Abstract PD7-12: Molecular subtyping of male breast cancer by the International male breast cancer program (IMBC): EORTC 10085/TBCRC 0-29/BIG 2-07/NABCG/BOOG 2009-04

Introduction. Male breast cancer (male BC) is a rare disease for which disease management is extrapolated from females. IMBC, an international consortium, which previously reported on clinico-pathological aspects, now reports on molecular subgroups revealed by RNA sequencing and their relation to patient outcome.

Methods. Tumor samples from the retrospective MALE BC registry diagnosed between 1990-2010 and with pathology and outcome data (relapse-free- (RFS) and overall survival (OS)) were included (n=699). To allow the discovery of prognostic features, we selected, stratified for known risk factors (TN stage, grade, age at diagnose and adjuvant endocrine treatment), from the cohort 152 cases with poor (RFS <= 4 yrs) and good outcome (RFS > 7yrs) evenly distributed. Here, we report RNA sequencing results of the first 73 cases, 38 with poor and 35 with good outcome. RNA sequencing reads were used to generate gene expression values and to report transcripts carrying driver mutations. Unsupervised clustering identified subgroups and within subgroups differentially expressed genes were identified. The reported prognostic male BC subgroups M1 and M2 (Johansson BCR 2012(14):R31) were also annotated. All identified subgroups were related to outcome using logistic regression (p-value using Wald test).

Results. Unsupervised clustering revealed 2 main subgroups of which group 1 was enriched for expression of ER target genes, WNT3 and genes from amplicons known for female BC, e.g. 19p13 (CCNE1), 8q24 (MYC), and 11q13 (CCND1). The biology of the smaller group 2 was less defined but TGFβ2 expression was high as were various kallikreins (KLK) including interestingly KLK3 (prostate specific antigen). Other known amplified regions [(8p11 (FGFR1), 20q13 (ZNF217) and 12q15 (MDM2)] and mutated transcripts [PIK3CA (H1047R/L/Q; E542K, E545K, N345K; 16% of cases), TP53 and SF3B1 (K700E) (2% of cases)] were identified. Profound tumor infiltrate gene expression was present in 5% of cases and one third of cases expressed proliferation markers. Except for TP53, none of these latter characteristics were unevenly distributed among the 2 main subgroups. ER and AR were highly correlated, particularly in group 1. The two main groups could be further subdivided. Group 1 comprised 3 subgroups of which subgroup 1a expressed TFF1/3 and NAT1, well-known ER targets, while subgroups 1b and 1c expressed other ER targets,respectively BEX1 and PITX1. HOXC cluster expression differentiated subgroup 1b from 1a and 1c. None of these intrinsic subgroups were, however, related to RFS. The previously reported M2 subgroup, which largely segregated with subclusters 1a and 1b, was associated with a better RFS than the M1 subgroup (OR=2.9; 95%CI 1.1-7.5; p-value=0.03).

Conclusions. 1) Intrinsic subtypes of male BC were revealed and their subgrouping is defined by ER associated subsets of genes. 2) The association of the reported M2 subgroup of male BC with longer RFS was validated; 3) Currently identified biological characteristics of male BC may improve future treatments. The full report on 152 cases including a comparison to female BC will be presented at the conference.

This research was funded by Breast Cancer Research Foundation

Citation Format: Martens JWM, Sieuwerts A, Ponchet C, Smid M, de Weerd V, Slaets L, Piper T, van Deurzen CHM, Schroder CP, Stangle C, Kloosterman W, van Leeuwen-Stok E, Nilsson C, Vermeij J, Peeters S, Goulioti T, Nowaczyk M, Aebi S, Rubio IT, Kelly C, Bayani J, Porter P, Murray M, Hudis C, Middleton L, Korde L, Ruddy K, Winer E, Bogler O, van den Weyngaert D, dal Lago L, Fraser J, Benstead K, van Asperen C, Linderholm B, Hedenfalk I, Tryfonidis K, Giordano S, Bartlett J, Cardoso F. Molecular subtyping of male breast cancer by the International male breast cancer program (IMBC): EORTC 10085/TBCRC 0-29/BIG 2-07/NABCG/BOOG 2009-04 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-12.

Ultrastructural, protein and photosynthetic alterations induced by Pb and Cd in Cynara cardunculus L., and its potential for phytoremediation

The effects of cadmium and lead were investigated in Cynara cardunculus L. Plant uptake by root and shoot, changes in cell ultrastructure and photosynthetic efficiency, photosynthetic key protein levels, as well as regulation of stress-induced Hsp70 were examined. Cynara cardunculus accumulated Cd and Pb in their tissue, with a different trend for the two metals. The prompt translocation of Cd to the shoot may justify the ultrastructural injuries, especially observed in chloroplasts. However, Cd- treated plants did not show any decline in photochemistry; it is likely that Cd in shoot tissue triggers defense mechanisms, increasing the level of proteins involved in photosynthesis (i.e., Rubisco and D1 increased 7 and 4.5 fold respectively) as a compensatory response to neutralize chloroplast damage. The accumulation of Pb mainly in root, can explain the increase in Hsp70 level (23 folds) in this tissue. Pb reached the shoots, even at low amounts, causing an overall significant change in some photochemical parameters (QY and NPQ decreases and increases of 25%, respectively). The results suggest a higher sensitivity of C. cardunculus to Pb than Cd, although maximal photochemical efficiency suggests that this species seems to tolerate Pb and Cd and hence, it is a suitable candidate for phytoremediation.

Laparoscopic Roux-En-Y Gastric Bypass in Elderly Patients (60 Years or Older): A Meta-Analysis of Comparative Studies

Background and Aims:

Elderly patient might experience an increased risk of complications after laparoscopic Roux-en-Y gastric bypass. We aimed to perform a meta-analysis of comparative studies on this issue in patients aged 60 years or older.

Material and Methods:

A systematic literature search was performed. Medline, Cochrane Library, Embase, Scopus, and Google Scholar were searched until July 2016 for studies on outcomes of laparoscopic Roux-en-Y gastric bypass in elderly versus younger patients. Primary outcomes were mortality and overall complications. Secondary outcomes were length of hospital stay, excess weight loss percentage, effect on diabetes, hypertension, hyperlipidemia and obstructive sleep apnea. Heterogeneity across the studies was evaluated by the I2 test, and a random effects model was used. Results were expressed as mean difference and risk ratio (RR).

Results:

Seven studies involving 3128 patients were retrieved and included in this study. A significantly increased risk of mortality and overall complications was observed among patients older than 60 years compared with younger ones (RR, 6.12; 95% confidence interval 1.08–34.83; p = 0.04; RR, 1.51; 95% confidence interval 1.07–2.11; p = 0.02). Particularly, elderly patients experienced 1% increased risk of mortality and 3% increased risk of overall complications. Length of stay, diabetes, and obstructive sleep apnea remission rates were similar among the groups. Excess weight loss percentage was significantly greater among younger patients (mean difference, −3.44; 95% confidence interval −5.20, −1.68; p < 0.001), as were hypertension (RR, 0.57; 95% confidence interval 0.42–0.76; p < 0.001) and hyperlipidemia (RR, 0.61; 95% confidence interval 0.45–0.83; p = 0.002) remission rates.

Conclusion:

Laparoscopic Roux-en-Y gastric bypass in patients older than 60 years may be a risky bariatric surgery operation due to higher complications and mortality and may not be as effective as in patients younger than 60 years. Thus, older patients should be carefully counseled before this procedure for individual risk–benefit assessment.

Sphagnum palustre clone vs native Pseudoscleropodium purum: A first trial in the field to validate the future of the moss bag technique

Although a large body of literature exists on the use of transplanted mosses for biomonitoring of air pollution, no article has addressed so far the use and the accumulation performance of a cloned moss for this purpose. In this work, a direct comparison of metal accumulation between bags filled with a Sphagnum palustre L. clone or with native Pseudoscleropodium purum Hedw., one of the most used moss species in biomonitoring surveys, was investigated. The test was performed in sites with different atmospheric contamination levels selected in urban, industrial, agricultural and background areas of Italy and Spain. Among the eighteen elements investigated, S. palustre was significantly enriched in 10 elements (Al, Ba, Cr, Cu, Fe, Hg, Pb, Sr, V and Zn), while P. purum was enriched only in 6 elements (Al, Ba, Cu, Hg, Pb and Sr), and had a consistently lower uptake capacity than S. palustre. The clone proved to be more sensitive in terms of metal uptake and showed a better performance as a bioaccumulator, providing a higher accumulation signal and allowing a finer distinction among the different land uses and levels of pollution. The excellent uptake performance of the S. palustre clone compared to the native P. purum and its low and stable baseline elemental content, evidenced in this work, are key features for the improvement of the moss bag approach and its large scale application.

Abstract P1-09-21: Clinical evaluation of miR-100 as a predictor of endocrine-responsiveness in hormone-receptor positive breast cancer

Background: Micro RNAs (miRNAs) are short, non-coding RNA molecules that act as negative regulators of gene-expression, mainly at the post-transcriptional level. Alterations in miRNA functions have been implicated in a variety of human diseases, including cancer

We demonstrated that the ectopic expression of miR-100 in cancer stem cells (CSCs) derived from aggressive, basal-like BC (HRs and HER2 negative) caused loss of stemness and the acquisition of a hormone receptor positive and endocrine treatment sensitive phenotype (Petrelli et al, Oncotarget 6;2315-30, 2015). We therefore sought to study whether miR-100 is a determinant of the endocrine-responsive phenotype in HR-positive BC patients (pts).

Methods: Women with newly diagnosed, estrogen-receptor and/or progesterone-receptor positive, HER2 negative BC were eligible for this study. Treatment consisting of tamoxifen for pre-menopausal and letrozole for post-menopausal pts was administered daily for 21 days (+/- 3 days) before breast surgery. MiR-100 levels in pre-treatment tumor biopsies, measured as fold-change with respect to a reference RNA and transformed to the natural logarithms to normalize the data, were correlated with proliferative response to endocrine therapy, as measured by Ki67 expression in the final surgical specimen. The primary end-point was a complete proliferative response (CPR), defined as a post-treatment Ki67≤1%. Additionally, we considered a “post-hoc” composite endpoint where response was defined as a post treatment Ki67 &lt;10% together with a Ki67 reduction ≥80% compared to pre-treatment values. The target accrual is 88 patients (pts). Here we report the results of the first interim analysis focusing on post-menopausal pts receiving letrozole.

Results: A total of 42 pts were evaluable for miR-100 levels and response to endocrine therapy. Median ER and PgR expression was 99% (58%-99%) and 96% (0-99%) respectively. Median pre-treatment Ki67 was 18% (5-76%). Thirty-one tumors were ductal carcinomas, 9 were lobular and 2 were “other” histotypes. The median (range) miR-100 values in pre-treatment specimens was 2.253 (0.460-3.750). After treatment, median Ki67 was 4% (1%-46%) and the median percentage variation with respect to baseline values was -74% (0% to -94%). A CPR was observed in 5/42 pts (12%, 95% C.I. 5%-25%). The median miR-100 levels in responders and non-responders were 3.058 and 2.198, respectively (p = 0.03). Logistic regression analysis showed that each unit increase in miR-100 was associated with a 7-fold increase in the likelihood of a CPR (OR 7.056, 95% C.I. 1.103-45.141, p = 0.04).

Considering the composite end-point, 17/42 pts (40%, 95% C.I. 27%-56%) were considered responders. Median miR-100 levels in responders and non-responders were 2.427 and 1.956, respectively (p = 0.05).

Conclusions: preliminary results of this prospective clinical trial suggest that miR-100 can be a modulator of the endocrine-responsive phenotype in post-m pts with HR-positive breast cancer. The study is completing its target accrual and an investigation of miR-100 targets is being conducted.

GZ and AP contributed equally to this work.

Supported by Associazione Italiana per la Ricerca Sul Cancro (Investigator Grant IG-2013 Ref. 14451).

Citation Format: Zucchini G, Petrelli A, Kubatzki F, Cargnelutti M, Di Virgilio MR, Sarotto I, Martincich L, Ponzone R, Martinello R, Sapino A, Nuzzo A, Giordano S, Montemurro F. Clinical evaluation of miR-100 as a predictor of endocrine-responsiveness in hormone-receptor positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-21.

Tracking the route of phenanthrene uptake in mosses: An experimental trial

In recent decades, mosses have been used as native species or as transplants in monitoring a wide range of pollutants from inorganic (i.e. metals and metalloids) to organic contaminants (mainly polycyclic aromatic hydrocarbons-PAHs). To implement the use of mosses as biomonitors of PAHs, one important issue is the study of the interactions between these compounds and moss tissues. In this study we investigated the mode of phenanthrene uptake in four moss species (Amblystegium humile, Plagiomnium affine, Hypnum cupressiforme and a clone of Sphagnum palustre) and its movements from air to plant surface and within the biomonitors, using fluorescent and confocal microscopy. The target compound, partitioned between gas and particulate phase depending on air conditions, was selected since it is one of the most abundant PAHs released into the atmosphere. Our findings support the hypothesis that phenanthrene aggregates in particles and in this form it is chiefly intercepted and uptaken onto moss surfaces, albeit with different frequency in the four species, with S. palustre>H. cupressiforme>P. affine=A. humile. Phenanthrene enters the dead, empty hyalocysts of S. palustre. Specific surface area and composition, frequency and distribution of binding groups may also explain the different ability of phenanthrene uptake by the four moss species.

Whole body PET/CT in the follow-up of asymptomatic patients with stage IIB-IIIB cutaneous melanoma. Acta Oncol 2016;55:1355-1359. [PMID: 27553064 DOI: 10.1080/0284186x.2016.1213879]

BACKGROUND

Whole body positron emission tomography (PET)/computed tomography (CT) is a sensitive imaging technique in patients with metastatic melanoma, but its role in the follow-up of asymptomatic high-risk patients is unclear. The aim was to study the role of PET/CT as a routine surveillance imaging tool in asymptomatic high-risk patients at the early stage of follow-up combined with a sufficient follow-up over several years.

MATERIAL AND METHODS

A total of 110 asymptomatic patients with clinically local American Joint Committee on Cancer (AJCC) stage IIB-IIIB melanoma underwent routine whole body PET/CT scanning after a mean interval of seven months after initial surgery. Clinical data were retrospectively analyzed after a median follow-up time of 4.6 years.

RESULTS

Recurrent melanoma was detected in 45 patients (41%) and 36 (33%) died of melanoma. In 11 asymptomatic patients (10%) occult disease was detected with a single PET/CT. In seven of these patients (64%), positive PET/CT finding had major influence in treatment decisions. Four patients underwent surgical metastasectomy and two of them remained disease-free. In 34 patients (31%) PET/CT revealed no disease, but recurrence was detected at a median time of 19 months after negative PET/CT scan. In 50 patients (45%) PET/CT finding was true negative. In 15 patients (14%) scan was false positive leading to additional management or repetitive imagings.

CONCLUSION

A single PET/CT could detect 24% of all recurrences in asymptomatic melanoma patients at the early stage of follow-up, but an earlier detection of occult metastases did not improve survival.

Best options for the exposure of traditional and innovative moss bags: A systematic evaluation in three European countries

To develop an internationally standardized protocol for the moss bag technique application, the research team participating in the FP7 European project "MOSSclone" focused on the optimization of the moss bags exposure in terms of bag characteristics (shape of the bags, mesh size, weight/surface ratio), duration and height of exposure by comparing traditional moss bags to a new concept bag, "Mossphere". In particular, the effects of each variable on the metal uptake from the air were evaluated by a systematic experimental design carried out in urban, industrial, agricultural and background areas of three European countries with oceanic, Mediterranean and continental climate. The results evidenced that the shape, the mesh size of the bags and the exposure height (in the tested ranges), did not significantly influence the uptake capacity of the transplanted moss. The aspects more affecting the element uptake were represented by the density of the moss inside the bags and the relative ratio between its weight and the surface area of the bag. We found that, the lower the density, the higher the uptake recorded. Moreover, three weeks of exposure were not enough to have a consistent uptake signal in all the environments tested, thus we suggest an exposure period not shorter than 6 weeks, which is appropriate in most situations. The above results were confirmed in all the countries and scenarios tested. The adoption of a shared exposure protocol by the research community is strongly recommended since it is a key aspect to make biomonitoring surveys directly comparable, also in view of its recognition as a monitoring method by the EU legislation.

Biomonitoring of atmospheric pollution by moss bags: Discriminating urban-rural structure in a fragmented landscape

In this paper we investigated the possibility to use moss bags to detect pollution inputs - metals, metalloids and polycyclic aromatic hydrocarbons (PAHs) - in sites chosen for their different land use (agricultural, urban/residential scenarios) and proximity to roads (sub-scenarios), in a fragmented conurbation of Campania (southern Italy). We focused on thirty-nine elements including rare earths. For most of them, moss uptake was higher in agricultural than in urban scenarios and in front road sites. Twenty PAHs were analyzed in a subset of agricultural sites; 4- and 5-ringed PAHs were the most abundant, particularly chrysene, fluoranthene and pyrene. Overall results indicated that investigated pollutants have a similar spatial distribution pattern over the entire study area, with road traffic and agricultural practices as the major diffuse pollution sources. Moss bags proved a very sensitive tool, able to discriminate between different land use scenarios and proximity to roads in a mixed rural-urban landscape.

Air pollution monitoring using emission inventories combined with the moss bag approach

Inventory of emission sources and biomonitoring with moss transplants are two different methods to evaluate air pollution. In this study, for the first time, both these approaches were simultaneously applied in five municipalities in Campania (southern Italy), deserving attention for health-oriented interventions as part of a National Interest Priority Site. The pollutants covered by the inventory were CO, NOx, particulate matter (PM10), volatile organic compounds (VOCs), and some heavy metals (As, Cd, Cr, Cu, Hg, Ni, Pb, Se, and Zn). The biomonitoring survey was based on the use of the devitalized moss Hypnum cupressiforme transplanted into bags, following a harmonized protocol. The exposure covered 40 agricultural and urban/residential sites, with half of them located in proximity to roads. The pollutants monitored were Al, As, Cd, Cr, Cu, Fe, Hg, Ni, Pb, Se, and Zn, as well as total polycyclic aromatic hydrocarbons (PAHs) only in five sites. Using the emission inventory approach, high emission loads were detected for all the major air pollutants and the following heavy metals: Cr, Cu, Ni, Pb and Zn, over the entire study area. Arsenic, Pb, and Zn were the elements most accumulated by moss. Total PAH postexposure contents were higher than the preexposure values (~20-50% of initial value). Moss uptakes did not differ substantially among municipalities or within exposure sites. In the five municipalities, a similar spatial pattern was evidenced for Pb by emission inventory and moss accumulation. Both approaches indicated the same most polluted municipality, suggesting their combined use as a valuable resource to reveal contaminants that are not routinely monitored.

Has racial difference in cause-specific death improved in older patients with late-stage breast cancer?

BACKGROUND

Research on temporal mortality trends for stage IV breast cancer is limited, especially among older patients by race. We evaluated factors associated with overall, breast cancer-specific and other-cause mortalities using contemporary population data.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked data, we identified older women (≥ 66 years) with stage IV breast cancer diagnosed in 2002-2009. Overall mortality was estimated by the Kaplan-Meier method, compared by log-rank tests, and modeled by Cox models. Competing risk analysis was used to evaluate breast cancer-specific and other-cause mortalities.

RESULTS

The median overall survival time for non-Hispanic blacks improved from 8.6 months in 2002-2003 to 9.9 months in 2007-2009, whereas that for non-Hispanic whites improved from 12.1 to 14.8 months. In the multivariate model, the risk of breast cancer-specific death for patients diagnosed in 2007-2009 was significantly lower (P = 0.02), whereas the risk of other-cause mortality changed little (P = 0.88) compared with those risks for patients diagnosed in 2002-2003. Non-Hispanic blacks had the higher risk of both mortality types compared with non-Hispanic whites; a diagnosis time-race interaction term was not statistically significant for either cause of death.

CONCLUSION

Breast cancer-specific mortality among older women modestly improved from 2002 to 2009 across all races, but not other-cause mortality. Racial disparity in mortality persisted, but did not widen in this period. Efforts should be devoted to improving other-cause mortality for all women, with special attention toward decreasing breast cancer mortality for non-Hispanic black women.

A single postdischarge telephone call by an occupational therapist does not reduce the risk of falling in women after hip fracture: a randomized controlled trial

BACKGROUND

Post-discharge telephone calls to reinforce targeted recommendations for fall prevention have scarcely been investigated in hip-fracture survivors.

AIM

To assess the effectiveness of a single telephone call by an occupational therapist in reducing the proportion of fallers (primary endpoint) and improving the adherence to targeted recommendations for fall prevention (secondary endpoint) after hospital discharge in hip-fracture women.

DESIGN

Randomized controlled trial.

SETTING

Post-acute rehabilitation hospital and community (post-discharge).

POPULATION

We randomized 169 of 228 women with a fall-related fracture of the hip. Data for analyses were available for 153 women (78 from the intervention group and 75 controls).

METHODS

All the women underwent a multidisciplinary program targeted at fall prevention during post-acute inpatient rehabilitation. Additionally, the intervention group received a telephone call by an occupational therapist to reinforce the targeted recommendations for fall prevention at a median of 18 days after discharge. The outcomes were assessed at a six-month follow-up.

RESULTS

Eleven of the 78 women (14.1%) from the intervention group, and 10 of the 75 (13.3%) from the controls sustained at least one fall during the follow-up (relative risk=1.06; 95% CI from 0.48 to 2.34). The mean adherence to the recommendations for fall prevention was 75.1% in the intervention group and 71.2% in the controls (between group difference 3.9; 95% CI from -3.4 to 11.3; P=0.29).

CONCLUSION

Our study does not support a post-discharge telephone call to reinforce the recommendations for fall prevention in hip-fracture women.

CLINICAL REHABILITATION IMPACT

We contribute to elucidate one aspect of multidisciplinary fall-prevention strategies in hip-fracture survivors.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: peri-operative and early outcomes

INTRODUCTION

Controversy exists between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding in super-obese patients.

METHODS

This is a retrospective review of prospectively collected data. A total of 102 consecutive super-obese (body mass index >50) patients underwent laparoscopic Roux-en-Y gastric bypass (Group 1), and 79 consecutive ones underwent laparoscopic adjustable gastric banding (Group 2). Early complications and weight loss outcomes were evaluated.

RESULTS

No significant difference was found in operative mean (± standard deviation) time (93.5 ± 33 vs 87.7 ± 39 min, p = 0.29), hospital stay (2.68 ± 2.27 vs 2.75 ± 1.84 days, p = 0.80), or overall early postoperative morbidity (17.65% and 10.12%, p = 0.20). Intra-operative complications occurred in six patients (5.9%) in Group 1 and none in Group 2 (0.0%, p = 0.04). Mean excess weight loss percent at 6 and 12 months in Group 1 was 44.75% ± 11.84% and 54.71% ± 18.18% versus 26.20% ± 12.42% and 31.55% ± 19.79% in Group 2 (p < 0.001).

CONCLUSION

There seems to be no significant differences in early complications between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding operations in the short term. Weight loss and excess weight loss percent at 6 and 12 months are significantly better after laparoscopic Roux-en-Y gastric bypass.

Medical treatment in gender dysphoric adolescents endorsed by SIAMS-SIE-SIEDP-ONIG

PURPOSE

Despite international guidelines being available, not all gender clinics are able to face gender dysphoric (GD) youth population needs specifically. This is particularly true in Italy. Centers offering specialized support are relatively few and a commonly accepted Italian approach to GD youth has still not been defined. The aim of the present Position Statement is to develop and adhere to Italian guidelines for treatment of GD adolescents, in line with the "Dutch Approach", the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH) guidelines.

METHODS

An in-depth brainstorming on the application of International guidelines in the Italian context was performed by several dedicated professionals.

RESULTS

A staged approach, combining psychological support as well as medical intervention is suggested. In the first phase, individuals requesting medical help will undergo a psycho-diagnostic procedure to assess GD; for eligible adolescents, pubertal suppression should be made available (extended diagnostic phase). Finally, from the age of 16 years, cross-sex hormonal therapy can be added, and from the age of 18 years, surgical sex reassignment can eventually be performed.

CONCLUSIONS

The current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behavior, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.