Oncological treatment administration at end of life: a retrospective study

Background: This work evaluated the proportion of patients who continue therapy until their last month of life or initiate a new therapy in the last 3 months of life (end of life [EOL]). Methods: Data for 486 patients were retrospectively collected. Results: In EOL, 205 (42.3%) received systemic therapy. Better performance status (last month overall response [OR]: 0.39; 95% CI: 0.25-0.60; p < 0.001; last 3 months OR: 0.47; 95% CI: 0.34-0.65; p < 0.001) and lack of activation of palliative care (last month OR: 0.26; 95% CI: 0.13-0.54; p < 0.001; last 3 months OR: 0.18; 95% CI: 0.10-0.32; p < 0.001) were associated with higher probability of EOL therapy. Conclusion: A non-negligible proportion of patients in real-life settings continue to receive systemic treatment in EOL.

Clinical presentation and outcome of patients with enteric-type adenocarcinoma of the lung: A pooled analysis of published cases

Enteric-type adenocarcinoma of the lung (lung-ETAC, former pulmonary enteric adenocarcinoma, PEAC) is a rare subtype of non-small cell lung cancer (NSCLC), which shares morphological and immunohistochemical features with lung and colorectal adenocarcinoma. Few data are available on patient prognosis, possible prognostic factors and systemic approach to metastatic disease. We performed a pooled analysis and a systematic review of published lung-ETAC, along with an additional case description. Thirty-one eligible publications were identified, providing data from 126 patients. In the 127 patients overall analyzed, median overall survival (OS) was 56.0 (range 36.7-75.3) months in early-stage patients and 14.0 (range 4.5-23.5) months in those with advanced/metastatic disease. Median disease-free survival (DFS) after radical surgery was 24 (range 22.6-35.1) months. Smoking status (HR 4.304, 95% CI: 1.261-14.693, p = 0.020) and node involvement (HR 1.853, 95% CI: 1.179-2.911, p = 0.007) were the negative independent prognostic factors at multivariate analysis. As regards systemic therapies for advanced cases, no firm conclusions were drawn about the efficacy of lung cancer-oriented chemotherapy regimens as opposed to colon cancer-oriented ones. Molecular analysis of lung-ETAC revealed a relatively high mutational rate, with alterations in several druggable molecular pathways, KRAS and NRAS (31%) were the most frequently mutated oncogenes, followed by ROS1 (15%), RET (13%), BRAF (11%), EGFR (8%) and ALK (6%). Moreover, 3 (15%) out of 20 cases showed DNA mismatch repair deficiency (dMMR). In conclusion, advanced lung-ETAC patients appeared to have a better prognosis compared to other subtypes of NSCLC. Moreover, the mutational rate and microsatellite instability found in lung-ETACs suggest that a significant proportion of these patients could benefit from target therapies and immunotherapy.

A self-adaptive hardware with resistive switching synapses for experience-based neurocomputing

Neurobiological systems continually interact with the surrounding environment to refine their behaviour toward the best possible reward. Achieving such learning by experience is one of the main challenges of artificial intelligence, but currently it is hindered by the lack of hardware capable of plastic adaptation. Here, we propose a bio-inspired recurrent neural network, mastered by a digital system on chip with resistive-switching synaptic arrays of memory devices, which exploits homeostatic Hebbian learning for improved efficiency. All the results are discussed experimentally and theoretically, proposing a conceptual framework for benchmarking the main outcomes in terms of accuracy and resilience. To test the proposed architecture for reinforcement learning tasks, we study the autonomous exploration of continually evolving environments and verify the results for the Mars rover navigation. We also show that, compared to conventional deep learning techniques, our in-memory hardware has the potential to achieve a significant boost in speed and power-saving.

JS09.7.A Reirradiation for recurrent high grade glioma (HGG) patients: results of a single arm prospective phase 2 study

Background

Standard of care for recurrent high grade glioma (HGG) is missing. Several treatment options have been investigated including re-irradiation (re-RT). Results are promising but provided by retrospective studies. We designed a single arm prospective phase II study aiming to evaluate efficacy, and toxicity of re-irradiation.

Material and Methods

Adults patients with good performance status, HGG diagnosis reclassified according to the new 2021 fifth edition WHO CNS classification, an interval time (IT) from previous RT ≥ 6 months were included. Outcome was evaluated by MRI imaging at 1 month, and every 3 months thereafter. Toxicities were evaluated in terms of radionecrosis occurrence, and neurocognitive status.

Results

Ninety recurrent HGG patients were treated, 11 oligodendroglioma grade 3, 18 astrocytoma grade 3 and 4, and 61 glioblastoma grade 4. The median age was 54 years, and majority had KPS 90-100. The median IT between first-RT and re-RT was 24 months. Re-surgery has been performed in 56.6%, and chemotherapy in 53.3%. The median follow up time was 64 months; median overall survival (OS) time,1,2,3-year OS rates were 17 months (95%CI 14-19), 66.7%±4.9, 32.6%±5.0, and 22.2 ± 4.7. Prognostic factors impacting on survival were age (p = 0.0154), IT between first RT and re-RT (p = 0.0051), glioma grade (p = 0.0090), and IDH status (p = 0.0001). Radionecrosis grade 2-3 occurred in 9 (10%) patients; neurocognitive functions remained stable until disease progression.

Conclusion

Re-RT proved to be a safe and feasible treatment option with low toxicity. Younger patients with grade 3 IDH mutated gliomas, and a longer IT had the better outcome.

Optical diffraction tomography of 3D microstructures using a low coherence source

Optical diffraction tomography (ODT) is a label-free technique for three dimensional imaging of micron-sized objects. Coherence and limited sampling of 3D Fourier space are often responsible for the appearance of artifacts. Here we present an ODT microscope that uses low temporal coherence light and spatial light modulators to retrieve reliable 3D maps of the refractive index. A common-path interferometer, based on a spatial light modulator, measures the complex fields transmitted by a sample. Measured fields, acquired while scanning the illumination direction using a digital micro-mirror device, are fed into a Rytov reconstruction algorithm to obtain refractive index maps whose accuracy is directly evaluated on microfabricated 3D test objects. Even for challenging shapes such as pyramids, bridges, and dumbbells, we obtain volumetric reconstructions that compare very well with electron microscopy images.

The impact of RF wattage level on local impedance and procedural parameters in AF ablation cases

Funding Acknowledgements

Type of funding sources: None.

Background

Local impedance (LI) measurement can provide information on catheter tip contact, but also changes in LI during ablation can inform the extent and effectiveness of RF energy delivery. To date the relationship between highly LI measurements and contact force (CF) during atrial fibrillation (AF) ablation at different levels of energy delivery is still lacking.

Purpose

We aimed to evaluate the impact of power setting on LI and key procedural parameters in AF ablation cases.

Methods

A novel CF ablation catheter equipped with dedicated algorithm was used to measure LI at the distal electrode of this catheter. Radiofrequency (RF) catheter applications ≥45 watts were categorized as high power (HP) and applications &lt;45w as standard power (SP). Ablations were also grouped according to different levels of CF (&lt;5g, 5-14g, 15-24g and ≥25g). Data are reported as mean±SD.

Results

Sixty-two consecutive pts undergoing RF catheter ablation of AF from the CHARISMA registry were included A total of 4619 ablation spots performed around PVs were analyzed (58% paroxysmal, 84% de novo, RF deliveries per pt=76±27, RF delivery time=9.1±5s, CF=12.3±8g). The majority of these were HP applications (n=4192, 91%). The mean LI was 158±17Ω prior to ablation and 138±14Ω after ablation (p&lt;0.0001, absolute LI drop of 21.9±8Ω) with a LI drop rate equal to 4.4±3Ω/s. HP ablations had significantly shorter RF delivery times, 8.8±4s vs 12±7s (p&lt;0.0001), larger LI drops (22.2±8Ω vs 19.3±9Ω, p&lt;0.0001) and higher LI drop rates (4.5±3Ω/s vs 3.6±2Ω/s, p&lt;0.0001) than SP, respectively. For both HP and SP settings, the magnitude of LI drop increased and RF delivery time decreased with increasing amounts of CF. The largest differences between HP and SP were found when CF was &lt;15g (RF delivery time: 9±5s at HP vs 12.9±7s at SP, percentage of difference 26.3%, p&lt;0.0001; LI drop: 21.2±8Ω at HP vs 18.6±9Ω, percentage of difference -14.3%, p&lt;0.0001). No major complications occurred during the procedures. All PVs were successfully isolated.

Conclusions

This preliminary experience suggests that, HP ablation is effective and safe and resulting in shorter RF delivery times and larger LI drops than SP ablation.

Novel cryo-balloon technology for a successful pulmonary vein isolation: acute outcome and follow-up from a large multicenter Italian clinical setting

Funding Acknowledgements

Type of funding sources: None.

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, limited data exist on acute and follow-up outcome of this system in a multicentric clinical practice.

Purpose

We reported the preliminary experience of this novel technology in a multicenter Italian registry.

Methods

Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 6 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred &gt;60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block. Rhythm monitoring during the follow-up examinations was performed via the clinical assessment of AF recurrence, ECG and Holter monitoring, according to the clinical practice of each center. All patients were followed-up for at least 6 months after the procedure. Arrhythmia recurrences within the first 3 months (blanking period) were classified as early recurrences and were not considered procedural failures

Results

Six-hundred twenty-four cryoapplications from 112 pts (439 PVs) were analyzed (n=89, 79.5% paroxysmal AF, n=23, 20.5% persistent AF, mean age 61.5±9 years, 76% male, 22% with an history of AT, mean LVEF 49±10%). PVI was achieved in all pts using only cryoablation. The mean number of freeze applications per pt was 5.6±2.1 (1.4±1.2 for LSPV, 1.5±1.1 for LIPV, 1.3±0.8 for RSPV and 1.3±0.8 for RIPV), with 318 (72.4%) PVs treated with a single cryoablation (92, 21% with 2 cryoablation; 29, 6.6% with more than 2 cryoablations). Fourty-four (39.3%) pts were treated with a single application to each of the PVs. Over a median of 296[245 to 382] days of follow-up, five (4.5%) patients experienced an early recurrence of AF/AT during the 90-day blanking period. Overall, 12 patients (10.7%) suffered an AF/AT recurrence after the 90-day blanking period (median time to recurrence 200[124 to 297] days). Specifically, 8 (7.1%) patients had AF recurrence only, 3 (2.7%) had AT recurrence only and 1 (0.9%) experienced both events. One (0.9%) patient underwent a repeated ablation procedure. The proportion of patients exhibiting AF/AT recurrences was similar between AF types (10 out 89, 11.2% for paroxysmal AF vs 2 out 23, 8.7% for persistent AF, p=1.00) with a hazard ratio of 0.9 (95%CI: 0.2 to 3.9, log-rank p=0.8894). One transient phrenic nerve palsy was observed, with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported.

Conclusion

In this first multicentric experience, the novel cryo-balloon system proved to be safe and effective and resulted in a very low rate of AF/AT recurrence during follow-up.

Accurate Triage of Oncological Patients for Safely Continuing Cancer Therapy During the SARS-CoV-2 Pandemic

Objective

To evaluate the efficacy of clinical triage of oncological patients for safe continuation of cancer therapy implemented during the first SARS-CoV-2 outbreak.

Methods

Between 25 February and 21 April 2020, patients attending the Medical Oncology Unit, Spedali Civili Hospital, Brescia (Italy) for cancer therapy underwent triage to identify those with no signs and symptoms suspicious for SARS-CoV-2 infection in which antineoplastic treatment could be continued as scheduled. Triage questions investigated common symptoms (e.g., fever, cough, dyspnea, anosmia, dysgeusia, headache, nasal congestion, conjunctival congestion, sore throat, diarrhea, nausea and vomiting); body temperature and pulse oximetry were also recorded. All patients were followed-up for overt SARS-CoV-2 through to 18^th May 2020.

Results

Overall, 1180 patients (median age 65 years) underwent triage during the study period. The most frequent primary malignances were breast (32%), gastrointestinal (18%), and lung (16.5%) cancer. Thirty-one (2.5%) presented with clinically evident SARS-CoV-2 infection and tested positive on nasopharyngeal swab testing and/or radiological imaging. Triage identified 69 (6%) grey zone patients with symptoms suspicious for SARS-CoV-2; 5 (7.2%) subsequently developed symptomatic disease. Neither the symptomatic nor the grey zone patients received their scheduled treatment; instead, they were referred for hospitalization or home quarantine.

Conclusion

Triage of oncological patients at our Unit provided for safe continuation of scheduled cancer treatment in 91.5% of patients during the initial SARS-CoV-2 outbreak.

Accuracy comparison of the new and previous Kodex occlusion tool software versions to assess pulmonary vein occlusion in atrial fibrillation cryoablation

Background

Atrial fibrillation (AF) is the most frequent sustained arrhythmia worldwide and Cryoballoon ablation (CB) has become a consolidated alternative to the radiofrequency pulmonary vein (PV) isolation. However, CB requires fluoroscopy and dye injections to verify the occlusion grade. The accuracy of the earlier version of the Kodex Occlusion Tool software has been studied.

Purpose

The purpose of this study was to verify the accuracy of the second generation Kodex Occlusion Tool Software of a new dielectric system imaging compared to its first generation to detect PV occlusion during CB ablation in patients with AF.

Methods

15 consecutive patients with paroxysmal AF were enrolled in the study and underwent the procedure with the guidance of the first generation version (1.4.6) of the Kodex Occlusion Tool software. The Kodex recorded procedural data were used to replay the case using the Kodex second generation version (1.4.7) of the Occlusion Tool software when clinically available. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octa-polar circular mapping catheter, PV occlusion was assessed with the Occlusion Tool Software and compared with standard dye injection and angiography, the cryoablation was then performed with a cryoballoon catheter.

Results

A total of 74 PVs CB occlusions were tested. The old version showed 90.7% sensitivity and 74.2% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 82.9%, and the negative predictive value was 85.2%. The new version showed 94.8% sensitivity and 93.7% specificity in assessing a complete PV occlusion verified with same contrast medium injection data. The positive predictive value was 98.2%, and the negative predictive value was 93.7%. Acute isolation was achieved in all PVs and no 30-day complication was observed.

Conclusion

This study demonstrates an increased accuracy of new Occlusion Tool software of the Kodex dielectric imaging system to assess the degree of PV occlusion during a CB ablation.

Funding Acknowledgement

Type of funding sources: None.

Maintenance versus discontinuation of androgen deprivation therapy during continuous or intermittent docetaxel administration in castration-resistant prostate cancer patients: A multicentre, randomised Phase III study by the Piemonte Oncology Network

BACKGROUND

This study was designed to demonstrate the non-inferiority (NI) in overall survival (OS) of suspension of androgen deprivation therapy (ADT) versus maintenance and intermittent versus continuous docetaxel administration in metastatic castration-resistant prostate cancer (mCRPC) patients.

PATIENTS AND METHODS

mCRPC patients were randomised to first-line docetaxel with maintenance or suspension of ADT. Patients attaining a prostate-specific antigen (PSA) response after four chemotherapy cycles underwent second randomisation to receive continuous or intermittent docetaxel therapy. Six hundred patients were to be randomised to achieve 80% statistical power to demonstrate an NI hazard ratio (HR) of 1.25 of interruption versus maintenance of ADT.

RESULTS

The trial was prematurely closed when 198 participants were randomised. OS was similar in patients who continued (N = 96) versus those who interrupted (n = 102) ADT during docetaxel therapy (HR 0.98, 95% confidence interval [CI] 0.72-1.33] and those on a continuous (N = 35) versus an intermittent (N = 42) docetaxel schedule (HR 0.86, 95% CI 0.55-1.43). No difference in radiological progression-free survival, PSA response, or toxicity was observed between the study arms. The actual NI hazard margins of OS in Arms A and B patients were 1.33 and 1.43, respectively.

CONCLUSIONS

This trial enrolled one-third of the planned patients; this main weakness dramatically limits the interpretation of the results. ADT discontinuation and switching to an intermittent schedule did not seem to affect docetaxel efficacy. The absence of testosterone recovery in the majority of patients could have been a contributory factor. In men with mCRPC, ADT discontinuation should only be done with regular biochemical and clinical monitoring, with the option of quickly restarting ADT at disease progression.

Outcome of a modified sympathicotomy for cardiac neuromodulation of untreatable ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

OBJECTIVES This study aimed to describe the results of a modified sympathicotomy (uniportal VATs with stellate ganglion sparing) for cardiac sympathetic denervation (CSD) in the setting of untreatable ventricular tachycardia.

BACKGROUND. CSD, in patients with refractory ventricular tachycardia (VT), is comprehensively recognized as an important treatment option for patients with structural heart disease as well as congenital inherited arrhythmia syndrome. A recent case series demostrated  the feasibility of the modified technique.

METHODS We consecutively enrolled 8 patients with refractory VT. Baseline demographic, medical, and surgical data as well as arrhythmia outcomes and procedural complications were evaluated.

RESULTS A total of 8 patients ( 7 pts NIDCM, 1 pt IDCM with mean age:68+-8 years) were enrolled for the treatment of refractory VT with a modified CSD technique. Mean sympathicotomy length were 7.3 (SD 3) min per side. 3/8 patients underwent monolateral (LCSD) sympathicotomy due to strong adesion in the right pleural cavity. Mean follow up was 13 months (SD 6). No complication occurred during the sympathicotomy. An overall reduction in VT burden and VT number was observed after the CSD despite an in-hospital early recurrence in 3 patients.

CONCLUSIONS A modified CSD (sympathicotomy T2–T5) with stellate ganglion sparing and the use of unipolar radiofrequency is feasible, effective, and safe in the setting of untreatable VT. Abstract Figure. VT trend

Novel cryo-balloon ablation technology for pulmonary vein isolation in patients with atrial fibrillation: preliminary experience from a multicenter clinical practice

Funding Acknowledgements

Type of funding sources: None.

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, no data exist on procedural characteristics of this system in a multicentric clinical practice.

Purpose

We aimed to characterize the initial experience of this technology in the Italian clinical practice.

Methods

Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 5 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred &gt;60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block.

Results

Two-hundred sixty-two cryoapplications from 49 pts (194 PVs) were analyzed. PVI was achieved with cryoablation only in all pts. The mean number of freeze applications per pt was 5.3 ± 1.5 (1.3 ± 0.6 for LIPV, LSPV and RSPV, 1.6 ± 1.3 for RIPV), with 143 (73.7%) PVs treated in a single-shot fashion (38, 19.6% with 2 shots; 13, 6.7% with more than 2 shots). Sixteen (33%) pts were treated with a single freeze to each of the PVs. The mean nadir temperature was -55.5 ± 6.9 °C and was colder than -50°C in 83% of the PVs. TTI information was evaluable in 120 (46%) cryoapplications with a median TTI of 47 [32-75] sec (median temperature at TTI = -49 [-53 to -42] °C). The mean time to target -40 °C (TTT) was 30.1 ± 6.9 sec with a TTT &lt; 60 sec achieved in 99.2% of the cryoapplications; the mean thaw time to 0 °C was 18.6 ± 5.8 sec (thaw time &gt;15 sec in 70.3% of the cryoapplications). The mean PV occlusion grade (rank 1-4) was 3.6 ± 0.6 (grade 2 in 5.2% of the cases, grade 3 in 25.6% and grade 4 in 69.2%). No complications were observed at 30 days post-procedure.

Conclusion

In this first multicentric experience in a clinical practice setting, the novel cryo-balloon system proved to be safe and effective and resulted in a high proportion of successful single-freeze isolation. Cooling parameters seem to be slightly different from reference cryo-balloon technology.

Accuracy comparison of the new and previous kodex occlusion tool software versions to assess pulmonary vein occlusion in atrial fibrillation cryoablation

Funding Acknowledgements

Type of funding sources: None.

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia worldwide and Cryoballoon ablation (CB) has become a consolidated alternative to the radiofrequency pulmonary vein (PV) isolation. However, CB requires fluoroscopy and dye injections to verify the occlusion grade. The accuracy of the earlier version of the Kodex Occlusion Tool software has been studied.

Purpose. The purpose of this study was to verify the accuracy of the second generation Kodex Occlusion Tool Software of a new dielectric system imaging compared to its first generation to detect PV occlusion during CB ablation in patients with AF.

Methods. 15 consecutive patients with paroxysmal AF were enrolled in the study and underwent the procedure with the guidance of the first generation version (1.4.6) of the Kodex Occlusion Tool software. The Kodex recorded procedural data were used to replay the case using the Kodex second generation version (1.4.7) of the Occlusion Tool software when clinically available. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octa-polar circular mapping catheter, PV occlusion was assessed with the Occlusion Tool Software and compared with standard dye injection and angiography, the cryoablation was then performed with a cryoballoon catheter.

Results. A total of 72 PVs CB occlusions were tested. The old version showed 90.7% sensitivity and 76.5% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 80.3%, and the negative predictive value was 88.6%. The new version showed 94.8% sensitivity and 93.7% specificity in assessing a complete PV occlusion verified with same contrast medium injection data. The positive predictive value was 98.2%, and the negative predictive value was 93.7%. Acute isolation was achieved in all PVs and no 30-day complication was observed.

Conclusion. This study demonstrates an increased accuracy of new Occlusion Tool software of the Kodex dielectric imaging system to assess the degree of PV occlusion during a CB ablation. Abstract Figure. Occlusion tool software 1.4.6 vs 1.4.7

A novel ventricular map of electrograms duration as a method to identify areas of slow conduction during ablation of ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

Background – Wave front inhomogeneous propagation is crucial for reentry circuit generation. Bipolar EGM duration is indicative of local conduction delay and may identify areas of low conduction as a functional substrate. This study aimed to create a map of EGM duration during the VT (VEDUM Map) to identify the area of the slowest conduction and to verify if RF delivery at this area allows to rapidly interrupt the VT.

Methods – 24 high-density VTs maps (21 patients) were analyzed. Activation maps and voltage maps during SR were performed. An offline remap confirmed with MathLab software was customized to visualize the longest duration electrogram during VT.

Results – All of the VTs were interrupted during the first RF delivery (mean time 7,3 ± 5,4 sec (range 3-25 sec)) at the area with the longest EGM duration (212 ± 47 ms (range 113-330 ms)). . In 9 pts (37,5%) the longest EGM was located at the entrance or exit area of the activation maps while in 5 pts (21%) the EGM covered the full diastolic phase. Finally, in 10 pts the longest EGM occurred in the mid-exit-diastolic phase.

Conclusions - A novel Ventricular map of Electrograms DUration (VEDUM Map) is highly accurate in defining a conductive vulnerable zone of the VT circuit. The longest EGM duration within the isthmus is highly predictive of rapid VT termination. Quantitative variablesQualitative variablesMeanMedianStandard DeviationAge71738.40BMI26.624.54.02LV EDV16315442.7LV EDD61.2629.9LV EF38.7369.74VT cycle lenght (TCL)35537556.4EGM max. duration in VT21220847EGM max dur / TCL58.260.512Maximum EGM duration localization in CLProto = 12.5%Meso = 33.3%Tele = 25%Full = 20.8%Myocardium voltage characteristics in VEDUM EGMHealthy = 25%Transition = 20.8%Scar = 41.7%Critical Isthmus area12.3107.3VT Interruption during RFYes = 79.2%No = 20.8%Time (seconds) to interruption765Access typeEndo = 58.3%Epi = 29.2%Clinical and procedural dataAbstract Figure.

Minimal fluoroscopic approaches and factors associated with radiation dose when high-definition mapping is used for supraventricular tachycardia ablation: insight from the CHARISMA registry

Funding Acknowledgements

Type of funding sources: None.

Background

Limited data exist on factors associated with radiation exposure during ablation procedures when a high definition mapping technology is used.

Purpose

To report factors associated with radiation exposure and data on feasibility and safety of a minimal fluoroscopic approach using the Rhythmia mapping system in supraventricular tachycardia (SVT) ablation procedures.

Methods

Consecutive patients indicated for arrhythmia ablation were enrolled in the CHARISMA study at 12 centers. We included in this analysis consecutive right-side procedures performed through a minimal fluoroscopy approach with the Rhythmia mapping system were analyzed. A 3D geometry of chambers of interest was reconstructed on the basis of the electroanatomic information taken from the mapping system. Fluoroscopy was used only if deemed necessary. The effective dose (ED) was calculated using accepted formula. For our purpose high dose exposure was defined as an ED greater than the median value of ED of the population exposed to radiation.

Results

This analysis included 325 patients (mean age = 56 ± 17 years, 57% male) undergoing SVT procedures (152 AVNRT, 116 AFL, 41 AP and 16 AT). During the study, 27481 seconds of fluoroscopy was used (84.6 ± 224 seconds per procedure), resulting in a mean equivalent ED of 1.1 ± 3.7 mSv per patient. The mean reconstructed RA volume was 99 ± 54 ml in a mean mapping time of 12.2 ± 7 min. The mean number of radiofrequency ablations (RFC) to terminate each arrhythmia was 9.4 ± 9 (mean RFC delivery time equal to 6.7 ± 6 min). 192 procedures (59.1%) were completed without any use of fluoroscopy; during the remaining 133 procedures (39.9%), 206.6 ± 313.4 seconds of fluoroscopy was used (median ED = 1.2 mSv). In a minority of the cases (n = 25, 7.7%) the fluoroscopy time was higher than 5 minutes (median ED = 6.5 mSv), whereas radiologic exposure time greater than 1 minute occurred in ninety cases (27.7%, median ED = 2.1 mSv). On multivariate logistic analysis adjusted for baseline confounders the RFC application time (OR = 1.0014, 95%CI: 1.0007 to 1.0022; p = 0.0001) was independently associated to an ED greater than 1.2 mSv, whereas female gender had an inverse association (0.54, 0.29 to 0.98; p = 0.0435). Acute success was reached in 97.8% of the cases. During a mean of 290.7 ± 169.6 days follow-up, no major adverse events related to the procedure were reported. Overall, the recurrence rate of the primary arrhythmia during follow-up was 2.5%.

Conclusions

In our experience, arrhythmias ablation through minimal fluoroscopy approach with the use of a novel ablation technology is safe, feasible, and effective in common right atrial arrhythmias. High-dose exposure occurred in a very limited number of cases, without any reduction of the safety and acute and long-term effectiveness profile.

Time in therapeutic range is lower in women than in men and is not explained by differences in age or comorbidity

BACKGROUND

Time in therapeutic range (TTR) measures the stability of the international normalized ratio in patients on vitamin K antagonists (VKA). Low values are associated with poor outcomes. Women were shown to have lower TTR than men, but the causes are poorly defined. It was suggested that women on VKA are older and more morbid than men, and this could affect the stability of anticoagulation. We aimed to identify variables that affect TTR differently in women and men.

MATERIALS AND METHODS

This is a retrospective study in patients referred to a University hospital anticoagulant clinic. Age, sex, comorbidities, number of daily medications, indication and type of anticoagulant, weekly dosage and distribution, were derived from electronic records. Differences by sex and regression analysis to identify significant modulators of TTR were computed.

RESULTS

1182 women and 1281 men on VKA were studied. Women were older than men (81.5 yrs. ± 11.2 vs 78.4 yrs. ± 12.2), and had lower TTR (65% ± 20.3 vs 69% ± 19.8). Comorbidity was similar between sexes and negatively affected TTR in both. Mechanical valves as an indication to anticoagulation and acenocoumarol as an anticoagulant as opposed to warfarin had a strong negative influence on TTR, while age increased TTR. Being a man rather than a woman afforded more than three TTR points. Number of medications and average anticoagulant dose were equal between sexes.

DISCUSSION

Women have a lower TTR than men, on average below the safety threshold. They were indeed older, but age positively influenced TTR. Since women and men were equally comorbid, neither age nor disease explains differences in TTR. None of the other variables included in the study could explain the gender gap in TTR. Since women are at increased risk of cardioembolic stroke in atrial fibrillation, an effort at defining other causes for the observed differences, closer monitoring and switching to direct anticoagulants whenever possible is warranted.

Risk assessment of biological hazards in University laboratories: checklist and critical control points

Results

The results highlighted that 40 laboratories fall into the "low risk" and the remaining 2 into the "moderate risk" category.

Conclusions

Labs with risk factors are a minority. These were properly identified using the proposed methodology.

Background and aim

Biomedical research in academic settings is an important issue for Public Health and Environment protection. As workplaces, the facilities for research expose their personnel to different hazards and health risks. The University of L'Aquila (Italy) carried out a field study aimed at creating and applying a checklist intended for laboratory staff.

Methods

The proposed checklist was derived from the procedure illustrated in the Appendix (procedure followed for the identification of a numerical index of biological risk for university facilities) and consists of 9 items. The study was conducted in 42 laboratories.

Outcome of Patients With Metastatic Lung Neuroendocrine Tumors Submitted to First Line Monotherapy With Somatostatin Analogs

OBJECTIVE

Antiproliferative activity of somatostatin analogs (SSAs) has been demonstrated in digestive neuroendocrine tumors (NETs), but few data have been published in patients with pulmonary NETs. We therefore conducted a retrospective study to provide additional data on the outcome of patients with metastatic lung NETs submitted to front line SSAs.

RESEARCH DESIGN AND METHODS

Patients with metastatic lung NET treated with first line SSA-monotherapy (octreotide or lanreotide) in two different reference Institutions were reviewed. Outcome measures were progression-free survival (PFS) overall survival (OS), overall response rate and safety. We also explored prognostic factors associated with PFS.

METHODS

The outcome of consecutive patients (pts) with metastatic lung NETs, who underwent first-line treatment with SSAs, recruited from 2014 on 2019 in two Italian reference Institutions, was retrospectively evaluated.

RESULTS

Thirty-one patients entered the study: 14 (45.2%) with typical and 17 (54.8%) atypical carcinoid. Six patients (19.4%) had a carcinoid syndrome. 60.0% of patients had Ki-67 ≤ 10%. Two (6.5%) patients obtained a partial response, 24 (77.4%) disease stabilization while 5 (16.1%) had progressive disease. Median progression free survival (PFS) was 28.6 months, median overall survival (OS) was not attained. Ki-67 ≤ 10%, typical carcinoid histotype and non-functioning disease, were associated with a non-significant PFS prolongation. PFS in patients with atypical carcinoids and in those with Ki-67 >10% was greater than 19 months.

CONCLUSIONS

The long PFS and OS obtained in this case series suggest that SSAs could be effective as first line approach in the management of patients with progressive, metastatic pulmonary NET.

Novel occlusion tool software for pulmonary vein occlusion verification in atrial fibrillation cryoballoon ablation

Background

Optimal pulmonary vein (PV) occlusion, checked with selective contrast injection, is mandatory to obtain an effective PV isolation with a cryoballoon.

Purpose

The purpose of this study was to verify the feasibility of a new dielectric sensing system in assessing PV occlusion during cryoballoon ablation in patients with atrial fibrillation (AF).

Methods

We enrolled 25 consecutive patients with paroxysmal or persistent AF. After transseptal access a detailed image reconstruction of left atrium and PVs was achieved with a decapolar circular mapping catheter and a novel dielectric imaging system. The degree of PV occlusion with the inflated cryoballoon catheter was verified by a new occlusion tool software of the dielectric imaging system and compared to the angiography with dye injection in each PV.

Results

A total of 114 PV cryoballoon occlusion were tested. The new occlusion tool software showed a 91.7% sensitivity and 81.5% specificity in assessing a complete PV occlusion verified with dye injection. The positive predictive value was 84.6% and the negative predictive value was 89.8%. Acute isolation was achieved in all PVs. No 30 days complications were observed.

Conclusion

This is the first study that demonstrates the feasibility of a new occlusion tool software, using the novel dielectric imaging system, in verifying the degree of PV occlusion during cryoballoon ablation.

Funding Acknowledgement

Type of funding source: None

Minimal fluoroscopy approach in current clinical practice with a novel ablation technology for supraventricular tachycardia: a large multicenter experience from an Italian registry

Background

Electrophysiological studies and ablation procedures expose both physicians and patients to a large amount of radiation. Most of 3-D mapping systems provide improved tracking of catheters, possibly allowing relevant reductions in radiation exposure. No data exists on the ability of the Rhythmia mapping system to minimize fluoroscopy time and dose.

Purpose

To report preliminary data on feasibility and safety of a minimal fluoroscopic approach using the Rhythmia mapping system in supraventricular tachycardia (SVT) procedures.

Methods

Consecutive patients indicated for arrhythmia ablation were enrolled in the CHARISMA study at 12 centers. For our purpose consecutive right-side procedures performed through a minimal fluoroscopy approach with the Rhythmia mapping system were analyzed. A 3D geometry of chambers of interest was reconstructed on the basis of the electroanatomic information taken from the mapping system. Fluoroscopy was used only if deemed necessary.

Results

This analysis included 266 patients (mean age = 57±17 years, 57% male) undergoing SVT procedures (120 AVNRT, 91 AFL, 32 AP, 11 AT and 12 other right atrial procedures). In all cases, diagnostic EP and ablation catheters were positioned using a low fluoroscopic electroanatomic guided approach. The mean fluoroscopy time needed for each procedure was 55±128 s. The median reconstructed RA volume was 92 [63–131] ml in a median mapping time of 11 [7–17] min. The median number of radiofrequency ablations to terminate each arrhythmia was 6 [3–12] (total RF delivery time of 291 [180–505] s). Sixty-five percent of the procedures (n=174) were completed with less than 10 s of fluoroscopy. Low fluoroscopy approach with less than 10 s (minimal fluoroscopy approach) was most frequently obtained in case of AVNRT (91, 76%) compared to other arrhythmias' ablation (83, 57%, p=0.001) Achievement of a minimal fluoroscopic approach was not affected by operator's experience (65% vs 66%, p=1.00, respectively within physician with more or less of 10 years of active practice), whereas it was affected by presence of a fellow in training during the procedure (72% without fellow vs 26% with fellow, p&lt;0.0001). A 100% rate of acute success was observed, and no procedure-related complications occurred. At multivariate logistic regression analysis adjusted for baseline confounders, both the total number of RF ablations (OR: 0.93 (95% CI:0.88 to 0.96; p=0.0053) and the presence of a fellow in training during the procedure (OR: 0.29; 95% CI: 0.1 to 0.87; p=0.0278) had an inverse association to the achievement of a minimal fluoroscopic approach.

Conclusions

In our preliminary experience, arrhythmias' ablation through minimal fluoroscopy approach with the use of a novel ablation technology seems to be safe, feasible, and effective in common right atrial arrhythmias. Use of fluoroscopy can be dramatically reduced in most cases, without any reduction of the safety and acute effectiveness profile.

Funding Acknowledgement

Type of funding source: None

Efficacy of the DigniCap System in preventing chemotherapy-induced alopecia in breast cancer patients is not related to patient characteristics or side effects of the device

BACKGROUND

The DigniCap System is an effective scalp cooling device for the prevention of chemotherapy-induced alopecia in early breast cancer patients.

AIM

This prospective study was designed to confirm the efficacy and tolerability of the device, to explore potential factors associated with its efficacy and to collect data on patient perceptions and satisfaction.

METHODS

Between January 2016 and June 2018, 163 early breast cancer patients eligible for adjuvant chemotherapy were enrolled. Hair loss was assessed using the Dean scale, where a score of 0-2 (hair loss ≤50%) was defined as successful.

RESULTS

Hair preservation was successful in 57% of patients in the overall series. The proportion was even higher (81%) in the patient subgroup treated with a paclitaxel and trastuzumab regimen. Side effects (feeling cold, headache, head heaviness, scalp and cervical pain) were mild to moderate and did not correlate with the rate of hair loss. Lifestyle, anthropometric factors and hair characteristics failed to be associated with device efficacy.

CONCLUSIONS

The DigniCap System was well tolerated and found to be effective in preventing alopecia in early breast cancer patients. Our study failed to identify factors other than type of chemotherapy regimen associated with hair preservation.

Sleep inhibition induced by amyloid-β oligomers is mediated by the cellular prion protein

Sleep is severely impaired in patients with Alzheimer's disease. Amyloid-β deposition in the brain of Alzheimer's disease patients is a key event in its pathogenesis and is associated with disrupted sleep, even before the appearance of cognitive decline. Because soluble amyloid-β oligomers are the key mediators of synaptic and cognitive dysfunction in Alzheimer's disease and impair long-term memory in rodents, the first aim of this study was to test the hypothesis that amyloid-β oligomers would directly impair sleep in mice. The cellular prion protein is a cell surface glycoprotein of uncertain function. Because cellular prion protein binds oligomeric amyloid-β with high affinity and mediates some of its neurotoxic effects, the second aim of the study was to test whether amyloid-β oligomer-induced sleep alterations were mediated by cellular prion protein. To address these aims, wild-type and cellular prion protein-deficient mice were given acute intracerebroventricular injections (on different days, at lights on) of vehicle and synthetic amyloid-β oligomers. Compared to vehicle, amyloid-β oligomers significantly reduced the amount of time spent in non-rapid eye movement sleep by wild-type mice during both the light and dark phases of the light-dark cycle. The amount of time spent in rapid eye movement sleep was reduced during the dark phase. Sleep was also fragmented by amyloid-β oligomers, as the number of transitions between states increased in post-injection hours 9-24. No such effects were observed in cellular prion protein-deficient mice. These results show that amyloid-β oligomers do inhibit and fragment sleep, and that these effects are mediated by cellular prion protein.

P441Targeted ablation of residual luminal pulmonary vein potentials through high density mapping: preliminary results from the CHARISMA registry

Background

A high incidence of pulmonary vein (PV) reconnection has been reported in patients (pts) with clinical recurrences of AF. Low-voltage activity beyond PVs (e.g. antral activity) may contribute to ablation failures in the long term. Detailed characterization of PV antra through high density mapping (HDM) and automated algorithm is still lacking. 

Purpose

to characterize PV gaps and the low-voltage activity in tissue such as the PV antra during and after ablation of PVs in AF pts. 

Methods

Consecutive pts undergoing AF ablation from the CHARISMA registry with complete characterization of residual PV antral activity were included. A complete map of the left atrium and PVs was performed prior and after ablation through the Rhythmia HDM system. A novel map analysis tool (Lumipoint - LM -) that automatically identifies split potentials and continuous activation was used sequentially on each PV component, in order to assess the presence of gaps (PVG) and residual potential within the antral scar (RAP, defined as any low voltage high frequency fractionated signal propagating within the antral scar without conduction into the vein) and characterize electrical propagation. After ablation we reassessed with repeat voltage and propagation maps that electrical quiescence was achieved. Ablation endpoint was PV isolation. 

Results

Thirty-six cases of AF ablation were analyzed (11 de novo, 25 redo). A total of 36 PVG in 13 (36%) patients were detected after remap (1 case of de novo) or initial map of redo patients (12 cases). A total of 34 RAP in 20 cases (56%) were found: 4 (36%) cases of de novo (all after ablation and remap) and 16 (64%) cases of redo (all after initial map). In 7 (19%) cases we found at least one RAP in pts with complete absence of PV conduction. 100% of PVG (n = 36) and 89% of RAP (n = 29) were fully detected though a first pass automated annotation. In 5 RAPs (11%) an additional temporal consistency of low-voltage signal relative to neighboring activation was needed due to the very low voltage EGM (≤0.1 mV). PVGs were more common at right PV sites (n = 26, 72%) and anterior PV sites (n = 20, 55.6%) whereas RAPs were detected more frequently at left PV sites (n = 20, 59%) and anterior PV sites (n = 21, 62%). RAP showed a lower median voltage compared with PVG (0.22[0.2-0.3]mV for RAP vs 0.97[0.6-1.3]mV for PVG, p &lt; 0.0001) whereas the median number of EGM peaks were higher (6.5[5-8] for RAP vs 3[2-4] for PVG, p &lt; 0.0001). No complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated and RAPs completely abolished in all study pts. 

Conclusion

In our preliminary experience, local vulnerabilities in antral lesion sets were commonly discernible using HDM system both in de novo or redo patients when no PV conduction was present. The applied workflow seemed to be useful to quickly pinpoint and accelerate the search of local PV activity or concealed low-voltage activity.

P1452Low fluoroscopy approach with a novel ablation technology in right side procedures: a large multicenter experience from the CHARISMA registry

Funding Acknowledgements

NO FUNDING

Background

Electrophysiological studies and ablation procedures expose both physicians and patients to a significant amount of radiation. Nowadays, most of 3-D mapping systems allow for improved tracking of catheters with possible reduction in radiation exposure. No data exists on the ability to minimize fluoroscopy time and dose while using the Rhythmia mapping system.

Purpose

To report preliminary data on feasibility and safety of a low fluoroscopic approach using the Rhythmia mapping system in SVT procedures.

Methods

The CHARISMA study is a non-randomized, multicenter, prospective study in which consecutive patients indicated for arrhythmia were enrolled. For our purpose consecutive right-side procedures performed through a low fluoroscopy approach with the Rhythmia mapping system were analyzed. The mapping system was used to create the 3D geometry of chambers of interest and anatomic reference points and to visualize the catheters from the beginning to the end of the procedure. Fluoroscopy was used only if deemed necessary.

Results

204 unselected consecutive cases of SVT from 11 centers were included in the study (mean age = 55 ± 18 years, 53% male, 85 AVNRT, 75 AFL, 28 AP, 9 AT and 7 other right atrial procedures). In all the cases, diagnostic EP and ablation catheters were positioned using only the low fluoroscopic guided mapping approach. During the study, a total of 7157 s of fluoroscopy was needed in 204 patients (51 ± 137 s per procedure). One hundred fourty-one procedures (69%) were completed with less than 10 seconds of fluoroscopy, whereas in 169 (83%) of the cases the fluoroscopy time was lower than 60 seconds. Low fluoroscopy approach with less than 10 seconds was less frequently obtained in case of AFL (46, 61.3%) compared to AVNRT ablation (65, 76.5%, p = 0.041) whereas no differences were found comparing with AP (21, 75%, p = 0.248). The median reconstructed RA volume was 94[65-133] ml in a median mapping time of 11 [6-16] min. The median number of radiofrequency ablations to terminate each arrhythmia was 5 [3-12] (total RF delivery time of 293 [180-505] sec). A 100% rate of acute success was observed in our case series. No complications occurred.

Conclusions

In our preliminary experience, arrhythmias ablation through low fluoroscopy approach and the use of a novel ablation technology seems to be safe, feasible, and effective in common right atrial arrhythmias. Use of fluoroscopy can be nearly avoided in most cases, without any reduction of the safety and effectiveness profile.

Vaginal delivery in SARS-CoV-2-infected pregnant women in Northern Italy: a retrospective analysis

OBJECTIVE

To report mode of delivery and immediate neonatal outcome in women infected with COVID-19.

DESIGN

Retrospective study.

SETTING

Twelve hospitals in northern Italy.

PARTICIPANTS

Pregnant women with COVID-19-confirmed infection who delivered.

EXPOSURE

COVID 19 infection in pregnancy.

METHODS

SARS-CoV-2-infected women who were admitted and delivered from 1 to 20 March 2020 were eligible. Data were collected from the clinical records using a standardised questionnaire on maternal general characteristics, any medical or obstetric co-morbidity, course of pregnancy, clinical signs and symptoms, treatment of COVID 19 infection, mode of delivery, neonatal data and breastfeeding.

MAIN OUTCOME AND MEASURES

Data on mode of delivery and neonatal outcome.

RESULTS

In all, 42 women with COVID-19 delivered at the participating centres; 24 (57.1%, 95% CI 41.0-72.3) delivered vaginally. An elective caesarean section was performed in 18/42 (42.9%, 95% CI 27.7-59.0) cases: in eight cases the indication was unrelated to COVID-19 infection. Pneumonia was diagnosed in 19/42 (45.2%, 95% CI 29.8-61.3) cases: of these, 7/19 (36.8%, 95% CI 16.3-61.6) required oxygen support and 4/19 (21.1%, 95% CI 6.1-45.6) were admitted to a critical care unit. Two women with COVID-19 breastfed without a mask because infection was diagnosed in the postpartum period: their newborns tested positive for SARS-Cov-2 infection. In one case, a newborn had a positive test after a vaginal operative delivery.

CONCLUSIONS

Although postpartum infection cannot be excluded with 100% certainty, these findings suggest that vaginal delivery is associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.

TWEETABLE ABSTRACT

This study suggests that vaginal delivery may be associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.

Assessing two-way interactions between cells and inorganic nanoparticles

A safe and effective use of nanoparticles in biology and medicine requires a thorough understanding, down to the molecular level, of how nanoparticles interact with cells in the physiological environment. This study evaluated the two-way interaction between inorganic nanomaterials (INMs) and cells from A549 human lung carcinoma cell line. The interaction between silica and zinc oxide INMs and cells was investigated using both standard methods and advanced characterization techniques. The effect of INMs on cell properties was evaluated in terms of cell viability, chemical modifications, and volume changes. The effect of cells and culture medium on INMs was evaluated using dynamic light scattering (DLS), scanning electron microscopy and energy-dispersive X-ray spectroscopy (SEM-EDS), high performance liquid chromatography (HPLC), gas chromatography-mass spectroscopy (GC-MS), Fourier transform infrared spectroscopy (FTIR), and thermogravimetric analysis (TGA). No cytotoxic effect was detected in the case of silicon oxide INMs, while for high doses of zinc oxide INMs a reduction of cell survival was observed. Also, increased cell volume was recorded after 24 h incubation of cells with zinc oxide INMs. A better dimensional homogeneity and colloidal stability was observed by DLS for silicon oxide INMs than for zinc oxide INMs. SEM-EDS analysis showed the effectiveness of the adopted dispersion procedure and confirmed in the case of zinc oxide INMs the presence of residual substances derived from organosilane coating. HPLC and GC-MS performed on INMs aqueous dispersions after 24 h incubation showed an additional peak related to the presence of an organic contaminant only in the case of zinc oxide INMs. FTIR Chemical Imaging carried out directly on the cells showed, in case of incubation with zinc oxide INMs, a modification of the spectra in correspondence of phospholipids, nucleic acids and proteins characteristic absorption bands when compared with untreated cells. Overall, our results confirm the importance of developing new experimental methods and techniques for improving the knowledge about the biosafety of nanomaterials.

Long-range detection of acoustic vibrations by speckle tracking

When a rough surface is illuminated by a laser beam, it scatters the light, producing a random interference pattern also known as speckle pattern. By imaging the speckle pattern with a line-scan CCD, we are able to measure the acoustic vibrations of a scattering surface, which can be up to 300 m distant. We also show that our instrument can be used as a laser microphone capable of detecting ambient sound such as a human voice.

Genetic variability of the measles virus hemagglutinin gene in B3 genotype strains circulating in Northern Italy

Sequencing the whole measles virus hemagglutinin (H) gene, in conjunction with a 450-nucleotide region of the nucleoprotein gene (N-450), is helpful for the identification of new genotypes and as an auxiliary in outbreak characterization. In addition, it is essential to be able to predict the antigenic changes of the H protein to gain a better monitoring of the response to the vaccine. In this study, we obtained the full-length H gene sequences from 19 measles virus (MV) strains belonging to two B3 genotype variants circulating in Lombardy (Northern Italy) between July 2015 and February 2016 and evaluated the variability of the whole MV-H gene. Furthermore, we compared the obtained H amino acid sequences to all MV sequences available in the GenBank database (n = 1152 in total) and analyzed the amino acid substitutions in the H protein within clades where the Italian strains were included. We identified a higher variability in the H gene compared to the N-450 region and our results support previous studies, highlighting that the H gene is more informative for characterizing the MV B3 genotype than the N-450 sequence. Some of the amino acid substitutions were fixed in the viral population and, remarkably, some of the amino acid substitutions were typically present only in the Italian sequences. Accumulating further molecular information about MV-H gene will be necessary to enable in-depth analyses of the variability of this gene in the vaccinated population.

Bone metastases from head and neck malignancies: Prognostic factors and skeletal-related events

BACKGROUND

We conducted a multicenter retrospective analysis to describe the characteristics, frequency of skeletal-related events (SREs), and prognosis of head and neck cancer (HNC) in patients with bone metastases (BM).

PATIENTS AND METHODS

The data of 192 HNC patients with BMs were collected. Analyses were conducted separately in 64 nasopharyngeal cancer (NPC) patients and in 128 non-NPC patients.

RESULTS

SREs occurred in 34 (27%) non-NPC and in 6 (9%) NPC patients, respectively. Median overall survival (OS) was 25 and 6 months in NPC and non-NPC patients, respectively. Locoregional recurrence (hazard ratio [HR] 2.33, 95% confidence interval (CI) 1.1-4.93), synchronous BM (HR 0.25, 95% CI 0.59-0.71) and bone-directed therapies (BDT) (HR 0.26, 95% CI 0.10-0.68) were independent prognostic factors for OS in NPC patients. Combined bone radiotherapy (RT) and BDT in NPC patients obtained longer survival (38 months) than either therapy alone (25 months) or neither of these therapies (8 months).

CONCLUSIONS

Patients with BMs from non-NPC have a poor prognosis and are at high risk of SREs. NPC patients with BMs are at relatively low risk of SREs. BDT may potentially improve survival, particularly when combined with bone RT. This last finding deserves prospective confirmation.

Abstract P3-12-07: Conservative breast reconstruction: Outcomes of 146 consecutive cases of prepectoral, subcutaneous implant-based breast reconstruction in a single-Institution series

Aims. To evaluate acute and late toxicity-related factors among breast cancer (BC) patients who underwent prepectoral breast reconstruction (BR).

Methods. We performed a retrospective analysis of BC patients who underwent therapeutic or prophylactic mastectomy from October 2012 to May 2016 at our Center. We recorded individual patient-related features (i.e. age, body mass index [BMI], smoke-history, comorbidity, BRCA-carrier), BC-related treatments characteristics (i.e. axillary surgery, adjuvant radiotherapy [RT], adjuvant chemotherapy, primary systemic therapy [PST], endocrine therapy, and use of trastuzumab). Toxicity profile was evaluated in terms of complications related to BR; we recorded acute and late toxicity data and prosthesis/implant explant rate.

Results. We analyzed 146 consecutive BC patients treated with subcutaneous BR, 117 therapeutic and 29 prophylactic mastectomies. Thirty-seven patients received postmastectomy RT. Significant factors related to acute toxicity were: previous RT (34.5% [RT] vs 8.5% [no RT]; p=0.001), BMI (31.3% [BMI ≥25] vs 8.8% [&lt;25]; p=0.003), previous breast surgery (22.2% [surgery] vs 8.7% [no surgery]; p=0.027), and diabetes (100% [diabetes] vs 11.9% [no diabetes]; p=0.002). Factors significantly correlated to implant/prosthesis explant were: current or previous smoking exposition (13.8% [smokers] vs 2.6% [non-smokers]; p=0.029) and PST (18.8% [PST] vs 3.5% [no PST]; p=0.022); axillary lymph node dissection (ALND) was significantly related to late toxicity (5.7% [ALND] vs 0%; p=0.04). At a 3-year median follow up, three deaths, five locoregional recurrences (LRR), and fourteen distant metastasis (DM) occurred among 117 patients treated by therapeutic mastectomy. Overall survival was 78.1%, LRR free-survival was 95%, and DM free-survival was 71.6%. Postmastectomy RT was not significantly related to acute, late toxicity, and explant occurrence.

Conclusions. In our experience prepectoral subcutaneous implant-based BR is a safe and effective approach, with low rates of acute toxicity. Major risk factors were evidenced for patients previously treated with RT or surgery, and in case of diabetes or BMI ≥25; postmastectomy RT seems not to be related to higher rate of toxicity. ALND seems to be the only factor significantly related to late toxicity. PST, and smoking exposition were significantly associated with higher rate of implant/prosthesis explant. However, further investigations and mature follow-up are warranted to confirm these encouraging results.

Citation Format: Meattini I, Bernini M, Saieva C, Desideri I, Scotti V, Salvestrini V, Visani L, Mariotti M, Delli Paoli C, Olmetto E, Maragna V, Orzalesi L, Sanchez L, Nori J, Bianchi S, Livi L. Conservative breast reconstruction: Outcomes of 146 consecutive cases of prepectoral, subcutaneous implant-based breast reconstruction in a single-Institution series [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 P3-12-07.

Abstract P4-16-04: Oral ibandronate for osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: secondary 5-year survival outcomes analysis of the single-center phase 2 BONADIUV trial

Background. Several randomized trials demonstrated aromatase inhibitors (AI) superiority in terms of disease-free survival (DFS) compared to tamoxifen treatment for postmenopausal hormone receptor-positive breast cancer (BC) patients. Anyway, AI toxicity profile is a concern due to estrogen suppression. Pivotal trials demonstrated a significant bone mineral density (BMD) loss due to AI, with a consistent 5-year risk of bone fractures, thus impacting on patients' quality of life. Bisphosphonates represent an effective treatment in postmenopausal osteoporosis fractures prevention. However, an adequate patient's selection for adjuvant bisphosphonates treatment during AI endocrine therapy is still a challenge. Final results of BONADIUV trial presented at San Antonio Breast cancer Symposium in 2016 showed that treatment with ibandronate, as compared to placebo, significantly improved BMD change in osteopenic women treated with adjuvant AI, and consistently protected patients' bone loss. We present the secondary 5-year analysis on survival outcomes of the trial.

Patients and methods. The BONADIUV trial is a single-blind, randomized, placebo-controlled phase 2 study designed to evaluate the impact of ibandronate treatment on BMD in osteopenic women taking AI. Between January 2011 and May 2014, 171 osteopenic patients (lumbar spine [LS] and/or trochanter -1&lt; T-score &lt;-2.5), were randomized in a 1:1 ratio to receive either placebo or oral monthly ibandronate (150 mg). Treatment duration was 2 years, with 6-months evaluation. Primary endpoint was the mean BMD difference between the two arms at a 2-year follow up. Secondary analysis on survival outcomes (overall survival [OS] and invasive DFS [iDFS]) have been performed at 5-year median follow-up time. ClinicalTrials.gov identifier: NCT02616744.

Results. At the database cutoff time for the present analysis on May 4, 2018, median follow up was 63.3 months (mean 61.2; range 2.7-87.3) for whole series, 64.9 months (range 33.8-84.0) for the placebo arm, and 62.2 months (range 24.2-87.3) for the ibandronate arm. Ten patients in the placebo group and 17 patients in the ibandronate group withdrew the allocated arm before any follow up data collection, and so were excluded from the analysis, performed on 144 patients (72 patients per arm). At the database cutoff time, the OS rate was 97.2% in the placebo group and 100% in the ibandronate arm. We observed four loco-regional relapse (three in the placebo arm, one in the ibandronate arm; p=0.33), three distant metastases (none in the placebo arm, three in the ibandronate arm; p=0.075), and three contralateral BC (one in the placebo arm, two in the ibandronate arm; p=0.65). The number of iDFS events did not differ between groups: four in the placebo group and six in the ibandronate group (p=0.56). Up to data cutoff, two deaths have occurred; none in the placebo arm and two in the ibandronate arm (p=0.15). The OS rate did not differ between arms.

Conclusions. The secondary analysis of survival outcomes showed no difference between arms in terms of OS and iDFS rates. Further large investigations and mature follow-up from the published ones are awaited.

Citation Format: Meattini I, Scotti V, Desideri I, Saieva C, Visani L, Salvestrini V, Cecchini S, De Feo ML, Mariotti M, Olmetto E, Delli Paoli C, Francolini G, Bernini M, Orzalesi L, Sanchez L, Nori J, Bianchi S, Livi L. Oral ibandronate for osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: secondary 5-year survival outcomes analysis of the single-center phase 2 BONADIUV trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-04.

AARS2-related ovarioleukodystrophy: Clinical and neuroimaging features of three new cases

INTRODUCTION

Adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP), previously known as hereditary diffuse leukoencephalopathy with axonal spheroids (HDLS) or pigmentary orthochromatic leukodystrophy (POLD), is the most frequent non-vascular adult-onset leukoencephalopathy. It is caused by autosomal dominant mutations in CSF1R gene. Recently, also autosomal recessive mutations in AARS2 gene were found to be the cause of an adult-onset leukodystrophy with axonal spheroids. Our aim was to achieve a genetic diagnosis in a cohort of CSF1R-negative patients, performing a sequence analysis of AARS2 gene.

MATERIAL AND METHODS

AARS2 sequencing was performed in 38 CSF1R-negative patients with clinical and magnetic resonance imaging (MRI) findings of adult-onset leukoencephalopathy.

RESULTS

Three patients carrying AARS2 compound heterozygous mutations have been found. All patients were female with ovarian failure and leukoencephalopathy. In 2 patients, MRI findings were consistent with previous reports while the third patient showed focal white matter (WM) lesions in the centrum semiovale and the corpus callosum in the absence of extensive involvement and rarefaction of the WM. MRI spectroscopy showed the presence of increased lactate in 2 patients, thus linking AARS2-related leukoencephalopathy with other mitochondrial leukoencephalopathies with high levels of cerebral lactate.

CONCLUSION

We recommend screening for mutations in AARS2 gene in CSF1R-negative patients, also in the absence of a clear family history and peculiar MRI findings. Our results also suggest that findings of conventional MRI and MR spectroscopy may be useful in prompting the genetic screening.

Long-Term Sequelae of Breast Cancer Surgery

Background

Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986.

Patients and Methods

The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed.

Results

Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88).

Conclusions

The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Histopathologic Classification of Breast Cancer in Sweden and Italy: A Comparison between two Pathologists

Two large series of breast cancers (BC), identified in the Pathology Departments of Malmö (Sweden) and Florence (Italy), were independently reviewed by two experienced pathologists, one from each department. Overall, comparison of diagnoses of 372 BCs according to a simplified WHO histologic classification system (in four combined categories) revealed agreement for 74 % of the cases. Concordance, as measured by the kappa statistic, was relatively good (0.53 overall). Kappa values for specific categories were also acceptable, being highest for « invasive lobular » BC (0.63) and lowest for « other types » (0.45). The kappa value for « noninvasive » versus all other categories of invasive BC was 0.53. Some BCs were systematically classified as « noninvasive » by one pathologist and as « invasive ductal with a predominant intraductal component » by the other. Invasive lobular BCs were also diagnosed more frequently by one pathologist. These findings suggest that when planning geographical or temporal comparisons of distribution for BC histologic categories, standardization of classification and a centralized review may play an important role.

Osteogenic Sarcoma of the Breast. A Case Report

A case of primary osteogenic sarcoma of the breast is reported. It should be distinguished from carcinoma with extensive osseous metaplasia. The results of light and electron microscopy including an immunohistochemical study are presented. Immunohistochemical and ultrastructural studies proved that the lesion, in the absence of epithelial differentiation, was a primary osteogenic sarcoma of the breast rather than a carcinoma with extensive osseous metaplasia. Diagnosis may be delayed because the tumor is confused clinically and mammographically with a calcific fibroadenoma.

Interobserver Reproducibility in Diagnosis of Breast Lesions. A Panel in Puglia (Italy)

Background

Given the incidence of breast cancer, histologic agreement is necessary to select the proper treatment.

Methods & study design

Twelve pathologists working in Puglia (Italy) independently evaluated a set of 88 slides of breast lesions. The set included 31 cases which presented difficulties at the moment of first diagnosis (problem cases) and 57 cases without problems (routine cases). Each pathologist was requested to classify lesions according to four categories: A, benign; B, atypical proliferation; C, in situ carcinoma; D, invasive carcinoma. For each case, the definite diagnosis was considered that provided by most of the pathologists (prevalent diagnosis). For the evaluation of degree of agreement, kappa statistics were utilized.

Results

Among routine cases, agreement was observed in 68.4% of cases (38/57) and in 29% of problem cases (9/31). The pair-wise comparison between all participating pathologists showed a good overall agreement, (kappa mean, 0.66; range, 0.57-0.76). The agreement of each pathologist with the prevalent diagnosis was high for invasive (mean kappa, 0.88) and benign lesions (mean kappa, 0.83) followed by in situ carcinoma (mean kappa, 0.64). The lowest value observed was for atypical lesions (mean kappa, 0.25).

Conclusions

The results showed a good overall degree of diagnostic concordance among participating pathologists, all working in the Italian region of Puglia. The findings emerging from the study are comparable to those of other studies performed with selected pathologists specifically specialized in breast pathology. Moreover, the study confirmed the diagnostic difficulties for borderline lesions and the necessity of further investigation for sclerosing lesions with discordant diagnoses.

Risk of Infiltrating Breast Cancer Subsequent to Lobular Carcinoma in Situ

The authors report on a retrospective consecutive multicentric series of 60 cases with histologic evidence of lobular carcinoma in situ (LCIS), followed for an average of 5.3 years. In the course of the follow-up, ipsilateral LCIS or infiltrating carcinoma occurred in 3 or 5 cases, respectively. Two LCIS reoccurrences and all ipsilateral infiltrating carcinomas were observed in 37 patients treated by limited surgery. Contralateral synchronous or metachronous carcinoma was observed in 3 or 2 cases, respectively (intraductal = 3, infiltrating = 2). Three patients died of breast cancer (2 with Ipsilateral, 1 with ipsilateral and contralateral infiltrating carcinoma). The study confirms the higher risk of ipsilateral and contralateral cancer in LCIS patients and warns about the possible hazards of limited surgery in these cases.

The Risk of Breast Cancer Subsequent to Histologic Diagnosis of Benign Intraductal Papilloma Follow-Up Study of 339 Cases

The risk of developing breast cancer was investigated in 339 patients in whom histologically confirmed intraductal papilloma had been surgically removed. Follow-up ranged from 2 to 14 years, (average, 6.62 years). Ten breast cancers were observed, whereas 3 were expected on the basis of age-specific incidence rates drawn from local cancer registries (relative risk = 3.33, 95% confidence interval = 1.60-6.13). No significant difference in the relative risk was observed as far as papilloma type (single or multiple) was concerned. All breast cancers observed occurred in the same breast as the papilloma. Women in whom a benign intraductal papilloma has been excised should be carefully followed since they at are higher risk for ipsilateral breast cancer.