OP0268 TREATMENT STATUS AFFECTS HOW PULMONARY BIOMARKERS PREDICT PROGRESSION OF SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE

Background:

The course of interstitial lung disease (ILD) varies considerably in patients with systemic sclerosis (SSc), and no biomarkers have been found to consistently predict ILD progression in this population. Treatment may affect how a candidate biomarker correlates with improvement/worsening of SSc-ILD. We hypothesized that specific proteins recovered from bronchoalveolar lavage (BAL) would differentially predict progression of SSc-ILD based on whether a patient was receiving ILD therapy.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1 and changes in radiographic extent of SSc-ILD; (2) To determine if treatment affects whether a specific protein predicts improvement or worsening of SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I (Cyclophosphamide [CYC] vs. placebo) with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis of 68 distinct cytokines, chemokines and growth factors. Quantitative imaging analysis (QIA) was used to calculate the extent of radiographic fibrosis (QLF) in the whole lung using HRCT of the chest at baseline and 12 months. Multivariable linear regression models were created to determine the key BAL proteins associated with change in QLF scores using a backward selection process adjusting for treatment arm and ILD severity. The bootstrap procedure was employed for internal validation.

Results:

A number of BAL proteins were significantly associated with change in QLF scores at 12 months; however, the directionality of these associations was often based on the presence/absence of treatment. For example, increased levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-1, monocyte chemoattractant protein (MCP)-3, chemokine ligand (CCL)-5, transforming growth factor (TGF)-β, hepatocyte growth factor (HGF), stem cell factor (SCF), IL-4, TGF-α, were associated with worse QLF scores in patients who received placebo; whereas, increased levels of these same proteins were associated with improved QLF scores in patients who received CYC (Figure). Increased levels of Fractalkine were associated with worse in QLF scores, and increased levels of IL-7 were associated with improved QLF scores, regardless of treatment arm. In the multivariable model adjusting for treatment arm and baseline severity of ILD, IL-1, MCP-3, surfactant protein C, IL-7, and CCL-5 were independently associated with change in QLF scores.

Figure 1.

Example of a specific BAL protein (GM-CSF) that predicts worse QLF scores in patients receiving placebo (Group B, Red dotted line) and improved QLF scores in patients receiving CYC (Group A, Blue solid line). Shaded areas represent 95% confidence intervals.

Conclusion:

Proteins that mediate both inflammation and fibrosis differentially affected progression of SSc-ILD based on treatment status. Higher levels of certain proteins predicted worsening of ILD in patients receiving placebo, but improvement in patients receiving CYC. Measuring these proteins could help to identify patients who: (1) are at risk for ILD progression, and (2) may preferentially benefit from treatment with immunosuppression.

References:

[1]Tashkin DP, et al. NEJM 2006.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus, Forbius, Donald Tashkin: None declared, Mei Leng: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

OP0267 SHORT-TERM CHANGES IN THE RADIOGRAPHIC EXTENT OF INTERSTITIAL LUNG DISEASE PREDICT LONG-TERM MORTALITY IN SYSTEMIC SCLEROSIS

Background:

The forced vital capacity (FVC) is often used as the primary endpoint in treatment trials for systemic sclerosis-interstitial lung disease (SSc-ILD), and while trends in FVC have been found to predict mortality in SSc-ILD,1,2 FVC measurements are also influenced by extra-pulmonary factors, such as cutaneous sclerosis, myopathy, and patient/technician effort. Change in the quantitative extent of ILD (QILD) on HRCT is an emerging endpoint in clinical trials; however, no studies have evaluated whether changes in radiographic extent ILD predict mortality in SSc-ILD.

Objectives:

To evaluate the relationship between changes QILD in the whole lung (WL) and long-term survival in patients who participated in the Scleroderma Lung Study (SLS) I3 and II.4

Methods:

SLS I randomized 158 SSc-ILD patients to 12 months of cyclophosphamide (CYC) vs. placebo. SLS II randomized 142 SSc-ILD patients to 12 months of CYC, followed by 12 months of placebo vs. 24 months of mycophenolate (MMF). QILD-WL scores were calculated at baseline and 12 months (SLS I) and 24 months (SLS II). Participants were followed for up to 12 (SLS I) and 8 years (SLS II). Using landmark survival analysis, Kaplan Meier curves were generated to compare survival between participants who had worse QILD-WL scores (≥2% increase) and those who had stable/improved QILD-WL scores (<2% increase). Cox proportional hazards models were created to determine whether the change in QILD-WL scores predicted survival after controlling other variables found to affect survival in these cohorts.

Results:

Among all the SLS I and II participants, 82 and 90 had follow up HRCT scans, respectively, and were included in these analyses. SLS I participants with an increase in QILD-WL scores of ≥2% at 12 months had significantly worse long-term survival (P= 0.01; Figure). Similarly, SLS II participants with an increase in QILD-WL scores of ≥2% at 24 months had significantly worse long-term survival (P= 0.019; Figure). After adjusting for baseline FVC, age, and modified Rodnan skin score (mRSS), an increase in QILD-WL scores of ≥2% remained associated with worse long-term survival in SLS I (trend: P=0.089) and SLS II (P=0.014).

Conclusion:

Progression of the radiographic extent of ILD of ≥2% was associated with worse long-term survival in two independent SSc cohorts with extensive long-term follow up. The findings provide compelling evidence that short-term changes in the radiographic extent of ILD may serve as a surrogate endpoint for mortality in patients with SSc.

References:

[1]Goh NS, et al. Arthritis Rheum 2017.

[2]Volkmann ER, et al. Ann Rheum Dis 2019.

[3]Tashkin DP, et al. NEJM 2006.

[4]Tashkin DP, et al. Lancet Resp Med 2016.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Corbus, Donald Tashkin: None declared, Michael Roth Grant/research support from: Genentech/Roche, Jonathan Goldin: None declared, Grace Kim: None declared

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Dynamics of right ventricle contractility after cardiac surgery of tricuspid valve

Funding Acknowledgements

Type of funding sources: None.

Background

The function of right ventricle (RV) is an independent prognostic factor for patients with valvular heart disease. However, changes in RV function parameters in patients with and without tricuspid valve operations after cardiac surgery are lack known. The aim of the study was to define changes in RV parameters after cardiac surgery in patients with left-sided valve diseases.

Methods

Fifty-five consecutive patients (33 men, 61 ± 10 years old), who were referred for the repair and/or replacement of left-sided valves, were included in the study. A transthoracic echocardiography assessment before and an average of 109 days (91-114) following the operation was performed. Tricuspid annular plane systolic excursion (TAPSE), fractional area change RV (FAC), strain of the RV free wall (SRV), and right atrial volume were assessed in groups of patients with and without tricuspid valve repair.

Results

Valve repair for secondary tricuspid regurgitation was performed in nineteen patients undergoing left-sided valve surgery. Thirty-six patients had repair and/or replacement of left-sided valves without a tricuspid valve operation. There was a strong correlation between TAPSE, FAC, and RV strain before the operation (R = 0.62-0.77, p &lt; 0.000002). However, there was no correlation between TAPSE and FAC; TAPSE and RV strain after the operation. TAPSE and RV strain significantly decreased after the operations and were below the normal range in both the groups of patients with and without tricuspid valve repair. TAPSE was 21 ± 5mm before the operation vs. 14 ± 4 mm after operation, p &lt; 0.0000001 for all patients (20 ± 5mm vs. 13 ± 3 mm, p &lt; 0.0003 for the group which underwent tricuspid valve repair; 22 ± 4mm vs. 14 ± 4 mm, p &lt; 0.000001 for tricuspid valves which were not operated on). RV strain was -19 ± 6 mm before operating vs. -16 ± 5mm after operating, p &lt; 0.0004 for all patients (-20 ± 6mm vs. -15 ± 5mm, p &lt; 0.006 for tricuspid valve repair; -19 ± 6mm vs. -16 ± 4 mm, p &lt; 0.02 for the tricuspid valves which were not operated on).  There was no difference in TAPSE and SRV among patients with and without tricuspid valve repair. Decreased longitudinal function parameters (TAPSE and SRV) didn’t correlate with patients’ clinical status or with normalized right chambers volumes. FAC was 39 ± 11% before operating vs. 41 ± 9% after the operation, p = 0.45 for all patients (37 ± 13% vs. 40 ± 8%, p = 0.69 for the group which underwent tricuspid valve repair; 40 ± 10% vs. 41 ± 9%, p = 0.52 for the group with tricuspid valves which were not operated on). An increase in FAC correlated with a decrease in right chamber sizes after operations (R=-0.37, p &lt; 0.03).

Conclusion

Longitudinal right ventricle parameters (TAPSE, SRV) significantly decrease after valve operations in groups with and without tricuspid valve repair. However, there is no correlation with the clinical status of patients. Global function parameters (FAC) correlates with the normalization of right chamber size after cardiac operation.

Design modifications to Rotating Modulation Collimators for extended field-of-view

Rotating Modulation Collimators (RMC) are devices that can be used to determine the location of a radiation source. In this work, a design with extended field-of-view (FOV) is proposed to allow faster measurements by providing a wider scanned area. Monte Carlo simulations were used to calculate the response of the RMC system, system matrix and modulation profiles. The Maximum Likelihood Expectation Maximization algorithm was used for image reconstruction. The proposed design provides a FOV up to 60° with a maximum error of 5° or up to 70° with a maximum error of 15°.