone on for decades before reversible testicular failure was shown to be a consequence of space flight in humans and animals at the end of the XXth century. This phenomenon was initially thought to depend on the psycho-physical stress expected to derive from a decidedly unusual environment, but the lack of consistent data concerning cortisol increase and/or gonadotrophin suppression pointed to the possibility of a primary defect. This was indirectly confirmed by the observation that a continuum of testicular androgen secretion potential exists from microgravity to centrifuge-derived hypergravity. Further experiments using tissue slices and suspended cells confirmed a direct inhibitory effect of microgravity upon testicular androgen production. A parallel deterioration of major physiological parameters, such as bone density, muscle mass/force, red blood cell mass, hydration and cardiopulmonary performance, has been repeatedly described during space missions, which, luckily enough, fully recover within days to weeks after landing, the time lag depending on single organ/system adaptation rates. According to the Authors of the present review, when taking together all reported changes occurring in space, a picture emerges closely resembling the so-called aging male syndrome, which is currently the object of daily screening and clinical care in their endocrine unit, so that microgravity may become a tool for better understanding subtle mechanisms of testicular senescence.

Grapevine downy mildew control in organic farming

Cupric products at low dose and alternative compounds have been tested to control the downy mildew in an organic vineyard. It has found that copper compounds control downy mildew in a satisfactory way, reducing, at the same time, the dose of copper metal. The alternative products were not satisfactory to control Plasmopara viticola.

Reduction of risk factors for cardiovascular diseases in morbid-obese patients following biliary-intestinal bypass: 3 years' follow-up

BACKGROUND

Obese patients are often affected by hypertension, dyslipidaemia, impaired glucose metabolism, and suffer from cardiovascular disease (CVD), related to the characteristic metabolic alterations.

AIM OF THE STUDY

To evaluate reduction of risk factors for CVDs in morbid-obese patients (body mass index (BMI)>40 kg/m2) after weight loss upon bariatric surgery intervention of biliary-intestinal bypass.

SUBJECTS

45 (17 men, 28 women) morbid-obese patients (age: 19-49 y, BMI>40 kg/m2). All patients were selected on the basis of medical history, physical and biochemical evaluation and of psychiatric tests, which were performed on all individuals admitted to our Day Hospital to verify the safety of surgical intervention.

MEASUREMENTS

Body weight, body composition (by dual X-ray absorptiometry, DXA), blood pressure, lipid profile, fibrinogen and glucose metabolism were monitored at baseline and 1, 3, 6, 9, 12, 24 and 36 months after surgery.

RESULTS

A significant and persistent weight loss was present in all patients at the end of the 3 y follow-up period (P<0.001), with a progressive reduction of total and trunk fat mass as evaluated by means of DXA. Additionally, a parallel significant reduction in systolic (P<0.001) and diastolic (P<0.001) blood pressure was observed. Total and LDL cholesterol were significantly reduced (P<0.001), while HDL showed no modifications; triglycerides declined progressively during the 3 y follow-up (P<0.001). Fibrinogen decreased from 364.5+/-82.4 to 266.4+/-45.7 mg/dl at the end of the period (P<0.001). Fasting glucose levels and glucose levels 120 min after an oral glucose tolerance test were reduced from 95.1+/-20.3 to 78.6+/-9.1 mg/dl (P<0.001) and from 116.9+/-34.7 to 77.6+/-15.5 mg/dl (P<0.001), respectively, at baseline and at the end of the study. Moreover, fasting insulin decreased from 30.0+/-20.4 to 8.6+/-2.9 microUI/ml (P<0.001) after 3 y, while insulin levels after (120 min) oral glucose load decreased from 105.5+/-61.5 to 12.0+/-6.0 microUI/ml (P<0.001).

CONCLUSION

Our results show that biliary-intestinal bypass may represent a valid and alternative therapeutic approach in patients with morbid obesity since it induces a significant and stable reduction of body weight and obesity-related risk factors for CVD.