Functional outcomes and quality of life during long-term follow-up after acute pulmonary embolism: analysis of the prospective multicentre FOCUS study

Background

It is unclear to which extent persistence of symptoms and/or residual haemodynamic impairment clinical course of pulmonary embolism are associated with worse quality of life (QoL).

Aims

To study the correlation between symptoms and haemodynamic impairment with QoL during the first year after acute pulmonary embolism (PE).

Methods

The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively enrolled and followed consecutive adult patients diagnosed with acute symptomatic objectively diagnosed PE. In the present analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at predefined visits 3 and 12 months after acute PE. The PEmb-QoL score ranges from 0% (best QoL) to 100% (worst QoL). We evaluated at these two time points the correlation between persisting symptoms (group: symptoms), elevation of natriuretic peptides or residual right ventricular dysfunction (group: RVD), or their combination (group: symptoms + RVD) and QoL.

Results

A total of 617 patients were included; their median age was 62 years, 44% were women; 8% had active cancer, and 21% previous venous thromboembolism. At 3 months, patients with neither symptoms nor RVD (n=302) had the highest quality of life (median score 18%, 25th–75th percentile: 8%–34%), followed by those without symptoms but with RVD (n=255; median score 19%, 25th–75th percentile: 7%–34%), and by those with symptoms only (n=131; median PEmb-QoL 31%, 25th–75th percentile: 18%–49%). Patients with both symptoms and RVD (n=170) had the worst quality of life (median score 38%, 25th–75th percentile: 19%–53%); Figure 1A. At 12 months, we found an overall improvement of PEmb-QoL score. The degree of this QoL improvement varied across groups, being largest for patients who recovered from having symptoms + RVD at 3 months to normalization of at least one at 12 months. The change in QoL from 3 to 12 months was smaller both in patients who had neither symptoms nor RVD and in patients who had no recovery in either symptoms or RVD; Figure 1B.

Conclusions

Persistent symptoms after PE, especially in patients with elevated biomarkers or residual echocardiographic dysfunction, were the main drivers of QoL at 3 months as well as of the course of QoL over time.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research

Shift in transcriptional landscape of human right ventricle in chronic thromboembolic pulmonary arterial hypertension

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is a sub group of pulmonary hypertension (PH). CTEPH is characterized by the existence of thromboemboli and vascular remodeling in pulmonary vessels. The effect of increase in pulmonary artery pressures causes right ventricle (RV) hypertrophy and dilatation and finally leads to right heart failure and death. Surgical intervention in operable patients makes the CTEPH as an only curable and unique form of ph. Pulmonary endarterectomy (PEA) is the surgical procedure to remove the thromboembolic clots from the pulmonary vasculature, which restores RV function back to normal with significant improvements in cardiovascular magnetic resonance.

Purpose

The aim of this study is to use transcriptomic profiling to identify signaling pathways, master regulators, and potentially new biomarkers that specifically indicate the effect of PEA on the RV of patients with chronic thromboembolic pulmonary hypertension.

Results

RNA -sequencing (RNA-seq) was performed on RV biopsies obtained from CTEPH patients at PEA baseline (before PEA surgery) and the results were compared with those from RV biopsies obtained during follow-up evaluation. Bioinformatic analysis of RNA-seq data identified 2799 genes (n=14, −0.585 ≤ Log2 fold change ≥0.585, FDR ≤0.05) differentially regulated between the PEA baseline and follow-up sample groups. The great number of genes (2799) differentially expressed after PEA surgery in CTEPH patients confirms a major shift in the transcriptional landscape of RV in these patients. To further identify potential biomarker candidates from the large pool of 2799 differentially expressed genes (DEGs), extensive bioinformatic analysis of different data sets shortlisted 250 DEGs that were functionally associated with cardiovascular development or disease. The findings of this study reveal prominent transcriptional changes that occur in response to PEA. Gene ontology enrichment and pathway analysis confirmed altered regulation of hypoxia-inducible factor 1 (HIF-1) signaling, advanced glycation end products and their receptors (AGE-RAGE), mitogen-activated protein kinase (MAPK) signaling, hippo signaling, the Janus kinase/ signal transducers and activators of transcription (Jak-STAT) signaling pathway, and proteoglycans after PEA compared with before PEA.

Conclusion

Comparison of the results of RNA-seq analysis of RV biopsies of CTEPH patients, pre and post PEA, revealed a major shift in the transcriptional landscape of these patients after reducing the pressure overload of the RV by PEA.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation (DFG)

Novel potential diagnostic targets revealed by plasma proteomic analysis in chronic thromboembolic pulmonary hypertension

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with poor outcome if untreated, although it is a curable form of pulmonary hypertension (PH). Successful treatment requires an optimized diagnostic work-up.

Purpose

The aim of this study was to identify non-invasive biomarkers that might serve as new diagnostic parameters in the multifaceted pathophysiology of CTEPH.

Methods

The biomarker profile of 64 CTEPH patients who underwent balloon pulmonary angioplasty (BPA) was analyzed prior to and after therapy and compared with that of a healthy control group (CG1, n=25) at baseline. Proteomes were analyzed by semiquantitative screening based on a proximity extension assay of three high-throughput, multiplex immunoassay panels. Serum levels of a subset of biomarkers identified in the screening were additionally measured by immunochemical methods.

Results

Fifty protein biomarkers were found to differ between CTEPH patients and CG1. Eight biomarkers changed significantly after therapy. The overlap of these two groups revealed six targets that were all upregulated in CTEPH at baseline and modifiable by treatment. In this group of biomarkers, the levels of DCN (decorin), HGF (hepatocyte growth factor), BNP (B-type natriuretic peptide), and PAPP-A (papalysin-1) decreased after therapy, whereas SPON-1 (spondin-1) and MEPE (matrix extracellular phosphoglycoprotein) further increased at follow-up. The differences in these biomarkers in CTEPH as well as the dynamics after therapy were confirmed and quantified in enzyme-linked immunosorbent assays.

Conclusions

This study identified 6 biomarkers that might serve as new diagnostic parameters or constitute new therapeutic targets in CTEPH. Further prospective studies will be necessary to determine the specific pathophysiological role of each marker.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01

Copeptin as a non-invasive biomarker in chronic thromboembolic pulmonary hypertension

Introduction

Copeptin is the C-terminal fragment of the precursor protein of vasopressin. In acute pulmonary embolism, copeptin has been suggested to be a strong predictor of outcome and to provide additional predictive value to the established cardiac biomarkers high-sensitivity cardiac troponin and N-terminal pro-brain natriuretic peptide (NT-proBNP). Chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in about 5% of patients who survive acute pulmonary embolism. Individualized risk stratification remains a challenge in the work-up of CTEPH patients.

Purpose

The current study investigated whether copeptin has the potential to aid the stratification of patients who have experienced pulmonary embolism and CTEPH patients. We examined the baseline (BL) levels and dynamics of copeptin during therapy in CTEPH patients who underwent balloon pulmonary angioplasty (BPA) or pulmonary endarterectomy (PEA). Moreover, the study compared copeptin levels between patients with or without therapy response.

Methods

The study included a total of 125 CTEPH patients scheduled for treatment. A total of 78 underwent staged BPA and 64 underwent PEA. In accordance with recent studies from our group, therapy success was defined as a decrease in meanPAP ≥25% and PVR ≥35% or a normalization below the thresholds defining pulmonary hypertension. Blood samples were collected at BL, prior to each BPA session in the BPA cohort, and at follow-up (FU) 6 months after BPA or 12 months after PEA. Copeptin was measured in thawed serum aliquots by an immunochemical method.

Results

The 78 patients in the BPA cohort underwent a mean of 6 BPA procedures each; there were a total of 413 interventions. The hemodynamic clinical and functional status the CTEPH patients improved after BPA and PEA therapy: meanPAP (BL: 43±9 mmHg vs. FU: 27±9 mmHg; p<0.001); PVR (BL: 7.6±3.4 WU vs. FU: 3.8±2.0 WU; p<0.001); RAP (BL: 7.9±5.8 mmHg vs. FU: 5.4±2.7 mmHg; p<0.001); WHO functional class [BL: I:0 / II:25 / III:80 / IV:20 vs. FU: I:56 / II:57 / III:10 / IV:2]; 6-minute-walk distance (BL: 405±99 m vs. FU: 456±112 m; p<0.001).

The median serum levels of copeptin [BL 7.7 (4.6–14.2) pmol/L vs. FU 6.3 (3.9–12.5); p=0.009] and NT-proBNP [BL: 811 (157–1857) ng/L vs. FU: 142 (72–335) ng/L p<0.001] decreased significantly after therapy. The copeptin levels did not correlate with hemodynamics at BL: PVR (rrs=0.02; p=0.79) and meanPAP (rrs=0.03; p=0.75). The copeptin levels at BL (AUC=0.61) and the relative change (AUC=0.53) did not predict the endpoint of therapy response.

Conclusions

Copeptin levels are elevated in CTEPH patients compared with normal values in the literature. Although copeptin is known to provide additional value in the context of risk stratification in acute pulmonary embolism, it failed to provide additional diagnostic benefit in CTEPH in the current study.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01

Abstract ES8-2: Future Directions in Endocrine Therapy for Advanced HR+/HER2- Breast Cancer

The majority of metastatic breast cancer is hormone receptor positive (HR+), HER2 negative. Substantial advances over the prior decades have demonstrated the efficacy of endocrine monotherapies, including aromatase inhibitors, tamoxifen, and fulvestrant, in controlling disease and prolonging survival. More recently, the introduction of targeted therapies used in concert with endocrine therapy have further improved outcomes. The CDK4/6 inhibitors (CDK4/6i): palbociclib, abemaciclib, and ribociclib, have uniformly demonstrated efficacy in the first-line and pretreated settings in prolonging progression free survival, with hazard ratios across at least 8 randomized trials (PALOMA, MONARCH, MONALEESA series) ranging from 0.50-0.55. Recent reports from these trials also support prolongation in overall survival with the use of CDK4/6i in combination with an endocrine backbone. Since initial approval in 2015, CDK4/6i in combination with an endocrine partner have become a mainstay of treatment for metastatic HR+ HER-2 negative breast cancer. Additionally, in the setting of endocrine resistance, a deeper understanding of resistance signaling, such as the mTOR/PI3kinase/AKT pathway, has led to the development and approval of active therapies, including everolimus and alpelisib, with further agents in development.

Despite substantial progress, a major challenge within the current landscape is to better identify mechanisms of resistance to these therapies, with a goal of utilizing a personalized approach to tailor subsequent treatment options. Significant ongoing work focuses on the post-CDK4/6i space, to identify molecular mechanisms of resistance, and whether resistance extends exclusively to CDK4/6i, or to endocrine therapy as well. Examination of tumor and blood samples post-CDK4/6i exposure has suggested a heterogenous mutational landscape. Loss of Rb is a rare observation, however other important events include alterations in AKT1, aurora kinase A (AURKA), FGFR1, cyclin E2 (CCNE2), ESR1, and RAS. Agents of interest post-CDK4/6i thus include SERDs (selective estrogen receptor down regulators), AKT inhibtors, FGFR1 antagonists, as well as aurora kinase inhibitors.

In conclusion, the area of empiric endocrine monotherapy has become a notion of the past. The advent of CDK4/6i has changed paradigms of therapy and introduced improved survival outcomes. Substantial ongoing work attempts to characterize the heterogenous genomic alternations which underlie resistance to endocrine and targeted therapies, and novel agents matched to these specific mutations are in development. Moving beyond CDK4/6i, we are now entering a new era of personalized and targeted therapy for metastatic HR+ HER-2 negative breast cancer, with the potential to provide significant benefit to the many patients with this disease.

Citation Format: E Mayer. Future Directions in Endocrine Therapy for Advanced HR+/HER2- Breast Cancer [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 ES8-2.

4283Exercise right heart catheterization before and after balloon pulmonary angioplasty in inoperable patients with chronic thromboembolic pulmonary hypertension

Background

Balloon pulmonary angioplasty (BPA) is an evolving treatment option for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). The main indicator for success is improvement in pulmonary hemodynamics, but outcome data are heterogeneous.

Purpose

The aim of the present study was to evaluate pulmonary hemodynamics not only at rest, but also during exercise before and 6 months after BPA.

Methods

We report a prospective series of 64 consecutive patients with inoperable CTEPH who were treated interventionally with BPA. All patients underwent standardized assessment prior to the first BPA and 6 months after the last intervention. Assessment included WHO FC, Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR), 6-minute walking distance (6MWD), serum levels of the N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP), and exercise RHC.

Results

The mean number of sessions per patient was 5.6 (± 1.3) and the mean number of pulmonary segments targeted in all interventions was 11 (± 3). BPA treatment led to improvements in pulmonary hemodynamics and exercise capacity (6MWD: 416±94 m vs. 463±96 m; p<0.0001) except for CO and CI during RHC at rest; these parameters showed improvements only during exercise RHC. MPAP at rest showed a reduction from 41±9 to 31±9 mmHg (p<0.0001) and PVR at rest decreased from 6.8±2.3 WU to 4.3±1.9 WU (p<0.0001). Further decreases were observed for systolic pulmonary arterial pressure, TPG, PVR, and TPR. Cardiac output (7.0±2.0 L/min vs. 8.3±2.0 L/min; p<0.0001) and cardiac index during exercise RHC (3.8±1.1 L/min/m2 vs. 4.4±1.1 L/min/m2; p<0.0001) improved significantly. Median NT-proBNP concentrations decreased from 741 ng/L (IQR 192–1425 ng/L) to 139 ng/L (IQR 60–266 ng/L) during BPA treatment (p<0.0001). Results from the CAMPHOR questionnaire showed significant improvements in symptoms (11±5.8 vs. 5.5±4.9, p<0.0001), activity limitations (9.2±5.6 vs. 5.2±4.5, p<0.0001), and quality of life (6.4±5.7 vs. 3.5±3.7, p<0.0001).

Conclusion

Significant improvements in pulmonary hemodynamics at rest and during exercise were observed 6 months after BPA. Exercise right heart catheterization offers a more discriminating evaluation of the changes in pulmonary hemodynamics after BPA.

P2774Galectin-3, GDF-15, and ST2 in noninvasive assessment of myocardial remodelling in chronic thromboembolic pulmonary hypertension

Background

In chronic thromboembolic pulmonary hypertension (CTEPH), pulmonary artery obstruction leads to impaired pulmonary hemodynamics and secondary right heart failure, which is highly predictive of outcome. Thus, the extent of myocardial -especially right heart- remodelling is an indicator of disease severity.

Purpose

The aim of the present study was to assess growth differentiation factor-15 (GDF-15), galectin-3, and suppression of tumorigenicity 2 (ST2) as non-invasive biomarkers of myocardial remodelling in patients suffering from CTEPH.

Methods

We analysed the serum levels of GDF-15, galectin-3 and ST2 in a cohort of 64 CTEPH patients and in a control group of 25 patients without cardiovascular disease. The biomarker levels were further correlated with clinical, laboratory, and hemodynamic data, including 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP), mean pulmonary artery pressure (meanPAP), pulmonary vascular resistance (PVR), and right atrial pressure (RAP).

Results

The biomarker levels in the control group were: galectin-3: 3.5 ng/l (IQR 2.7–4.0), GDF-15: 92.6 pg/ml (IQR 78.5–129.1), and ST2: 48.65 ng/l (IQR 35.5–57.0). CTEPH patients had higher levels of GDF-15 (196.7 pg/ml; IQR 128.4–302.8; p<0.001) and ST2 (52.6 ng/l; IQR 44.5–71.9; p=0.05) but not galectin-3 (3.4 ng/l; IQR 2.7–4.3; p=0.84). In the CTEPH cohort, patients with a meanPAP >35 mmHg (GDF-15: p=0.01; ST2: p=0.04) and patients with a PVR >500 dyn sec cm–5 (GDF-15: p=0.004; ST2: p=0.002) had significantly increased biomarker levels. For the detection of a meanPAP >35mmHg, ROC analysis revealed an AUC of 0.71 for GDF-15 and 0.67 for ST2. The level of GDF-15 correlated with the level of NT-proBNP (rrs=0.69; p≤0.001) and the RAP (rrs=0.54; p≤0.001) and inversely with the 6-MWD (rrs=−0.47; p≤0.001). The level of ST2 correlated with the level of NT-proBNP (rrs=0.67; p≤0.001) and the RAP (rrs=0.54; p≤0.001) and inversely with the 6-MWD (rrs=-0.31; p=0.02).

Conclusion

Our results demonstrate that GDF-15 and ST2, non-invasive biomarkers of myocardial remodelling, are significantly elevated in patients suffering from CTEPH. The correlation of biomarker levels with established outcome predictors suggests a use as indicators of disease severity.

P2540Sex-specific differences in the clinical presentation, surgical complications, and course of chronic thromboembolic pulmonary hypertension

Background

Women are more susceptible to develop several forms of pulmonary hypertension, but they may have better survival rates than men. Sparse data are available concerning sex-specific differences in chronic thromboembolic pulmonary hypertension (CTEPH).

Purpose and methods

We investigated sex-specific differences in the clinical presentation of CTEPH, functional parameters, exposure to pulmonary endarterectomy (PEA), and survival.

Results

Women constituted half of the study population (N=679 treatment-naïve patients from the European CTEPH registry) and were characterized by a lower prevalence of some cardiovascular risk factors (e.g. prior acute coronary syndrome, smoking habit, chronic obstructive pulmonary disease), but more prevalent obesity, cancer, and thyroid diseases. Median age was 62 (IQR 50–73) years in women and 63 (IQR 53–70) in men. Women underwent PEA less often than men (54% vs 65%; Figure 1, Panel A) and were exposed to fewer additional cardiac procedures, notably coronary artery bypass graft surgery (0.5% vs. 9.5%). The prevalence of specific reasons for not being operated, including the patient's refusal and the proportion of proximal vs. distal lesions, did not differ between sexes. A total of 57 (17.0%) deaths in women and 70 (20.7%) in men were recorded over long-term follow-up. Female sex was positively associated with long-term survival (adjusted Hazard Ratio 0.66; 95% Confidence Interval 0.46–0.94). Short-term mortality was identical in the two groups (Figure 1, Panel B).

Conclusions

Women with CTEPH had a lower prevalence of cardiovascular risk factors and underwent PEA less frequently than men, who, in turn, were more often exposed to additional major cardiac surgery procedures. Women had more favorable long-term survival.

Acknowledgement/Funding

The CTEPH registry is supported by a research grant from Actelion Pharmaceuticals Ltd.

Abstract P1-15-01: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Metzger Filho O, Janiszewska M, Guo H, Yardley D, Mayer I, Spring L, Arteaga C, Wrabel E, DeMeo M, Freedman R, Tolaney S, Waks A, Bardia A, Parsons H, Partridge A, Mayer E, King T, Polyak K, Viale G, Winer E, Krop I. Withdrawn [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 P1-15-01.

Prospective Risk Factor Analysis for the Development of Post-operative Urinary Retention Following Ambulatory General Surgery

Aims

Post-operative urinary retention (POUR) is a common cause of unplanned admission following day-case surgery and has negative effects on both patient and surgical institution. We aimed to prospectively evaluate potential risk factors for the development of POUR following day-case general surgical procedures.

Methods

Over a 24-week period, consecutive adult patients undergoing elective day-case general surgery at a single institution were prospectively recruited. Data regarding urinary symptoms, comorbidities, drug history, surgery and perioperative anaesthetic drug use were collected. The primary outcome was the incidence of POUR, defined as an impairment of bladder voiding requiring either urethral catheterisation, unplanned overnight admission or both. Potential risk factors for the development of POUR were analysed by logistic regression.

Results

A total of 458 patients met the inclusion criteria during the study period, and data were collected on 382 (83%) patients (74.3% male). Sixteen patients (4.2%) experienced POUR. Unadjusted analysis demonstrated three significant risk factors for the development of POUR: age ≥ 56 years (OR 7.77 [2.18–27.78], p = 0.002), laparoscopic surgery (OR 3.37 [1.03–12.10], p = 0.044) and glycopyrrolate administration (OR 5.56 [2.00–15.46], p = 0.001). Male sex and lower urinary tract symptoms were not significant factors. Multivariate analysis combining type of surgery, age and glycopyrrolate use revealed that only age ≥ 56 years (OR 8.14 [2.18–30.32], p = 0.0018) and glycopyrrolate administration (OR 3.48 [1.08–11.24], p = 0.0370) were independently associated with POUR.

Conclusions

Patients aged at least 56 years and/or requiring glycopyrrolate—often administered during laparoscopic procedures—are at increased risk of POUR following ambulatory general surgery.

Electronic supplementary material

The online version of this article (10.1007/s00268-018-4697-4) contains supplementary material, which is available to authorized users.

Abstract OT3-05-08: PALLAS: PALbociclib CoLlaborative Adjuvant Study: A randomized phase 3 trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for HR+/HER2- early breast cancer

Background:

Cell cycle inhibition is a proven target for novel cancer therapeutics. Palbociclib (P) is an orally active inhibitor of CDK4/6, and arrests the cell cycle at the G1-S transition. P in combination with endocrine therapy (ET) has demonstrated efficacy in phase II and III randomized trials for patients with newly diagnosed and recurrent hormone receptor positive/HER2 negative (HR+/HER2-) metastatic breast cancer (MBC), and is approved in these settings. Given confirmed benefits of P and ET for MBC, the PALLAS study was designed to determine if the addition of P to adjuvant ET improves outcomes over ET alone in HR+/HER2- early breast cancer.

Trial Design:

PALLAS is an international open-label phase III trial randomizing (1:1) patients (pts) to 2 years of P (125 mg daily, 21 days on 7 days off in a 28-day cycle) combined with at least 5 years of provider choice ET (AI, tamoxifen, +/- LHRH agonist), versus ET alone. The primary objective of the study is to compare invasive disease-free survival (iDFS) for the combination of P and ET, versus ET alone. Secondary objectives include comparison of iDFS excluding cancer of non-breast origin, DRFS, LRRFS, OS, as well as safety. The principal objective of the translational investigations is to determine the predictive or prognostic utility of defined genomic subgroups with respect to iDFS and OS. Additional objectives include evaluation of cfDNA and tissue biomarkers predictive of benefit or resistance, pharmacogenomics, adherence, and patient-reported QOL. Eligible pts are pre- or post-menopausal women or men with stage II-III, HR+/HER2- breast cancer. Patients may have already initiated ET, but must be randomized within 12 months of diagnosis and 6 months of initiation of adjuvant ET. Trial sample size is 4600 pts and stage IIA pts will be capped at a total accrual of 1000 pts. Interim analyses for safety, futility/efficacy and sample size re-estimation are planned. PALLAS opened in 9/2015 and accrual is ongoing. Contact information: emayer@partners.org

Key words: palbociclib, CDK4/6 inhibition, HR+/HER2- early breast cancer, adjuvant endocrine therapy.

Citation Format: Mayer E, DeMichele A, Gnant M, Barry W, Pfeiler G, Metzger O, Burstein H, Miller K, Rastogi P, Loibl S, Goulioti T, Zardavas D, Fesl C, Koehler M, Huang-Bartlett C, Huang X, Piccart M, Winer E, Wolff A. PALLAS: PALbociclib CoLlaborative Adjuvant Study: A randomized phase 3 trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for HR+/HER2- early breast cancer [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 OT3-05-08.

An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK

BACKGROUND

Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood.

METHODS

In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England.

RESULTS

Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission.

CONCLUSION

This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.

Brain networks associated with cognitive and hedonic responses to a meal

BACKGROUND

We recently reported interrelated digestive, cognitive, and hedonic responses to a meal. The aim of this study was to identify brain networks related to the hedonic response to eating.

METHODS

Thirty-eight healthy subjects (20-38 age range) were evaluated after a 5-hour fast and after ingestion of a test meal (juice and warm ham and cheese sandwich, 300 mL, 425 kcal). Perceptual and affective responses (satiety, abdominal fullness, digestive well-being, and positive mood), and resting scans of the brain using functional MRI (3T Trio, Siemens, Germany) were evaluated immediately before and after the test meal. A high-order group independent component analysis was performed to investigate ingestion-related changes in the intrinsic connectivity of brain networks, with a focus on thalamic and insular networks.

KEY RESULTS

Ingestion induced satiation (3.3±0.4 score increase; P<.001) and abdominal fullness (2.4±0.3 score increase; P<.001). These sensations included an affective dimension involving digestive well-being (2.8±0.3 score increase; P<.001) and positive mood (1.8±0.2 score increase; P<.001). In general, thalamo-cortical connectivity increased with meal ingestion while insular-cortical connectivity mainly decreased. Furthermore, larger meal-induced changes (increase/decrease) in specific thalamic connections were associated with smaller changes in satiety/fullness. In contrast, a larger meal-induced decrease in insular-anterior cingulate cortex connectivity was associated with increased satiety, fullness, and digestive well-being.

CONCLUSIONS AND INFERENCES

Perceptual and emotional responses to food intake are related to brain connectivity in defined functional networks. Brain imaging may provide objective biomarkers of subjective effects of meal ingestion.

Abstract P6-12-12: Phase I study of the JAK 1/2 inhibitor ruxolitinib with weekly paclitaxel for the treatment of HER2 negative metastatic breast cancer (MBC)

This abstract was not presented at the symposium.

[Chronic thromboembolic pulmonary hypertension: Recommendations of the Cologne Consensus Conference 2016]

The 2015 European Guidelines on Pulmonary Hypertension did not cover only pulmonary arterial hypertension (PAH), but also other significant subgroups of pulmonary hypertension (PH). In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany to discuss open and controversial issues surrounding the practical implementation of the European Guidelines. Several working groups were initiated, one of which was dedicated to the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). In every patient with PH of unknown cause CTEPH should be excluded. The primary treatment option is surgical pulmonary endarterectomy (PEA) in a specialized multidisciplinary CTEPH center. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. For balloon pulmonary angioplasty (BPA), there is currently only limited experience. This option - as PEA - is reserved to specialized centers with expertise for this treatment method. In addition, a brief overview is given on pulmonary artery sarcoma, since its surgical treatment is often analogous to PEA. The recommendations of this working group are summarized in the present paper.

[Treatment of acute and chronic right ventricular failure]

Acute or chronic right ventricular failure is an often misdiagnosed cause of cardiopulmonary insufficiency. In addition to clinical symptoms or laboratory testing, echocardiography and invasive hemodynamic measurement by means of right-heart catheterization are essential for diagnosis and treatment control. In case of acute right ventricular failure, adequate symptomatic treatment of the life-threatening situation is important. Main issues are maintenance of coronary artery perfusion pressure and myocardial oxygen delivery as well as reduction of right ventricular afterload. In persistent right ventricular failure extracorporeal or intracorporeal assist devices are increasingly used as bridging or destination therapy. On a long-term basis, the targeted therapy of the underlying disease is crucial.

[Pulmonary embolism]

Pulmonary embolism is a potentially fatal disorder and frequently seen in critical care and emergency medicine. Due to a high mortality rate within the first few hours, the accurate initiation of rational diagnostic pathways in patients with suspected pulmonary embolism and timely consecutive treatment is essential. In this review, the current European guidelines on the diagnosis and therapy of acute pulmonary embolism are presented. Special focus is put on a structured patient management based on the individual risk of early mortality. In particular risk assessment and new risk-adjusted treatment recommendations are presented and discussed in this article.

Deficient habituation to repeated rectal distensions in irritable bowel syndrome patients with visceral hypersensitivity

BACKGROUND

Irritable bowel syndrome (IBS) patients show evidence of altered central processing of visceral signals. One of the proposed alterations in sensory processing is an altered engagement of endogenous pain modulation mechanisms. The aim was to test the hypothesis that IBS patients with (IBS-S) and without visceral hypersensitivity (IBS-N) differ in their ability to engage endogenous pain modulation mechanism during habituation to repeated visceral stimuli.

METHODS

Brain blood oxygen level dependent (BOLD) response was measured during repeated rectal distension and its anticipation in 33 IBS patients with and without visceral hypersensitivity and 18 healthy controls (HCs). BOLD response to early and late phase of the distension series was compared within and between groups.

KEY RESULTS

While BOLD response was similar during the early phase of the experiment, IBS-S showed greater BOLD response than IBS-N and HCs during the late phase of the distension series. IBS-S showed increasing BOLD response both to the anticipation and delivery of low intensity rectal distensions in brain regions including insula, anterior and mid cingulate cortex. IBS-N showed decreasing BOLD response to repeated rectal distensions in brain regions including insula, prefrontal cortex and amygdala.

CONCLUSIONS & INFERENCES

These findings are consistent with compromised ability of IBS-S to respond to repeated delivery of rectal stimuli, both in terms of sensitization of sensory pathways and habituation of emotional arousal. The fact that both IBS subgroups met Rome criteria, and did not differ in terms of reported symptom severity demonstrates that similar symptom patterns can result from different underlying neurobiological mechanisms.

[Chronic thromboembolic pulmonary hypertension--a position paper]

This position paper summarises current developments in chronic thromboembolic pulmonary hypertension (CTEPH) including diagnostic approaches and treatment options. Based on the guidelines of the task force of CTEPH experts at the 5th World Symposium on Pulmonary Hypertension in Nice 2013. Open questions arising during the treatment of patients with CTEPH are addressed. Patients with suspected CTEPH should undergo echocardiography and cardiopulmonary exercise testing. A ventilation/perfusion scan is the recommended imaging test for screening in the diagnostic algorithm for the evaluation of CTEPH. CTEPH-patients should be discussed in an expert center with an interdisciplinary team and an experienced PEA surgeon to decide the further treatment. Pulmonary endarterectomy (PEA) is the treatment of choice for patients with CTEPH. Medical therapy with PH-targeted medications for inoperable CTEPH and residual disease after PEA should only be initiated if evaluation reveals that the patient is no candidate for a PEA. Current data suggest that CTEPH patients treated with PEA have a better long-term survival rate and quality of life than patients treated with medical therapy.

Chronic thromboembolic pulmonary hypertension (CTEPH) - potential role of multidetector-row CT (MD-CT) and MR imaging in the diagnosis and differential diagnosis of the disease

Chronic thromboembolic pulmonary hypertension (CTEPH) can be defined as pulmonary hypertension (resting mean pulmonary arterial pressure of 25 mm Hg or more determined at right heart catheterization) with persistent pulmonary perfusion defects. It is a rare, but underdiagnosed disease with estimated incidences ranging from 0.5% to 3.8% of patients after an acute pulmonary embolism (PE), and in up to 10% of those with a history of recurrent PE. CTEPH is the only form of pulmonary hypertension that can be surgically treated leading to normalization of pulmonary hemodynamics and exercise capacity in the vast majority of patients. The challenges for imaging in patients with suspected CTEPH are fourfold: the imaging modality should have a high diagnostic accuracy with regard to the presence of CTEPH and allow for differential diagnosis. It should enable detection of patients suitable for PEA with great certainty, and allow for quantification of PH by measuring pulmonary hemodynamics (mPAP and PVR), and finally, it can be used for therapy monitoring. This overview tries to elucidate the potential role of ECG-gated multidetector CT pulmonary angiography (MD-CTPA) and MR imaging, and summarizes the most important results that have been achieved so far. Generally speaking, ECG-gated MD-CTPA is superior to MR in the assessment of parenchymal and vascular pathologies of the lung, and allows for the assessment of cardiac structures. The implementation of iodine maps as a surrogate for lung perfusion enables functional assessment of lung perfusion by CT. MR imaging is the reference standard for the assessment of right heart function and lung perfusion, the latter delineating typical wedge-shaped perfusion defects in patients with CTEPH. New developments show that with MR techniques, an estimation of hemodynamic parameters like mean pulmonary arterial pressure and pulmonary vascular resistance will be possible. CT and MR imaging should be considered as complementary investigations providing comprehensive information in patients with CTEPH.