Long-term evaluation of the Hernia Compact course of the German Hernia School

INTRODUCTION

Since 2011, the German Hernia Society has developed the German Hernia School (GHS) as a standardized hernia surgery training program for younger surgeons, consisting of the Hernia Compact basic module. It is a standardized three day training program (cadaver workshop, ultrasound simulation training, and hands-on training). After 12 years of experience, a survey was conducted to evaluate the long term effect of this training.

METHOD

Using an anonymous online-questionnaire, we contacted from September 2023 to October 2023 the Hernia Compact course participants via the congress organizer "Weitmeer" and the German Hernia Society. This online questionnaire contains 18 multiple choice questions regarding participants' age, gender, professional experience, participation in other modules of the German Hernia School, the effect of the course on their daily practice and their specific interest in hernia and abdominal wall surgery.

RESULTS

A total of 146 participants responded to the anonymous online questionnaire. A majority of 132 of 146 participants (90.42%) responded that this course improved the quality of surgical and hernia training (n = 146, no missing data). 141 of 146 individuals (96.58%) recommended the course to surgical colleagues (n = 146, no missing data). There were 89.73% of participants, (n = 146, no missing data) that developed a specific interest in hernia and abdominal wall surgery after the course. For 78.08% (n = 146, no missing data) of participants hernia and abdominal wall surgery was one of the most important activities in their daily surgical practice.

CONCLUSION

The standardized Hernia Compact basic course of the German Hernia School appears to have a huge impact on the quality of hernia surgery training in Germany and Austria. It might also help generate a specific interest in hernia surgery among participants.

How often is prophylactic parastomal mesh placement performed after rectal resection without sphincter preservation? An analysis of German nationwide hospital discharge data among 41,697 patients

PURPOSE

The European Hernia Society guidelines of parastomal hernias, published in 2017, strongly recommend prophylactic synthetic non-absorbable mesh upon the construction of a permanent end colostomy to reduce the incidence of parastomal hernias. This study aims to evaluate the implementation of the guidelines in Germany.

METHODS

This is a retrospective multicentric analysis conducted in December 2022 at the University Hospital Brandenburg an der Havel. Anonymous data on rectal resection without sphincter preservation in the period 2010-2020 were extracted from the German nationwide hospital discharge data set. Individuals with a hernia and < 18 years old were excluded. Another exclusion criterion was a performed colectomy or proctocolectomy with an ileoanal pouch and placement of an absorbable mesh. The primary endpoint was the annual rate of prophylactic parastomal mesh placement following rectal resection without sphincter preservation in Germany. Cases reporting both non-absorbable mesh placement and rectal resection without sphincter preservation were considered prophylactic mesh insertions.

RESULTS

A total of 41,697 patients received a rectal resection without sphincter preservation and without non-absorbable mesh placement. Among these individuals, 27,089 were male and 14,608 were female. The rate of reoperations (3.1%) and the length of hospital stay (25.3 days ± 19.32) remained almost constant during these 10 years. The rate of prophylactic mesh placement was increasing from 0.2% (n = 8) in 2010 to 6.4% (n = 198) in 2020.

CONCLUSIONS

Currently, only the minority of patients who have undergone rectal resection without sphincter preservation receive prophylactic mesh insertion.

Favorable impact of therapy management by an interactive eHealth system on severe adverse events in patients with hormone receptor-positive, HER2-negative locally advanced or metastatic breast cancer treated by palbociclib and endocrine therapy

BACKGROUND

Oral cancer medications offer advantages but also pose challenges for therapy management and adherence. An eHealth-based platform such as CANKADO can help to support therapy management by probing the patient's quality of life (QoL) continuously throughout the course of treatment.

MATERIAL AND METHODS

AGO-B WSG PreCycle (NCT03220178) is a multicenter, randomized phase IV intergroup trial evaluating the impact of eHealth-based Patient-Reported Outcome (ePRO) assessment on QoL in patients with hormone receptor-positive (HR + )/HER2-negative (HER2-) advanced breast cancer treated with palbociclib and endocrine therapy. Patients were randomized (2:1) to CANKADO-active arm (supported by CANKADO PRO-React) or CANKADO-inform arm (drug intake documentation only) This exploratory analysis reports the impact of CANKADO PRO-React on safety. Time to first serious adverse event (SAE) was estimated taking competing risks into account.

RESULTS

While distributions of adverse events (AEs) were similar by arm overall, patients in the CANKADO-active arm had a favorable hazard ratio of 0.67 (95%CI 0.46-0.97; p = 0.04) for time to first SAE and were significantly less likely overall to suffer an SAE than patients in the inform arm. At 24 months, 22.9% [17.9%-27.8%] of patients in CANKADO-active had suffered an SAE vs. 30.3% [22.6%-38.0%] in CANKADO-inform. AE-related dose reductions affected approximately 20% of patients (CANKADO-active: 18.2%, CANKADO-inform: 21.1%).

CONCLUSION

Exploratory safety analysis of PreCycle demonstrates for the first time in a randomized prospective trial that interactive autonomous eHealth-based support has a substantial favorable impact on the risk of SAEs and mitigates their severity for patients with advanced HR+/HER2- breast cancer on oral tumor therapy.

Anti-hormonal maintenance treatment with the CDK4/6 inhibitor ribociclib after 1st line chemotherapy in hormone receptor positive / HER2 negative metastatic breast cancer: A phase II trial (AMICA)

PURPOSE

This phase II study evaluated the impact of adding ribociclib to maintenance endocrine therapy (ET) treatment of physicians' choice following the first palliative chemotherapy in pre- and post-menopausal women with hormone receptor positive (HR+)/human epidermal growth factor 2 negative (HER2-) metastatic breast cancer (mBC).

PATIENTS AND METHODS

The initial randomized study design was later amended into a single-arm study, and all subsequent patients received ribociclib and ET. The primary end point was locally assessed progression-free survival (PFS). Secondary end points included overall survival (OS), clinical benefit rate (CBR), safety, compliance, and quality of life (QoL).

RESULTS

A total of 43 patients received ribociclib + ET and 10 patients received ET only. Median PFS was 12.4 months [95% CI 8.7-24.4] for patients who received ribociclib + ET and 4.75 months [95% CI 1.0-10.3] for those who received ET only. Median OS was not reached for patients who received ribociclib + ET, and 28 (65.1%) patients experienced clinical benefit [95% CI 49.1-79.0]. For patients who received ribociclib + ET, grade 3-4 hematological adverse events (AEs) occurred in 25 (58.1%) patients, and grade 3-4 non-hematological AEs occurred in 17 (39.5%) patients. During the study, 15 patients died - 14 of whom due to tumor-related reasons, and one patient due to pneumonia, which was not treatment-related.

CONCLUSION

The results of the AMICA study show a promising efficacy and safety of maintenance treatment with ribociclib added to ET after at least stable disease following the first metastatic chemotherapy in patients with HR+/HER2-mBC.

TRIAL REGISTRATION

Anti-hormonal Therapy With Ribociclib in HR-positive/HER2- Negative Metastatic Breast Cancer (AMICA), NCT03555877, https://clinicaltrials.gov/ct2/show/NCT03555877.

Association Between Obesity and Circulating Tumor Cells in Early Breast Cancer Patients

BACKGROUND

Obesity and the presence of circulating tumor cells (CTCs) before and/or after chemotherapy are associated with poor outcome in breast cancer (BC) patients. The activation of oncogenic pathways in fatty tissue leads to cell proliferation, suggesting a possible link between obesity and CTCs.

MATERIALS AND METHODS

In the phase III SUCCESS A trial, 3754 patients with early BC were randomized to 3 cycles of fluorouracil, epirubicin and cyclophosphamide followed by 3 cycles of docetaxel with or without gemcitabine. Data of 1088 patients with CTC assessments (CellSearch-System; Menarini Silicon Biosystems, Italy) and body mass index (BMI) measurements both before and after chemotherapy were available. Patients were classified according to the WHO's international definitions as underweight, normal weight, overweight, or obese, and according to their weight-change during chemotherapy into a weight-loss group (> 5% decrease), stable-weight group (≤ 5% weight-change) or weight-gain group (>5% increase). Associations between CTC positivity and, BMI or weight-change group were analyzed using frequency-table methods.

RESULTS

At study entry, 47.4% patients were underweight or normal weight, 33.6% were overweight and 18.9% were obese. Before and after chemotherapy, CTCs were detected in 20.1% and 22.6% of patients, respectively. There was no association between CTC positivity and BMI before (P = 0.104) or after (P = 0.051) chemotherapy. Furthermore, there was no association between weight-change group and CTC status before/after chemotherapy (P = 0.332).

CONCLUSIONS

According to our analysis, the risk factors obesity and prevalence of CTCs are not associated and may represent independent prognostic factors.

Significantly longer time to deterioration of quality of life due to CANKADO PRO-React eHealth support in HR+ HER2- metastatic breast cancer patients receiving palbociclib and endocrine therapy: Primary outcome analysis of the multicenter randomized AGO-B WSG PreCycle trial

BACKGROUND

The multicenter, randomized phase IV intergroup AGO-B WSG PreCycle trial (NCT03220178) evaluated the impact of CANKADO-based ePRO (electronic patient-reported outcomes) assessment on quality of life (QoL) in HR+ HER2- locally advanced or metastatic breast cancer (MBC) patients receiving palbociclib (P) and an aromatase inhibitor or P+fulvestrant. CANKADO PRO-React, an EU-registered medical device, is an interactive autonomous application reacting to patient self-reported observations.

PATIENTS AND METHODS

Between 2017 and 2021, 499 patients (median age 59 years) from 71 centers were randomized (2:1, stratified by therapy line) between an active version of CANKADO PRO-React (CANKADO-active arm) or a version with limited functionality (CANKADO-inform arm). 412 patients (271 CANKADO-active; 141 CANKADO-inform) were available for analysis of the primary endpoint, time to deterioration (TTD) of QoL (10-point drop on FACT-G), using an Aalen-Johansen estimator for cumulative incidence function of TTD DQoL with 95% pointwise confidence intervals (CI). Secondary endpoints included PFS, OS, and DQoL (QoL deterioration).

RESULTS

In all pts (ITT-ePRO), cumulative incidence of DQoL was significantly more favorable (lower) in the CANKADO-active arm (HR=0.698, 95%CI [0.506 - 0.963]). Among 1^stL patients (n=295), the corresponding HR was 0.716 (0.484-1.060; p=0.09), and in 2^ndL patients (n=117) it was 0.661 (0.374-1.168; p=0.2). Absolute patient numbers declined in later visits; FACT-G completion rates were 80% and higher until about visit 30; mean FACT-G scores showed steady decline from baseline and an offset in favor of CANKADO-active. No significant differences in clinical outcome were observed between arms: Median PFS (ITT population) was 21.4 (95%CI 19.4-23.7) (CANKADO-active) and 18.7 (15.1-23.5) months (CANKADO-inform); median OS was not reached (CANKADO-active) and 42.6 months (CANKADO-inform).

CONCLUSIONS

PreCycle is the first multicenter randomized eHealth trial demonstrating a significant benefit for MBC patients receiving oral tumor therapy when using an interactive autonomous patient empowerment application.

[Inguinal hernia operations-Always outpatient?]

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

Largest recent impact craters on Mars: Orbital imaging and surface seismic co-investigation

Two >130-meter-diameter impact craters formed on Mars during the later half of 2021. These are the two largest fresh impact craters discovered by the Mars Reconnaissance Orbiter since operations started 16 years ago. The impacts created two of the largest seismic events (magnitudes greater than 4) recorded by InSight during its 3-year mission. The combination of orbital imagery and seismic ground motion enables the investigation of subsurface and atmospheric energy partitioning of the impact process on a planet with a thin atmosphere and the first direct test of martian deep-interior seismic models with known event distances. The impact at 35°N excavated blocks of water ice, which is the lowest latitude at which ice has been directly observed on Mars.

Does the Presence of Circulating Tumor Cells in High-Risk Early Breast Cancer Patients Predict the Site of First Metastasis—Results from the Adjuvant SUCCESS A Trial

Simple Summary

Due to recent advances in breast cancer detection and treatment strategies, the number of breast cancer survivors has increased over the past decades. However, breast cancer follow-up guidelines have not changed for years. The presence of CTCs detected during follow-up has been shown to indicate poor prognosis in high-risk breast cancer patients. Here, we evaluated if the presence of CTCs also indicates the site of metastatic disease by analyzing CTC status and metastatic location in 206 patients with distant recurrence from the large adjuvant breast cancer trial SUCCESS A. Patients who were CTC-positive both before and after chemotherapy were more likely to show bone-only first distant disease (37.5% vs. 21.0%) and first distant disease at multiple sites (31.3% vs. 12.6%) than patients without CTCs. These data indicate that CTCs might serve as a liquid biopsy surveillance-marker enabling risk-stratification for deciding on further adjuvant add-on-treatment.

Abstract

The prognostic relevance of circulating tumor cells (CTCs) in breast cancer is well established. However, little is known about the association of CTCs and site of first metastasis. In the SUCCESS A trial, 373 out of 3754 randomized high-risk breast cancer patients developed metastatic disease. CTC status was assessed by the FDA-approved CellSearch^®-System (Menarini Silicon Biosystems, Bologna, Italy) in 206 of these patients before chemotherapy and additionally in 159 patients after chemotherapy. CTCs were detected in 70 (34.0%) of 206 patients before (median 2 CTCs, 1–827) and in 44 (27.7%) of 159 patients after chemotherapy (median 1 CTC, 1–124); 16 (10.1%) of 159 patients were CTC-positive at both timepoints. The site of first distant disease was bone-only, visceral-only, and other-site-only in 44 (21.4%), 60 (29.1%), and 74 (35.9%) patients, respectively, while 28 (13.6%) patients had multiple sites of first metastatic disease. Patients with CTCs at both timepoints more often showed bone-only first distant disease (37.5% vs. 21.0%) and first distant disease at multiple sites (31.3% vs. 12.6%) than patients without CTCs before and/or after chemotherapy (p = 0.027). In conclusion, the presence of CTCs before and after chemotherapy is associated with multiple-site or bone-only first-distant disease and may trigger intensified follow-up and perhaps further treatment.

Prospective, multicenter study on non-pharmacological, patient related predictive factors of chemotherapy induced nausea and vomiting (CINV): A NOGGO-EMRISK trial

e24107

Background: Despite many years of clinical research and development, nausea and vomiting remain challenging toxicities related to chemotherapy. The aim of our study was assessment of non-pharmacological, patient-related risk factors for chemotherapy-induced nausea and vomiting and development of unique predictive score in patients with gynaecological malignancies planned for chemotherapy. Methods: A research-based questionnaire of 27 risk factors was generated and provided to patients diagnosed with gynaecological malignancies prior to indicated chemotherapy. The data on nausea and vomiting from at least 3 cycles therapy was collected. Variable selection via stepwise and LASSO regression combined with patients history was used to identify a small set of questions with high predictive power. As risk prediction model, a Bayesian logistic regression was implemented with a cut-off chosen to yield a sensitivity of 80%. Area under the curve analysis (AUC) was conducted, and accuracy of prediction was calculated. Results: In total 191 patients were enrolled. The most frequent diagnosis and chemotherapy was ovarian cancer (69%) and carboplatinum/paclitaxel combination (57.7%), respectively. Six factors (emetogenic potential of the therapy, educational status, nausea and vomiting due to other medication, motion sickness, anxiety from therapy in general and anxiety from nausea due to therapy) were identified as most important predictive factors. All questions were answered by 132 (69.1%) patients. Among those 97 (68%) reported nausea or vomiting. The AUC of the predictive score consisting mentioned factors was 0.741, with a sensitivity of 80.4%, specificity of 51.4% and an overall accuracy of 72.7%. Conclusions: Patients related risk factors are missing in selection of the antiemetic prophylaxis in patients under chemotherapy. Presented predictive score showed very promising predictive power and is going to be validated in further phase of the trial. Clinical trial information: DRKS-ID: DRKS00015151.

The application of AMSTAR 2 in overviews of systematic reviews shows a need for improvement

Background

Overviews of systematic reviews (SR) summarise and appraise the quality of research relevant for evidence-based decision-making. ‘A Measurement Tool to Assess Systematic Reviews' (AMSTAR 2) is a valid and moderately reliable appraisal instrument with 16 items that can be used to derive the overall confidence rating (OCR). OCR (high, moderate, low or critically low) can be derived based on the original algorithm with 7/9 critical/non-critical items. We aimed to assess the methods for deriving OCR in overviews of SRs of clinical interventions.

Methods

Our cross-sectional study was conducted using 45 overviews of SRs with at least 20 AMSTAR 2 appraisals selected by two authors from a title/abstract search for ‘AMSTAR 2' in Medline, Epistemonikos and CINAHL in 09/2020. One author coded the data. OCR methods and outcomes were compared using descriptive and univariate statistics.

Results

The 45 overviews were published in 2018-2020 by 2-16 authors. The overviews appraised on average 44 SRs (range: 20-158). OCRs of 1.412 SRs were derived in 41 overviews (91%). OCR were derived according to the original algorithm (22; 54%), own algorithm (9; 22%), unspecified algorithm (9; 22%) or AMSTAR 2 website (1; 2%). The OCR were high (190; 13%), moderate (182; 13%), low (267, 19%) or critically low (773; 55%). The original algorithm was more likely to generate the critically low+low ratings than either own algorithms (OR = 2.28, 95% CI [1.66-3.13]) or unclear algorithms (OR = 3.78 [2.81-5.09]).

Conclusions

High quality SRs are needed for making public health decisions. AMSTAR 2 assigns mostly low and critically low OCR to SRs in various clinical areas. These SRs should not be relied on as a source of accurate evidence. Furthermore, our results show that SR reporting guidelines need to be better followed and that AMSTAR 2 users should explicitly report their OCR methods.

Key messages

The methodological quality of the majority of systematic reviews (SRs) in various clinical fields is disappointing, highlighting the requirement for better adherence to reporting guidelines. There is a need for improvement on reporting how AMSTAR 2 is applied in overviews of SRs.

Prognosis of Patients With Early Breast Cancer Receiving 5 Years vs 2 Years of Adjuvant Bisphosphonate Treatment: A Phase 3 Randomized Clinical Trial

Importance

Bisphosphonate treatment in patients with early breast cancer has become part of care, but the optimal treatment duration is still unclear.

Objective

To compare 2 vs 5 years of zoledronate treatment following adjuvant chemotherapy in patients with early breast cancer.

Design, Setting, and Participants

The SUCCESS A phase 3 multicenter randomized open-label clinical trial with a 2 × 2 factorial design enrolled 3754 patients from September 21, 2005, to March 12, 2007 (last patient out, May 7, 2014). Final data analysis was conducted from September 2019 to October 2020. In 250 German study centers, patients were eligible for participation in the SUCCESS A trial if they had either node-positive or high-risk node-negative (defined as at least 1 of the following: tumor size ≥ pT2, histologic grade 3, negative hormone receptor status, or age ≤35 years) primary invasive breast cancer.

Interventions

Patients were first randomized to adjuvant chemotherapy with 3 cycles of fluorouracil, epirubicin, and cyclophosphamide followed by 3 cycles of docetaxel with or without gemcitabine (not presented in this report). After chemotherapy, patients underwent a second randomization of 5 years of zoledronate treatment (4 mg intravenously every 3 months for 2 years, followed by 4 mg intravenously every 6 months for 3 years) vs 2 years of zoledronate treatment (4 mg intravenously every 3 months for 2 years).

Main Outcomes and Measures

The primary end point of the study was disease-free survival; secondary end points were overall survival, distant disease-free survival, and the incidence of skeletal-related adverse events. Survival times were measured from 2 years after the start of zoledronate treatment (landmark analysis).

Results

Overall, data on 2987 patients were available for analysis; median age was 53 (range, 21-86) years. Disease-free survival, overall survival, and distant disease-free survival did not differ significantly between the 2 treatment arms (5 vs 2 years) as shown by adjusted multivariable Cox proportional hazards regression models (disease-free survival: hazard ratio [HR], 0.97; 95% CI, 0.75-1.25; P = .81; overall survival: HR, 0.98; 95% CI, 0.67-1.42; P = .90; distant disease-free survival: HR, 0.87; 95% CI, 0.65-1.18; P = .38). Adverse events were observed more often in the 5-year (46.2%) vs 2-year (27.2%) zoledronate treatment arm, which was particularly true for the skeletal-related events bone pain (5 years, 8.3% vs 2 years, 3.7%) and arthralgia (5 years, 5.1% vs 2 years, 3.1%).

Conclusions and Relevance

The results of this phase 3 randomized clinical trial indicate that extending the zoledronate treatment beyond 2 years does not improve the prognosis of high-risk patients with early breast cancer receiving chemotherapy, suggesting that the currently recommended bisphosphonate treatment duration of 3 to 5 years could be reduced.

Trial Registration

ClinicalTrials.gov Identifier: NCT02181101.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.

METHODS

A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.

RESULTS

In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.

CONCLUSION

Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Treatment of small (< 2 cm) umbilical hernias: guidelines and current trends from the Herniamed Registry

INTRODUCTION

Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years.

METHODS

Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented.

RESULTS

A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013.

CONCLUSIONS

A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

Gemcitabine as adjuvant chemotherapy in patients with high-risk early breast cancer-results from the randomized phase III SUCCESS-A trial

Background

When chemotherapy is indicated in patients with early breast cancer, regimens that contain anthracyclines and taxanes are established standard treatments. Gemcitabine has shown promising effects on the response and prognosis in patients with metastatic breast cancer. The SUCCESS-A trial (NCT02181101) examined the addition of gemcitabine to a standard chemotherapy regimen in high-risk early breast cancer patients.

Methods

A total of 3754 patients with at least one of the following characteristics were randomly assigned to one of the two treatment arms: nodal positivity, tumor grade 3, age ≤ 35 years, tumor larger than 2 cm, or negative hormone receptor status. The treatment arms received either three cycles of 5-fluorouracil, epirubicin, and cyclophosphamide, followed by three cycles of docetaxel (FEC → Doc); or three cycles of FEC followed by three cycles of docetaxel and gemcitabine (FEC → Doc/Gem). The primary study aim was disease-free survival (DFS), and the main secondary objectives were overall survival (OS) and safety.

Results

No differences were observed in the 5-year DFS or OS between FEC → Doc and FEC → Doc/Gem. The hazard ratio was 0.93 (95% CI, 0.78 to 1.12; P = 0.47) for DFS and 0.94 (95% CI, 0.74 to 1.19; P = 0.60) for OS. For patients treated with FEC → Doc and FEC → Doc/Gem, the 5-year probabilities of DFS were 86.6% and 87.2%, and the 5-year probabilities of OS were 92.8% and 92.5%, respectively.

Conclusion

Adding gemcitabine to a standard chemotherapy does not improve the outcomes in patients with high-risk early breast cancer and should therefore not be included in the adjuvant treatment setting.

Trial registration

Clinicaltrials.gov NCT02181101 and EU Clinical Trials Register EudraCT 2005-000490-21. Registered September 2005.

Alterations in the mechanical, chemical and biocompatibility properties of low-cost polyethylene and polyester meshes after steam sterilization

Introduction

In Africa and other Low Resource Settings (LRS), the guideline-based and thus in most cases mesh-based treatment of inguinal hernias is only feasible to a very limited extent. This has led to an increased use of low cost meshes (LCMs, mostly mosquito meshes) for patients in LRS. Most of the LCMs used are made of polyethylene or polyester, which must be sterilized before use. The aim of our investigations was to determine changes in the biocompatibility of fibroblasts as well as mechanical and chemical properties of LCMs after steam sterilization.

Material and methods

Two large-pored LCMs made of polyester and polyethylene in a size of 11 x 6 cm were cut and steam sterilized at 100, 121 and 134 °C. These probes and non-sterile meshes were then subjected to mechanical tensile tests in vertical and horizontal tension, chemical analyses and biocompatibility tests with human fibroblasts. All meshes were examined by stereomicroscopy, scanning electron microscopy (SEM), LDH (cytotoxicity) measurement, viability testing, pH, lactate and glycolysis determination.

Results

Even macroscopically, polyethylene LCMs showed massive shrinkage after steam sterilization, especially at 121 and 134 °C. While polyester meshes showed no significant changes after sterilization with regard to deformation and damage as well as tensile force and stiffness, only the unsterile polyethylene mesh and the mesh sterilized at 100 °C could be tested mechanically due to the shrinkage of the other specimen. For these meshes the tensile forces were about four times higher than for polyester LCMs. Chemical analysis showed that the typical melting point of polyester LCMs was between 254 and 269 °C. Contrary to the specifications, the polyethylene LCM did not consist of low-density polyethylene, but rather high-density polyethylene and therefore had a melting point of 137 °C, so that the marked shrinkage described above occurred. Stereomicroscopy confirmed the shrinkage of polyethylene LCMs already after sterilization at 100 °C in contrast to polyester LCMs. Surprisingly, cytotoxicity (LDH measurement) was lowest for both non-sterile LCMs, while polyethylene LCMs sterilized at 100 and 121 °C in particular showed a significant increase in cytotoxicity 48 hours after incubation with fibroblasts. Glucose metabolism showed no significant changes between sterile and non-sterile polyethylene and polyester LCMs.

Conclusion

The process of steam sterilization significantly alters mechanical and structural properties of synthetic hernia mesh implants. Our findings do not support a use of low-cost meshes because of their unpredictable properties after steam sterilization.

Necessary duration of follow-up to assess complications of mesh in hernia surgery: a time-lapse study based on 460 explants

PURPOSE

Risk of complications following hernia repair is the key parameter to assess risk/benefit ratio of a technique. As mesh devices are permanent, their risks are life-long. Too many reports in the past assessed mesh safety prematurely after short follow-ups. We aimed to explore what length of follow up would reveal the full extent of complications.

METHODS

Time lapses between implantation and excision were analyzed in 460 cases of meshes excised for complications after hernia repair. Patterns of percentage growth and time lapses at 50th and 95th percentiles were used to compare groups of different hernia type, age, gender and reason for excision.

RESULTS

The 50th and 95th case percentiles in the dataset were at 3.75 and 15.0 years between mesh implantation and excision. For hernia types, the longest time lapses were for groin hernias (4.0 and 16.11 years at 50th and 95th percentiles). The shortest were for umbilical hernias (2.16 and 9.68 years). Males had later excisions than females (4.11 and 16.1 vs. 2.47 and 9.79 years). Younger patients (< 45 y.o.) had later excisions than older patients (4.12 and 17.68 vs. 3.37 and 10.0 years). Out of all subgroups, the longest time lapses were for groin hernias in younger males (4.77 and 18.89 years) and for mesh erosion into organs (4.67 and 17.0 years).

CONCLUSIONS

Follow-up of more than 15 years is needed to fully assess complications after mesh hernia repair. Especially longer periods are needed to detect mesh erosion into organs and complications in younger males. Presently, short observations and lack of reporting standard in the literature prohibit accurate assessment of complication risks. We propose to use cumulative incidence for standardized risk reporting (y% risk at x years). This will show time-dependent patterns and allow comparisons between different techniques and studies of variable duration. Standardization will also help to predict long-term risks beyond shorter (practical) follow-ups and facilitate real-time monitoring during surveillance.

Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients

INTRODUCTION

How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors.

METHODS

The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up.

RESULTS

31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates.

CONCLUSION

Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

Differences in the outcomes of scrotal vs. lateral vs. medial inguinal hernias: a multivariable analysis of registry data

INTRODUCTION

There are hardly any studies on the outcome of scrotal compared with medial and lateral inguinal hernias. Therefore, this present multivariable analysis of data from the Herniamed Registry compared the outcome of scrotal vs. lateral vs. medial inguinal hernias and explored the relationship between hernia localization and outcomes.

METHODS

Included in the analysis were all primary elective unilateral inguinal hernias in men with scrotal, lateral or medial defect localization whose details had been entered into the Herniamed Registry by 712 participating institutions (status February 1, 2019). The relation of the hernia localization with the outcome parameters adjusted for pre-defined confounding patient- and procedure-related variables was analyzed via multivariable binary logistic models.

RESULTS

Details of 98,321 patients were thus available for multivariable analysis. These related to 65,932 (67.1%) lateral, 29,697 (30.2%) medial and 2,710 (2.7%) scrotal inguinal hernias. Scrotal hernias were associated with higher patient age, higher BMI, higher ASA score, larger defect, more risk factors and more frequent use of Lichtenstein repair. On the other hand, scrotal hernias were associated less commonly with preoperative pain. Multivariable analysis revealed that scrotal hernias had a highly significantly unfavorable association with postoperative complications, complication-related reoperations and general complications. But scrotal hernias had a highly significantly favorable relation with the pain rates at 1-year follow-up. Medial hernias were the hernia type most often related with recurrence and also had an unfavorable association with the pain rates at 1-year follow-up.

CONCLUSION

Scrotal inguinal hernias demonstrated a very unfavorable relation with the postoperative complication rate, the rate of complication-related reoperations and the rate of general complications. But a very favorable association with chronic pain rates was identified at 1-year follow-up. Medial inguinal hernia had an unfavorable relation with the recurrence and pain rates.

Do drains have an impact on the outcome after primary elective unilateral inguinal hernia repair in men?

INTRODUCTION

The use of drains continues to be a controversial topic in surgery. In a review of that topic for incisional hernia it was not possible to find sufficient evidence of the need for a drain. Likewise, for inguinal hernia surgery the data available are insufficient.

METHODS

In a multivariable analysis of data from the Herniamed Registry for 98,321 patients with primary elective unilateral inguinal hernia repair in men, the role of a drain was investigated.

RESULTS

A drain was used in 24.7% (n = 24,287/98,321) of patients. These patients were on average older, had higher BMI, longer operating time and received a smaller mesh. Drains were also used more often for patients with higher ASA score, risk factors, larger defects and scrotal hernia localization as well as for Lichtenstein, TEP and suture repair. The use of drains was highly significantly associated with intra- and postoperative complications as well as with complication-related reoperations. Hence, drains are used selectively in inguinal hernia repair for patients at higher risk of perioperative complications. Despite the use of drains, the outcome in this risk group is less favorable. It remains unclear if drains prevent further complications in high-risk patients.

CONCLUSION

Drains are used selectively in high-risk men with primary elective unilateral inguinal hernia repair. Drains are associated with intra- and postoperative complications rates and complication-related reoperation rate. Drains can serve as an indicator for early detection of complications.

0229 Exploring the Relationships Between Sleep, Stress, and Performance in Simulation-Based Learning

Introduction

Sleep deprivation and stress may affect performance among students. Simulation-based learning (SBL) in undergraduate nursing programs provides the opportunity for students to practice critical decision-making without fear of patient harm; however, students still report experiencing stress during SBL. Current research is unclear on the effect of sleep deprivation combined with stress on performance in SBL. The purpose of this study was to explore the association between stress, functional outcomes of sleep, and performance in SBL.

Methods

Elements of the Theory of Stress, Appraisal, and Coping and the National League for Nursing Jeffries Nursing Education Simulation Framework guided this study. Baccalaureate nursing students consented to participate in a 1-hour SBL experience that included the collection of one hair and 4 saliva samples for cortisol concentration. Participants completed the Functional Outcomes of Sleep- Short Form and the Perceived Stress Questionnaire. An experienced faculty member evaluated student performance using the Creighton Competency Evaluation Inventory.

Results

Participants (N=35) were mainly female (n=32, 91.4%), white (n=29, 82.9%), with ages ranging between 18–22 years (n=32, 91.4%), and employed outside of nursing school (n=32, 91.4%). Other ethnicities represented include Asian and African American. Kendall’s Tau correlations revealed a significant relationship between functional outcomes of sleep and perceived stress (r=-.281, p=.020). Although not significant, a small relationship was observed between functional outcomes of sleep and performance (r=.145, p=.236). No significant relationship between performance and perceived stress (r=-.099, p=.423) was identified.

Conclusion

This study suggests that daytime dysfunction related to sleep is related to perceived stress and performance in undergraduate nursing students during participation in SBL. Due likely to small sample size, the relationship between sleep and performance was unable to achieve significance. These findings support the need for future research exploring the effects of sleep on stress and performance with larger more heterogeneous samples of students.

Support

This researcher would like to acknowledge and thank the following funding sources for their generous support of this work: Marion Bender Scholarship (Saint Louis University School of Nursing), Dissertation Award from Sigma Theta Tau International-Epsilon Eta Chapter, and Southern Illinois University Edwardsville School of Nursing Faculty Scholar Award.

Improving surgical education in East Africa with a standardized hernia training program

INTRODUCTION

Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa.

MATERIAL AND METHODS

Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees.

RESULTS

Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course.

CONCLUSION

We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.

Abstract P4-01-01: Presence of circulating tumor cells in high-risk early breast cancer do not predict site of metastatic lesions - Results of the SUCCESS A trial

Background: The prognostic relevance of circulating tumor cells (CTCs) during adjuvant breast cancer treatment and follow up has been well established. However, little information is available regarding CTC-detection and its association to site of first metastatic disease. Methods: The adjuvant phase III SUCCESS A trial, an open label, randomized, multicenter study, compared chemotherapy with three cycles of epirubicin, fluorouracil and cyclophosphamide followed by either three cycles of docetaxel or three cycles of docetaxel plus gemcitabine in patients with early high-risk breast cancer. Following chemotherapy, patients were randomized to two or five years of zoledronate treatment. CTC status was assessed before and after chemotherapy using the FDA-approved CellSearch® System (Menarini Silicon Biosystems; Bologna, Italy). The association between the presence of CTCs and the site of first distant disease was assessed using Chi Square tests. Findings: Of 3754 SUCCESS A patients, 373 developed metastatic disease. 206 of these patients participated in the translational research program of the trial so the CTC status at baseline was assessed. These patients were included into the analysis. At least one CTC before chemotherapy was detected in 70 (34.0%) of patients (median 2 CTCs, range 1 - 827 CTCs). For 159 patients, CTC status after chemotherapy could also be evaluated. Disease progression in terms of first distant disease occurred in 44 patients (21.4 %) in the bones, in 60 (29.1 %) in visceral sites (lung, liver), in 23 (11.2 %) in the brain or neural system, and in 51 patients (24.7 %) in other sites. In 28 patients (13.6 %), more than one site of metastatic disease was overt at the time of first distant recurrence. The median time to metastatic disease (measured from date of randomization) was 33.0 months (range 0.7 - 92.4 months). Overall, patients with bone-only first distant disease were numerically most likely to be CTC positive before chemotherapy (40.9 %); however, there was no significant association between site of first metastatic disease (bones, visceral, other) and the presence of CTCs before chemotherapy (p.224). Adding CTC status after chemotherapy did not change the results. However, patients with persistently positive CTCs were significantly more likely to show first distant disease at multiple sites than patients with a negative CTC status before and/or after chemotherapy. Interpretation: Although the presence of CTCs predicts poor prognosis in early breast cancer, no association of positive CTC status before and after chemotherapy with the site of metastatic disease was found. Therefore, a positive CTC status should trigger routine diagnostic intervention depending on clinical evaluation.

Citation Format: Elisabeth Katharina Trapp, Peter A Fasching, Tanja Fehm, Andreas Schneeweiss, Volkmar Mueller, Nadia Harbeck, R. Lorenz, Claudia Schumacher, Georg Heinrich, Amelie deGregorio deGregorio, Marie Tzschaschel, Inga Bekes, Christoph Scholz, Brigitte Rack, Wolfgang Janni, Thomas WP Friedl. Presence of circulating tumor cells in high-risk early breast cancer do not predict site of metastatic lesions - Results of the SUCCESS A trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-01-01.

Abstract P1-19-33: Real-world efficacy of ribociclib + aromatase inhibitor, or endocrine monotherapy, or chemotherapy as first-line treatment in postmenopausal women with HR-positive, HER2-negative locally advanced or metastatic breast cancer: Second interim analysis from the RIBANNA study

Background: Ribociclib (RIB, a selective CDK4/6 inhibitor) plus an aromatase inhibitor (AI) or fulvestrant (FUL) is approved for the treatment of premenopausal and postmenopausal women with HR+/HER2- advanced breast cancer (aBC). Real-world evidence for the effectiveness, safety and tolerability of RIB + AI/FUL in routine clinical practice is needed to support the use of this combination. Methods: RIBANNA is a noninterventional study ongoing in Germany since October 2017. Premenopausal and postmenopausal patients (N=3020) treated with RIB + AI/FUL, or endocrine monotherapy (ET), or chemotherapy (CT) as first-line treatment for HR+/HER2- aBC in accordance with German guidelines were included. Data are being collected from clinical practice in all 3 cohorts. Further lines of treatment are noted to examine outcomes of sequential therapy. Results: For the first interim analysis, 461 patients were enrolled until October 9, 2018, while full analysis set comprised 282 patients (Table 1). The first-line mean daily dose of RIB was 382 mg including and 540 mg excluding dose interruptions, respectively. RIB was prescribed mainly in combination with letrozole (83%), anastrozole (8%), and exemestane (7%); ET included nonsteroidal AI (64%), selective estrogen receptor degrader (25%), selective estrogen receptor modulator (7%), and steroidal AI (5%); CT included taxane-based monotherapy (30%) or combination therapy (27%), other monotherapy (23%) or other combination therapy (13%), and anthracycline-based combination therapy (5%). Conclusion: RIBANNA study showed diverse population characteristics among patients who received RIB treatment in a real-world setting. Based on the baseline demographics data, RIB (CDK4/6 inhibitor) treatment was found to be very well adopted among premenopausal and postmenopausal patients with HR+/HER2- aBC. The second interim analysis is planned for October 2019. Updated baseline data of approximately 1200 to 1300 patients and information on safety and dose modification for first-line patients from all cohorts will be presented.

Table 1. Baseline demographic characteristicsTotal (N = 282)RIB + AI (n = 216)Endocrine therapy (n = 26)Chemotherapy (n = 40)Mean age, years (SD)67 (11)67 (10)71 (12)62 (10)Mean time since initial diagnosis, years5.45.56.53.9T stage at initial diagnosis, n (%)T0+T161 (100)48 (79)6 (10)7 (11)T2-T4198 (100)149 (75)17 (9)32 (16)N stage at initial diagnosis, n (%)N0+N1186 (100)144 (77)16 (9)26 (14)N2+N364 (100)48 (75)5 (8)11 (17)M stage at initial diagnosis, n (%)M0156 (100)121 (78)14 (9)21 (13)M1101 (100)75 (74)9 (9)17 (17)Locally advanced, n (%)101 (100)73 (72)9 (9)19 (19)Metastatic, n (%)101 (100)75 (74)9 (9)17 (17)Metastatic location, n (%)CNS, liver, lungs119 (100)96 (81)1 (1)22 (18)Bone only84 (100)62 (74)17 (20)5 (6)Skin, lymph nodes, other52 (100)37 (71)6 (11)9 (17)

Citation Format: Achim Wöckel, Pawel Basiora, Michael Bohlmann, Thomas Decker, Jörg Falbrede, Peter Fasching, Helmut Forstbauer, Tobias Hesse, Oliver Hoffmann, Christian Jackisch, Anna Kaczerowsky, Ralf Lorenz, Kerstin Lüdtke-Heckenkamp, Diana Lüftner, Frederik Marmé, Thomas Mueller, Christoph Mundhenke, Arnd Nusch, Volker Petersen, Gabriele Prange-Krex, Toralf Reimer, Thomas Resch, Christian Roos, Oliver Tomé, Anja Weishap. Real-world efficacy of ribociclib + aromatase inhibitor, or endocrine monotherapy, or chemotherapy as first-line treatment in postmenopausal women with HR-positive, HER2-negative locally advanced or metastatic breast cancer: Second interim analysis from the RIBANNA study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-19-33.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances

Background

Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management.

Methods

The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed.

Results

Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence.

Conclusion

This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

Exome analysis of oncogenic pathways and tumor mutational burden (TMB) in triple-negative breast cancer (TNBC): Results of the translational biomarker program of the neoadjuvant double-blind placebo controlled GeparNuevo trial

509

Background: GeparNuevo (G9) showed a numerical increase in pCR rate of 53% vs 44%; p = 0.287 compared to placebo in TNBC with the addition of the anti-PD-L1 antibody durvalumab (D) to a neoadjuvant anthracycline-taxane containing chemotherapy (Loibl S et al. ASCO 2018). Somatic mutations in malignant cells manifest over the evolutionary history of a tumor. Reports in selected tumor types suggest that TMB may predict clinical outcomes on immune-checkpoint inhibitors (ICI). The clinical relevance of TMB in breast cancer has not been studied widely. Here, we investigated the hypothesis that TMB predicts response to ICI. Methods: Whole exome sequencing was conducted on patient-matched fresh-frozen core biopsies and blood samples with Illumina (n = 149/174). SNVs and indels were called with Mutect and pureCN was used for copy number calls. Mutational signatures were identified as described by Alexandrov et al. (Cell Rep. 3, 2013). Data from G9 were compared to The Cancer Genome Atlas (TCGA) TNBC cohort. Results: A similar genomic landscape was observed between G9 and TCGA with primary mutations in TP53 (69%), c-MYC (26%), BRCA1 (13%), BRCA2 (6%), PIK3CA (11%) and PTEN (11%). Median TMB was 1.52 mut/MB. TMB in G9 was slightly lower than TCGA TNBC. TMB correlated with older age, higher mutation rates in BRCA2, ARID1A, and TP53, and higher burden in variant signatures such as DDR, HRD, GFRs, APOBEC and Alexandrov’s signatures 3 and 6. Continuous TMB predicted pCR in univariate (OR = 1.62, 95%-CI: 1.20 - 2.20, p = 0.0018) and multivariate (OR = 2.06, 95%-CI: 1.33 - 3.20, p = 0.0012) logistic regression models, but did not predict a D effect. After dichotomisation of TMB at the top tertile, 50 patients had high TMB and 29 of these (58%) achieved a pCR, while 99 had low TMB and only 38 of these (38%) had a pCR (p = 0.0242). Conclusions: Results show that TMB may predict pCR in primary TNBC. The trial was financially supported by Astra Zeneca and Celgene. Clinical trial information: NCT02685059.

An in vitro study on the biocompatibility of fibroblasts in sterile and non-sterile low-cost and commercial meshes

INTRODUCTION

Despite several successful studies with low-cost meshes (LCM) for the treatment of inguinal hernias in India and Africa, a nationwide application has not been possible for a variety of reasons. One problem is the special preparation and sterilization of these meshes-naturally, they should comply with international standards and demands, which is often difficult to achieve in Africa. Our primary approach was to determine whether there are differences in the biocompatibility of fibroblasts between non-sterile and sterile LCMs and commercial meshes (CM).

MATERIALS AND METHODS

Two polyester CMs with different pore size and a polyester LCM were examined as both sterile and non-sterile. LCM was plasma sterilized at 60 °C and steam sterilized at 134 °C. Sterile and non-sterile meshes were soaked with an antibiotic (penicillin/streptomycin) and antimycotic solution (amphotericin B). Human fibroblasts from healthy subcutaneous tissue were used. Various tests for evaluating the growth behavior and cell morphology of human fibroblasts were conducted. Semiquantitative (light microscopy) and qualitative (scanning electron microscopy) analyses were performed after 1 week and again after 12 weeks. The metabolism of fibroblasts was checked by pH measurements and glucose analyses. Biocompatibility of fibroblasts on sterile and non-sterile meshes was carried out by luminescence methods (cell viability and apoptosis) as well as calorimetric methods for proliferation determination (BrDU assay) and cytotoxicity (LDH assay).

RESULTS

Light and electron microscopy revealed a moderate growth of fibroblasts on all investigated mesh types. The results of glycolysis and the pH value were within the normal range for all sterile and non-sterile meshes. In biocompatibility studies, no elevated level of apoptosis was detected. The viability measurement of mitochondrial activity of fibroblasts showed a 50% inhibition of mitochondria in all nets, with the exception of non-sterile CM, whereas mitochondrial activity was increased in the non-sterile CM. A proliferation measurement (BrdU test) revealed different growth inhibition in the sterile and non-sterile meshes. This growth inhibition was significantly stronger, particularly for non-sterile CM light meshes, than it was for the non-sterile LCM.

CONCLUSION

Again, our studies show no significant differences in biocompatibility of fibroblasts between expensive and low-cost meshes. In addition, we detected fibroblast growth even in sterile meshes, independent of the mesh group. To our knowledge, the present study is the first of its kind in terms of qualitative equivalence of sterile and non-sterile in vitro mesh samples. We do not wish to create future patient studies with non-sterilized meshes saturated with antibiotics/antimycotics. However, perhaps we can prove in future studies that under semi-sterile conditions with certain LCMs, wound infection rates can be acceptable.

Abstract GS5-03: Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study

Background:

Recent trials have provided evidence that obesity and a low level of physical activity are not only associated with a higher risk of developing breast cancer, but also with an increased risk for recurrence and reduced survival in breast cancer patients (pts). The SUCCESS C study is the first randomized Phase III trial to evaluate the effect of an intensive lifestyle intervention program, focusing on both physical activity and healthy diet following adjuvant chemotherapy on disease-free survival in women with early breast cancer.

Methods:

SUCCESS C is a German multicenter, 2×2 factorial design, randomized phase III study comparing disease-free survival (DFS) in pts with HER2-negative early breast cancer treated with either 3 cycles of epirubicine, fluorouracil, cyclophosphamide chemotherapy followed by 3 cycles of docetaxel (FEC-D) or 6 cycles of docetaxel-cyclophosphamide (DC). The second randomization compares DFS in pts with a body mass index (BMI) of 24—40 kg/m2 receiving either a telephone-based individualized lifestyle intervention (LI) program aiming at moderate weight loss for 2 years (LI arm) or general recommendations for a healthy lifestyle alone (non-LI arm). DFS according to lifestyle intervention was analyzed using both univariable cox regressions and multivariable cox regressions adjusted for age (years, continuous), BMI (kg/m2, continuous), menopausal status (premenopausal, postmenopausal), tumor size (pT1, pT2, pT3/pT4), nodal stage (pN0, pN1, pN2, pN3), hormone receptor status (positive, negative), grading (G1, G2, G3), histological type (ductal, lobular, other) and chemotherapy randomization (FEC-D, DC). Median follow-up was 64.2 months.

Results:

Overall, 2292 of the 3643 pts recruited for the SUCCESS C study were randomized for the lifestyle intervention program (1146 pts in both the non-LI arm and the LI arm). The Intention-to-treat analysis revealed no difference in DFS between the two treatment arms (LI vs. non-LI) in univariable analysis (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.76 — 1.28, p = 0.922) and in adjusted multivariable cox regression (HR 0.91, 95% CI 0.70 — 1.18, p = 0.48). At the 2-year follow up, pts in the LI arm lost on average 1.0 kg weight compared to the start of the LI program, while pts in the non-LI arm gained on average 0.95 kg (p &lt; 0.001). Overall, 1477 pts completed the 2-year LI program (non-LI arm: 80.7%, 925 of 1146 pts; LI arm: 48.2%, 552 of 1146 pts; p &lt; 0.001). Pts that completed the 2-year LI program had a significant better DFS than non-completers (HR 0.35, 95% CI 0.27 — 0.45, p &lt; 0.001). Among completers, pts in the LI arm had a significantly better DFS than pts in the non-LI arm both in univariable analysis (HR 0.53, 95% CI 0.35 — 0.82, p = 0.004) and in adjusted multivariable cox regression (HR 0.51, 95% CI 0.33 — 0.78, p = 0.002).

Conclusions:

This explorative and non-planned interim analysis indicates that the completion of a systematic telephone life style intervention program may positively impact patient outcome in early breast cancer.

Citation Format: Janni W, Rack BK, Friedl TW, Müller V, Lorenz R, Rezai M, Tesch H, Heinrich G, Andergassen U, Harbeck N, Schochter F, De Gregorio A, Tzschaschel M, Huober J, Hepp P, Fehm TN, Schneeweiss A, Lichtenegger W, Blohmer J, Hauner D, Beckmann MW, Häberle L, Fasching PA, Hauner H. Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study [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 GS5-03.

Has Shouldice Repair in a Selected Group of Patients with Inguinal Hernia Comparable Results to Lichtenstein, TEP and TAPP Techniques?

Background

In the new international guidelines only the mesh-based Lichtenstein, TEP and TAPP techniques are recommended. This present analysis of data from the Herniamed Registry compares the outcome for Shouldice versus Lichtenstein, TEP and TAPP.

Methods

Propensity score matching analyses were performed to obtain homogeneous comparison groups for Shouldice versus Lichtenstein (n = 2115/2608; 81.1%), Shouldice versus TEP (n = 2225/2608; 85.3%) and Shouldice versus TAPP (2400/2608; 92.0%).

Results

The most important characteristics of the Shouldice patient collective were younger patients with a mean age of 40 years, a large proportion of women of 30%, a mean BMI value of 24 and a proportion of defect sizes up to 3 cm of over 85%. For this selected patient collective, propensity score matched-pair analysis did not identify any difference in the perioperative and one-year follow-up outcome compared with TAPP, fewer intraoperative (0.5 vs. 1.3%; p = 0.009) but somewhat more postoperative complications (2.3 vs. 1.5%; p = 0.050) compared with TEP and advantages with regard to pain at rest (4.6 vs. 6.1%; p = 0.039) and on exertion (10.0 vs. 13.4%; p < 0.001) compared with the Lichtenstein technique.

Conclusion

For a selected group of patients the Shouldice technique can be used for primary unilateral inguinal hernia repair while achieving an outcome comparable to that of Lichtenstein, TEP and TAPP operations.

Sorafenib plus topotecan versus placebo plus topotecan for platinum-resistant ovarian cancer (TRIAS): a multicentre, randomised, double-blind, placebo-controlled, phase 2 trial

BACKGROUND

Antiangiogenic therapy has known activity in ovarian cancer. The investigator-initiated randomised phase 2 TRIAS trial assessed the multi-kinase inhibitor sorafenib combined with topotecan and continued as maintenance therapy for platinum-resistant or platinum-refractory ovarian cancer.

METHODS

We did a multicentre, double-blind, placebo-controlled, randomised, phase 2 trial at 20 sites in Germany. Patients (≥18 years) with platinum-resistant ovarian cancer previously treated with two or fewer chemotherapy lines for recurrent disease were stratified (first vs later relapse) in block sizes of four and randomly assigned (1:1) using a web-generated response system to topotecan (1·25 mg/m² on days 1-5) plus either oral sorafenib 400 mg or placebo twice daily on days 6-15, repeated every 21 days for six cycles, followed by daily maintenance sorafenib or placebo for up to 1 year in patients without progression. Investigators and patients were masked to allocation of sorafenib or placebo; topotecan treatment was open label. The primary endpoint was investigator-assessed progression-free survival, analysed in all patients who received at least one dose of study drug. This completed trial is registered with ClinicalTrials.gov, number NCT01047891.

FINDINGS

Between Jan 18, 2010, and Sept 19, 2013, 185 patients were enrolled, 174 of whom were randomly assigned: 85 to sorafenib and 89 to placebo. Two patients in the sorafenib group had serious adverse events before treatment and were excluded from analyses. 83 patients in the sorafenib group and 89 in the placebo group started treatment. Progression-free survival was significantly improved with sorafenib versus placebo (hazard ratio 0·60, 95% CI 0·43-0·83; p=0·0018). Median progression-free survival was 6·7 months (95% CI 5·8-7·6) with sorafenib versus 4·4 months (3·7-5·0) with placebo. The most common grade 3-4 adverse events were leucopenia (57 [69%] of 83 patients in the sorafenib group vs 47 [53%] of 89 in the placebo group), neutropenia (46 [55%] vs 48 [54%]), and thrombocytopenia (23 [28%] vs 20 [22%]). Serious adverse events occurred in 49 (59%) of 83 sorafenib-treated patients and 45 (51%) of 89 placebo-treated patients. Of these, events were fatal in four patients (5%) in the sorafenib group (dyspnoea and poor general condition, septic shock, ascites and dyspnoea, and sigma perforation) and seven (8%) in the placebo group (pulmonary embolism in two patients, disease progression in two patients, and one case each of sepsis with fever, pleural effusion, and tumour cachexia). Sorafenib was associated with increased incidences of grade 3 hand-foot skin reaction (three [13%] vs 0 patients) and grade 2 alopecia (24 [29%] vs 12 [13%]).

INTERPRETATION

Sorafenib, when given orally in combination with topotecan and continued as maintenance therapy, showed a statistically and clinically significant improvement in progression-free survival in women with platinum-resistant ovarian cancer. These encouraging results support the crucial role of antiangiogenesis as the treatment backbone in combination with chemotherapy, making this approach attractive for further assessment with other targeted strategies.

FUNDING

Bayer, Amgen, and GlaxoSmithKline.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Abstract P1-13-09: Withdrawn

This abstract was withdrawn by the authors.

Abstract P5-20-09: Pharmacokinetic results of a subcutaneous injection of trastuzumab into the thigh versus into the abdominal wall in patients with HER2-positive primary breast cancer (BC) treated within the neo-/adjuvant GAIN-2 study

Background

A new subcutaneous (s.c.) formulation of trastuzumab became available in 2013 based on equivalent efficacy, pharmacokinetic (PK) profile and safety with the standard intravenous (i.v.) administration, where the s.c. trastuzumab was administered only into the thigh. As an s.c. injection into the abdominal wall (abdw) might be more convenient for patients (pts) and health care professionals, the PK profile of s.c. trastuzumab injected into the thigh vs the abdw in pts with HER2+ early BC needs to be evaluated.

Methods

GAIN-2 study compared two intense dose-dense (idd) anthracycline/taxane containing regimens. After completion of the anthracycline and i.v. trastuzumab given concurrently with taxanes, HER2+ BC pts were randomized in a 1:1 ratio to continue adjuvant s.c. trastuzumab 600mg fixed dose injected every 3 weeks either into the thigh or the abdw. Randomization was stratified according to CT arm [(iddEnPC) vs tailored dd CT (dtEC-dtD)] and age (≤50 vs &gt;50). Pts in the EnPC arm received 14 and in the dtEC-dtD arm 15 cycles of s.c. trastuzumab.

For the PK profile of s.c. trastuzumab serum samples collected before cycle 7, on days 2, 4, 8, 15 and 21 of cycle 7 are evaluated. With a total sample size of 30 (15 per group), the simulated 90% two-sided CI for the area under the plasma concentration (AUC0-last) will be (0.79-1.27) and for the peak drug concentration (Cmax) will be (0.77-1.30). Allowing for a dropout rate of 15%, 18 pts per group will be included in the PK analysis.

The primary objective was to assess the PK profile of s.c. trastuzumab injected into the thigh vs the abdw. The secondary objectives included safety and tolerability.

Results

The per-protocol (pp) set consists of 30 pts (17 in the thigh group and 13 in the abdw group). Baseline characteristics were well balanced between the groups. The log-transformed Geometric Least Square Means (GLSM) for Cmax were 11.77 and 11.52 in the thigh and the abdw group, respectively. The geo-mean ratio (on the original scale) for Cmax was 1.29 (90% CI 1.05-1.58). The log-transformed GLSM for AUC0-last were 14.54 and 14.28 in the thigh and the abdw group, respectively. The geo-mean ratio for AUC0-last was 1.29 (90% CI 1.02-1.63).

Overall 29 pts (96.7%) reported any grade and 5 pts (16.7%) high grade adverse events (AEs). The incidence of any grade AEs was similar between the two groups. The most common AEs were anemia (70.6% for the thigh vs 61.5% for the abdw group, p=0.705), leukopenia (80.0% for both groups, p=1.000) and fatigue (47.1% for the thigh vs 76.9% for the abdw group, p=0.141). 6 serious AEs were reported (2 in the thigh vs 4 in the abdw group). The final PK results of s.c. trastuzumab will be presented at the meeting.

Conclusions

Bioavailability of s.c. trastuzumab as reflected by peak and total exposure measured in cycle 7 was approx. 30% higher if administered into the thigh than into the abdw in pts with HER2+ primary BC treated after dose-dense CT plus i.v. trastuzumab. However, no increased toxicity was observed. Study limitations were that no cross-over design was used and number of pts satisfying criteria for pp-set were different in the arms.

Citation Format: Möbus V, Mahlberg R, Janni W, Tomé O, Marmé F, Forstbauer H, Reimer T, von der Assen A, Reinisch M, Lorenz R, Schmatloch S, Schmidt M, Sinn B, Klutinus N, Stickeler E, Untch M, Seiler S, Burchardi N, von Minckwitz G, Loibl S. Pharmacokinetic results of a subcutaneous injection of trastuzumab into the thigh versus into the abdominal wall in patients with HER2-positive primary breast cancer (BC) treated within the neo-/adjuvant GAIN-2 study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-20-09.

Whole blood microRNAs as potential biomarkers in post-operative early breast cancer patients

BACKGROUND

microRNAs (miRNAs) are considered promising cancer biomarkers, showing high reliability, sensitivity and stability. Our study aimed to identify associations between whole blood miRNA profiles, presence of circulating tumor cells (CTCs) and clinical outcome in post-operative early breast cancer patients (EBC) to assess the utility of miRNAs as prognostic markers in this setting.

METHOD

A total of 48 post-operative patients, recruited in frame of the SUCCESS A trial, were included in this retrospective study and tested with a panel of 8 miRNAs (miR-10b, -19a, - 21, - 22, -20a, - 127, - 155, -200b). Additional 17 female healthy donors with no previous history of cancer were included in the study as negative controls. Blood samples were collected at different time points (pre-adjuvant therapy, post-adjuvant therapy, 2 years follow up), total RNA was extracted and the relative concentration of each miRNA was measured by quantitative PCR and compared in patients stratified on blood collection time or CTC detection. Furthermore, we compared miRNA profiles of patients, for each time point separately, and healthy donors. CTCs were visualized and quantified with immunocytochemistry analysis. Data were analyzed using non-parametric statistical tests.

RESULTS

In our experimental system, miR-19a, miR-22 and miR-127 showed the most promising results, differentiating patients at different time points and from healthy controls, while miR-20a, miR-21 and miR-200b did not show any difference among the different groups. miR-10b and miR-155 were never detectable in our experimental system. With respect to patients' clinical characteristics, we found a significant correlation between miR-200b and lymph node status and between miR-20a and tumor type. Furthermore, miR-127 correlated with the presence of CTCs. Finally, we found a borderline significance between Progression Free Survival and miR-19a levels.

CONCLUSIONS

This pilot study suggests that profiling whole blood miRNAs could help to better stratify post-operative EBC patients without any sign of metastasis to prevent later relapse or metastatic events.

Nuclear medical inpatient treatment in Germany

All public licensed hospitals of Germany are obligated since 2004 to establish and to publish a structured biennial quality report. The aim of this study was to analyse the quality reports from 2008 of clinics with nuclear-medicine therapy ward and to investigate developments for the inpatient nuclear-medicine therapy by comparing the results with the quality reports of the years 2004 and 2006. Methods: All available structured quality reports of clinics with a nuclear-medicine therapy ward of the years 2004, 2006 and 2008 were evaluated. Results: The total number of inpatient treatment cases in 2008 amounted to 54 190 (2006: 54 884; 2004: 57 366). This corresponds to a decrease of 5.5% in comparison to 2004. The number of the therapy wards decreased at the same time to currently 117 (2006: 120; 2004: 124). Remarkable changes were found in the spectrum of the main diagnosis. Thus, the most frequent diagnosis with the ICD-code E05 (hyperthyroidism) decreased continuously from 37 747 treatments in 2004 and 34 764 in 2006 to 31 756 in the year 2008. In contrast, the ICD-diagnoses for thyroid cancer (C73, Z08) with 14 761 cases in 2008 increased with time (2006: 13 426; 2004: 12 581). Conclusions: In analogy to the observations from Europe after introduction of an iodine prophylaxis the improved iodine supply in Germany has led to a decline of the radioiodine therapy due to hyperthyroidism.

Stationäre nuklearmedizinische Therapie 2010 bis 2012 in Deutschland

Das Ziel dieser Analyse war es, deutschlandweite Daten über den Status und die Entwicklung der stationären nuklearmedizinischen Therapie zu ermitteln. Als Datenquelle wurden die gesetzlichen Qualitätsberichte der Krankenhäuser verwendet. Methodik: Die vom Gemeinsamen Bundesausschuss (G-BA) aus den maschinenverwertbaren XML-Daten der Qualitätsberichte erstellten Referenzberichte aller Kliniken Deutschlands mit nuklearmedizinischer Therapiestation wurden für die Jahre 2010 und 2012 analysiert. Für die Beurteilung der längerfristigen Entwicklung dienten Ergebnisse aus eigenen Voruntersuchungen der strukturierten Qualitätsberichte für die Jahre 2004, 2006 und 2008. Zur Ermittlung der deutschlandweiten Häufigkeit von Schilddrüsenoperationen und der Radioiodtherapie wurden öffentliche Datenbanken des Instituts für das Entgeltsystem im Krankenhaus (InEK) für die Jahre 2004 bis 2012 ausgewertet. Ergebnisse: Die Gesamtzahl der stationären nuklearmedizinischen Behandlungsfälle hat von 2010 mit 50 363 Patienten bis 2012 auf 47 314 Patienten gering abgenommen. Im längeren Verlauf von 2004 bis 2012 findet sich ein deutlicher Rückgang der Fälle von 17,5%. Der Rückgang ist vor allem durch eine Abnahme an Erkrankungen mit Hyperthyreose (ICD-Code E05) bedingt. Seit 2009 ist auch die Anzahl der Schilddrüsenoperationen rückläufig. Ein moderater Anstieg der Fallzahlen von 23,7% zeigt sich für die Diagnose Schilddrüsenkarzinom (ICD-Code C73) von 2004 bis 2012. Schlussfolgerungen: Vermutlich führt die verbesserte Iodversorgung in Deutschland zu einem Rückgang an stationären Patienten mit Hyperthyreose in der Nuklearmedizin und in der Folge zu einer Abnahme sowohl der Anzahl an Radioiodtherapien als auch der Schilddrüsenoperationen in der Chirurgie. Im Gegensatz hierzu ist die Anzahl der Patienten mit der Diagnose Schilddrüsenkarzinom auf nuklearmedizinischen Therapiestationen moderat ansteigend, dies korreliert mit der weltweit zu beobachtenden Steigerung der Inzidenz des Schilddrüsenkarzinoms.

Abstract P2-05-02: Active surveillance with a combination of tumor marker CA27.29 and detection of circulating tumor cells two year after primary diagnosis strongly predicts subsequent prognosis

Introduction

The prognosis of patients with early breast cancer is commonly estimated by prognostic factors obtained at the time of the initial diagnosis. However, patients and physicians alike are seeking for factors evaluating the prognosis years thereafter during follow-up. The identification of a patient group with an unfavourable prognosis could lead to secondary treatment intervention, potentially improving outcome. Aim of the study was to assess the added prognostic value of circulating tumor cells (CTCs) and CA27.29 beyond established predictors.

Materials and Methods

Patients of the phase III SUCCESS-A study were included into this analysis (n=1005). SUCCESS-A is a chemotherapy study for high risk patients with a comprehensive translational research program, which included the determination of CTCs and CA27.29 two years after the initial diagnosis. A Cox regression model with disease-free survival (DFS) as outcome and well-established predictors (age, BMI, pT, pN, histology, grading, ER, PR, Her2neu) was compared with an extended Cox model with the well-established predictors and additionally CTC (&gt;0 versus 0) two years after randomization, and CA27.29 (in U/mL) measured after chemotherapy and again two years after randomization using a likelihood ratio test. In case of significance, the extended model was applied to predict for each patient the risk of disease recurrence within the next 12 months (0 to 100%). Cross-validated AUC, sensitivity and specificity values were determined to assess clinical usefulness of risk prediction.

Results

The markers CA27.29 and CTC were both significantly associated with subsequent prognosis (p &lt; 0.000001). The detection of CTCs increased the risk of subsequent DFS events (HR=2.14, 95%CI: 1.31-3.48), while CA27.29 after two years increased the risk for DFS events with a HR of 1.12 per U/mL increase (95%CI: 1.09-1.15). The combination of the two markers significantly empowered the prognostic relevance, with a HR of 6.64 for patients with CTCs and an elevated CA27.29 by 10 U/mL compared to patients without CTCs and without CA27.29 elevation. The mean risk of disease recurrence in the third year after randomization was 2.38%. Discrimination of patients with and without disease recurrence based on risk prediction from the extended Cox model (AUC: 0.80) was better than discrimination based on the clinical model without the markers CTC and CA27.29 (AUC: 0.64). Sensitivity with regard to decision thresholds 1%, 2%, 3%, and 4% predicted risk was 0.89, 0.77, 0.65, and 0.55, respectively. The corresponding specificity was 0.42, 0.69, 0.81, and 0.88.

Discussion

Both CTCs and CA29.27 values determined 2 years after primary diagnosis are clinically relevant predictors of subsequent prognosis for those patients. This study extends evidence for active surveillance of breast cancer survivors. Identifying a group of women with a high recurrence risk after two years could be the basis for the development of secondary adjuvant treatment.

Citation Format: Janni W, Rack B, Häberle L, Friedl TWP, Tesch H, Lorenz R, Jäger B, Fehm T, Müller V, Schneeweiß A, Lichtenegger W, Blohmer J, Beckmann MW, Scholz C, Pantel K, Trapp E, Fasching PA. Active surveillance with a combination of tumor marker CA27.29 and detection of circulating tumor cells two year after primary diagnosis strongly predicts subsequent prognosis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-02.

Abstract P1-01-03: Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial

Background: The presence of circulating tumor cells (CTCs) before chemotherapy is known to be associated with reduced disease free survival (DFS) and overall survival (OS) in early breast cancer (EBC). In addition, recent findings suggest that CTCs persisting after adjuvant chemotherapy indicate poor prognosis. In an explorative analysis of the SUCCESS A trial, we evaluated the prognostic relevance of changes in CTC counts during the course of adjuvant chemotherapy across molecular subtypes to assess whether the prognostic role of persisting CTCs varies according to tumor biology.

Methods: The SUCCESS A trial is a phase III study, where patients with high-risk EBC (stage pN1-3 or pT2-4 or grade 3 or age ≤ 35 or hormone-receptor negative) were randomized to adjuvant chemotherapy with 3 cycles of epirubicin-fluorouracil-cyclophosphamide followed by either 3 cycles of docetaxel or 3 cycles of gemcitabine-docetaxel. CTC enumeration was performed before and after chemotherapy using the FDA-approved CellSearch® System (Janssen Diagnostics, LLC), and CTC positivity was defined as ≥ 1 CTC in 23 ml blood. Molecular subtypes were defined as luminal A like (hormone-receptor positive, grading 1 or 2), luminal B like (hormone-receptor positive, grading 3), triple-negative or HER2-positive. Patient outcome in terms of DFS and OS was analyzed using univariate log-rank tests and Cox regression models (median follow-up time 65.2 months).

Results: Data on both molecular subtypes and CTC status before and after chemotherapy were available for 1485 (39.6%) of 3754 patients randomized. This cohort contained 577 (38.9%) luminal A like, 236 (15.9%) luminal B like, 379 (25.5%) HER2-positive and 293 (19.7%) triple negative tumors. Overall, 917 (61.8%) patients were CTC negative before and after chemotherapy (neg/neg), 260 (17.5%) patients had a negative CTC status before and a positive CTC status after chemotherapy (neg/pos), 229 (15.4%) patients converted from positive to negative CTC status (pos/neg), and 79 (5.3%) patients were positive for CTCs at both time points (pos/pos). There were significant differences in DFS and OS among these four groups in patients with luminal A like tumors (log rank test, both p &lt; 0.003) and patients with luminal B like tumors (log rank test, both p &lt; 0.001). In both patients with luminal A like or luminal B like tumors, persistently CTC positive patients had the worst outcome (relative to persistently CTC-negative patients) in terms of DFS and OS. In contrast to luminal-like tumors, no significant differences with regard to DFS or OS were found among the four groups (neg/neg, neg/pos, pos/neg, pos/pos) in patients with HER2-positive or triple-negative tumors (log rank test, all p &gt; 0.13).

Conclusion: The presence of CTCs both before and after adjuvant chemotherapy was associated with poor survival in luminal A like and luminal B like tumors, but not in HER2-positive or triple-negative tumors. Further research is needed to evaluate the effect of chemotherapy on CTC prevalence in different molecular subtypes of EBC.

Citation Format: Tzschaschel MLJ, Rack B, Andergassen U, Friedl TWP, Schneeweiss A, Mueller V, Tanja F, Pantel K, Gade J, Lorenz R, Rezai M, Tesch H, Soeling U, Polasik A, Alunni-Fabbroni M, Trapp EK, Mahner S, Schindlbeck C, Lichtenegger W, Beckmann MW, Fasching PA, Janni W. Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-01-03.