Abstract 538: Liquid biopsy approaches for determining pathologic response to neoadjuvant immunotherapy in esophageal cancer

We examined the utility of serial liquid biopsies to monitor clonal dynamics and predict pathologic response in patients with esophageal/gastroesophageal junction (E/GEJ) cancer undergoing treatment with neoadjuvant immunotherapy and concurrent chemoradiation (CA209-906; NCT03044613).

Methods: Using Targeted Error Correction sequencing (TEC-Seq), we performed high-depth next generation sequencing on 79 serial plasma samples from 16 patients with operable stage II/III E/GEJ cancer undergoing treatment with neoadjuvant nivolumab, followed by nivolumab plus chemo-radiation and surgery as part of the CA209-906 trial. Liquid biopsies were evaluated pre-treatment, after each of two cycles of neoadjuvant nivolumab, and after concurrent nivolumab and chemoradiation immediately prior to surgery, for an average of 4 time points per patient. Deep sequencing of matched leukocyte DNA and whole exome sequencing (WES) of pre-treatment tumors was performed. The origin of plasma variants was determined by comparison to tumor WES (tumor-derived) and leukocyte TEC-Seq (clonal hematopoiesis (CH)-derived or germline) and their clonal dynamics over time were evaluated. Resected tumors were reviewed by central pathology and percent residual tumor was estimated. Patients were followed for an average of 2 years post-surgery.

Results: Eight of 16 patients had detectable circulating tumor-derived DNA (ctDNA) at any time point. Additionally, 13 CH-derived mutations were detected in plasma of 8 patients. The number of CH-derived mutations was correlated with increasing patient age. Identification and removal of CH-derived mutations via comparison to matched leukocyte sequencing allowed for accurate assessment of kinetics of bona fide tumor-derived mutations in plasma. Tumor mutation burden as determined by tumor WES was not associated with pathological response (mean baseline mutations per exome 90 vs 81 for patients with residual disease >20% and <20% respectively). Detectable ctDNA at the last pre-surgery time point was found in 3 patients and was associated with residual tumor >20% (50% vs 23% with or without detectable ctDNA respectively). ctDNA clearance, defined as detectable ctDNA at one or more earlier time points that subsequently becomes undetectable before surgery, occurred in 5 patients and was associated with improved pathologic response (80% of patients with ctDNA clearance had residual tumor <=20% and no evidence of disease progression). Furthermore, of the three patients who did not have ctDNA clearance, two subsequently developed disease progression.

Conclusion: Comprehensive analyses of ctDNA from E/GEJ patients undergoing neoadjuvant immunotherapy with concurrent chemoradiation revealed ctDNA dynamics that were associated with pathologic response and disease recurrence. These approaches may be used to identify patients at high risk for disease progression.

Citation Format: Jenna VanLiere Canzoniero, Vincent Lam, Zineb Belcaid, Mara Lanis, Lamia Rhymee, Blair Landon, Archana Balan, Kristen Marrone, Patrick Forde, Benjamin Levy, David Ettinger, Heather Schneider, Hanika Rodavia, Richard Battafarano, Stephen Yang, Stephen Broderick, Jinny Ha, Blair Jobe, Ali Zaidi, Elizabeth Thompson, Julie Brahmer, Victor Velculescu, Ronan Kelly, Josephine Feliciano, Valsamo Anagnostou. Liquid biopsy approaches for determining pathologic response to neoadjuvant immunotherapy in esophageal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 538.

Simple Vision Function Tests that Distinguish Eyes with Early to Intermediate Age-related Macular Degeneration

PURPOSE

To present and compare baseline vision findings in eyes with early age-related macular degeneration (E-AMD), intermediate AMD (I-AMD), and age-similar participants with normal aging changes to the retina (No-AMD).

METHODS

Two hundred and thirty-seven eyes of 125 individuals (66.4% female, mean age 75.3 years) were tested monocularly using several simple, rapid psychophysical tests: high contrast visual acuity, low contrast visual acuity at reduced luminance, contrast sensitivity, shape discrimination hyperacuity, colour vision, reading rate, and glare recovery. Retinal status was determined using colour fundus photographs that were graded according to the Beckman Initiative for Macular Research Classification Committee scale. Logistic regression analyses with generalized estimating equations were used to assess the association between each vision variable and AMD category, while taking into account the correlation between the two eyes.

RESULTS

Three vision measures (contrast sensitivity [CS], shape discrimination hyperacuity [SDH], and colour discrimination [DesatCCS]) were significantly and independently associated with intermediate AMD. Relative Risk Ratios (RRR), 95% Confidence Intervals (in parentheses), beta coefficients, and significance (p) for the I-AMD vs. No-AMD model are: CS: RRR = 6.5 (1.91-22.0), beta = 1.87, p < .01; SDH: RRR = 2.34 (1.24-4.44), beta = 0.85, p < .001; DesatCCS: RRR = 1.43 (1.22-1.68), beta = 0.36, p < .001. Performance on these measures was significantly poorer for participants with I-AMD vs. No-AMD.

CONCLUSIONS

Simple screening tests distinguish eyes with intermediate AMD from eyes with less severe AMD or normal aging changes. This suggests that these vision measures may be significant predictors of which participants will go on to develop advanced AMD.

Quantum Chemistry of Cocaine and its Isomers I: Energetics, Reactivity and Solvation

ABSTRACT We investigate the rich stereochemistry of cocaine and its diastereoisomers from a theoretical perspective using density functional theory. The relative stability of the eight considered isomers is discussed, and a comparison of the corresponding internal coordinates is given. Our results reveal that the S-pseudococaine isomer is the most stable conformation, whereas the natural occurring isomer (R-cocaine) lies higher in energy. The different isomers' chemical reactivity is discussed based on the calculation of the hardness, softness, electrophilicity and dipole moment. It was found that the dipole moment varies over a broad range from 0.65 to 4.60 D, whereas the other properties are slightly modified. The solvent effect on the energy stability of the cocaine isomers was studied by considering chloroform, dimethyl-sulfoxide (DMSO) and water as implicit solvents. Our calculations show that the different isomers' energy order and their energy gaps are slightly modified due to solvent effects. However, in all cases, the S-pseudococaine remains the most stable isomer. However, the dipole moment and the chemical reactivity of the cocaine isomers increase with the solvent polarity. Keywords: Cocaine isomers,DFT, stability, solvent effect, chemical reactivity.

Visual Function in Eyes with Intermediate AMD with and without Retinal Pigment Abnormalities

SIGNIFICANCE

In intermediate AMD, a simple, clinically feasible vision test of sensitivity to radial deformation is significantly more impaired in eyes with hyperpigmentation than in eyes with large drusen but normal retinal pigmentation, consistent with the former's increased risk of progression to advanced AMD. This ongoing longitudinal study will determine whether this vision measure is predictive of progression to advanced AMD.

PURPOSE

This study aimed to determine whether simple, clinically feasible psychophysical measures distinguish between two levels of intermediate AMD that differ in their risk of progression to advanced AMD: eyes with large macular drusen and retinal pigment abnormalities versus eyes with large macular drusen without pigment abnormalities. Abnormal pigmentation in the presence of large drusen is associated with a higher risk of development of advanced AMD.

METHODS

Each eye of 39 individuals with the same form of intermediate AMD in both eyes was tested monocularly on a battery of vision tests. The measures (photopic optotype contrast sensitivity, discrimination of desaturated colors, and sensitivity to radial deformation [shape discrimination hyperacuity]) were compared for both dominant and nondominant eyes. ANOVA with eye (dominant or nondominant) as a within-subject factor and retinal status (pigmentary abnormalities present or absent from the macula) as a between-subject factor was used to determine statistical significance.

RESULTS

Sensitivity to radial deformation was significantly reduced in eyes with large drusen and pigment changes compared with eyes with large drusen and normal retinal pigmentation (-0.40 ± 0.04 vs. -0.61 ± 0.02, respectively; F = 13.31, P = .001).

CONCLUSIONS

In the presence of large macular drusen, performance on a shape discrimination task is related to the presence versus absence of abnormal retinal pigmentation, being poorer in the higher-risk group, supportive of the measure's potential to predict progression to advanced AMD.

P323Triage-HF Plus: identification of heart failure and non-heart failure events in an ambulatory population using remote monitoring and the triage heart failure risk score Algorithm

Background/introduction

Previous studies examining the utility of cardiac implantable electronic devices (CIEDs) to remotely monitor heart failure patients for decompensation have not demonstrated an impact on hard end-points. However, a key limitation of these prior studies (REM-HF and MORE-CARE) has been the failure to stratify patients according to their risk of worsening heart failure (WHF) prior to randomization (usual care vs active monitoring). We examined a different approach, using a single manufacturer’s remote monitoring platform, whereby only patients with CIED-derived data indicating the highest risk of WHF are contacted for assessment. The validated ‘Triage Heart Failure Risk Score’ (Triage-HFRS) is a medical algorithm within Medtronic CIEDs that can risk-stratify patients as low-, medium- or high-risk of WHF in the next 30 days based on integrated monitoring of physiological parameters.

Purpose

 This study is the largest prospective evaluation of the Triage-HFRS, and examines the additional role of contacting those patients with a ‘High-Risk’ Triage-HFRS alert by telephone (Triage-HF Plus pathway).

Methods

 Prospective, real-world evaluation of the Triage-HF Plus pathway undertaken between June 2016 and September 2019. 326 high-risk Triage-HFRS transmissions were contacted for telephone triage assessment. Screening questions were designed to identify episodes of WHF and non-heart failure events. Interventions were at the discretion of the clinical practitioner and in line with guideline-directed practice. An additional 3-month consecutive sample of low and medium Triage-HFRS transmissions (control group) were also contacted for telephone triage assessment (n= 98).

Results

Successful telephone contact was made following 245 high-risk Triage-HFRS alerts. Following contact, 194 (79.1%) patients reported an acute medical issue: 137 (70.6%) reported symptoms consistent with worsening heart failure (WHF) requiring intervention; and 57 (29.4%) had an alternative acute medical problem. 51 (26.2%) had no apparent reason for the high score. The sensitivity and specificity of CIED-based remote monitoring to identify any HF and non-HF events requiring intervention was 99.5% (97.2-99.9%) and 65.5% (57.3-73.2%) respectively; positive predictive value was 79.2%. The negative predictive value of a non-high risk score to rule out an acute event was 98.9%. Overall accuracy of the pathway to identify an acute issue (HF or non-HF related) was 84.8%.

Conclusion

The Triage-HF Plus clinical pathway is a potentially useful remote monitoring tool for patients with heart failure. The pathway has high diagnostic accuracy to identify patients with WHF and a wide range of non-HF issues which are just as relevant in a population who often have multiple complex co-morbidities and are known for their high health care utilisation.

Proximity to risk-appropriate perinatal hospitals for pregnant women with congenital heart defects in New York state

BACKGROUND

Women with congenital heart defects (CHDs) experiencing pregnancies require specialized delivery care and extensive monitoring that may not be available at all birthing hospitals. In this study, we examined proximity to, and delivery at, a hospital with an appropriate level of perinatal care for pregnant women with CHDs and evaluated predictors of high travel distance to appropriate care. Appropriate care was defined as Level 3 perinatal hospitals and Regional Perinatal Centers (RPCs).

METHODS

Inpatient delivery records for women with CHD in New York State (NYS) between 2008 and 2013 were obtained. Driving time and transit time were calculated between the pregnant woman's residence and the actual delivery hospital as well as the closest Level 3 or RPC hospital using Geographic Information Systems (GIS). Linear and logistic regression models evaluated predictors of high distance to, and utilization of, appropriate delivery care respectively.

RESULTS

From 2008 to 2013, there were 909 deliveries in a NYS hospital by women with CHDs. Approximately 75% of women delivered at a Level 3 or RPC hospital. Younger women, those who reside in rural and smaller urban areas, and those who are non-Hispanic White had a greater drive time to an appropriate care facility. After adjustment for geographic differences, racial/ethnic minorities and poor women were less likely to deliver at an appropriate delivery care center.

CONCLUSIONS

Although most women with CHDs in NYS receive appropriate delivery care, there are some geographic and socio-demographic differences that require attention to ensure equitable access.

Safety of hospital discharge before return of bowel function after elective colorectal surgery

BACKGROUND

Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function.

METHODS

A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien-Dindo classification system.

RESULTS

A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4-7) and 7 (6-8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110).

CONCLUSION

Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients.

Safety and efficacy of non-steroidal anti-inflammatory drugs to reduce ileus after colorectal surgery

BACKGROUND

Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery.

METHODS

A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury.

RESULTS

A total of 4164 patients were included, with a median age of 68 (i.q.r. 57-75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1-3, of whom 1061 (92·0 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001).

CONCLUSION

NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

Report from the 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; 28-29 September 2018

The 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, 28-29 September 2018. This interactive multidisciplinary conference is attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancers. In addition, invited speakers from other provinces participate. Surgical, medical, and radiation oncologists, and allied health care professionals participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancers.

P3683Diagnosis of arrhythmogenic cardiomyopathy and overlap with cardiac adaptation to exercise: insights from a cardiac magnetic resonance study

Background

The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging and some structural abnormalities typical of the disease may overlap with changes reflective of cardiac adaptation to exercise.

Purpose

The aim of the study was to assess the performance of the cardiac magnetic resonance (CMR) 2010 Task Force Criteria (TFC) in a cohort of patients with definite diagnosis of ARVC and define the overlap with a cohort of highly trained athletes of similar age and sex.

Methods

We compared the CMR features of 43 patients (mean age 49±17 years, 49% males, 32 (74%) genotyped) with a definite diagnosis of ARVC according to the revised TFC to 97 (mean age 45±16 years, 61% males) highly-trained athletes of similar age and sex, in whom cardiac disease was excluded after comprehensive work-up.

Results

The CMR was abnormal in 37 (86%) patients. The right ventricle (RV) was affected in isolation in 17 (39%) patients, with 18 (42%) patients exhibiting biventricular involvement and 2 (5%) patients showing isolated left ventricular (LV) involvement. The most common RV abnormalities were regional wall motion abnormalities (RWMA) (n=34; 79%), RV dilatation fulfilling a major or minor volume TFC (n=18; 42%), impaired systolic function (RV ejection fraction (EF) ≤45%: n=17; 40%) and myocardial fibrosis (n=13; 30%). The predominant LV abnormality was myocardial fibrosis (n=20; 47%), with a small proportion of patients exhibiting RWMA (n=6; 14%) and impaired systolic function (LVEF <50%: n=6; 14%). Twenty-three (53%) patients fulfilled a major (n=14; 32%) or a minor (n=9; 21%) CMR TFC. Sixteen (16%) athletes exceeded the cut-off values for RV volumes used as a major (n=10; 10%) or a minor (n=6; 6%) TFC with an inverse relationship between age and RV volumes (r=−41, p=0.001). None of the athletes fulfilled the TFC for RV ejection fraction. Applying the CMR TFC to the ARVC patient population showed a sensitivity of 33% for the major and 28% for the minor criteria. Applying the RV volume and systolic function TFC values in the entire study population showed a sensitivity of 53%, a specificity between 83% and an accuracy of 0.68.

Conclusions

The great majority (86%) of patients with ARVC demonstrates structural abnormalities suggestive of cardiomyopathy on CMR but only 53% fulfills any of the CMR TFC. Only a small proportion (16%) of older athletes demonstrate significant RV dilatation that overlaps with the volume criteria for ARVC, in juxtaposition to younger athletes who exhibit a greater degree of overlap. The emergence of ARVC as a biventricular disease provides an opportunity to re-evaluate the diagnostic criteria and include LV involvement in conjunction with RV involvement to improve diagnostic accuracy.

Acknowledgement/Funding

CRY (Cardiac Risk in the Young) charity

Surveillance of Congenital Heart Defects among Adolescents at Three U.S. Sites

The prevalence, co-morbidities, and healthcare utilization in adolescents with congenital heart defects (CHDs) is not well understood. Adolescents (11 to 19 years old) with a healthcare encounter between January 1, 2008 (January 1, 2009 for MA) and December 31, 2010 with a CHD diagnosis code were identified from multiple administrative data sources compiled at 3 US sites: Emory University, Atlanta, Georgia (EU); Massachusetts Department of Public Health (MA); and New York State Department of Health (NY). The estimated prevalence for any CHD was 4.77 (EU), 17.29 (MA), and 4.22 (NY) and for severe CHDs was 1.34 (EU), 3.04 (MA), and 0.88 (NY) per 1,000 adolescents. Private or commercial insurance was the most common insurance type for EU and NY, and Medicaid for MA. Inpatient encounters were more frequent in severe CHDs. Cardiac co-morbidities included rhythm and conduction disorders at 20% (EU), 46% (MA), and 9% (NY) as well as heart failure at 3% (EU), 15% (MA), and 2% (NY). Leading noncardiac co-morbidities were respiratory/pulmonary (22% EU, 34% MA, 16% NY), infectious disease (17% EU, 22% MA, 20% NY), non-CHD birth defects (12% EU, 23% MA, 14% NY), gastrointestinal (10% EU, 28% MA, 13% NY), musculoskeletal (10% EU, 32% MA, 11% NY), and mental health (9% EU, 30% MA, 11% NY). In conclusion, this study used a novel approach of uniform CHD definition and variable selection across administrative data sources in 3 sites for the first population-based CHD surveillance of adolescents in the United States. High resource utilization and co-morbidities illustrate ongoing significant burden of disease in this vulnerable population.

Starfish in the heart: Congenital anomaly of the papillary muscles

Most common congenital anatomical abnormalities of the subvalvular apparatus (papillary muscles and chordae tendineae) are parachute or parachute like mitral valve. This is more commonly reported among the pediatric population as they develop heart failure symptoms shortly after birth. Reports of adult cases are rare and incidental. Multimodality imaging has an important role in evaluating such anatomical abnormalities, and identification of possible related complications. We are describing a rare atypical variant of parachute like mitral valve.

Improvement in Infection Prevention and Control Measures at The Children Hospital, Lahore. A My Child Matters Collaborative Project

Background: Overcrowding, lack of operational funds, and healthcare associated infections are major challenges at the Children Hospital Lahore, a public healthcare facility in Pakistan with 900 new pediatric cancer admissions annually. In 2014, a collaboration between My Child Matters (MCM), St. Jude Global Infectious Diseases Program (SJ-GID), and our institution was established to address these issues. Aim: To describe the effect of a collaborative improvement strategy on the infection prevention and control (IPC) standards in a pediatric oncology unit in a resource-limited setting. Methods: Our study was a prospective before-and-after study. We compare the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and 4 modules of the St. Jude modified Infection Control Assessment Tool (ICAT) scores. Our strategy included: (1) creating a multidisciplinary team of pediatric hematology-oncology, infectious disease physicians, nurses, microbiologist, and a data manager, (2) engaging on monthly online IPC mentoring sessions with the SJ-GID and MCM mentors, (3) performing daily inpatient healthcare associated (HAI) surveillance rounds, and (4) providing regular hand hygiene training and compliance audits. Results: Our hand hygiene facility level per WHO scores increased from “Inadequate” during the baseline assessment to “Intermediate/Consolidation” by the end of 3-year implementation (122 vs 352 HHSAF scores). The sink: bed and hand sanitizer: bed ratios improved to 1:6 and 1:1 respectively. Six washrooms were added to our unit. ICAT general infection control module increased by 40% (45 vs 78 ICAT score) and hygiene compliance improved by 20% from baseline. Identification of HAI increased from baseline (4.07 vs 8.7 infections per 1000 patient days). A 25% of the isolates were multidrug-resistant microorganisms. Conclusion: Implementing a collaborative improvement strategy improved the IPC standards in our pediatric cancer center. The increase of HAI might be a result of a better surveillance and laboratory identification. Further targeted interventions should be develop to decrease HAI rates and infection-related morbidity and mortality in our population.

Report from the 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Winnipeg, Manitoba; 29-30 September 2017

The 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference (wcgccc) was held in Winnipeg, Manitoba, 29-30 September 2017. The wcgccc is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer.

Pulmonary Hypertension and Atrial Septal Defect: Management Dilemma

The decision making in patients with an atrial septal defect (ASD) in setting of pulmonary hypertension is complex. In the era of pulmonary arterial vasodilator therapy, every patient should undergo evaluation by pulmonary hypertension experts especially if defect closure is being considered. Defect closure in the inappropriate group can lead to poor outcomes.