Cancers of Unknown Primary Origin: Real-World Clinical Outcomes and Genomic Analysis at the European Institute of Oncology

BACKGROUND

Cancer of unknown primary origin (CUP) poses a significant challenge due to poor clinical outcomes and limited treatment options. As such, further definition of clinicopathological factors and genomic profile to better adapt treatment strategies is required.

METHODS

Medical records were interrogated to retrospectively include CUP with available clinical and genomics data at the European Institute of Oncology. Next-generation sequencing (NGS) included targeted panels. Statistical analyses were conducted with R Software 4.2.2.

RESULTS

A total of 44 patients were included. With a median follow-up of 39.46 months (interquartile range [IQR] 35.98-47.41 months), median PFS (mPFS) to first-line regimen was 3.98 months (95% CI 3.22-5.98), with a clinical benefit rate of 26% (95% CI 14%-49%), and disease control rate (DCR) limited to 48.28%. Most patients (26 of 31, 83.87%) received platinum-doublet chemotherapy, with no statistically significant difference between first-line treatment regimens. Median OS (mOS) was 18.8 months (95% CI 12.3-39.9), with a 12-month OS rate of 66% (95% CI 50%-85%). All patients received comprehensive genomic profiling (CGP). For 11 patients, NGS was unsuccessful due to low sample quantity and/or quality. For the remaining, TP53 (n = 16, 48%) and KRAS (n = 10, 30%) represented the most altered (alt) genes. No microsatellite instability was observed (0 of 28), while 6 of 28 (21.43%) tumors carried high TMB (≥10 mutation per megabase). Eight of 33 tumors (24.2%) displayed at least one actionable alteration with potential clinical benefit according to ESCAT. Only 2 of them received targeted therapy matched to genomic alterations, with a combined mPFS of 2.63 months (95% CI 1.84-not evaluable) as third-line regimens. Six patients received anti-PD1/PD-L1 therapy, showing a meaningful mPFS of 13 months (95% CI 2.04-not evaluable).

CONCLUSION

CUP exhibits poor prognosis with limited benefits from standard treatment regimens. A significant proportion of CUPs carry actionable alterations, underscoring the importance of genomic profiling to gather additional treatment opportunities. In addition, immunotherapy might represent a valuable treatment option for a subset of CUP. Finally, accurate definition of sequencing methods and platforms is crucial to overcome NGS failures.

Immune-Related Adverse Event Likelihood Score Identifies "Pure" IRAEs Strongly Associated With Outcome in a Phase I-II Trial Population

BACKGROUND

Immune-related adverse events (IRAE) pose a significant diagnostic and therapeutic challenge in patients treated with immune-oncology (IO) drugs. IRAEs have been suggested to correlate with better outcome, but studies are conflicting. Estimating the true incidence of IRAEs is particularly difficult in the early phase I/II trial setting. A key issue is the lack of IRAE diagnostic criteria, necessary to discriminate "pure" IRAEs from other treatment-related adverse events not sustained by an autoimmune process.

METHODS

In patients treated with immune-oncology (IO) drugs in phases I-II trials at our institute, we identified high confidence (HC) or low confidence (LC) IRAEs by clinical consensus. We empirically developed an IRAE likelihood score (ILS) based on commonly available clinical data. Correlation with outcome was explored by multivariate Cox analysis. To mitigate immortal time-bias, analyses were conducted (1) at 2-month landmark and (2) modeling IRAEs as time-dependent covariate.

RESULTS

Among 202 IO-treated patients, 29.2% developed >1 treatment-related adverse events (TRAE). Based on ILS >5, we classified patients in no IRAE (n = 143), HC IRAE (n = 24), or LC IRAE (n = 35). hazard ratios (HR) for HC were significantly lower than LC patients (HR for PFS ranging 0.24-0.44, for OS 0.18-0.23, all P < .01).

CONCLUSION

ILS provides a simple system to identify bona fide IRAEs, pruning for other treatment-related events likely due to different pathophysiology. Applying stringent criteria leads to lower and more reliable estimates of IRAE incidence and identifies events with significant impact on survival.

Evaluation of the Geographical Accessibility of Genome-Matched Clinical Trials on a National Experience

BACKGROUND

Molecular-driven oncology allows oncologists to identify treatments that match a cancer's genomic profile. Clinical trials are promoted as an effective modality to deliver a molecularly matched treatment. We explore the role of geographical accessibility in Italy, and its impact on patient access to clinical trials.

MATERIAL AND METHODS

We retrospectively reviewed molecular data from a single-institutional case series of patients receiving next-generation sequencing testing between March 2019 and July 2020. Actionable alterations were defined as the ones with at least one matched treatment on Clinicaltrials.gov at the time of genomic report signature. We then calculated the hypothetical distance to travel to reach the nearest assigned clinical trial.

RESULTS

We identified 159 patients eligible for analysis. One hundred and one could be potentially assigned to a clinical trial in Italy, and the median distance that patients needed to travel to reach the closest location with a suitable clinical trial was 76 km (interquartile range = 127.46 km). Geographical distribution of clinical trials in Italy found to be heterogeneous, with Milan and Naples being the areas with a higher concentration. We then found that the probability of having a clinical trial close to a patient's hometown increased over time, according to registered studies between 2015 and 2020.

CONCLUSIONS

The median distance to be travelled to the nearest trial was generally acceptable for patients, and trials availability is increasing. Nevertheless, many areas are still lacking trials, so efforts are required to increase and homogenize the possibilities to be enrolled in clinical trials for Italian patients with cancer.

Clinicopathological features and survival outcomes of luminal-like breast tumors with estrogen receptor loss at metastatic recurrence: A case-control study

INTRODUCTION

Estrogen receptor (ER) loss at metastatic relapse occurs in up to 20% of luminal-like primary breast tumors. Data about clinicopathological features associated with ER loss and its prognostic significance are limited.

METHODS

In a nested-case-control study, we compared clinicopathological characteristics and clinical outcomes between a cohort of 51 patients with primary ER+ /HER2- and paired triple-negative metastasis (LUM-TN) and two control cohorts of paired early-metastatic ER+ /HER2- (LUM-LUM, n = 50) and triple-negative (TN-TN, n = 49) breast cancers. Stromal tumor-infiltrating lymphocytes (TILs) were assessed according to the TILs Working Group recommendations as continuous and discrete variables with cutoffs (20%, 40%).

RESULTS

LUM-TN tumors had lower ER expression than LUM-LUM tumors, but lower grade and Ki67 than TN-TN cases. Median distant-metastasis free survival was similar for LUM-TN and LUM-LUM cohorts, but significantly longer than in TN-TN cases (log-rank P < 0.001). LUM-TN and TN-TN cohorts had a comparable survival from the time of metastatic recurrence, which was significantly shorter than in patients with LUM-LUM tumors (log-rank P < 0.001). High TILs were associated with worse outcomes in patients with ER loss (P < 0.001).

CONCLUSIONS

Breast tumors with ER loss at metastatic relapse have intermediate features and outcomes compared with metastatic luminal-like and ab initio triple-negative tumors. Further investigation on the biological mechanisms underpinning the loss of ER expression is ongoing.

Predicting Response to Antibody Drug Conjugates: A Focus on Antigens' Targetability

Antibody-drug conjugates (ADCs) represent a cornerstone in the treatment of many cancers nowadays. ADCs fulfill their function by binding a target on tumor cell membrane to deliver a cytotoxic payload; in addition, those moieties capable of crossing cancer cell membranes can achieve near-by cells that do not express the target antigen, exerting the so-called "bystander" cytotoxic effect. The presence of a specific target antigen expressed on cancer cells has been for long considered crucial for ADCs and commonly required for the inclusion of patients in clinical trials with ADCs. To date, only ado-trastuzumab-emtansine, fam-trastuzumab deruxtecan-nxki, and mirvetuximab soravtansine-gynx are approved according to the expression of a target antigen in solid tumors, while the clinical use of other ADCs (eg, sacituzumab govitecan) is not conditioned by the presence of a specific biomarker. Given the ever-growing number of approved ADCs and those under investigation, it is essential to find new biomarkers to guide their use, especially in those settings for which different ADCs are approved to establish the best therapeutic sequence based on robust biomarkers. Hence, this work addresses the role of target antigens in predicting response to ADCs, focusing on examples of antigens' targetability according to their expression on cancer cells' surface or to the presence of specific target aberrations (eg, mutation or over-expression). New methods for the assessment and quantification of targets' expression, like molecular imaging and in vitro assays, might be key tools to improve biomarker analysis and eventually deliver better outcomes by refined patient selection.

A demand-offer critical analysis of current drug development. Phase I drugs versus TCGA sequencing data

BACKGROUND

Phase I clinical trials have become increasingly critical to regulatory approvals of novel agents. In phase I drug development, a global problem of unknown magnitude is the multiplicity of similar drugs being investigated against the same target, colloquially known as the 'me too' phenomenon.

METHODS

Ranging from December 2020 to December 2022 we annotated phase I clinical trials present on clinicaltrials.gov. Public databases were queried for annotation of investigational agents (IAs). Extensive literature research and data mining were performed to annotate agents not present in public databases. The Cancer Genome Atlas (TCGA) pan-cancer sequencing cohort was used to perform second-level analyses to evaluate tumour types with a higher number of IA matches.

RESULTS

A total of 1054 unique drug targets were identified. The most frequent IA classes were: cell products (1223), small-molecule inhibitors (1110), antibodies (733), and vaccines (346). Only a minority (8.9%) of phase I IAs were explored against a target without a competitive agent; 7% of agents shared targets with 2-3 other agents. Unfortunately, the majority (84%) shared targets with at least four other agents. Using data from the TCGA pan-cancer sequencing potentially underserved histologies were identified. Analysis of alteration-IA matches revealed potentially frequent and unexplored alterations in many tumour types.

CONCLUSIONS

The majority of IAs (86%) shared targets with at least three other agents. We argue that these duplicative efforts could be redirected toward unmet needs instead.

Molecular tumour board at European Institute of Oncology: Report of the first three year activity of an Italian precision oncology experience

BACKGROUND

Precision oncology aims to improve clinical outcomes by personalising treatment options for patients with cancer. Exploiting vulnerabilities identified in a patient's cancer genome requires reliable interpretation of a huge mole of alterations and heterogeneous biomarkers. ESMO Scale for Clinical Actionability of Molecular Targets (ESCAT) allows evidence-based evaluation of genomic findings. Molecular tumour boards (MTBs) convey the required multi-disciplinary expertise to enable ESCAT evaluation and strategical treatment choice.

MATERIALS AND METHOD

We retrospectively reviewed the records of 251 consecutive patients discussed by European Institute of Oncology MTB between June 2019 and June 2022.

RESULTS

One-hundred eighty-eight (74.6%) patients had at least one actionable alteration. After MTB discussion, 76 patients received molecularly matched therapies (MMTs) while 76 patients received standard of care. Patients receiving MMT displayed higher overall response rate (37.3% versus 12.9%), median progression-free survival (mPFS 5.8 months, 95% confidence interval [CI] 4.1-7.5 versus 3.6 months, 95% CI 2.5-4.8, p = 0.041; hazard ratio 0.679, 95% CI 0.467-0.987) and median overall survival (mOS 35.1 months, 95% CI not evaluable versus 8.5 months, 95% CI 3.8-13.2; hazard ratio 0.431, 95% CI 0.250-0.744, p = 0.002). Superiority in OS and PFS persisted in multivariable models. Among 61 pretreated patients receiving MMT, 37.5% of patients had PFS2/PFS1 ratio ≥1.3. Patients with higher actionable targets (ESCAT tier I) had better OS (p = 0.001) and PFS (p = 0.049), while no difference was observed in lower evidence levels.

CONCLUSIONS

Our experience shows that MTBs can yield valuable clinical benefit. Higher actionability ESCAT level appears to be associated with better outcomes for patients receiving MMT.

Abstract P1-14-05: Pembrolizumab and Oral Metronomic Cyclophosphamide in Patients with Chest Wall Breast Cancer (PERICLES): an immune-biomarker analysis of tumor infiltrating lymphocytes (TILs) and programmed cell death ligand protein 1 (PD-L1)

Background: Breast cancer (BC) with lymphangitic spread to the chest wall is a rare clinical entity affecting about 2% of pts, with poorer survival outcomes. A brisk immune infiltrate is typically reported, with up-regulation of inflammation and immune-tolerogenic genes. PERICLES clinical trial is testing the administration of pembrolizumab 200 mg Q3w plus cyclophosphamide 50 mg daily for BC with chest wall disease. In this exploratory biomarker analysis, we assessed the prevalence of the TILs score and the PD-L1 combined positive score (CPS) obtained from skin biopsies performed at screening.

Methods: PERICLES (NCT03971045) is a single-center, single-arm, interventional phase 2 trial. Main inclusion criteria: histologically confirmed, inoperable, locally recurrent and/or metastatic BC with lymphangitic spread to the chest wall (including and not limited to inflammatory BC); PD-L1 positive (CPS≥1; 22C3 pharmDx®) and/or TILs positive (≥1% of CD3 or CD20-positive cells) disease on skin biopsy obtained at screening; progression to at least one prior cytotoxic treatment; no prior immune checkpoint inhibitors. The primary endpoint is objective response rate as per immune-related RECIST criteria. 46 pts will be required for the study to power for the primary hypothesis. In this analysis, we describe the baseline immune-biomarker status, in the overall population enrolled based on hormone receptor status and HER2. Correlative analyses were provided (significance at p-value&lt; 0.05).

Results: 37 pts were screened with skin biopsy of the chest wall disease (June 2020-June 2022). Biopsy and biomarker analysis were successful in 35 pts. Median age was 58 years (range: 35-79). Among the 35 pts included in the biomarker analysis, 25 (71%) pts had visceral disease and 20 (57%) had skin metastases at the diagnosis of metastatic disease; median number of previous lines of therapies was 4 (range: 1-12) and of chemotherapies was 4 (range: 1-10). 2 (6%) pts had HER2-positive disease, 13 (37%) HR-positive/HER2-negative disease, and 20 (20%) had triple-negative breast cancer (TNBC).

TILs and PD-L1 CPS were &lt; 1 in 15 (43%) pts; 20 pts (57%) were eligible for CPS and/or TILs criteria: 16 (43%) were both PD-L1 positive and TILs positive, 4 only PD-L1 positive. Median PD-L1 CPS score was 5 (range: 0-80%) in the overall population and 17 (range: 2-80%) in eligible patients; 16/35 pts (43%) had CPS≥10. Median TILs score was 0% (range: 0-55%) in the overall population, 0% (range: 0-40%) in the HER2-negative (n=16), 0% (range 0-20%) in the HER2-low (n=18), and 37.5% (range 20-55%) in the HER2-positive (n=2).

No significant differences in baseline characteristics were found between positive and negative biopsies (Table). Considering only the TILs, a statistically significant correlation between HER2-positive status and TILs score was demonstrated (p&lt; 0.001); no other correlations between receptor status (estrogen receptor, progesterone receptor, HER2) and PD-L1 CPS or TILs emerged.

Conclusions: 57% of patients with chest wall BC have skin metastases positive for PD-L1 CPS and/or TILs score ≥1%. To our knowledge, these are the first prospective data on the prevalence of PD-L1 and TILs in metastatic BC with lymphangitic spread to the chest wall, highlighting potential actionability through therapeutic strategies with new immune-oncology agents in this setting.

Table: Characteristics of patients included in the biomarker analysis (n=35) *Calculated with T test or Fisher’s exact test, as appropriate. Keys: BC, breast cancer; CPS, combined positive score; CT, chemotherapy; HR; hormone receptor; n, number; NA; not available; PD-L1, Programmed cell death ligand protein 1; TILs, tumor infiltrating lymphocytes; TNBC, triple negative breast cancer.

Citation Format: Carmine Valenza, Pier Paolo Maria Berton Giachetti, Paola Zagami, Eleonora Nicolò, Dario Trapani, Laura Boldrini, Beatrice Taurelli Salimbeni, Liliana Ascione, Gabriele Antonarelli, Chiara Corti, Angela Esposito, Carmen Criscitiello, Nicola Fusco, Giuseppe Curigliano. Pembrolizumab and Oral Metronomic Cyclophosphamide in Patients with Chest Wall Breast Cancer (PERICLES): an immune-biomarker analysis of tumor infiltrating lymphocytes (TILs) and programmed cell death ligand protein 1 (PD-L1) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-14-05.

Evolution of biological features of invasive lobular breast cancer: comparison between primary tumor and metastases

BACKGROUND

Invasive lobular carcinoma (ILC) has unique clinical-biological features. Phenotypical differences between primary tumours (PTs) and metastases (M) have been described for invasive ductal carcinoma, but data on ILC are limited.

METHODS

We retrospectively analysed patients with recurrent ILC from our institution from 2013 to 2020. We evaluated the discordance of the oestrogen receptor (ER), progesterone receptor (PgR) and HER2 between PT and M, to understand prognostic and therapeutic implications.

RESULTS

Thirteen percent (n = 91) of all patients had ILC. We observed 15%, 44% and 5% of ER, PgR and HER2 status discordance between PT and M. ER/PgR discordance was related to receptor loss and HER2 mainly due to gain. PT presented a luminal-like phenotype (93%); 6% and 1% were triple-negative (TNBC) and HER2-positive. In M, there was an increase in TNBC (16%) and HER2-positive (5%). Metastasis-free survival and overall survival (OS) were different according to clinical phenotype, with poorer prognosis for HER2+ and TNBC (p < 0.001); OS after metastatic progression did not differ across phenotypes (p = 0.079). In luminal-like ILC (n = 85) at diagnosis, we found that OS after relapse was poorer in patients experiencing a phenotype switch to TNBC but improved in patients with HER2 gain (p = 0.0028). Poorer survival was reported in patients with a PgR and/or ER expression loss of ≥25%. There was HER2-low enrichment in M1 (from 37% to 58%): this change was not associated with OS (p > 0.05).

CONCLUSION

Our results suggest that phenotype switch after metastatic progression may be associated with patients' outcomes. Tumour biopsy in recurrent ILC could drive treatment decision-making, with prognostic implications.

Screening Programs for Breast Cancer: Toward Individualized, Risk-Adapted Strategies of Early Detection

Early detection of breast cancer (BC) comprises two approaches: screening of asymptomatic women in a specified target population at risk (usually a target age range for women at average risk), and early diagnosis for women with BC signs and symptoms. Screening for BC is a key health intervention for early detection. While population-based screening programs have been implemented for age-selected women, the pivotal clinical trials have not addressed the global utility nor the improvement of screening performance by utilizing more refined parameters for patient eligibility, such as individualized risk stratification. In addition, with the exception of the subset of women known to carry germline pathogenetic mutations in (high- or moderately-penetrant) cancer predisposition genes, such as BRCA1 and BRCA2, there has been less success in outreach and service provision for the unaffected relatives of women found to carry a high-risk mutation (i.e., "cascade testing") as it is in these individuals for whom such actionable information can result in cancers (and/or cancer deaths) being averted. Moreover, even in the absence of clinical cancer genetics services, as is the case for the immediate and at least near-term in most countries globally, the capacity to stratify the risk of an individual to develop BC has existed for many years, is available for free online at various sites/platforms, and is increasingly being validated for non-Caucasian populations. Ultimately, a precision approach to BC screening is largely missing. In the present chapter, we aim to address the concept of risk-adapted screening of BC, in multiple facets, and understand if there is a value in the implementation of adapted screening strategies in selected women, outside the established screening prescriptions, in the terms of age-range, screening modality and schedules of imaging.

Loss of HER2 in breast cancer: biological mechanisms and technical pitfalls

Loss of HER2 in previously HER2-positive breast tumors is not rare, occurring in up to 50% of breast cancers; however, clinical research and practice underestimate this issue. Many studies have reported the loss of HER2 after neoadjuvant therapy and at metastatic relapse and identified clinicopathological variables more frequently associated with this event. Nevertheless, the biological mechanisms underlying HER2 loss are still poorly understood. HER2 downregulation, intratumoral heterogeneity, clonal selection, and true subtype switch have been suggested as potential causes of HER2 loss, but translational studies specifically investigating the biology behind HER2 loss are virtually absent. On the other side, technical pitfalls may justify HER2 loss in some of these samples. The best treatment strategy for patients with HER2 loss is currently unknown. Considering the prevalence of this phenomenon and its apparent correlation with worse outcomes, we believe that correlative studies specifically addressing HER2 loss are warranted.

The return of RET GateKeeper mutations? an in-silico exploratory analysis of potential resistance mechanisms to novel RET macrocyclic inhibitor TPX-0046

TPX-0046 is designed to overcome resistance to FDA approved RET inhibitors Selpercatinib and Pralsetinib. Early prediction of resistance mechanisms to investigational drugs may facilitate subsequent drug and trial designs. This study aims to predict potential mutations inducing resistance to TPX-0046. We conducted an in-silico analysis of TPX-0046 macrocyclic structure and predicted the binding mode on RET. We used as reference literary examples of resistance mechanisms to other macrocyclic inhibitors (Lorlatinib on ALK/ROS1) to construct RET secondary resistance mutations. We conducted docking simulations to evaluate impact of mutations on TPX-0046 binding. TPX-0046 binding mode on RET appears to not be influenced by Solventfront G810X mutation presence. Bulky Gatekeeper V804X mutations affect predicted TPX-0046 binding mode. Mutations in Beta 7 strand region L881F and xDFG S891L impair TPX-0046 docking. Our findings suggest that development of second generation RET inhibitors focused mainly on Solventfront G810X mutations granting resistance to selective RET inhibitors Selpercatinib and Pralsetinib. If these findings are confirmed by identification of Gatekeeper V804X mutations in patients progressing to TPX-0046, explanation of acquired resistance and loss of benefit will be easier These findings might accelerate development of third generation RET inhibitors, as well as clinical trial design in precision oncology settings.

Challenges and Obstacles in Applying Therapeutical Indications Formulated in Molecular Tumor Boards

Considering the rapid improvement of cancer drugs' efficacy and the discovery of new molecular targets, the formulation of therapeutical indications based on the multidisciplinary approach of MTB is becoming increasingly important for attributing the correct salience to the targets identified in a single patient. Nevertheless, one of the biggest stumbling blocks faced by MTBs is not the bare indication, but its implementation in the clinical practice. Indeed, administering the drug suggested by MTB deals with some relevant difficulties: the economical affordability and geographical accessibility represent some of the major limits in the patient's view, while bureaucracy and regulatory procedures are often a disincentive for the physicians. In this review, we explore the current literature reporting MTB experiences and precision medicine clinical trials, focusing on the challenges that authors face in applying their therapeutical indications. Furthermore, we analyze and discuss some of the solutions devised to overcome these difficulties to support the MTBs in finding the most suitable solution for their specific situation. In conclusion, we strongly encourage regulatory agencies and pharmaceutical companies to develop effective strategies with medical centers implementing MTBs to facilitate access to innovative drugs and thereby allow broader therapeutical opportunities to patients.

Pathophysiological, haemodynamic and prognostic implications of left atrial dysfunction in cardiac amyloidosis and other cardiomyopathies with hypertrophic phenotype

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND & PURPOSE. Left atrial function (LAF) is a determinant of clinical status and outcome in many cardiac disorders, including cardiac amyloidosis (CA). Aim of this study is to explores the LAF in CA and other cardiomyopathies with hypertrophic phenotype, and its consequences on cardiovascular haemodynamics, right ventricular function and survival.

METHODS. We enrolled 50 patients with CA (26 AL and 24 wtATTR) and 75 with hypertrophic phenotype (LVH group) [25 hypertrophic cardiomyopathy (HCM) pts, 25 hypertensive pts (HypCM), and 25 pts with aortic stenosis (AS)]. LAF was analysed using the phasic method [LAEI as reservoir, LAPEF as conduit, LAAEF as active pump and TLAEF as total emptying function; see figure 1] by LA volumes determination.

RESULTS. ATTR patients showed higher LA dimensions and impaired reservoir and total LA emptying function (TLAEF) compared to AL without differences LAF. Compared to the LVH group, CA patients showed higher LA dimension with impaired LAF in all phasic parameters, higher LV filling pressures and reduced biventricular function. We further divided CA and LVH patients into four subgroups based on the presence or absence of LA dysfunction (LADys+ for TLAEF values below the median: &lt;50.2%; range 9.3-70.9%]. Among the groups, patients with CA/LADys+ showed worst clinical status, higher pulmonary pressures (sPAP) and lower TAPSE and TAPSE/sPAP ratio values. After a median follow-up of 24 months, 19 patients died from cardiovascular (CV) causes (15 in CA/LADys+ group and 4 in LVH/LADys+). The overall survival free of CV death was  64% in CA/LADys+ and 85% in LVH/LADys+ (4/26) group [log-rank χ2 29.6; p &lt; 0.0001]. A sequential multivariate model was employed to assess whether LAF could predict CV deaths: TLAEF was entered together with established clinical and echocardiographic parameters (NYHA functional class, LAVI, E/Em, sPAP, TAPSE and TAPSE/sPAP ratio). At the final backward analysis, LAVI, TAPSE/sPAP and TLAEF were independent prognosticators of CV death.

CONCLUSIONS. LAF is significantly more impaired in CA than LVH group and is associated with worst clinical status, RV dysfunction and higher LV filling and pulmonary pressure. Moreover, LADys is a frequent feature of CA and significantly associated with higher CV mortality. We suggests that LADys in LVH group could results from chronic pressure overload due to LA"s exposure to high LV diastolic pressure (impaired LV compliance). In CA, LADys could also be determined by direct LA infiltration. The pathophysiological result is a progressive LA remodelling with increased LA pressure, consequent backward transmission to the pulmonary venous system and, ultimately, RV dysfunction. TLAEF is parameter of LAF that correlates with increased pulmonary vascular resistance (measured elsewhere with cardiac catheterisation) and RV dysfunction. In CA, it  seems  promising as marker of the haemodynamic consequences of LADys and CV mortality. Abstract Figure 1  Abstract Figure 2

Diagnostic and prognostic implications of myocardial work in cardiac amyloidosis and in genetic and non-genetic cardiomyopathies with hypertrophic phenotype

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND & PURPOSE. Cardiac amyloidosis (CA) is an infiltrative disorder characterized by left ventricular (LV) thickening with early systolic and diastolic dysfunction. Due to it poor prognosis, and the beneficial impact of novel treatments when started in early stages of disease, its forward detection is crucial. Aim of this study is comparing the diagnostic accuracy of classical and novel echocardiographic parameters in detecting CA among other forms of genetic and non-genetic cardiomyopathies with hypertrophic phenotype.

METHODS. We enrolled 50 pts with CA (26 AL and 24 wtATTR) and 75 phenocopies (LVH group) [25 hypertrophic cardiomyopathy (HCM) pts, 25 hypertensive (HypCM) pts, and 25 pts with non-severe aortic stenosis (AS)]. Standard and novel LV morpho-functional echo parameters [LV ejection fraction (LVEF), myocardial contraction fraction (MCF), global longitudinal strain (GLS), relative regional strain ratio (RRSR), ejection fraction on strain ratio (EFSR)], and novel Myocardial Work (MW) parameters [Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), Global Work Efficiency (GWE)] were analyzed.

RESULTS. LV standard, novel and MW-derived systolic parameters were more impaired in CA compared to LVH group. At ROC curve analysis, GCW showed the best performance in discriminating CA from other forms of LVH (AUC 0.886; 95% CI: 0.819-0.954; P &lt; 0.0001), with a cut-off value &lt; 1473 mmHg% showing 90% of sensitivity and 82% of specificity). At linear regression analysis, GCW correlated with many echocardiographic parameters (IVSD, PWD, RWT ratio, LVMi, MCF, LVESV, LVEF, EFSR and RRSR). At multivariate analysis, PWD (P &lt; 0,029) and RWT ratio (p &lt; 0,014) were the only parameters associated with GCW. At 24 months follow-up, there were 15 deaths in CA and 4 in LVH group. At Kaplan-Meier analysis the overall survival free of cardiovascular death was reduced in the lowest GCW interquartile ranges (log-rank χ2 21.5; p &lt; 0.0001). At Cox hazard ratio analysis, GCW was the only prognostic parameter associated with cardiovascular mortality (β 1.006; 95% CI: 1.003-1.009; P &lt; 0.0001).

CONCLUSIONS. Despite CA and LVH patients shows a similar phenotype, the systolic function differs greatly. In the present study, the GCW showed the best ability in detecting CA among other forms of LVH. Its reduction in CA seems reflect the infiltrative burden and its consequences on myocardial deformation properties, while its reduction in LVH group has been attributed elsewhere to fibrotic derangement. GCW showed to be a promising novel diagnostic and prognostic factor in this setting. Abstract Figure 1  Abstract Table 1

Diagnostic and prognostic implications of right ventricular-arterial coupling in cardiac amyloidosis and in genetic and non-genetic cardiomyopathies with hypertrophic phenotype

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND & PURPOSE. Right ventricular (RV) dysfunction in cardiomyopathies is a consequence of chronic overload (i.e. aortic stenosis, AS) or direct involvement of systemic disorders (i.e. cardiac amyloidosis, CA). The Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure (TAPSE/sPAP) ratio has been recently proposed as a surrogate of RV-arterial coupling (RVAC). This study aims to compare RVAC between CA subgroups and between CA and other forms of genetic and non-genetic cardiomyopathies with hypertrophic phenotype.

METHODS. We enrolled 50 patients with CA (26 AL and 24 wtATTR) and 75 cardiomyopathies with hypertrophy phenotype (LVH group) [25 pts with hypertrophic cardiomyopathy (HCM), 25 hypertensive pts(HypCM), and 25 pts with AS]. Besides routine echocardiographic measurements, we analysed right chambers dimensions and classical and novel parameters of RV function [TAPSE, TAPSE/sPAP, St wave, global (RVGLS) and free-wall (RVFWS) strain].

RESULTS. Compared to AL, the ATTR group showed higher right chambers dimensions, without differences in all RV systolic parameters. Compared to the LVH group, CA patients showed no differences in RV dimensions while RV systolic parameters,  including the TAPSE/sPAP ratio, were significantly reduced in the presence of significantly higher LV filling pressures.  At ROC curve analysis, TAPSE (AUC 0.877; 95% CI: 0.811-0.943; p &lt; 0,0001) and TAPSE/sPAP ratio (AUC 0.859; 95% CI: 0.783-0.935; p &lt; 0,0001) showed the best ability in discriminating CA among other forms of LVH (cut-off 20.5 mm for TAPSE with sensibility of 80.5% and specificity of 78.8%, respectively; cut-off 0.62 for TAPSE/sPAP ratio with  sensibility of 85.4% and specificity 81.8%). At 24 months follow-up, there were 15 deaths in CA (30%) and 4 in LVH group (5%). At Kaplan-Meier estimation, the TAPSE/sPAP ratio showed progressively a significantly reduced survival in the lowest interquartile ranges. Moreover, at multivariate analysis, TAPSE/sPAP was the only independent prognostic factor (β -5,644; 95% IC: 0,000-0,522; p &lt; 0,027).

CONCLUSIONS. The RVAC is significantly impaired in CA compared to the LVH group but not between CA subgroups. Its reduction seems attributable to both increase LV filling pressure, due to the restrictive nature of the infiltrative cardiomyopathy, and reduced RV systolic function, due to either indirect RV chronic overload and direct myocardial infiltration. The TAPSE/sPAP ratio is a surrogate of RVAC and proved to be a novel echocardiographic parameter useful in both discriminating CA among genetic and non-genetic forms of LVH, and stratifying the prognosis. Abstract Table 1  Abstract Figure 1

Therapeutic cancer vaccines revamping: technology advancements and pitfalls

Cancer vaccines (CVs) represent a long-sought therapeutic and prophylactic immunotherapy strategy to obtain antigen (Ag)-specific T-cell responses and potentially achieve long-term clinical benefit. However, historically, most CV clinical trials have resulted in disappointing outcomes, despite promising signs of immunogenicity across most formulations. In the past decade, technological advances regarding vaccine delivery platforms, tools for immunogenomic profiling, and Ag/epitope selection have occurred. Consequently, the ability of CVs to induce tumor-specific and, in some cases, remarkable clinical responses have been observed in early-phase clinical trials. It is notable that the record-breaking speed of vaccine development in response to the coronavirus disease-2019 pandemic mainly relied on manufacturing infrastructures and technological platforms already developed for CVs. In turn, research, clinical data, and infrastructures put in place for the severe acute respiratory syndrome coronavirus 2 pandemic can further speed CV development processes. This review outlines the main technological advancements as well as major issues to tackle in the development of CVs. Possible applications for unmet clinical needs will be described, putting into perspective the future of cancer vaccinology.

Myocardial performance is impaired in cardiac amyloidosis: role of myocardial work-derived parameter in differential diagnosis with phenocopies and prognostic implications

Background

Cardiac amyloidosis (CA) is an infiltrative disorder characterized by left ventricular (LV) thickening and dysfunction. Due to it poor prognosis its early detection and differential diagnosis among other forms of cardiomyopathies is fundamental.

Purpose

This study aimed to compare the diagnostic accuracy of LV classical and and novel echocardiographic parameters in differentiating CA from other forms of genetic and non-genetic cardiomyopathies with hypertrophic phenotype.

Methods

We included 50 patients with CA (26 pts with AL and 24 pts with wild type ATTR form) and 75 patients with LV hypertrophy (LVH) [25 patients with hypertrophic cardiomyopathy (HCM), 25 with hypertensive cardiomyopathy (HypCM), and 25 with aortic stenosis (AS)]. Besides routine echocardiographic measurements, we analysed standard and novel echo parameters implied in LV assessment [LV ejection fraction (LVEF), myocardial contraction fraction (MCF), global longitudinal strain (GLS), relative regional strain ratio (RRSR), ejection fraction on strain ratio (EFSR)], included novel Myocardial Work (MW) parameters [Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), Global Work Efficiency (GWE)].

Results

Patients in CA group showed a smallest LV cavity size, higher LV mass and, consequently, a more pronounced concentric hypertrophy compared to LVH group. All LV systolic parameters where more impaired in CA than in LVH group. At ROC curve analysis, among all others, GCW showed the best performance in discriminating CA from LVH (AUC 0.886; 95% CI: 0.819–0.954; P&lt;0,0001), with a cut-off value &lt;1473 mmHg% showing good sensitivity and specificity (90% and 82%, respectively). At linear regression analysis GCW correlated with IVSD (P&lt;0,0001), PWD (p&lt;0,0001), RWT ratio (p&lt;0,0001), LVMi (p&lt;0,0001), MCF (P&lt;0,0001), LVESV (p&lt;0,002), LVEF (P&lt;0,0001), EFSR (p&lt;0,0001) and RRSR (p&lt;0,0001). At multivariate analysis, PWD (P&lt;0,029) and RWT ratio (p&lt;0,014) were the only parameters associated. At 24 months follow-up there were 15 deaths in the CA group and 4 in LVH group. At Kaplan-Meier analysis the overall survival free of cardiovascular death was reduced in the lowest GCW interquartile ranges (log-rank χ2 21,5; p&lt;0,0001). At Cox hazard ratio analysis GCW (β 1,233; 95% CI: 1,201–1,246; P&lt;0,0001) was the only prognostic parameter associated with cardiovascular mortality.

Discussion

Although CA and and LVH have with similar phenotype, they differ greatly in terms of systolic function. The MW, estimated by non-invasive pressure-strain loops, is a novel method for a load-independent LV systolic function assessment. In the present study the GCW showed the best ability in detecting CA in comparison to other parameters usually implied in clinical practice.

Conclusion

Myocardial performance is significantly reduced in CA compared to other forms of LVH. GCW showed to be a promising novel diagnostic and prognostic factor in this setting.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Left atrial function is impaired in cardiac amyloidosis and other cardiomyopathies with hypertrophic phenotype: haemodynamic correlations, pathophysiological consequences and prognostic implications

Background

Left atrial function (LAF) is emerging as a novel determinant of clinical status and outcome in cardiomyopathies. However, few studies compare LAF between CA subgroups and between CA and other hypertrophic cardiomyopathies.

Purpose

This study explores the LAF in cardiomyopathies with hypertrophic phenotype and between CA subgroups and its consequences on clinical status, haemodynamic consequences and survival.

Methods

We enrolled 50 patients with CA (26 with AL and 24 with wild type ATTR form), 75 patients with LV hypertrophy (LVH) [25 with hypertrophic cardiomyopathy (HCM), 25 with hypertensive cardiomyopathy (HypCM), and 25 with aortic stenosis (AS)]. Besides routine echocardiographic measurements, we analysed LAF using the phasic method (LAEI as reservoi, LAPEF as conduit, LAAEF as pump and TLAEF as total emptying LA function).

Results

The ATTR showed higher atrial dimensions with a significant reduction in the reservoir and total LA emptying function compared to the AL group (see Table 1). Instead, compared to the LVH group, CA patients showed higher atrial dimension with all LAF phasic parameters reduced, higher LV filling pressures and reduced biventricular function. Then, we further divided the CA and LVH group into subgroups based on the presence or absence of LA dysfunction (LADys+) defined as TLAEF values below the median [TLAEF &lt;50,2%; range 9,3–70,9%]. Patients in CA/LADys+ group showed the worst NYHA class, higher sPAP and lower values of TAPSE and TAPSE/sPAP ratio (see Figure 2). After a follow-up of 24 months, 19 patients died from cardiovascular causes [0/8 in CA/LADys-, 15/42 in CA/LADys+, 0/60 in LVH/LADys- and 4/26 in LVH/LADys+ group; (log-rank χ2 29,6; p&lt;0,0001)]. To predict whether LAF could predict cardiovascular deaths sequential multivariate model was employed, and TLAEF was entered together with established clinical and echocardiographic parameters (NYHA class, LAVI, E/Em, sPAP, TAPSE and TAPSE/sPAP ratio). At the final backward analysis, LAVI, TAPSE/sPAP and TLAEF were the independent prognosticators for adverse events.

Discussion

The LAF is significantly impaired in CA and associated with worst clinical status, higher incidence of RV dysfunction and higher LV filling and pulmonary pressure. Moreover, LADys is significant associated with higher cardiovascular mortality. LADys results from chronic pressure overload due to LA's exposition to the higher LV diastolic pressure due to impaired LV compliance, and from direct infiltration in CA The result is a progressive LA remodelling with an increased LA pressure and consequenT backward transmission to the pulmonary venous system and to RV.

Conclusions

The TLAEF is a novel parameter of LAF that correlates with increased pulmonary vascular resistance and RV dysfunction. It seems a promising novel prognosticator and amarker of the haemodynamic consequences of LADys.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

The role of right ventricular-arterial coupling in cardiac amyloidosis: a comparison between subtypes and with other genetic and non-genetic hypertrophic cardiomyopathies and prognostic consequences

Background

Right ventricular (RV) dysfunction in cardiomyopathies is a consequence of chronic overload (i.e. aortic stenosis) or direct involvement of systemic disorders (i.e. cardiac amyloidosis, CA). The Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure ratio (TAPSE/sPAP) has been recently proposed as a surrogate of RV-arterial coupling (RVAC) in many cardiac disorders.

Purpose

This study aims to compare RVAC between CA subgroups and between CA and other forms of genetic and non-genetic cardiomyopathies with hypertrophic phenotype.

Methods

We enrolled 50 patients with CA (26 pts with AL and 24 pts with wild type ATTR form), 75 patients with LV hypertrophy (LVH) [25 patients with HCM, 25 with hypertensive cardiomyopathy (HypCM), and 25 with aortic stenosis]. We analysed right chambers dimensions and classical and novel parameters of RV function [TAPSE, TAPSE/sPAP, St (S' wave at RV TDI), global (RVGLS) and free-wall (RVFWS) strain].

Results

The ATTR group showed higher right dimensions than AL, without differences in all RV systolic parameters (see Table 1). Compared to the LVH group, CA patients showed no differences in RV dimensions while RV systolic parameters, included the TAPSE/sPAP ratio, were significantly reduced. At ROC curve analysis TAPSE (AUC 0.877; 95% CI: 0.811–0.943; p&lt;0,0001) and TAPSE/sPAP ratio (AUC 0.859; 95% CI: 0.783–0.935; p&lt;0,0001) showed the best ability in discriminating CA among other forms of LVH (cut-off 20,5 mm for TAPSE with a sensibility of 80,5% and specificity of 78,8%; cut-off 0,62 for TAPSE/sPAP ratio with a sensibility of 85,4% and a specificity 81,8%). At Kaplan-Meier estimation, the TAPSE/sPAP ratio showed a significantly reduced survival in the lowest interquartile ranges. Moreover, at multivariate analysis TAPSE/sPAP was the only independent prognostic factor (β −5,644; 95% IC: 0,000–0,522; p&lt;0,027).

Discussion

The RVAC is significantly impaired in CA compared to the LVH group but not between CA subgroups. TAPSE/sPAP proved to be a novel echocardiographic parameter useful in discriminating CA among genetic and non-genetic forms of LVH, and that also show prognostic significance.

Funding Acknowledgement

Type of funding sources: None. Figure 1. K-M for TAPSE/sPAP ratio IQ rangesTable 1

Investigational immunomodulatory drugs for enhancement of triple negative breast cancer (TNBC) immunotherapy: early phase development

INTRODUCTION

Immunotherapy through the blockade of PD1-PDL1 axis has shown to improve outcomes in advanced and early triple negative breast cancer (TNBC). To further enhance immune-stimulation, and ultimately improve patient outcomes, a wide variety of next-generation immunotherapies (NGIO) is being developed for this disease.

AREAS COVERED

In the present article, we discuss the immune landscape of TNBC and recapitulate the rationale and available clinical evidence of NGIO under early phase development for TNBC, highlighting challenges and opportunities in this emerging field of research.

EXPERT OPINION

Multiple immunotherapeutic strategies beyond PD-(L)1 blockade have been tested for TNBC, including the targeting of further inhibitory checkpoints, the agonism of costimulatory molecules, the intratumoral administration of immunotherapies and cancer vaccines. Most of these strategies have demonstrated to be safe in early clinical trials, with some exhibiting early signs of antitumor activity. To optimally harness the potential of NGIO, a refined patient selection based on emerging immune biomarkers will be required, through an adaptation of immunotherapeutic strategies based on patient and tumor characteristics. More mature data from ongoing clinical trials, added to the progressively increasing knowledge on breast cancer immune landscape, will hopefully clarify the role of NGIO for the treatment of TNBC.

Antibody-Drug Conjugates for the Treatment of Breast Cancer

Metastatic breast cancer (BC) is currently an incurable disease. Besides endocrine therapy and targeted agents, chemotherapy is often used in the treatment of this disease. However, lack of tumor specificity and toxicity associated with dose exposure limit the manageability of cytotoxic agents. Antibody-drug conjugates (ADCs) are a relatively new class of anticancer drugs. By merging the selectivity of monoclonal antibodies with the cytotoxic properties of chemotherapy, they improve the therapeutic index of antineoplastic agents. Three core components characterize ADCs: the antibody, directed to a target antigen; the payload, typically a cytotoxic agent; a linker, connecting the antibody to the payload. The most studied target antigen is HER2 with some agents, such as trastuzumab deruxtecan, showing activity not only in HER2-positive, but also in HER2-low BC patients, possibly due to a bystander effect. This property to provide a cytotoxic impact also against off-target cancer cells may overcome the intratumoral heterogeneity of some target antigens. Other cancer-associated antigens represent a strategy for the development of ADCs against triple-negative BC, as shown by the recent approval of sacituzumab govitecan. In this review, we discuss the current landscape of ADC development for the treatment of BC, as well as the possible limitations of this treatment.

The right heart in cardiac amyloidosis: a comparison between subtypes and with other genetic and non-genetic causes of left ventricular hypertrophy

Background

Right chambers involvement is common in cardiac amyloidosis (CA) but has been ever compared to control groups.

Purpose

Aim of this study is to compare right heart involvement between CA subgroups (AL vs. ATTR amyloidosis) and between CA and other forms of genetic and non-genetic left ventricular hypertrophy.

Methods

We enrolled 25 patients with CA (10 pts with AL and 15 pts with wild type ATTR amyloidosis) and 75 patients with LVH (25 HCM pts; 25 HypCMP pts; 25 AS pts). Beside routine echocardiographic measurements, we analysed right chambers dimensions and classical and novel parameters for right ventricular (RV) function [TAPSE (Tricuspid Anulus Plane Systolic Excursion), St (S' wave at RV TDI), global and free-wall strain].

Results

ATTR group showed higher right dimensions compared to AL, without differences in RV systolic parameters (see table). CA patients, compared to LVH group, showed no differences in right dimensions. RV systolic parameters were significantly reduced while diastolic Doppler parameters were higher (E/E' 21.7±9.0 vs. 11.2±5.0; p&lt;0.0001). At ROC curve analysis TAPSE showed the best ability in discriminating CA among other forms of LVH (AUC 0.936; 95% CI: 0.879–0.993; p&lt;0.0001), with a sensibility of 94.7% and specificity of 87.3% for a cut-off value of 19.5 mm. At Kaplan-Meier estimation CA patients showed a significantly higher cardiovascular mortality compared to LVH group (9/25 deaths vs. none). At multivariate analysis TAPSE was the only independent prognostic factor (β 1.324; 95% IC: 1.086–1.614; p&lt;0.006).

Discussion

CA group showed a significantly impaired RV systolic function with higher pulmonary pressures compared to LVH group. TAPSE proved to be the only able to discriminate CA among genetic and non-genetic forms of LVH and also to have prognostic significance.

Funding Acknowledgement

Type of funding source: None

P664 Relationship of left atrial function assessed by 2D speckle tracking echocardiography with left ventricular systolic function in patients with degenerative mitral regurgitation

Funding Acknowledgements

none

Background

In degenerative mitral regurgitation (DMR), left ventricle (LV) and left atrium (LA) undergo progressive volume overload leading to chamber remodelling and dysfunction in advanced stages. Speckle tracking echocardiography (STE) is an estabilished technique able in detecting subclinical LA and LV dysfunction in this setting. However data are lacking on the relationship of LA and LV function in DMR patients.

Purpose

Our aim was to assess LA function in patients with DMR and to explore its possible correlations with LV dimensions and systolic function.

Methods

We enrolled 95 patients with mild to severe DMR, dichotomizing them on the basis of mitral regurgitation severity (DMR 1-2: mild and mild-to-moderate MR; DMR 3-4: at least moderate to severe MR). LA function was assesed with 2D speckle tracking echocardiography.

Results

The two groups were well matched. DMR 3-4 group (n= 48) showed higher LA and LV volumes, lower right ventricle longitudinal systolic function and higher values of systolic pulmonary pressure. There was not significant difference in LV ejection fraction (LVEF) and global longitudinal strain (GLS). Among LA function indexes, only peak systolic reservoir strain was significantly reduced in DMR 3-4 group (21,9± 6,2% vs 24,7± 7,2% ; p= 0,04). Then population study was further divided in two groups according to the presence (LA dys+) or absence (LA dys-) of LA dysfunction, defined as reservoir strain values below the median [median 23.7%; LAdys- group (n. 49), LAdys+ group (n.46) ]. At the comparison of continuous variables (Tab.1), LAdys+ group showed larger LV end systolic diameter and more impaired LVEF (60,9± 9,8% vs 65,4± 4,8%; p: 0,004) and GLS (20,04 ± 3,7% vs 23,53 ± 2,7%; p &lt;0,001).

Conclusions

Our data showed that LA reservoir strain was impaired in patients with moderate to severe DMR. Furthermore, patients with LA dysfunction showed reduced LVEF and GLS values. Consequently, LA dysfunction assessed with STE may be a novel marker of early LV systolic dysfunction in patients with degenerative mitral regurgitation.

Tab.1 LAdysf- (n = 49) LAdysf+ (n = 46) P value LVESD (mm) 31.78 ± 4.1 34.74 ± 7.6 0.020 LAVI (mL/mq) 44.5 ± 15.1 55.6 ± 25.6 0.015 TAPSE (mm) 26.30 ± 3.96 24.02 ± 3.31 0.004 sPAP (mmHg) 31.4 ± 7.0 36.4 ± 10.9 0.009 LVEF (%) 65.4 ± 4.8 60.9 ± 9.8 0.004 GLS (%) 23.5 ± 2.7 20.0 ± 3.7 &lt;0.001 Comparison of continuous variables between patients with and without LA dysfunction.

Effect of Elongational Flow and Polarity of Organomodified Clay on Morphology and Mechanical Properties of a PLA Based Nanobiocomposite

In biodegradable polymer world nanobiocomposites represent a new group of materials filled with inert nanoparticles that shows very interesting properties and the biodegradability of the matrix. In this work we have studied the effect of the polarity of the organomodified montmorillonite and of the elongational flow on the morphology and the rheological and mechanical properties of a new nanobiocomposite with a matrix of biodegradable PLA based blend. The elastic modulus enhances in presence of the nanofiller and this increase is larger and larger with the increment of the orientation. The tensile strength does not show any significant change at the same level of orientation. Moreover, a brittle-to-ductile transition is observed in the anisotropic sample and this effect is again more evident for the nanocomposite. The raise of the interlayer distance is higher for the more polar montmorillonite, even if the two nanocomposites show about the same final interlayer distance and morphology. Some exfoliation is also observed as a result of the application of the elongational flow.

Efficacy and tolerability of fitostimoline (vaginal cream, ovules, and vaginal washing) and of benzydamine hydrochloride (tantum rosa vaginal cream and vaginal washing) in the topical treatment of symptoms of bacterial vaginosis

Two hundred and 91 patients showing signs and symptoms of bacterial vaginosis (BV) were randomized to receive topical treatment with Fitostimoline (vaginal cream and vaginal ovules + vaginal washing) or benzydamine hydrochloride (vaginal cream + vaginal washing) for 7 days. Signs (leucorrhoea, erythema, oedema, and erosion) and symptoms (burning, pain, itching, vaginal dryness, dyspareunia, and dysuria) (scored 0–3) were evaluated at baseline and at the end of treatment; the total symptoms score (TSS) was also calculated. In 125 patients, a bacterial vaginosis was confirmed by vaginal swab test. The primary efficacy variable analysis, that is, the percentage of patients with therapeutic success (almost complete disappearance of signs and symptoms), demonstrated that Fitostimoline ovules and vaginal cream were therapeutically equivalent and that pooled Fitostimoline treatment was not inferior to benzydamine hydrochloride. All the treatments were well tolerated, with only minor local adverse events infrequently reported. The results of this study confirmed that gynaecological Fitostimoline is a safe and effective topical treatment for BV.

Association between Intraventricular Myocardial Systolic Dyssynchrony and Ventricular Arrhythmias in Patients with Hypertrophic Cardiomyopathy

BACKGROUND

The distribution and magnitude of left ventricular (LV) hypertrophy are not uniform in patients with hypertrophic cardiomyopathy (HCM), which results in regional heterogeneity of LV systolic and diastolic function. The aim of the study was to evaluate LV regional systolic asynchrony in patients with HCM by pulsed Doppler myocardial imaging (DMI).

METHODS

We studied 35 HCM patients and 45 age- and sex-matched controls. By the use of DMI, the following five different basal myocardial segments were measured: systolic peak velocity (Sm); early- and late-diastolic peak velocities; pre-contraction time (Q-Sm) (from the beginning of Q-wave of ECG to the onset of Sm); intraventricular systolic delay (IntraV-Del) (difference of Q-Sm in different LV myocardial segments); interventricular delay (InterV-Del) (difference of Q-Sm between the most delayed LV segment and right ventricular lateral wall).

RESULTS

DMI analysis showed in HCM lower myocardial systolic and early-diastolic peak velocities of all the analyzed segments. As for time intervals, controls showed homogeneous systolic activation of the ventricular walls. Conversely, HCM group, despite the absence of intraventricular conduction defects by surface ECG, showed significant both Inter- and IntraV-Del (P < 0.0001). Linear regression models pointed out independent positive associations of IntraV-Del with LV outflow gradient and septal wall thickness in HCM (P < 0.001). An IntraV-Del >30 msec well differentiated controls and HCM. In addition, an IntraV-Del > 45 msec (ROC curve) identified a subgroup of HCM patients with nonsustained ventricular tachycardia during Holter monitoring (90.9% sensitivity and 95.8% specificity).

CONCLUSIONS

The impairment of intrarventricular systolic synchronicity is strongly related to increased septal thickness and LV outflow-tract gradient in HCM. DMI analysis may be able to select subgroups of HCM patients at an increased risk of ventricular tachyarrhythmias.

Right ventricular functional recovery after acute myocardial infarction: relation with left ventricular function and interventricular septum motion. GISSI-3 echo substudy

OBJECTIVE

To evaluate the pattern of right ventricular (RV) functional recovery and its relation with left ventricular (LV) function and interventricular septal (IVS) motion in low risk patients after acute myocardial infarction (AMI).

DESIGN AND SETTING

Multicentre clinical trial carried out in 47 Italian coronary care units.

PATIENTS

500 patients from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico) -3 echo substudy, who underwent serial echocardiograms 24-48 hours after symptom onset and at discharge, six weeks, and six months after AMI.

RESULTS

Tricuspid annular plane systolic excursion (TAPSE) increased significantly during follow up (mean (SD) 1.79 (0.46) cm at 24-48 hours to 1.92 (0.46) cm at six months, p < 0.001) and the increase was already significant at discharge (1.88 (0.47) cm, p < 0.001). LV ejection fraction (LVEF) was the best correlate of TAPSE at 24-48 hours (r = 0.15, p = 0.001). TAPSE increased significantly in patients both with reduced (< 45%) and with preserved (> or = 45%) LVEF, but the magnitude of increase was higher in patients with lower initial LVEF (p = 0.001). Improvement in IVS wall motion score index (IVS-WMSI) was the only independent predictor of TAPSE changes during follow up (r = -0.12, p = 0.007).

CONCLUSIONS

In low risk patients after AMI, RV function recovered throughout six months of follow up and was already significant at discharge. TAPSE was significantly related to LVEF at 24-48 hours. The magnitude of RV functional recovery was higher in patients with lower initial LVEF. RV functional recovery is best related to IVS-WMSI improvement, suggesting that IVS motion has an important role in RV functional improvement in this setting.

Right ventricular myocardial dysfunction in adult patients late after repair of tetralogy of fallot

AIM OF THE STUDY

To detect in adult patients late after repair of Tetralogy of Fallot (TOF) possible correlation between myocardial parameters assessed at rest by Tissue Doppler (TD) and cardiac performance during physical effort.

METHODS

Doppler echo, treadmill test and pulsed TD of both mitral and tricuspid annulus were performed in 25 healthy subjects and in 40 adult patients who had undergone surgery for TOF at a mean age of 1.4+/-0.5 years. Exclusion criteria were echocardiographic evidence of residual pulmonary, either stenosis or regurgitation. By use of TD, the following parameters were assessed: systolic peak velocities (Sm), pre-contraction time, contraction time, early (E(m)) and late (A(m)) diastolic velocities, E(m)/A(m) ratio, relaxation time. By treadmill test, we measured: maximal heart rate (HR), systolic blood pressure (SBP), rate-pressure product, maximal workload, time duration of the exercise.

RESULTS

the two groups were comparable for left ventricular measurements and for all transmitral and transtricuspid Doppler indexes, while tricuspid ring diameter was increased in TOF. TD analysis showed in TOF lower S(m), E(m) and E(m)/A(m) ratio and prolonged PCT(m) and Rt(m) at tricuspid annulus level, despite comparable TD mitral annulus indexes. By treadmill test, TOF showed reduced time of exercise, number of METS reached and rate-pressure product. Multiple linear regression models evidenced in TOF independent positive association between tricuspid Em velocity and time of exercise (p<0.0001), achieved METS at peak effort (p<0.001) and rate-pressure product (p<0.001). An E(m) peak velocity of tricuspid annulus lower than 0.13 m/s showed 90% sensitivity and 93% specificity in identifying TOF patients unable to perform maximal exercise test.

CONCLUSIONS

despite normal Doppler parameters, adult patients late after correction of TOF showed impaired right ventricular myocardial function. In these patients pulsed TD may be taken into account as a valuable supporting tool to predict the effort response and possibly to assess long-term follow-up of cardiac functional reserve.

Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy

OBJECTIVE

To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus.

DESIGN AND SETTING

Multicentre clinical trial carried out in 47 Italian coronary care units.

PATIENTS AND METHODS

757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views.

RESULTS

In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m(2), p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m(2), p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction.

CONCLUSIONS

Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent determinant of left ventricular thrombosis is the extent of the akinetic-dyskinetic area detected on echocardiography between 24-48 hours from symptom onset.

Aortic atheroma. An unknown source of ischemic stroke

Cerebrovascular mortality represents 25% of all cardiovascular mortality. Defining the pathological mechanism of an episode of ischemic stroke is important for epidemiological, prognostic and overall therapeutic purposes. About 1/4 of ischemic strokes are defined as being of unknown cause. The use of transesophageal echocardiography for studying the aortic arch and thoracic aorta, revealed that aortic atheroma can be considered as an embolic source. Retrospective studies documented a significant prevalence of atheroma >4 mm in the aortic arch in patients with previous stroke (15%); while prospective studies documented an increased risk for cardiovascular events in patients with plaque of =/> 4 mm in thickness at the level of the thoracic aorta compared with controls without these lesions: in particular, the incidence of recurrent stroke is 12%/year, while the incidence of cardiovascular events is 26%. Plaques defined unstable and at risk of embolic event are protrudent, >4 mm in thickness, without calcification and have on their surface mobile thrombus. Embolization from a protrudent atheroma can have a iatrogenic cause, that is cardiac catheterization or placement of an intra-aortic balloon- pump or during cardiopulmonary bypass. The management of the subject with aortic atheroma is not well defined. Encouraging dates with the use of statins are from a recent meta-analysis also anticoagulant treatment versus antiplatelet treatment, reduced incidence of stroke in a significant manner. The surgical therapy of aortic endoarterectomy, has, at this moment, a limited indication, because is not without risk. Transesophageal ecocardiography is a method of choice for the study of the aortic atheroma and it should be done in every patient with stroke by unknown cause.

[Non-invasive evaluation of the endothelial function using high-resolution B-mode ultrasonography]

The vascular endothelium has a central role in regulating vasomotor tone, smooth muscle cell proliferation, platelet and leukocyte adhesion to the arterial wall, thrombosis and fibrinolysis. Disturbances of these endothelial functions have been suggested to be important in the early and advanced phases of atherosclerosis. The development of a simple, valid ultrasound-based method allowed to non-invasively evaluate endothelial function in a large number of individuals with traditional and non-traditional cardiovascular risk factors. The ultrasound technique measures changes in brachial artery diameter in response to an increase in blood flow (reactive hyperemia) and thus in shear stress, which causes endothelium-dependent dilation. This methodology is not yet perfect. The critical issues today involve the definition of "normal values", and standardized scanning and reading protocols to reduce variability.

[Instability determinants of the carotid plaque: from histology to ultrasound]

Over the last decade, it has become progressively clear that the most important mechanism responsible for acute coronary and cerebrovascular events is atherosclerotic plaque rupture with superimposed thrombus formation. Anatomo-pathological studies have shown that the risk of rupture depends on plaque type rather than plaque size. The determinants of carotid plaque vulnerability to rupture are similar to those responsible for coronary instability: 1) size and consistency of the lipid-rich atheromatous core, 2) ongoing inflammation and repair processes within the fibrous cap, and 3) the thickness of the fibrous cap covering the core. Unstable plaques contain a soft, lipid-rich core that is covered by a thin and inflamed cap of fibrous tissue. External factors such as mechanical and hemodynamic stresses may be important not only in precipitating disruption of vulnerable plaques, but also in their cellular differentiation. Several imaging techniques have been used to identify plaques at high risk of events. High-resolution B-mode ultrasound is a noninvasive, inexpensive technique which allows a characterization of carotid plaque dimension, internal structure and surface. Nevertheless, such a method is not perfect. The subjective evaluation of plaque morphology on B-mode ultrasound, the need of improving reproducibility and the lack of a uniform terminology are critical issues, which need to be addressed.

[Maternal-fetal transmission of HCV. Role of HIV as a risk factor]

BACKGROUND

The aim of this study is to determine the rate of vertical transmission of hepatitis C and to analyse the concomitant infection by HIV as a risk factor.

METHODS

We have studied the perinatal transmission of HCV in 22 pregnancies: 14 in women HCV+/HIV-, 8 in women HCV+/HIV+. We have performed the following tests on sera: test RIBA II to search for Ab anti-HCV, alanine transaminase (ALT) evaluation and HCV-RNA research by PCR. These tests were performed on sera from infants at birth and, then, during one year every three months.

RESULTS

Within one year Ab anti-HCV disappeared in 20 of 22 pregnancies: two infants positive by Ab anti-HCV were born to HIV+ mothers and they were the only two who showed abnormal ALT values and detectable levels of HCV-RNA. Finally 10 of 14 infants born to HCV+/HIV- mothers were breast-fed and none was infected.

CONCLUSIONS

We conclude that HCV mother-to-child transmission is an uncommon event, breast-milking is safety, and the concomitant infection by HIV could represent a risk factor for vertical transmission of hepatitis C.

Diagnostic value of transesophageal echocardiography in the assessment of congenitally corrected transposition of the great arteries in adult patients

This study was designed to evaluate the relative diagnostic values of transthoracic (TTE) and transesophageal (TEE) echocardiography in the assessment of congenitally corrected transposition of the great arteries in adult patients. Twelve patients (mean age 29 years, range 21 to 39 years) with congenitally corrected transposition of the great arteries underwent both TTE and TEE examinations to assess this complex cardiac lesion. Of the 12 patients evaluated, situs solitus and inversus were present in 8 and in 4 patients, respectively. TTE correctly identified atrial situs in only 10 patients, whereas TEE, directly evaluating the morphologic features of either appendage, correctly determined situs in every patient. In all 11 patients with intact inlet ventricular septum, the spatial relationship between the septal leaflets of atrioventricular valves was correctly evaluated by both techniques. However, the chordal attachments of both valves were clearly elucidated by TEE in all patients, whereas TTE could obtain images of these in only three patients. TTE was able to evaluate the discordant connection between the right ventricle and the anterior vessel (aorta) in 10 patients, whereas the connection between the left ventricle and the posterior vessel was clearly shown only in 7 patients. Transesophageal longitudinal planes better elucidated these two discordances in all patients irrespective of the position of the heart in the chest and atrial situs. Four patients had an associated ventricular septal defect (inlet defect in one, perimembranous in two, and muscular in one); the inlet defect was unrestrictive and could be easily detected by either imaging technique, whereas the membranous was detected by TTE and by the horizontal transesophageal planes; the muscular defect was recognized only by TTE. Three patients had an associated pulmonary stenosis; Doppler transthoracic echocardiography showed a left outflow peak gradient of 100 mm Hg in two patients and of 80 mm Hg in one but failed to adequately assess the morphologic features of the stenosis, whose features were clearly visualized by transesophageal longitudinal planes in all patients. In conclusion, in our experience TEE is superior to transthoracic imaging in studying congenitally corrected transposition of the great arteries in adult patients; the horizontal plane is best suited to the evaluation of atrial situs and the atrioventricular junction, whereas the longitudinal plane is most valuable in the study of the morphologic features of the ventriculoarterial connections. These findings should be equally applicable to multiplane transesophageal studies.

[Value of transesophageal echocardiography in the diagnosis of paravalvular aortic abscess]

Paravalvular abscesses are a serious complication of aortic endocarditis. Echocardiography is the method of choice for the visualization of the valve-attached vegetations, however the detection of endocarditis-associated abscesses by transthoracic approach is extremely difficult. Recently transesophageal echocardiography has been proved as an excellent tool to correctly detect these lesions. We report on two patients with endocarditis-associated abscesses in whom transesophageal echocardiography allowed us to diagnose paravalvular abscesses not recognized by transthoracic echocardiography; furthermore in the first patient, performing two successive transesophageal examinations before and after antibiotic therapy, we could follow the evaluation of aortic abscess which became a fistula draining into the left ventricular outflow tract. In conclusion these two cases suggest that transesophageal echocardiography should be always performed in patients suspected or known to have endocarditis and that a following examination is indicated to assess any evolving echocardiographic finding.

[Abnormalities of cardiovascular baroreflex control in renal failure and cardiac insufficiency. Experimental study and brief critical review of the literature]

We attempted to determine the relevance and relative prevalence of autonomic dysfunction in 7 patients with end-stage renal disease (ESRD) but no heart disease, 8 patients with left ventricular dysfunction (LVD) with no renal disease and 8 patients with ESRD + LVD. In each group, the assessment of autonomic function and location of the lesion was performed by using the baroreflex sensitivity tests, based upon heart rate (ie Valsalva, deep breathing, lying to standing) to study the parasympathetic system as well as based upon blood arterial pressure (ie standing and sustained handgrip) to evaluate the sympathetic system. The same tests were performed in 7 healthy volunteers enrolled as control group. Separate studies were performed on the efferent parasympathetic arc (atropine test) and the efferent sympathetic arc (cold pressor test). There was evidence of parasympathetic damage in 100% of ESRD patients, in 87.5% of ESRD + LVD patients, and in 62.5% of LVD. Only 1 of ESRD patients showed defective response to atropine whereas the remaining had a normal response, suggesting an afferent lesion alone. No abnormalities were found in the response to cold pressor test, thereby suggesting a lack of involvement of the efferent sympathetic arc. The response to handgrip was higher in LVD patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reference values for the echocardiographic calculation of left ventricular mass in normal children between the ages of 0 and 6]

BACKGROUND

Echocardiographic assessment of left ventricular mass (LVM) and mass/volume ratio (LVM/V) is an accurate method for evaluating left ventricular hypertrophy. However, reference values for LVM and left ventricular volume (V) in children under 6 years of age have not been well established.

METHODS

Therefore, we evaluated 106 consecutive children (60 males, 46 females, mean age +/- SD 35 +/- 28 months, range 0-72) free of cardiovascular disease by clinical, electrocardiographic and echocardiographic examination. LVM and V were determined by M-mode echocardiography.

RESULTS

The 5th and 95th percentile values of LVM were: 7 and 21 grams for infants aged 0 to 6 months; 13 and 32 grams for 7 to 24 months; 23 and 41 grams for 25 to 36 months; 23 and 59 grams for 37 to 48 months; 30 and 60 grams for 49 and 60 months; 36 and 98 grams for 61 and 72 months. The 5th and 95th percentile values of V were: 4 and 20 ml for infants aged 0 to 6 months; 12 and 36 ml for 7 to 24 months; 16 and 43 ml for 25 to 36 months; 20 to 55 ml for 37 to 48 months; 27 to 64 ml for 49 to 60 months; 39 to 74 ml for 61 to 72 months. The 5th and 95th percentile values of M/V ranged between 1 and 2.3 for infants aged 0 to 6 months, and 0.7-1.2 for those aged 61 to 72 months. LVM, V and LVM/V were significantly (p < 0.0001) related to age, height, weight and body surface area, but were unrelated to gender.

[Surgical risk in patients with heart valve disease in non-cardiac surgery]

Our purpose was to retrospectively evaluate major risk of non cardiac surgery in patients with valvular heart disease. We studied retrospectively 136 patients, 44 affected by aortic, 81 by mitral and 11 by mitroaortic valve disease. NYHA class was I-II in 130 and III in 6 patients. Sixty four patients underwent orthopedic surgery, 57 patients occulistic surgery and 5 patients urological surgery. There were no hospital deaths. Fifteen patients developed major perioperative complication: 7 serious ventricular arrhythmias, 6 hypotension, 2 "hypertensive attacks". We conclude that non cardiac surgery is safe in patients with valvular heart disease.

Relationship between QT interval duration and exercise-induced ventricular arrhythmias

This study was performed to determine if QT prolongation before and during early exercise is related to the occurrence of exercise-induced ventricular arrhythmias (EIVA). EIVA occurred in 47 of 142 patients with angiographic evidence of coronary artery disease (CAD); no EIVA occurred among the 22 patients without CAD (OV). Resting QTc and QT intervals during early exercise were similar in patients without EIVA, irrespective of the presence or absence of CAD; however resting QTc was significantly longer in CAD patients who showed EIVA (443 +/- 40 ms; P less than 0.01) than in CAD patients without EIVA (424 +/- 37 ms) and in OV patients (421 +/- 32 ms). During early exercise, the QT interval remained significantly longer in patients with than in those without EIVA. There was a trend toward increasing resting QTc in patients who exhibited EIVA more severe than grade 3. When resting QTc was longer than 440 ms, subsequent EIVA were correctly predicted in CAD patients with a sensitivity of 43%, a specificity of 72% and a predictive accuracy of 63%. Thus, a trend toward longer resting QTc values exists in CAD patients who develop EIVA; however, a long resting QTc (greater than 440 ms) appears to be only a weak predictor of subsequent EIVA.