Real world outcomes in patients with neuroendocrine tumor receiving peptide receptor radionucleotide therapy

Aim

¹⁷⁷Lu-Dotatate (Lu-177), a form of peptide receptor radionuclide therapy (PRRT), was approved by Food and Drug Administration (FDA) for the treatment of somatostatin-receptor-positive neuroendocrine tumors (NETs) in 2018. Clinical trials prior to the FDA approval of Lu-177 showed favorable outcomes but there is limited published real world outcomes data. This study aims to describe and analyze real world outcomes of patients with NET who received Lu-177.

Methods

After obtaining institutional review board approval, retrospective evaluation was performed to analyze the efficacy of Lu-177 for somatostatin receptor-positive gastro-entero-pancreatic NETs (GEP-NETs) patients at the University of Kansas Cancer Center between June 2018 and September 2021. This study aims to determine the response rate to the treatment of the entire cohort and subgroups.

Results

A total of 65 patients received Lu-177 of which 58 completed treatment. The 58 patients had a median age of 61.5 years, 24 females and 34 males, 86% Caucasian and 12% black. The origins of NETs were primarily small bowel (n = 24) and pancreatic (n = 14). Pathology showed grades 1 (n = 21), 2 (n = 25), and 3 (n = 4) and were primarily well-differentiated tumors (n = 4). Among the cohort, 52 patients had imaging to assess response with 14 (26.9%) patients with partial response (PR), 31 (59.6%) with stable disease (SD), and 7 (13.5%) with progressive disease (PD). In a subset analysis, patients with non-functional disease (n = 29) had higher rates of PR 42.3% (compared to 11.5%, P = 0.0147) and higher disease control rate of 96% (compared to 78%, P = 0.042) than patients with functional disease (n = 29). Patients with non-functional disease had a lower PD of 3.85% (compared to 23%, P = 0.0147) than those with functional disease.

Conclusions

This real world outcomes analysis of NETs treated with Lu-177 shows improved PR when compared to the initial clinical trials and is promising for patients. In addition, patients with non-functional tumors were found to have a statistically significant improved response rate which has not been described in the literature before. If these study findings are validated in a larger cohort they may guide patient selection for Lu-177 therapy in the future.

A Multicenter Retrospective Chart Review of Clinical Outcomes Among Patients With KRAS G12C Mutant Non-Small Cell Lung Cancer

BACKGROUND

On May 28, 2021, the United States Food and Drug Administration (FDA) granted accelerated approval to sotorasib for second-line or later treatment of patients with locally advanced or metastatic KRAS G12C mutant non-small cell lung cancer (NSCLC). This was the first FDA-approved targeted therapy for this patient population. Due to a paucity of real world data describing clinical outcomes in patients with locally advanced or metastatic KRAS G12C mutated NSCLC in the second-line or later, we sought to compile a large, academic medical center-based historical dataset to clarify clinical outcomes in this patient population.

MATERIALS AND METHODS

The clinical outcomes of 396 patients with stage IV (n = 268, 68%) or recurrent, metastatic (n = 128, 32%) KRAS G12C mutant NSCLC were evaluated in this multicenter retrospective chart review conducted through the Academic Thoracic Oncology Medical Investigator's Consortium (ATOMIC). Patients treated at 13 sites in the United States and Canada and diagnosed between 2006 and 2020 (30% 2006-2015, 70% 2016-2020) were included. Primary outcomes included real-world PFS (rwPFS) and overall survival (OS) from time of stage IV or metastatic diagnosis, with particular interest in patients treated with second-line docetaxel-containing regimens, as well as clinical outcomes in the known presence or absence of STK11 or KEAP1 comutations.

RESULTS

Among all patients with stage IV or recurrent, metastatic KRAS G12C mutant NSCLC (n = 201 with KRAS G12C confirmed prior to first line systemic therapy), the median first-line rwPFS was 9.3 months (95% CI, 7.3-11.8 months) and median OS was 16.8 months (95% CI, 12.7-22.3 months). In this historical dataset, first line systemic therapy among these 201 patients included platinum doublet alone (44%), PD-(L)1 inhibitor monotherapy (30%), platinum doublet chemotherapy plus PD-(L)1 inhibitor (18%), and other regimens (8%). Among patients with documented second-line systemic therapy (n = 123), the second-line median rwPFS was 8.3 months (95% CI, 6.1-11.9 months), with median rwPFS 4.6 months (95% CI, 1.4-NA) among 10 docetaxel-treated patients (9 received docetaxel and 1 received docetaxel plus ramucirumab). Within the total study population, 49 patients (12%) had a co-occurring STK11 mutation and 3 (1%) had a co-occurring KEAP1 mutation. Among the 49 patients with a co-occurring KRAS G12C and STK11 mutation, median rwPFS on first-line systemic therapy (n = 23) was 6.0 months (95% CI, 4.7-NA), and median OS was 14.0 months (95% CI, 10.8-35.3 months).

CONCLUSION

In this large, multicenter retrospective chart review of patients with KRAS G12C mutant NSCLC we observed a relatively short median rwPFS of 4.6 months among 10 patients with KRAS G12C mutant NSCLC treated with docetaxel with or without ramucirumab in the second-line setting, which aligns with the recently reported CodeBreak 200 dataset.

SYST-14 CLINICAL EFFICACY OF ONC201 IN RECURRENT H3 K27M-MUTANT DIFFUSE MIDLINE GLIOMA (DMG) PATIENTS

BACKGROUND

H3 K27M-mutant DMG predominantly affects children and young adults; no effective therapy is known. ONC201 is a first-in-class, anti-cancer DRD2 antagonist and ClpP agonist.

METHODS

Fifty pediatric and adult patients with recurrent H3 K27M DMG who received oral ONC201 monotherapy in clinical trials and expanded access were selected for a planned efficacy analysis. Eligibility criteria included measurable contrast-enhancing disease by RANO-HGG criteria (excluding pontine and spinal cord tumors), KPS/LPS≥60, ≥90 days from prior radiation, and adequate washout from prior anti-cancer therapy. The primary endpoint was overall response rate (ORR) by RANO-HGG criteria. Secondary endpoints included duration of response, time to response, progression-free survival (PFS), overall survival (OS), corticosteroid response rate, performance status response rate, and ORR by RANO-LGG criteria. Radiographic endpoints were assessed by dual-reader blinded independent central review. Data cutoff was May 31, 2021.

RESULTS

ORR was 20.0% (95%CI, 10.0–33.7) by RANO-HGG criteria. Median duration of response was 11.2 months (95%CI, 3.8–not reached) and median time to response was 8.3 months (range, 1.9–15.9). PFS at 6 months was 35.1% (95%CI, 21.2–49.3). The ORR was 26.0% (95%CI, 14.6–40.3) by RANO-LGG criteria. Fifteen patients (30.0%; 95%CI, 17.9–44.6) achieved an objective response by RANO-HGG and/or RANO-LGG criteria. Of 15 patients receiving ≥4 mg daily dexamethasone at baseline, 7 (46.7%; 95%CI, 21.3–73.4) achieved ≥50% confirmed reduction in dose. Of 34 patients with baseline KPS/LPS <80, 7 (20.6%; 95%CI, 8.7–37.9) achieved a confirmed performance status improvement. With a median follow-up of 18.8 months, median OS was 13.7 months (95%CI, 8.0–20.3) and OS at 24 months was 34.7% (95%CI, 20.7–49.2). Twenty-five patients had serious adverse events with one possibly related to ONC201 by investigator assessment.

CONCLUSIONS

ONC201 monotherapy exhibits durable and clinically meaningful efficacy in recurrent H3 K27M-mutant DMG.

Association of pathologic response and survival after peri-operative therapy in resected pancreatic adenocarcinoma: KU cancer center experience

e16254

Background: Neo-adjuvant therapy (NAT) and associated pathologic complete response (pCR) rates have correlated with improved survival in resected pancreatic ductal adenocarcinoma (PDAC). In this study, we explored the relationship between pathologic response, peri-operative therapy, and survival, especially the impact of change in adjuvant therapy in patients with no/poor path response to NAT. Methods: Retrospectively reviewed 66 PDAC patients who received NAT ± radiation and underwent resection at KU Cancer Center between 2011-2022. We compared DFS and OS between Path Responders vs Non-Responders based on standard Tumor Regression Scores from pathology reports. A subanalysis was performed in path non-responders based on switch in adjuvant therapy (AT) versus not. Results: Patient characteristics are summarized in the table. Among 66 PDAC patients, 50 (75.8%) achieved a path response (G0-G2), 16 (24.2%) experienced no/poor path response (G3). Of the 50 pts who achieved a path response, 4 (8.0%) had a complete path response (pCR; G0), 5 (10%) marked response (G1), 41 (82%) moderate response (G2). Median DFS (mDFS) was 17.3 months (95% CI: 12.7-22.4) in Path Responders vs 15.9m (95% CI: 9.6-35.8) in Non-Responders [p=0.59]. Median OS (mOS) was 32.9m (95% CI: 23.4-41.5) vs 27.7m (95% CI: 15.2-38.2), respectively [p=0.39). A sub-analysis in the Non-Responders (n=16) based on switch in AT (n=8) vs not (n=3), revealed mDFS 16.4m (95% CI: 9.6-41.8) when AT was switched vs mDFS 11.3m (95% CI: 5.9-16.6) when AT was not switched [p=0.24]; and mOS 30.6m (95% CI: 15.7-60.3) vs 17.2 months (95% CI: 6.7-27.7), respectively [p=0.18]. Conclusions: Our study found no statistical difference in DFS and OS between Pathologic Responders and Non-Responders to neo-adjuvant therapy. However, a sub-analysis within Pathologic Non-Responders revealed a longer DFS and OS after switching adjuvant therapy without reaching statistical significance, likely due to small sample size. Our findings warrant validation in a larger cohort as switch in adjuvant therapy could potentially change the treatment landscape for Pathologic Non-Responders.[Table: see text]

Effect of Covid-19 pandemic: tourism and hospitality industry

The coronavirus, which causes COVID-19 disease, has unimaginably affected every industry. Among all industries, the tourism and hospitality industry is considered the worst-hit industry, contributing 9% of India’s total GDP; this paper presents an overview of the Indian tourism and hospitality industry before COVID-19. While sending out survey forms, we included general questions like gender, occupation, age, level of education, yearly income, what used to be their choice of location for a holiday before COVID-19, how much they yearly spent on holiday, how they plan their holiday trip, to understand the basic details and reliability of participants, also we did not ask the name of a participant to maintain the anonymity and privacy of a participant, which helped us to get an accurate data. How customers’ changed mindsets different priorities forced the tourism and hospitality industry to change the way of providing service also how the changed time has forced businesses to look for other opportunities to survive in the industry, Moreover here we have test different Sanitization and safety measurements using Friedman test to understand what are the factors that can affect the business of tourism and hospitality industry after the COVID-19 pandemic, as observed by Assaf & Scuderi.

A194 THE ADDITION OF DEAMIDATED GLIADIN PEPTIDE TO TISSUE TRANSGLUTAMINASE ANTIBODIES DOES NOT INCREASE THE ODDS OF CELIAC DISEASE DIAGNOSIS IN AN IGA SUFFICIENT POPULATION

Background

Previous studies proposed that the combination of IgA anti-tissue transglutaminase 2 IgA (TTG) and IgG deamidated gliadin peptide IgG (DGP) antibodies increases celiac disease (CeD) detection rates. However, this remains controversial.

Aims

To evaluate the performance of adding DGP to TTG antibodies, for the diagnosis of celiac disease (CeD) in the immunoglobulin A (IgA)-sufficient population.

Methods

We included consecutive patients with suspected CeD who had both TTG and DGP serology performed simultaneously from 2017–2020 in Hamilton, Canada. Chart review was performed by 3 reviewers to extract data on biopsies, diagnosis of CeD and genetic HLA-DQ2/DQ8. CeD was defined as positive serology (either TTG and/or DGP) and villous atrophy in duodenal biopsies (≥Marsh-3a). A case was defined as an instance of TTG and DGP performed at a single timepoint. A single patient could have represented multiple cases if TTG and DGP were measured at multiple time points. Sensitivity, specificity, negative and positive predictive values were calculated, and ROC curves were generated. Diagnostic odds ratios (DOR) assessed the performance of each serological strategy compared to duodenal biopsies.

Results

There were 580 patients constituting 823 cases that met inclusion criteria, of whom 441 had CeD. IgA-deficient patients (n=100) were excluded. Of the 723 cases remaining, 337 (214 adult;123 pediatric) had serology performed at the time of CeD diagnosis. TTG increased the odds of CeD diagnosis compared with DGP, Diagnostic Odds Ratio (DOR)=53.22 (95% CI 22.63–119.80) vs DOR=21.28 (95% CI 10.67–42.46). The addition of DGP to TTG did not increase the odds of CeD diagnosis [DGP+TTG DOR=51.39 (95% CI 19.36–135.61) vs TTG alone DOR=53.22 (95% CI 22.63–119.80)]. There were 37 discordant cases where only one of either TTG or DGP was positive. HLA-DQ2/DQ8 were absent in 2/9 cases with isolated increased DGP. Among the discordant cases, TTG outperformed DGP (DOR TTG= 4.29; 95% CI 1.09–16.83 vs DOR DGP=0.23; 95% CI 0.06–0.92).

Conclusions

In the IgA-sufficient population, the addition of DGP to TTG testing does not increase the diagnostic accuracy of CeD serologic screening. This has implications in health-care costs as false positive results prompt further investigations. Given these findings, larger prospective studies should be completed prior to adding DGP antibodies to routine TTG serology.

Funding Agencies

None

Real-world outcomes in patients with neuroendocrine tumor receiving peptide receptor radionucleotide therapy

504

Background: (177)Lu-Dotatate, a form of Peptide Receptor Radionuclide Therapy (PRRT), was approved by FDA for treatment of somatostatin-receptor-positive NETs in 2018. Clinical trials prior to the FDA approval of (177)Lu-Dotatate showed favorable outcomes but there is limited published real world outcomes data. Methods: After obtaining IRB approval we retrospectively evaluated the efficacy of (177)Lu-Dotatate PRRT for somatostatin receptor positive gastroenteropancreatic NET patients at University of Kansas Cancer Center between June 2018 and September 2021. Results: A total of 65 patients received PRRT of which 58 completed treatment and 7 are still undergoing therapy. The 58 patients who completed treatment had a median age of 61.5 years, included 24 females and 34 males, and were 86% Caucasian and 12% black. These patients had primarily NETs of small bowel (n=24) and pancreatic (n=14) origin. Pathology showed grades 1 (21), 2 (25), and 3 (4) with a majority of well-differentiated tumors (47). All 4 treatments of PRRT were completed by 43 patients. In the entire cohort, response assessment to PRRT revealed 14 (26.9%) partial response (PR), 31 (59.6%) with stable disease (SD) and 7 (13.5%) with progressive disease (PD). In subset analysis, we found that patients with nonfunctional disease (n=29) had a higher rate of PR 42.3% vs 11.5% (p=0.0147) and higher disease control rate 96% vs 78% (p=0.042) than functional disease (n=29). Patients with nonfunctional disease had a lower PD 3.85% vs 23% (p=0.0147) and 53% vs 65% stable disease than functional disease. The table below shows clinical characteristics of these patients. Conclusions: Our real world outcomes analysis of NET treated with PRRT shows improved PR when compared to the initial clinical trials which is promising for patients. In addition, we found that there was statistically significant improved response rate in patients with non functional tumors which has not been described in literature before. If our study findings are validated in a larger cohort then it may guide patient selection for PRRT therapy in the future.[Table: see text]

Inflammatory Bowel Disease Does Not Impact Mortality but Increases Length of Hospitalization in Patients with Acute Myocardial Infarction

BACKGROUND AND AIM

Inflammatory bowel diseases (IBD) have been associated with increased risk of cardiovascular events. We aimed to investigate the outcomes of myocardial infarction (MI) in patients with IBD.

METHODS

We performed a cross-sectional study utilizing data from the Nationwide Inpatient Sample from the years 1998 to 2010. ICD-9-CM codes were used to identify patients with Crohn's disease (CD) (555.X), ulcerative colitis (UC) (556.X), and acute MI (410.X). Outcomes in patients with MI with and without IBD were compared. Univariate analysis was performed. Multivariate logistic regression was used to determine the effect of UC and CD on in-hospital MI mortality after adjusting for confounders.

RESULTS

A total of 2,629,161 MI, 3,607 UC and 3784 CD patients were analyzed. UC (odds ratio [OR], 1.12; 95% CI 0.98-1.29) and CD (OR 0.99; 95% CI 0.86-1.15) did not affect in-hospital mortality in patients with MI. There was no difference between in-hospital mortality in patients with MI with or without UC (7.75% vs. 7.05%; p = 0.25) or in patients with MI with or without CD (6.50% vs. 6.59%; p = 0.87). The length of stay (LOS) was higher in IBD patients and total charges were statistically higher in patients with UC as compared to non-IBD patients ($65,182 vs. $53,542; p < 0.001).

CONCLUSIONS

This study shows that IBD does not impact in-hospital mortality from MI. However, patients with MI with IBD have longer LOS. Patients with UC have higher total hospitalization charges than patients with MI without IBD. Further prospective studies are needed to assess the outcomes of MI in IBD patients.

Resveratrol protects against inorganic arsenic-induced oxidative damage and cytoarchitectural alterations in female mouse hippocampus

Prolonged inorganic arsenic (iAs) exposure is widely associated with brain damage particularly in the hippocampus via oxidative and apoptotic pathways. Resveratrol (RES) has gained considerable attention because of its benefits to human health. However, its neuroprotective potential against iAs-induced toxicity in CA1 region of hippocampus remains unexplored. Therefore, we investigated the neuroprotective efficacy of RES against arsenic trioxide (As₂O₃)-induced adverse effects on neuronal morphology, apoptotic markers and oxidative stress parameters in mouse CA1 region (hippocampus). Adult female Swiss albino mice of reproductive maturity were orally exposed to either As₂O₃ (2 and 4 mg/kg bw) alone or in combination with RES (40 mg/kg bw) for a period of 45 days. After animal sacrifice on day 46, the perfusion fixed brain samples were used for the observation of neuronal morphology and studying the morphometric features. While the freshly dissected hippocampi were processed for biochemical estimation of oxidative stress markers and western blotting of apoptosis-associated proteins. Chronic iAs exposure led to significant decrease in Stratum Pyramidale layer thickness along with reduction in cell density and area of Pyramidal neurons in contrast to the controls. Biochemical analysis showed reduced hippocampal GSH content but no change in total nitrite (NO) levels following iAs exposure. Western blotting showed apparent changes in the expression levels of Bax and Bcl-2 proteins following iAs exposure, however the change was statistically insignificant. Contrastingly, iAs +RES co-treatment exhibited substantial reversal in morphological and biochemical observations. Together, these findings provide preliminary evidence of neuroprotective role of RES on structural and biochemical alterations pertaining to mouse hippocampus following chronic iAs exposure.

Prognostic impact of obesity in cancer patients with COVID-19 infection: A systematic review and meta-analysis

e18578

Background: Obesity is a bona fide risk factor for ICU admission, mechanical ventilation, and mortality in patients (pts) with COVID-19 in the general population. However, whether obesity is a risk factor in cancer pts remains unknown. Herein, we have conducted a systematic review/meta-analysis of obesity and all-cause mortality in cancer pts with COVID-19. Methods: Following PRISMA guidelines,a systematic search of PubMed and Embase as well as major conference proceedings (ASCO/ESMO/AACR) was conducted for publications from inception to 14 January 2020. Observational studies that reported all-cause mortality in cancer pts with lab confirmation or clinical diagnosis of COVID-19 and BMI (obese (>30 kg/m2) vs. non-obese) were included in the analysis. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated with the fixed-effects model based on low heterogeneity. Small sample publication bias was evaluated using the Begg’s Funnel Plot and Egger’s test. Results: After reviewing 3387 studies,3 retrospective cohort studies of 419 obese and 1694 non-obese cancer pts (N=2117) with COVID-19 in both inpatient/outpatient settings that reported outcomes based on obesity were found. The 3 studies were conducted multi-nationally in North America, in France, and in the Netherlands respectively. The median ages of the cohorts ranged 66-68. All studies included various cancers of various stages and were of high quality per Newcastle Ottawa scale (scores 7-9). Fixed effects meta-analysis showed no association between obesity and all-cause mortality (OR 0.95, 95% CI 0.74-1.23) in cancer pts with COVID-19. Heterogeneity was low (I2 = 33%). No significant funnel plot asymmetry was detected per Egger’s test (P=0.2273). The reported OR of each study is outlined in the table. Conclusions: In contrast to the general population, our analysis reveals that obesity is not associated with increased all-cause mortality in cancer pts with COVID-19. Limitations of this study include a limited number of included studies, reliance on retrospective studies, non-use of ethnicity-specific WHO BMI criteria, and limited granularity of the study-reported BMI. Future prospective studies are warranted to assess the complex interplay among anthropomorphic measures, cachexia/sarcopenia, comorbidities associated with the metabolic syndrome, and COVID-19 outcomes in the cancer pt population.[Table: see text]

In-hospital outcomes of CAR T-cell therapy in United States in 2018: A nationwide analysis

6556

Background: CAR T-cell therapy is a type of adoptive cell transfer (ACT). In 2017 CAR T-cell therapy was approved by the Food and Drug Administration (FDA) for management of diffuse large B-cell lymphoma refractory to at least two prior lines of therapy (DLBCL) including primary mediastinal large B-cell lymphoma (PMBCL), and B cell precursor acute lymphoblastic leukemia (ALL) up to 25 years of age that is refractory or in second or later relapse. Since its inception, several patients underwent CAR T-cell therapy but data on real world outcome is limited. In this study we aim to evaluate the in-hospital outcomes of CAR T-cell therapy in the United States in 2018. Methods: This is a cross-sectional study using National Inpatient Sample 2018 database. Discharges with the ICD-10-PCS code for CAR T-cell therapy and ICD-10-CM code of ALL, DLBCL or PMBCL were included in the study. We analyzed their in-hospital outcomes (Total discharges, length of stay in days, hospitalization cost, and mortality - number of deaths). We applied the cost to charge ratio to hospitalization charges to estimate the mean hospitalization cost. The weighted sample represents national estimates. Results: We identified 785 discharges with CAR T cell therapy and diagnosis of ALL, DLBCL or PMBCL. 155 (19.75 %) were ALL, 620 (78.98%) DLBCL, and 10 (1.27%) PMBCL. Mean length of stay for the study cohort was 23.26 days. Specifically, for ALL mean LOS was 33.67 days, DLBCL 20.76 days, and PMBCL 17 days. Mean hospitalization cost for the study cohort was $285,989, specifically for ALL it was $342,228, DLBCL $274,102, PMBCL $179,431. There were a total of 60 (7.6%) deaths in the study cohort. Diagnosis specific mortality was 20 (12.9%) in ALL, 40 (6.4%) in DLBCL and none in PMBCL. Conclusions: Majority of discharges who underwent CAR T-cell therapy were DLBCL followed by ALL and PMBCL. CAR-T Cell hospitalizations have high costs and long length of stays. Mean length of stay was highest in ALL discharges, least in PMBCL. Mean hospitalization cost was higher in DLBCL discharges compared to ALL and was least in PMBCL discharges. The in-hospital mortality with the CAR-T cell therapy appears to be higher than reported in clinical trials, especially for ALL. [Table: see text]

Combination of atezolizumab and pirfenidone in second-line and beyond NSCLC: A phase I/II study

TPS2678

Background: Checkpoint inhibitors (CPI) targeting the PD1/PD-L1 axis significantly improved patient outcomes in stage IV non-small cell lung cancer (NSCLC). However, these patients will eventually develop resistance and progression. There is a need to identify novel treatment options. Poor response to PD-L1 antibody was correlated with increase in cancer-associated fibroblasts (CAF), which is known to interact with cytotoxic T cells (CTLs) by suppressing their function in a manner similar to regulatory T cells (Tregs). Production of cytokines by CAFs leads to impaired antitumor immunity by impairing CTL function (TGF beta) and prevent recruitment/mobilization of CTLs into tumors. These effects suggesting that CAF can be a therapeutic target in lung cancer resistant to checkpoint inhibitors. Pirfenidone (P) is approved to treat pulmonary fibrosis with anti-fibrotic effect by blocking the differentiation of fibroblasts into CAFs and suppress the production of TGF beta and TGF beta-induced signaling pathways/collagens. Atezolizumab is a humanized immunoglobulin (Ig) G1 monoclonal antibody that targets PD-L1 and inhibits the interaction between PD-L1 and its receptors, PD-1 and B7-1 (CD80), both of which function as inhibitory receptors expressed on T cells. We proposed a phase I/II trial to test the combination of atezolizumab (A) with P in patients with recurrent non-small cell lung cancer (NSCLC) after progression with CPI. The primary objective of phase I is to determine the maximum tolerated (MTD) dose of P in combination with A and assess the safety and tolerability of this combination. The secondary objective is to determine the efficacy of AP in all NSCLC participants treated in this study. Exploratory objectives include the measurement of circulating levels of TGF beta and research in expression of CAF related proteins. Methods: The initial phase I will enroll 3 patients using P at 801 mg po TID. A will be at 1200mg iv every 3 weeks. If there is ≤ 1 DLT, the study will proceed to phase II If there are 2- 3 DLT, P will be reduced to 534 mg TID. If there is ≤ 1 DLT, then this dose will proceed to phase II. If there is 2-3 DLT, then the study will be terminated. The phase II will enroll 16 patients to assess efficacy. Main inclusion criteria are patients with recurrent NSCLC after progression with first-line therapy CPI with or without chemotherapy, measurable disease, ECOG 0-2, and adequate organ function. Clinical trial information: NCT04467723.

Association of losartan with outcomes in metastatic pancreatic cancer patients treated with chemotherapy

BACKGROUND

Previous trials have shown improved efficacy of neoadjuvant treatment when combined with angiotensin II receptor antagonist, losartan in patients with locally advanced pancreatic ductal adenocarcinoma (PDA). However, role of losartan is unknown in metastatic PDA. In this retrospective observational study, we examined the relationship between losartan use at time of diagnosis and continued through chemotherapy treatment with clinical outcomes in patients with metastatic PDA that received chemotherapy.

METHODS

We retrospectively evaluated 114 metastatic PDA patients treated at University of Kansas Cancer Center between January 2000 and November 2019. We compared overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR) between patients using losartan at time of their cancer diagnosis and a control group of patients who were not on losartan. A subgroup analysis was performed based on patients who were on a 100 mg dose of losartan along with chemotherapy versus patients treated with chemotherapy (without losartan). Another subgroup analysis was performed based on chemotherapy regimen: Fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX) versus Gemcitabine and Abraxane.

RESULTS

No significant difference was found in OS (p=0.466) or PFS (p=0.919) in patients on losartan (median 274 day, 83 day) and control patients (median 279 day, 111 day). No significant difference was found in ORR (p=0.621) or in DCR (p=0.497). No significant difference was found in OS (p=0.771) or PFS (p=0.0604) in losartan patients (median 347 day, 350 day) and control patients (median 333 day, 101 day) treated with FOLFIRINOX. No significant difference was found in OS (p=0.916) or PFS (p=0.341) in losartan (median 312 day, 69 day) and control patients (median 221 day, 136 day) treated with Gemcitabine plus Abraxane. No significant difference was found in OS (p=0.727) or PFS (p=0.790) in 100 mg losartan patients (median 261 day, 84 day) and control (median 279 day, 111 day).

CONCLUSIONS

Patients on losartan at time of diagnosis and continued through chemotherapy treatment had no significant difference in OS, PFS, ORR, DCR than control patients. Subgroup analysis of patients treated with FOLFIRINOX revealed a longer PFS with losartan than control but did not reach statistical significance, likely due to small sample size. Our findings should be validated in a larger cohort to confirm if the benefit of losartan and FOLFIRINOX seen in a neoadjuvant setting for locally advanced cancer also applies to metastatic cancer.

RELEVANCE FOR PATIENTS

This research adds to growing data on the efficacy of angiotensin receptor blocking drugs as adjunctive treatment in addition to chemotherapy in pancreatic cancer with specific focus on metastatic disease.

Relating Gut Microbiome and Its Modulating Factors to Immunotherapy in Solid Tumors: A Systematic Review

Background: Gut microbiome is proved to affect the activity of immunotherapy in certain tumors. However, little is known if there is universal impact on both the treatment response and adverse effects (AEs) of immune checkpoint inhibitors (ICIs) across multiple solid tumors, and whether such impact can be modulated by common gut microbiome modifiers, such as antibiotics and diet.

Methods: A systematic search in PubMed followed by stringent manual review were performed to identify clinical cohort studies that evaluated the relevance of gut microbiome to ICIs (response and/or AEs, 12 studies), or association of antibiotics with ICIs (17 studies), or impact of diet on gut microbiome (16 studies). Only original studies published in English before April 1st, 2020 were used. Qualified studies identified in the reference were also included.

Results: At the phylum level, patients who had enriched abundance in Firmicutes and Verrucomicrobia almost universally had better response from ICIs, whereas those who were enriched in Proteobacteria universally presented with unfavorable outcome. Mixed correlations were observed for Bacteroidetes in relating to treatment response. Regarding the AEs, Firmicutes correlated to higher incidence whereas Bacteroidetes were clearly associated with less occurrence. Interestingly, across various solid tumors, majority of the studies suggested a negative association of antibiotic use with clinical response from ICIs, especially within 1-2 month prior to the initiation of ICIs. Finally, we observed a significant correlation of plant-based diet in relating to the enrichment of “ICI-favoring” gut microbiome (P = 0.0476).

Conclusions: Gut microbiome may serve as a novel modifiable biomarker for both the treatment response and AEs of ICIs across various solid tumors. Further study is needed to understand the underlying mechanism, minimize the negative impact of antibiotics on ICIs, and gain insight regarding the role of diet so that this important lifestyle factor can be harnessed to improve the therapeutic outcomes of cancer immunotherapy partly through its impact on gut microbiome.

Abstract P13: Prospective voluntary SARS-CoV-2 virus and anti-COVID-19 antibody tests in asymptomatic medical and research staff who work in direct contact with cancer patients: A single center study

Background The SARS–CoV-2 pandemic has assaulted all aspects of daily life. Medical professionals in oncology face additional challenges with balancing prompt cancer diagnosis and urgent treatment against potential COVID-19 exposure risk in these high-risk patients. We designed this prospective freewill study to offer testing for SAR2-CoV-2 viral RNA and/or anti-COVID-19, respectively in asymptomatic medical and research staff who work in direct contact with cancer patients. The overall goal was to evaluate the prevalence of infection in this group of asymptomatic healthcare providers to reduce exposure of cancer patients to asymptomatic staff. Methods Asymptomatic medical and research staff who work in direct contact with cancer patients were asked to voluntarily be tested for either SARS–CoV-2 viral RNA or antibodies or both. Either NP swabs and/or blood samples (EDTA tube) were collected. Tests are performed at Sinochips Kansas LLC, Sinochips Diagnostics (CLIA number:17D2176068, CAP number: 8709463). The PCR test is performed with FDA authorized 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel EUA. The Elecsys® Anti-SARS-CoV-2 (Roche Diagnostics) immunoassay was used to qualitative detection of antibodies to SARS-CoV-2 in human plasma. Results From 06/18/2020 to 12/18/2020, 861 participated in the study. 1095 tests were completed for SAR2-CoV-2 virus infection, and 918 were completed for antibody. Amount participants, 530 had both virus and antibody tested. 235 were tested more than once for viral infection and 166 were tested more than once for the antibody. Median age of participants was 39 years (IQR 32-51 years). Among these 84.7% were females, 84.4% white, 6.7% African American, 4.8% Asian and 84.7% non-Hispanic. The cumulative incidence of a positive test for the virus was 2.2% (16/712), and for the antibody test was 3.8% (26/679). 5 had both viral and antibody tests positive, with an average time of 4.1 weeks from viral testing positivity to detectable antibody among 3 cases and 2 cases with both viral infection and antibody detected at same time. There were 3 cases virus was detected more than once after turning positive. 2 remained positive at 16 and 22 days after initial test and one turned negative at 36 days as of last follow up. There were 7 cases where the antibody was tested more than once after turning positive and all 7 remained positive as of last follow up (range 7-103 days). Conclusion Prospective voluntary testing in asymptomatic medical and research staff who work in direct contact with cancer patients was feasible and resulted in identification of asymptomatic carriers who then placed in quarantine, thereby limiting exposure to cancer patients. Medical and research staff who work with cancer patients are general very cautious and the frequency of infections were significantly lower than general society. In addition, it seems that 1) virus and antibody may co-exist in the same person after exposure, and 2) the antibody may last for a relatively long time.

Citation Format: Weijing Sun, Andrew K. Godwin, Kathan Mehta, Natalie Streeter, Elizabeth Wulff-Burchfield, Anup Kasi, Tara L. Lin, Joaquina Baranda, Joseph McGuirk, Ziyan Pessetto, Adam Pessetto, B.J. Broome, Terry Tsue, Roy Jensen. Prospective voluntary SARS-CoV-2 virus and anti-COVID-19 antibody tests in asymptomatic medical and research staff who work in direct contact with cancer patients: A single center study [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr P13.

Randomized Phase II Trial of Anthracycline-free and Anthracycline-containing Neoadjuvant Carboplatin Chemotherapy Regimens in Stage I-III Triple-negative Breast Cancer (NeoSTOP)

PURPOSE

Addition of carboplatin (Cb) to anthracycline chemotherapy improves pathologic complete response (pCR), and carboplatin plus taxane regimens also yield encouraging pCR rates in triple-negative breast cancer (TNBC). Aim of the NeoSTOP multisite randomized phase II trial was to assess efficacy of anthracycline-free and anthracycline-containing neoadjuvant carboplatin regimens.

PATIENTS AND METHODS

Patients aged ≥18 years with stage I-III TNBC were randomized (1:1) to receive either paclitaxel (P) weekly × 12 plus carboplatin AUC6 every 21 days × 4 followed by doxorubicin/cyclophosphamide (AC) every 14 days × 4 (CbP → AC, arm A), or carboplatin AUC6 + docetaxel (D) every 21 days × 6 (CbD, arm B). Stromal tumor-infiltrating lymphocytes (sTIL) were assessed. Primary endpoint was pCR in breast and axilla. Other endpoints included residual cancer burden (RCB), toxicity, cost, and event-free (EFS) and overall survival (OS).

RESULTS

One hundred patients were randomized; arm A (n = 48) or arm B (n = 52). pCR was 54% [95% confidence interval (CI), 40%-69%] in arm A and 54% (95% CI, 40%-68%) in arm B. RCB 0+I rate was 67% in both arms. Median sTIL density was numerically higher in those with pCR compared with those with residual disease (20% vs. 5%; P = 0.25). At median follow-up of 38 months, EFS and OS were similar in the two arms. Grade 3/4 adverse events were more common in arm A compared with arm B, with the most notable differences in neutropenia (60% vs. 8%; P < 0.001) and febrile neutropenia (19% vs. 0%; P < 0.001). There was one treatment-related death (arm A) due to acute leukemia. Mean treatment cost was lower for arm B compared with arm A (P = 0.02).

CONCLUSIONS

The two-drug CbD regimen yielded pCR, RCB 0+I, and survival rates similar to the four-drug regimen of CbP → AC, but with a more favorable toxicity profile and lower treatment-associated cost.

Abstract PO-082: Preliminary analysis of factors associated with COVID-19-related disease severity in cancer patients: University of Kansas Cancer Center experience

Background: There is insufficient evidence to support clinical decision-making for oncology patients diagnosed with COVID-19 due to the limited studies focusing on factors affecting COVID-19-associated disease severity/death in cancer patients.

Methods: We retrospectively analyzed data from KU Cancer Center to assess demographic/clinical characteristics and ferritin levels of 40 cancer patients with a confirmed COVID19 diagnosis by viral RNA detection in a nasopharyngeal swab between 3/1/20 through 6/9/20. Chi square test and Mann-Whitney U test were used to identify whether demographic/clinical characteristics and ferritin were associated with COVID-19 severity/death.

Results: Median age was 59.5 years, 16 (40%) were aged 65 years or older, and 18 (45%) patients were male. 31 (77.5%) were non-Hispanic, 21 (52%) were Caucasians, 11 (27%) were African Americans, and 21 (52.5%) were current/former smokers. 14 (35%) were obese. Breast cancer n=9 (22.5%) was the most prevalent malignancy. 28 (70%) had ECOG of 0/1. 27 (67.5%) were on active anticancer treatment, and 13 (32.5%) had active (measurable) cancer. 12 (30%) had recent surgery. 6 (15%) were asymptomatic and 34 (85%) were symptomatic. Fever (47.5%), cough (57.5%), productive cough (50%), and shortness of breath (47.5%) were the most common symptoms. At analysis (June 9, 2020), 3 (7.5%) patients had died. 8 (38.1%) had mild/moderate COVID-19 illness and 13 (61.9%) had severe illness (ICU admission, intubation, death). Patients with mild/moderate illness were significantly younger (median age 56.5 years) vs. those with severe illness (median age 67.5 years), p=0.02. Sex, race and ethnicity, obesity, ECOG, cancer type, active cancer treatment, and recent surgery were not associated with COVID-19 severity. However, productive cough (p=0.01) and shortness of breath (p=0.006) were associated with COVID-19 severity. In 19 patients with available ferritin levels, asymptomatic patients (n=2) had a significantly lower ferritin (median 68.5 NG/ML) vs. symptomatic (n=17), who had higher ferritin (median 422 NG/ML) p=0.04.

Conclusions: Age was associated with an increased risk of COVID-19-related disease severity/death in cancer patients. This may possibly reflect the effects of more advanced malignant disease, anticancer treatment, and comorbidities on the impact of this infection. Ferritin levels appear to have a role in screening and monitoring for COVID-19 infection in cancer patients. Hence, our findings warrant validation in a larger cohort. A prospective study is under way at the University of Kansas Cancer Center to validate the factors associated with COVID-19-related disease severity/death in cancer patients.

Citation Format: Anup Kasi, Elizabeth Wulf-Burchfield, Natalie Streeter, Stephen Jackson, David Streeter, Eric Crowder, Kathan Mehta, Weijing Sun. Preliminary analysis of factors associated with COVID-19-related disease severity in cancer patients: University of Kansas Cancer Center experience [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-082.

Abstract PO-085: Sex bias in COVID-19-associated Illness severity and mortality in cancer patients: A systematic review and meta-analysis

Importance: There is strong evidence that COVID-19 is associated with higher morbidity and mortality in males compared to females in the general population. However, whether the same sex bias exists in the cancer patient population is unknown. Several published studies have examined this question, but the results are inconclusive and inconsistent and the association remains unclear.

Objective: To evaluate the sex differences in the risk of severe illness and mortality attributable to COVID-19 in the cancer patient population.

Data Sources: Published articles that evaluated clinical outcomes associated with severe illness or death attributable to COVID-19 in the cancer patient population from inception to June 1, 2020, were identified by searching PubMed and EMBASE, as well as the ASCO 2020 Virtual Annual Conference, ESMO conferences held from January 2020 to June 1, 2020, and the preprint databases medRxiv and bioRxiv.

Study Selection: Prospective or retrospective analyses, studies published in English, providing clinical outcomes data with sex differences in the cancer patient population.

Data Extraction and Synthesis: Author, date of publication, country, type of studies, median and range of age, cancer types included in the studies, definitions of clinical outcomes, and the odds ratios (OR) for severe illness or death attributable to COVID-19 were retrieved. Where OR data were not available, raw data were used to calculate the OR in a univariate analysis model and included in the meta-analysis.

Main Outcome(s) and Measure(s): The primary outcome of interest was OR of (1) severe illness, (2) death, and (3) composite outcome of severe illness and death attributable to COVID-19 in males versus females.

Results: Overall, 2,764 patients (9 studies) were analyzed in retrospective study settings. Of the included studies, two studies were multinational whereas the rest were conducted in China (4), France (1), United Kingdom (1), and United States (1). Median ages were similar across studies (range 62-70). Three studies reported outcomes for death and six studies reported outcomes for severe illness. Of the seven studies, all but one defined severe illness as illness requiring ICU admission or leading to death and attributable to COVID-19. Pooled ORs for the composite outcome was 1.68 (95% CI, 1.27-2.24), death was 1.98 (95% CI, 1.21-3.26), and severe illness was 1.48 (95% CI, 1.05-2.10), all disfavoring males. Random effects model was used with the Dersimonian-Laird Model throughout analyses and significant heterogeneity was subsequently confirmed (I2, 48.1%; tau2, 0.0816). No significant between-study bias was detected per Begg’s funnel plot.

Conclusions and Relevance: The male sex was associated with higher risk of severe illness, death, and the composite outcome of both attributable to COVID-19. This finding has implications in informing the clinical prognosis and decision making regarding oncologic patients.

Citation Format: Robin Park, Anusha Chidharla, Kathan Mehta, Weijing Sun, Anup Kasi. Sex bias in COVID-19-associated Illness severity and mortality in cancer patients: A systematic review and meta-analysis [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-085.

Sex-bias in COVID-19-associated illness severity and mortality in cancer patients: A systematic review and meta-analysis

BACKGROUND

Whether there is sex-bias within the adverse outcomes associated with COVID-19 in the cancer population is unknown. In this regard, several published studies have examined this question, but the results are inconclusive and inconsistent. To evaluate the sex-difference in the risk of adverse outcomes associated with COVID-19 in the cancer population, we have conducted a systematic review and meta-analysis.

METHODS

Published articles evaluating adverse outcomes associated with COVID-19 in the cancer population from inception to June 2020 were identified by searching PubMed and EMBASE, ASCO 2020 Virtual Annual Conference, AACR 2020 COVID-19 and Cancer, ESMO conferences held from January to June 2020, and medRxiv and bioRxiv. Prospective or retrospective analyses in English, providing outcomes data with sex differences in the cancer population were included. The primary outcomes of interest were pooled ORs of severe illness, all-cause death, and the composite of severe illness and death attributable to COVID-19 in males versus females in cancer patients.

FINDINGS

Overall, 3968 patients (17 studies) were analyzed in retrospective study settings. Overall, pooled ORs of the composite of severe illness and all-cause death in the setting of COVID-19 in males versus females was 1.60 (95% CI, 1.38-1.85). The risk of severe illness or death were both independently increased in males versus females.

INTERPRETATION

Male sex was associated with a higher risk of severe illness and death attributable to COVID-19. This finding has implications in informing the clinical prognosis and decision making in the care of cancer patients.

FUNDING

This study received no funding.

Changing demography of homeless adult populations

As the demographic characteristics of the US population have changed over the past decade, the characteristics of different homeless populations have changed as well. This study tracked changes in demographic characteristics of homeless adult, veteran, and healthcare service user populations against general adult and veteran populations from 2007-2017. The results showed that changing demographics of homeless populations largely reflected broader trends in the general population, and attention is needed on the clinical needs of aging homeless populations. There may be some unique changes in the demography of some homeless populations, such as younger homeless veterans seeking healthcare services.

In-hospital outcomes of splanchnic vein thrombosis including Budd Chiari syndrome associated with GI malignancies

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Background: Patients with gastrointestinal (GI) malignancies are at increased risk of developing splanchnic vein thrombosis (SVT). However, there is a dearth of information about the epidemiology of splanchnic vein thrombosis associated with specific GI malignancies. We sought to compare the differences in hospitalizations and mortality related to SVT among various GI malignancies. Methods: We included the top three discharge diagnoses to identify cases of splanchnic vein thrombosis (portal/mesenteric/hepatic and splenic vein thrombosis) along with a secondary diagnosis of a GI malignancy, namely esophagus, gastric, hepatic, colorectal, pancreatic and cholangiocarcinoma within the 2010-2014 Nationwide Inpatient Sample (NIS). Outcomes including mortality, hospitalization charges and length of stay were compared for different types of GI malignancies for SVT hospitalizations using the chi-square test. Complications related to SVT were also identified. Data was analyzed using STATA 15. Results: There were 320,804 total weighted admissions for SVT, of which 33,556 or 11.6% occurred in patients with GI malignancies. Hepatic cancer was the most common GI malignancy associated with SVT, responsible for 5.1% of all cases, followed by pancreatic cancer (2.76% cases). Hepatic vein thrombosis was the commonest type of SVT occurring in patients with GI malignancy. Hospitalizations for SVT in GI malignancies increased from 5743 in 2010 to 8415 in 2014, representing an increase of 46% over 5 years. On univariate analysis, patients with esophageal cancer and SVT had higher rates of cardiac arrest (3.5% vs 0.7% average for other cancers, p = 0.03), but there were no significant differences in rates of other complications studied including intracranial hemorrhage, requirement for blood transfusion, mechanical ventilation or variceal bleeding. Inpatient mortality rate for admission with SVT was the highest for esophageal cancer (21.1%), followed by gastric cancer (17%) against an average of 9.3% for all GI malignancies (p < 0.05).The median cost of an admission for a patient with SVT were highest for esophageal cancer $102,452, followed by colorectal cancer ($97,491) and the least for hepatic cancer ($67,007). Conclusions: We found that hospitalizations for splanchnic vein thrombosis in patients with GI related malignancies has been steadily increasing and represent a significant burden. Hospitalizations for SVT in esophageal, gastric and colorectal cancer patients bear poorer outcomes as compared to hepatic cancer.

Association of losartan use with outcomes in metastatic pancreatic cancer patients treated with chemotherapy

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Background: A phase II trial has shown improved efficacy of neoadjuvant therapy when combined with losartan (by remodeling desmoplasia) in locally advanced pancreatic ductal adenocarcinoma (PDA). However, role of losartan is unknown in metastatic PDA. We examined the relationship between the use of the angiotensin II receptor antagonist, losartan, at time of diagnosis with clinical outcomes in metastatic PDA pts that received chemo. Methods: We retrospectively evaluated 114 metastatic PDA pts treated at our center between Jan 2000 and Nov 2019. We compared OS, PFS, objective response rate (ORR), and disease control rate (DCR) between pts using losartan at time of cancer diagnosis and a control group of pts not on losartan. A subanalysis was performed based on losartan dose: 100mg dose versus control pts. and based on chemo: FOLFIRINOX or gemcitabine+abraxane. Results: Table shows baseline demographics. No significant difference was found in OS [p = 0.455] or PFS [p = 0.919] in pts on losartan (median 274d, 83d) vs control (median 279d, 111d) [p = 0.466]. No significant difference was found in ORR [p = 0.621] or in DCR [p = 0.497]. No significant difference was found in OS [p = 0.771] or PFS [p = 0.064] in losartan pts (median 347d, 350d) vs control (median 333d, 101d) treated with FOLFIRINOX. No significant difference was found in OS [p = 0.916] or PFS [p = 0.341] in losartan (median 312d, 69d) vs control (median 221d, 136d) [p = 0.916] treated with gemcitabine+abraxane. No significant difference was found in OS [p = 0.727] or PFS [p = 0.790] in 100mg losartan pts (median 261d, 84d) vs control (median 279d, 111d). Conclusions: Pts on losartan at time of diagnosis had no significant difference in OS, PFS, ORR, DCR than control pts. However, a subanalysis of pts treated with FOLFIRINOX revealed a longer PFS with losartan than control but did not meet statistical significance, likely due to small sample size. To confirm if the benefit of losartan + FOLFIRINOX seen in neoadjuvant setting for locally advanced cancer also applies to metastatic cancer, our findings need to be validated in a larger cohort. [Table: see text]

Epidemiology, treatment, and outcomes in locally advanced spindle cell lung cancer

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Background: Spindle cell lung cancer (SpCC) is a rare type of NSCLC which portends a poor prognosis. Due to the rarity of diagnosis, there is a dearth of information about the epidemiology and overall survival for these patients. Methods: We performed a retrospective analysis using the SEER database from 1975-2016 to study the demographics, treatment modalities and outcomes for patients with locally advanced SpCC. Data regarding age, sex, race, pathological grade, staging, treatment, overall and disease specific survival was extracted. Hazards ratios were calculated to identify any difference in mortality between patients who received surgery alone versus those who received adjuvant chemotherapy or radiation. Results: A total of 936 cases of SpCC were identified, out of which 367 (39%) patients had locally advanced disease. 84% cases were diagnosed after the age of 60, with peak incidence occurring in the 70-74 age group. 87% were Caucasians, and 56% were males. 68% of the tumors were poorly differentiated. In terms of the treatment modalities for locally advanced SpCC, surgical resection was performed only in 58.5% cases. 27% patients received systemic chemotherapy, out of which 50% was in the adjuvant setting after surgery. 32 % patients received radiation therapy, only 38.5% of which was in the adjuvant setting. No statistically significant difference in mortality was seen in patients who received surgery alone vs adjuvant RT vs adjuvant chemotherapy. However, pts who did not receive surgery had a higher odds of mortality (OR = 4.2, p value 0.0001). Similarly, pts who only received chemotherapy alone had a higher odds of mortality vs those who received chemotherapy along with surgery (OR = 3.4, p-0.045), Overall survival was 25% for patients with localized disease, 9.5% for regional and only 2.6% for distant metastatic disease. For locally advanced SpCC, the observed cumulative 1-year survival was 54.8 % and declined to 29.2% after 5 years. Conclusions: Majority of the spindle cell carcinoma cases are poorly differentiated and present at an advanced stage at the time of diagnosis. For locally advanced SpCC, surgical resection can improve survival. Randomized trials are needed to test efficacy of adjuvant therapies.

Thirty-day readmissions due to Venous thromboembolism in patients discharged with syncope

A recent study found that approximately 1 in every 6 patients hospitalized for the 1st episode of syncope had an underlying pulmonary embolism (PE). As current guidelines do not strongly emphasize evaluation for PE in the workup of syncope, we hypothesize that there might be a higher rate of 30-day readmission due to untreated venous thromboembolism (VTE). The objective of this study is to measure the 30-day readmission rate due to VTE and identify predictors of 30-day readmission with VTE among syncope patients. We identified patients admitted with syncope with ICD9 diagnoses code 780.2 in the Nationwide Readmission Database (NRD-2013), Healthcare Cost and Utilization Project (HCUP). The 30-day readmission rate was calculated using methods described by HCUP. Logistic-regression was used to identify predictors of 30-day readmission with VTE. Discharge weights provided by HCUP were used to generate national estimates. In 2013, NRD included 207,339 eligible patients admitted with syncope. The prevalence rates of PE and DVT were 1.1% and 1.4%, respectively. At least one syncope associated condition was present in 60.9% of the patients. Among the patients who were not diagnosed with VTE during index admission for syncope (N = 188,015), 30-day readmission rate with VTE was 0.5% (0.2% with PE and 0.4% with DVT). In conclusion, low prevalence of VTE in patients with syncope and extremely low 30-day readmission rate with VTE argues against missed diagnoses of VTE in index admission for syncope. These results warrant further studies to determine clinical impact of work up for PE in syncope patients without risk factors.

Epidemiology and Outcomes of Hematopoietic Stem Cell Transplantation in Human Immunodeficiency Virus-Positive Patients From 1998 to 2012: A Nationwide Analysis

Background

Prior studies have shown that outcomes of hematopoietic stem cell transplantation (HSCT) in human immunodeficiency virus (HIV)-positive patients have been similar to outcomes in HIV-negative patients since effective implementation of highly active antiretroviral therapy by 1998, but they are limited by small sample size or noninclusion of recent data.

Methods

We queried National Inpatient Sample, a large inpatient data set in the United States, from 1998 to 2012 for HSCT, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code 41.0. HIV-positive patients were identified by the presence of ICD-9-CM diagnostic codes 042, 043, 044, V08, and 079.53. The primary outcome was in-hospital mortality rate, and the secondary outcome the in-hospital complication rate of HSCT. Outcomes were assessed by means of univariate, multivariate regression and matched-pair analysis.

Results

A total of 39517 patients who underwent HSCT were identified. Among these, 108 patients had HIV infection. There were no differences in in-hospital mortality rates or rates of intubation, sepsis, bacteremia, or graft-vs-host disease between HIV-positive and HIV-negative patients after allogeneic or autologous HSCT. In allogeneic HSCT, HIV-positive patients had a significantly higher incidence of nontuberculous mycobacterial and cytomegalovirus infection than HIV-negative patients.

Conclusion

Although HIV-positive patients may have a higher risk of certain opportunistic infections, they are not at higher risk of serious in-hospital complications of HSCT. Allogeneic and autologous HSCT can be safely performed in HIV-positive patients.

Evaluating the addition of bevacizumab to endocrine therapy as first-line treatment for hormone receptor-positive metastatic breast cancer: a pooled analysis from the LEA (GEICAM/2006-11_GBG51) and CALGB 40503 (Alliance) trials

BACKGROUND

Randomised trials comparing the efficacy of standard endocrine therapy (ET) versus experimental ET + bevacizumab (Bev) in 1st line hormone receptor-positive patients with metastatic breast cancer have thus far shown conflicting results.

PATIENTS AND METHODS

We pooled data from two similar phase III randomised trials of ET ± Bev (LEA and Cancer and Leukemia Group B 40503) to increase precision in estimating treatment effect. Primary end-point was progression-free survival (PFS). Secondary end-points were overall survival (OS), objective response rate (ORR), clinical benefit rate (CBR) and safety. Exploratory analyses were performed within subgroups defined by patients with recurrent disease, de novo disease, prior endocrine sensitivity or resistance and reported grades III-IV hypertension and proteinuria.

RESULTS

The pooled sample consisted of 749 patients randomised to ET or ET + Bev. Median PFS was 14.3 months for ET versus 19 months for ET + Bev (unadjusted hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.66-0.91; p < 0.01). ORR and CBR with ET and ET + Bev were 40 versus 61% (p < 0.01) and 64 versus 77% (p < 0.01), respectively. There was no difference in OS (HR 0.96; 95% CI 0.77-1.18; p = 0.68). PFS was superior for ET + Bev for endocrine-sensitive patients (HR 0.68; 95% CI 0.53-0.89; p = 0.004). Grade III-IV hypertension (2.2 versus 20.1%), proteinuria (0 versus 9.3%), cardiovascular (0.5 versus 4.2%) and liver events (0 versus 2.9%) were significantly higher for ET + Bev (all p < 0.01). Hypertension and proteinuria were not predictors of efficacy (interaction test p = 0.33).

CONCLUSION

The addition of Bev to ET increased PFS overall and in endocrine-sensitive patients but not OS at the expense of significant additional toxicity.

TRIALS REGISTRATION

ClinicalTrial.Gov NCT00545077 and NCT00601900.

Utilization and outcomes of high-dose chemotherapy and stem-cell rescue in patient with testicular cancer from 2005 to 2014 in United States

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Background: Testicular tumors are potentially curable by means of high-dose chemotherapy plus hematopoietic stem-cell rescue. This regimen is commonly used as salvage therapy, third-line or later therapy in patients with platinum-refractory disease. The utilization and real-world outcomes and complications of patients with testicular cancer undergoing autologous hematopoietic stem cell transplant (aHSCT) in United States are unknown. Methods: We queried National Inpatient Sample, a large inpatient data set in the United States, from 2005 to 2014 for male patients with testicular cancer or multiple myeloma (control group) receiving aHSCT and compared outcomes between these groups. The primary outcome was in-hospital mortality rate, and the secondary outcomes included in-hospital complications of aHSCT, length of stay and total charges. Outcomes were assessed by means of univariate analysis, multivariate regression and propensity score matched-pair analysis. Results: A total of 391 patients (weighted N = 1,909) with testicular cancer and 4,809 male patients (weighted N = 23,501) with multiple myeloma who underwent aHSCT from 2005 to 2014 were identified. Mean age of patients with testicular cancer was 32.3 years vs 59 years for multiple myeloma patients (p < 0.001) There were no differences in in-hospital mortality rates (1.5% vs 1.4%, p = 0.85) or rates of intubation (2.3% vs 1.6%, p = 0.36), sepsis (7.7% vs 7.5%, p = 0.94), bacteremia (13.5% vs 15.6%, p = 0.42), or stomatitis (43.8% vs 38.8%, p = 0.87) between patients with testicular cancer and multiple myeloma receiving autologous HSCT. However, utilization of total parenteral nutrition was higher in patients with testicular cancer (12.9% vs 4.7%, p < 0.001). There was no difference in length of stay (17.5 vs 17.5 days, p = 0.77) and total charges (121,120$ vs 123,729$, p = 0.74) between two groups. The results were consistent in multivariate and propensity score matched-pair analysis. Conclusions: The in-hospital outcomes of patients with testicular cancer receiving aHSCT appears to be similar to patients with multiple myeloma. However, overall utilization of aHSCT for testicular cancer appears to be low in United States.

Abstract P2-08-01: Factors predicting relapse in early breast cancer patients with a pathological complete response after neoadjuvant therapy – Results of a pooled analysis based on the GBG meta-database

Background

Even though patients with a pCR following neoadjuvant chemotherapy have an excellent prognosis still some of these patients will eventually relapse. A better identification of pts with an increased risk of relapse despite a pCR would be helpful to select these patients for additional post-neoadjuvant treatment strategies. Thus, the rationale of this retrospective analysis was to identify factors predicting relapse despite a pCR.

Methods

This pooled retrospective analysis based on the GBG meta-database includes the neoadjuvant trials GeparTrio, GeparQuattro, GeparQuinto, GeparSixto and GeparSepto. In these trials 2188 (27%) of 7933 pts had a pCR according to ypT0/ypTis ypN0 Definition and were included. The primary endpoint was disease-free survival (DFS), secondary endpoints were distant DFS (DDFS) and overall survival (OS). A multivariate Cox proportional hazards model was used to report hazard ratios with 95% confidence interval (CI). The two-sided significance level was set to α=0.05. Endpoints were analysed for all pts and in subgroups defined by intrinsic subtypes. The potential risk factors intrinsic subtype (HER2 negative/hormone receptor (HR) positive, triple negative, HER2 positive/HR positive, HER2 positive/HR negative), histological tumor type (lobular vs other), grade (G1/G2 vs G3), KI67 (≤20% vs higher), initial cT and cN stadium (cT1 vs cT2 vs cT3/4; cN0 vs cN+), age (≤40 vs 41-59 vs ≥60), BMI (&lt; 25 vs 25-29 vs ≥ 30), planned number of cycles of chemotherapy (≤6 vs &gt; 6), menopausal status (pre- vs postmenopausal) and clinical response after 2-4 cycles (SD vs PR vs CR vs PD) were included as covariates in multivariate Cox regression models as well as study identification.

Results

From 2188 evaluable patients DFS, DDFS and OS events were observed in 290/197/130 pts respectively; the median follow-up over all studies was 59 months. In multivariate analysis including study and all potential risk factors DFS was significantly different with regard to the initial cN status (cN+ vs cN0, hazard ratio (HR) 1.70; 95% CI [1.2, 2.4], p=0.002). Of borderline significance was histological type (non-lobular vs lobular, HR 0.52 95% CI [0.3, 1.1]; p=0.076) and initial tumor stage (cT3/4 vs cT1, HR 1.61 95% CI [1.0, 2.7]; p=0.064). In terms of DDFS significant differences were seen for the initial cN status (cN+ vs cN0, HR 2.34; 95% CI [1.5, 3.6], p&lt;0.001) and initial tumor stage (cT3/4 vs cT1, HR 1.83 95% CI [1.0, 3.3]; p=0.044); histological type was again close to significance (non-lobular vs lobular, HR 0.46 95% CI [0.2, 1.1]; p=0.067). Multivariate analysis showed significantly worse OS with initial cT3/4 tumors (cT3/4 vs cT1, HR 2.48 95%CI [1.1, 5.7]; p=0.030), and the lobular type (non-lobular vs lobular, HR 0.35 95% CI [0.1, 0.9]; p=0.026) and a trend for worse OS in pts with cN+ (cN+ vs cN0, HR 1.67 95% CI [1.0, 2.9]; p=0.067).

Conclusions

Initial tumor load before start of neoadjuvant chemotherapy (tumor stage and nodal status) and lobular subtype were predictors of long term outcome after a pCR following neoadjuvant chemotherapy. Intrinsic subtype, KI67, grade and planned number of cycles were not predictive for a relapse.

Citation Format: Huober J, Schneeweiss A, Blohmer J-U, Denkert C, Tesch H, Hanusch CA, Salat C, Rhiem K, Rezai M, Solbach C, Fasching PA, Jackisch C, Mehta K, Nekljudova V, Seither F, von Minckwitz G, Loibl S, Untch M. Factors predicting relapse in early breast cancer patients with a pathological complete response after neoadjuvant therapy – Results of a pooled analysis based on the GBG meta-database [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 P2-08-01.

Zoonotic Influenza and Human Health-Part 1: Virology and Epidemiology of Zoonotic Influenzas

PURPOSE OF REVIEW

Zoonotic influenza viruses are those that cross the animal-human barrier and can cause disease in humans, manifesting from minor respiratory illnesses to multiorgan dysfunction. They have also been implicated in the causation of deadly pandemics in recent history. The increasing incidence of infections caused by these viruses worldwide has necessitated focused attention to improve both diagnostic as well as treatment modalities. In this first part of a two-part review, we describe the structure of zoonotic influenza viruses, the relationship between mutation and pandemic capacity, pathogenesis of infection, and also discuss history and epidemiology.

RECENT FINDINGS

We are currently witnessing the fifth and the largest wave of the avian influenza A(H7N9) epidemic. Also in circulation are a number of other zoonotic influenza viruses, including avian influenza A(H5N1) and A(H5N6); avian influenza A(H7N2); and swine influenza A(H1N1)v, A(H1N2)v, and A(H3N2)v viruses. Most recently, the first human case of avian influenza A(H7N4) infection has been documented. By understanding the virology and epidemiology of emerging zoonotic influenzas, we are better prepared to face a new pandemic. However, continued effort is warranted to build on this knowledge in order to efficiently combat the constant threat posed by the zoonotic influenza viruses.

In-patient outcomes of Hematopoietic Stem Cell Transplantation in Patients with Immune Mediated Inflammatory Diseases: A Nationwide Study

The impact of underlying immune-mediated inflammatory diseases (IMID) in patients undergoing hematopoietic stem cell transplant (HSCT) is unclear. Hematopoietic cell transplantation co-morbidity index (HCT-CI) is gaining acceptance as a reliable clinical method to score pre-transplant co-morbidities. Higher HCT-CI from a co-morbid IMID implies higher NRM. However, HCT-CI integrates many IMIDs with different pathogenesis and treatment together which may lead to spurious results. We performed a cross-sectional study using Nationwide Inpatient Sample dataset from 1998 to 2011 to compare the outcomes of HSCT in patients with different co-morbid IMIDs with patients without any co-morbid IMIDs. In both our multivariate and stringent matched-pair analysis, ulcerative colitis (UC) was associated with increased mortality while rheumatoid arthritis and psoriasis were associated with lower mortality as compared to no IMID group. Furthermore, in allogeneic HSCT subgroup, UC was associated with higher mortality and psoriasis was associated with lower mortality. In conclusion, we found that depending on the type of HSCT, each IMID has a different impact on outcomes of HSCT. Furthermore, UC patients had increased mortality if they had primary sclerosing cholangitis and had a higher risk of opportunistic infections like tuberculosis and cytomegalovirus suggesting the need for increased vigilance in this cohort.

Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics

Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Acute Kidney Injury of Infectious Etiology in Monsoon Season: A Prospective Study Using Acute Kidney Injury Network Criteria

The epidemiological pattern of acute kidney injury (AKI) in tropical countries during monsoon reflects infectious disease as the most important cause. AKI is a confounding factor and may be overlooked by primary health-care providers and underreported in health statistics. The present study prospectively helps estimate the burden of disease and analyze etiology, clinical profile, and outcome in a tertiary care hospital of a metropolitan city in a tropical country. The study period included monsoon season of 2012 and 2013, a total of 8 months. AKI staging was done as per the AKI Network (AKIN) criteria. Patients were treated for primary disease. Renal replacement therapy (RRT) was given as required. Patients were followed up during hospitalization till recovery/death. Out of a total of 9930 admissions during this period, 1740 (17.52%) were for infections and 230 (2.31%) had AKI secondary to infectious diseases during monsoon. The incidence of AKI (230/1740) in infectious diseases during monsoon was 13.21%. The study population (n = 230) comprised 79.5% of males and the mean age was 40.95 ± 16.55 years. Severe AKI: AKIN Stage III was seen in 48.26% of patients and AKIN Stage I in 41.74%. The most common etiology of AKI was malaria (28.3%) followed by acute gastroenteritis (23%), dengue (16.5%), leptospirosis (13%), undifferentiated fever (10.4%), more than one etiology (5.4%), and enteric fever (3.5%). RRT was required in 44.78% of patients. Requirement for RRT was maximum in patients with more than one etiology followed by leptospirosis, malaria, dengue, and least in typhoid. The overall mortality was 12.17%. In multivariate analysis, vasopressor support and assisted ventilation were risk factors for mortality.

Abstract WP240: Regional Disparities in Stroke Transfers for Endovascular Treatment- Outcomes from the Early Years of Neurointervention

Introduction: Acute stroke care has been revolutionized with the advent of intravenous alteplase and endovascular therapy. The number of centers in the United States equipped to offer endovascular therapy are limited, often necessitating inter-hospital transfer. We studied the outcomes of such patients in terms of mortality and disability, and attempted to determine the possible contributory factors in the early years of neurointervention for acute stroke management.

Methods: We used the Nationwide Inpatient Sample data to identify the acute stroke patients requiring transfer for endovascular treatment, the National Center for Health Statistics data to determine their location, the United States Census Bureau website for determining the population demographics, the Joint Commission data on the distribution of Primary Advanced and Comprehensive Stroke Centers, and the Human Resources and Services Administration data on delivery of medical care. We compared the outcomes in the four major regions of the country in terms of mortality and disability at discharge.

Results: Age above 80 years (p<0.05) and a high Charlson’s co-morbidity index (p<0.01) were consistent predictors for increased disability in transferred patients receiving endovascular therapy. Age greater than 80 years was also a predictor for higher mortality (p<0.001) in all regions. The prevalence of significant disability was higher in the Midwest compared to the national average (p=0.0147).

Conclusion: Distribution of healthcare facilities capable of offering endovascular treatments affects time to treatment and consequently, outcomes. Strategic triage system and distribution of Primary Advanced and Comprehensive Stroke Centers could help reduce disparities of outcomes.

Comparative study of lung and extrapulmonary poorly differentiated neuroendocrine carcinomas: A SEER database analysis of 162,983 cases

BACKGROUND

Extrapulmonary neuroendocrine carcinomas (NECs) are poorly studied and are managed similar to lung NECs, which may not account for differences between the 2 groups of tumors as well as the heterogeneity within extrapulmonary NEC.

METHODS

Data from the Surveillance, Epidemiology, and End Results program between 1973 and 2012 were used to estimate the relative percentages of lung NECs and subgroups of extrapulmonary NECs, epidemiological patterns at these sites, and the median and 5-year overall survival rates.

RESULTS

Of 162,983 NEC cases, 14,732 were extrapulmonary; of these, 5509 were gastrointestinal (37.44%), 4151 were of unknown primary (28.2%), and 5072 were of other sites (34.4%). Lung NEC had the highest percentage of small cell morphology (95.2%) and gastrointestinal NEC had the least (38.7%), with the rest being other morphologies. Significant differences were noted with regard to median age (range, 48-74 years), percentage of cases of distant stage disease (24%-77%), and incidence according to sex and race. The median survival of patients with lung NEC was 7.6 months, that for patients with gastrointestinal NEC was 7.5 months (range, 25.1 months for NEC at the small intestine to 5.7 months for NEC at the pancreas), and that for patients with unknown NEC was 2.5 months. The 5-year survival rate for patients with local stage disease ranged from 58% to 60% for NECs of the female genital tract and small intestine to 25% for esophageal NECs. The primary tumor site remained statistically significant for survival even after adjusting for known prognostic variables (P<.0001).

CONCLUSIONS

To the authors' knowledge, the current study is the largest study of NECs performed to date and also the first with comprehensive epidemiological data. Significant differences in incidence patterns and large variations in survival depending on anatomical site and morphological subtype were noted. A curative approach is possible for patients with nonmetastatic NECs. Cancer 2018;124:807-15. © 2017 American Cancer Society.

Expression of Cyclin D1 protein in residual tumor after neoadjuvant chemotherapy for breast cancer

PURPOSE

Hormone receptor (HR)-positive breast cancer (BC) shows a poor response to neoadjuvant chemotherapy (NACT). New treatment targets like the Cyclin D1-CDK4/CDK6 complex are promising adjuvant/post-neoadjuvant therapeutic strategies. Evaluating Cyclin D1 overexpression in residual tumor could recognize those patients that benefit most from such post-neoadjuvant treatment. In this study, we determined Cyclin D1 expression in residual BC after NACT. Secondary aims were to correlate Cyclin D1 expression levels with clinicopathological parameters and to assess its prognostic value after NACT.

METHODS

We retrospectively assessed the nuclear expression of Cyclin D1 on tissue microarrays with residual tumor from 284 patients treated in the neoadjuvant GeparTrio (n = 186) and GeparQuattro (n = 98) trials. Evaluation was performed with a standardized immunoreactive score (IRS) after selecting a cut-off value.

RESULTS

A high expression level (IRS ≥ 6) of Cyclin D1 was found in 37.3% of the assessed specimens. An increased Cyclin D1 expression was observed in HR-positive tumors, compared to HR-negative tumors (p = 0.02). Low Cyclin D1 levels correlated with clinical tumor stage 1-3 (p = 0.03). Among patients with HR-positive/Her2-negative tumors and high Cyclin D1 expression, a better disease-free survival (DFS) was graphically suggested, but not significant (p = 0.21).

CONCLUSION

Our study demonstrates a measurable nuclear expression of Cyclin D1 in post-neoadjuvant residual tumor tissue of HR-positive BC. Cyclin D1 expression was not prognostic for DFS after NACT. Our results and defined cut-off suggest that the marker can be used to stratify tumors according to protein expression levels. Based on this, a prospective evaluation is currently performed in the ongoing Penelope-B trial.

Practice makes perfect: relationship between hospital procedure volume and permanent pacemaker implantation after paroxysmal supraventricular tachycardia ablation

PURPOSE

Paroxysmal supraventricular tachycardia (PSVT) ablation can result in injury to the atrioventricular (AV) node causing complete heart block requiring permanent pacemaker (PPM) implantation. Few studies have examined the impact of hospital PSVT ablation volume and PPM implantation rates post ablation.

METHODS

We included adult patients from the Nationwide Inpatient Sample (NIS) database, from 1998 to 2011, using ICD-9 diagnoses codes 427.0 and 427.89 for PSVT and ICD-9 procedure code 37.34 for ablation. Patients with concomitant arrhythmias, prior pacemaker/defibrillator implants, or pre-existing sinus node dysfunction were excluded. Multivariate logistic regression analysis was performed to identify predictors of PPM implantation.

RESULTS

There were 119,938 PSVT ablations from 1998 to 2011 with a mean age of 54.6 ± 17.5 years and 64.1% females. The overall PPM implantation rate was 3.2%. PPM implantation rates in the first (1-14 ablations/year), second (15-32 ablations/year), and third (> 32/ablations/year) tertiles of annual PSVT ablation volume were respectively 4.4, 3.3, and 1.9% (p < 0.001). Increasing age, female gender, bifascicular, or trifascicular block and teaching hospital status were independent predictors of PPM implantation. The adjusted odds ratio for PPM implantation in hospitals performing > 32 PSVT ablations/year compared to hospitals performing ≤ 14 PSVT ablations/year was 0.54 (95% confidence interval 0.3-0.9, p = 0.026).

CONCLUSIONS

PPM implantation rates are significantly lower in hospitals performing > 32 PSVT ablations/year, indicating that hospital experience is an important determinant of outcomes after PSVT ablation.

Trends in Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhages

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) accounts for 5% of all strokes; 30-day mortality is as high as 40%. We sought to evaluate outcomes of aSAH patients treated 2004-2014 by endovascular therapy (EVT), to demonstrate associated trends, and to evaluate angioplasty use for aSAH-related cerebral vasospasm.

Methods

The Nationwide Inpatient Sample (NIS) database 2004-2014 was used to derive a study cohort using ICD-9 codes. Survey procedures were used to adjust for stratified cluster design of NIS. NIS trend weights were used to generate national estimates. Mortality during hospitalization and use of angioplasty for aSAH-induced cerebral vasospasm trends were evaluated with multivariate regression analysis.

Results

We identified n = 10,822 (weighted n = 52,062) EVT-treated aSAH hospitalizations. Increasing years independently predicted decreased mortality (odds ratio [OR] 0.926, 95% confidence interval [CI] 0.905-0.948, p < 0.0001), decreased utilization of angioplasty (age ≥50 years [OR 0.916, 95% CI 0.867-0.968, p = 0.0019] and age <50 years [OR 0.922, 95% CI 0.879-0.967, p = 0.0009]) after controlling for increasing age, Charlson comorbidity index, and external ventricular drain placement. Angioplasty rates were higher in age <50 years compared to age ≥50 years (5 vs. 3.63%, p < 0.001).

Conclusion

It is notable that EVT for aSAH management will be an integral and increasingly useful tool for initial aneurysm management. Advances in procedural techniques, operator experience, and periprocedural management could be significant contributors of decreasing mortality and reducing the need for angioplasty for cerebral vasospasm in patients admitted with aSAH.

Therapeutic Hypothermia and Stent Thrombosis: A Nationwide Analysis

OBJECTIVES

This study sought to determine whether "real-world" data supported the hypothesis that therapeutic hypothermia (TH) led to increased rates of stent thrombosis.

BACKGROUND

TH, which is often instituted after cardiac arrest (CA) to improve neurologic outcomes, alters pharmacokinetics of antiplatelet medications, leading to a theoretical risk of stent thrombosis after percutaneous coronary intervention (PCI).

METHODS

CA patients with acute myocardial infarction undergoing PCI were identified from the Nationwide Inpatient Sample from 2006 to 2011, with a defined primary outcome of stent thrombosis. The incidence of stent thrombosis in patients undergoing TH versus those not undergoing TH was compared using both logistic regression and propensity score matching.

RESULTS

In this dataset, 49,109 CA patients underwent PCI for acute myocardial infarction from 2006 to 2011, of whom 1,193 (2.4%) underwent TH. The incidence of stent thrombosis in the TH group was 3.9% (43 of 1,193), compared to 4.7% (2,271 of 47,916) in the no TH group (p = 0.61). Logistic regression showed that TH was not a significant predictor of stent thrombosis with an adjusted odds ratio of 0.71 (95% confidence interval: 0.28 to 1.76; p = 0.46). Propensity matching was performed to adjust for baseline differences between the TH and no TH groups, matching 1,155 patients in the TH group with 3,399 patients in the no TH group. No difference was observed in the incidence of stent thrombosis in the TH and the no TH groups after propensity matching (3.5% vs. 6.1%; p = 0.17).

CONCLUSIONS

TH does not increase the incidence of stent thrombosis after primary PCI in patients with acute myocardial infarction presenting as CA.

Causes and Predictors of 30-Day Readmissions in Atrial Fibrillation (from the Nationwide Readmissions Database)

Atrial fibrillation (AF) is the most common cause of arrhythmia-related hospitalizations. We assessed 30-day readmissions in patients admitted with AF in a national sample of US population. Data were extracted from Nationwide Readmissions Database for the calendar year 2013. Patients with primary discharge diagnosis of AF were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification, code 427.31. Patients who died during hospitalization and those <18 years were excluded. Our primary outcome was 30-day readmission rate. Causes and independent predictors of 30-day readmissions were examined. We identified 388,340 patients admitted with AF, of whom 58,634 patients (15.1%) were readmitted within 30 days. Patients who were readmitted tended to be older and have a higher burden of co-morbidities. AF and heart failure were the main causes of 30-day readmissions in our cohort. Advanced age, female gender, and multiple co-morbidities were independently associated with 30-day readmissions. In conclusion, 15% of patients admitted for AF were readmitted within 30 days. More than 1/3 of these readmissions were for AF or heart failure.

Catheter ablation of accessory pathway: 14-year trends in utilization and complications in adults in the United States

BACKGROUND

The aim of this study was to determine the temporal trends in utilization of catheter ablation of accessory pathways in the United States.

METHODS

All patients from the Nationwide Inpatient Sample (NIS) ≥18years of age with a primary diagnosis of anomalous atrioventricular excitation syndrome (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 426.7) were included in the study. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Patients with a concomitant diagnosis of atrial fibrillation, atrial flutter, atrial tachycardia or ventricular arrhythmias were excluded from the analysis. Annual hospital volume was identified using unique hospital identification number and was divided into tertiles for further analysis.

RESULTS

A total of 11,601 catheter ablations for anomalous atrioventricular excitation syndrome were studied from 1998 to 2011. The mean length of stay was 1.8days (median 1day). The utilization trends of accessory pathway ablation have steadily declined from 3.9 ablation procedures/million US population in 1998-1999 to 2.5 ablation procedures/million US population in 2010-2011. The second tertile (adjusted OR 0.41; 95% CI 0.20-0.83, p=0.01) and third tertile (adjusted OR 0.39; 95% CI 0.18-0.85, p=0.02) of hospital volume were associated with reduction in cardiac complications as compared to first tertile of hospital volume. Advanced age (OR 1.02, 95% CI 1.01-1.04, p=0.002) was independent predictor of cardiac complications. There were no in-hospital deaths.

CONCLUSION

Despite decline in ablation trends, it still remains a relatively safe procedure associated with low morbidity and no mortality.

Demographic, clinicopathologic and survival differences among left sided versus right sided metastatic colorectal adenocarcinoma

e15068

Background: Clinical outcomes may differ between left versus right sided (CA) independent of stage. We utilized a large database to identify real world differences in characteristics and overall survival (OS) of left versus right sided CA. Methods:We used the National Cancer Database (NCDB) to identify 36,271 patients with metastatic (stage IV) CA diagnosed between the years 2010 to 2012. Right-sided CA was defined as CA of the cecum, ascending colon or hepatic flexure, and left-sided CA was defined as CA of splenic flexure, descending colon, sigmoid colon and rectum. We compared demographic and pathologic features (tumor size, grade, lymphovascular invasion, metastatic site) as well as OS of CA based on laterality. Results:36% of metastatic CAs were right sided. Left versus right sided CAs were more likely to be diagnosed in older patients (median age 68 vs. 62 yr; p<0.01), females (52% vs. 43%; p<0.01), and African Americans (17% vs. 13%; p <0.01). Left-sided CAs were more likely to be >5 cm (58% vs. 54%, p<0.01), grade 3 or 4 (35% vs. 22%; p<0.01), have lymphovascular invasion (62% vs. 50%; p <0.01) and liver metastasis (72% vs 67%; p<0.01) and less likely to have lung (20% vs. 27%;p <0.01) or bone metastasis (5% vs. 6%; p value <0.01). The median OS was lower in right versus left-sided CAs(12 vs. 20 months; p <0.01) Conclusions:Our study suggests important differences in metastatic CAs based on laterality. Patients with right-sided CAs are more likely to be older, females and African Americans, present with larger tumor, lymphovascular invasion and differ in sites of metastases. Future studies should assess any difference in molecular characteristics and tumor biology based on laterality. [Table: see text]

Immunotherapy in genitourinary malignancies

Treatment of cancer patients involves a multidisciplinary approach including surgery, radiotherapy, and chemotherapy. Traditionally, patients with metastatic disease are treated with combination chemotherapies or targeted agents. These cytotoxic agents have good response rates and achieve palliation; however, complete responses are rarely seen. The field of cancer immunology has made rapid advances in the past 20 years. Recently, a number of agents and vaccines, which modulate the immune system to allow it to detect and target cancer cells, are being developed. The benefit of these agents is twofold, it enhances the ability the body’s own immune system to fight cancer, thus has a lower incidence of side effects compared to conventional cytotoxic chemotherapy. Secondly, a small but substantial number of patients with metastatic disease are cured by immunotherapy or achieve durable responses lasting for a number of years. In this article, we review the FDA-approved immunotherapy agents in the field of genitourinary malignancies. We also summarize new immunotherapy agents being evaluated in clinical studies either as single agents or as a combination.