What predicts survival in glioblastoma? A population-based study of changes in clinical management and outcome

Background

Glioblastoma is the most common and most aggressive primary brain tumor in adults. Despite multimodal treatment, the median survival time is 15-16 months and 5-year survival rate 5%-10%. The primary goal of this study was to identify prognostic factors for survival in an unselected population of patients operated for glioblastoma. The secondary goal was to explore changes in outcome and the clinical management of this patient group over time.

Methods

We identified 222 consecutive adults operated for glioblastoma between November 2012 and June 2016 at the Department of Neurosurgery, Sahlgrenska University Hospital in Gothenburg, serving a health care region in the western part of Sweden with 1.900.000 inhabitants. Clinical variables were identified and tested as predictors for prognosis in extended Poisson regression models. The results were compared with a previously published cohort from 2004 to 2008, before current standard of care based on molecular tumor diagnosis was fully implemented.

Results

Median overall survival was 1.07 years, which was significantly longer than in the 2004-2008 cohort (1.07 vs. 0.73 y, age- and sex adjusted HR = 1.89, p < 0.0001). Variables associated with longer survival in the multivariable model were MGMT promoter hypermethylation, non-central tumor location, complete resection of enhancing tumor, WHO performance status 0-1, unilateral tumor location, fewer lobes involved, younger age and no comorbidities.

Conclusion

The median survival for patients with glioblastoma treated according to current standard treatment has moderately but significantly increased, with MGMT promoter hypermethylation as the strongest predictor for survival.

Maternal metabolic health and fertility: we should not only care about but also for the oocyte!

Metabolic disorders due to obesity and unhealthy lifestyle directly alter the oocyte's microenvironment and impact oocyte quality. Oxidative stress and mitochondrial dysfunction play key roles in the pathogenesis. Acute effects on the fully grown oocytes are evident, but early follicular stages are also sensitive to metabolic stress leading to a long-term impact on follicular cells and oocytes. Improving the preconception health is therefore of capital importance but research in animal models has demonstrated that oocyte quality is not fully recovered. In the in vitro fertilisation clinic, maternal metabolic disorders are linked with disappointing assisted reproductive technology results. Embryos derived from metabolically compromised oocytes exhibit persistently high intracellular stress levels due to weak cellular homeostatic mechanisms. The assisted reproductive technology procedures themselves form an extra burden for these defective embryos. Minimising cellular stress during culture using mitochondrial-targeted therapy could rescue compromised embryos in a bovine model. However, translating such applications to human in vitro fertilisation clinics is not simple. It is crucial to consider the sensitive epigenetic programming during early development. Research in humans and relevant animal models should result in preconception care interventions and in vitro strategies not only aiming at improving fertility but also safeguarding offspring health.

Obese outbred mice only partially benefit from diet normalization or calorie restriction as preconception care interventions to improve metabolic health and oocyte quality

STUDY QUESTION

Can diet normalization or a calorie-restricted diet for 2 or 4 weeks be used as a preconception care intervention (PCCI) in Western-type diet-induced obese Swiss mice to restore metabolic health and oocyte quality?

SUMMARY ANSWER

Metabolic health and oocyte developmental competence was already significantly improved in the calorie-restricted group after 2 weeks, while obese mice that underwent diet normalization showed improved metabolic health after 2 weeks and improved oocyte quality after 4 weeks.

WHAT IS KNOWN ALREADY

Maternal obesity is linked with reduced metabolic health and oocyte quality; therefore, infertile obese women are advised to lose weight before conception to increase pregnancy chances. However, as there are no univocal guidelines and the specific impact on oocyte quality is not known, strategically designed studies are needed to provide fundamental insights in the importance of the type and duration of the dietary weight loss strategy for preconception metabolic health and oocyte quality.

STUDY DESIGN, SIZE, DURATION

Outbred female Swiss mice were fed a control (CTRL) or high-fat/high-sugar (HF/HS) diet. After 7 weeks, some of the HF mice were put on two different PCCIs, resulting in four treatment groups: (i) only control diet for up to 11 weeks (CTRL_CTRL), (ii) only HF diet for up to 11 weeks (HF_HF), (iii) switch at 7 weeks from an HF to an ad libitum control diet (HF_CTRL) and (iv) switch at 7 weeks from an HF to a 30% calorie-restricted control diet (HF_CR) for 2 or 4 weeks. Metabolic health and oocyte quality were assessed at 2 and 4 weeks after the start of the intervention (n = 8 mice/treatment/time point).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Changes in body weight were recorded. To study the impact on metabolic health, serum insulin, glucose, triglycerides, total cholesterol and alanine aminotransferase concentrations were measured, and glucose tolerance and insulin sensitivity were analyzed at PCCI Weeks 2 and 4. The quality of in vivo matured oocytes was evaluated by assessing intracellular lipid droplet content, mitochondrial activity and localization of active mitochondria, mitochondrial ultrastructure, cumulus cell targeted gene expression and oocyte in vitro developmental competence.

MAIN RESULTS AND THE ROLE OF CHANCE

Significant negative effects of an HF/HS diet on metabolic health and oocyte quality were confirmed (P < 0.05). HF_CTRL mice already showed restored body weight, serum lipid profile and glucose tolerance, similar to the CTRL_CTRL group after only 2 weeks of PCCI (P < 0.05 compared with HF_HF) while insulin sensitivity was not improved. Oocyte lipid droplet volume was reduced at PCCI Week 2 (P < 0.05 compared with HF_HF), while mitochondrial localization and activity were still aberrant. At PCCI Week 4, oocytes from HF_CTRL mice displayed significantly fewer mitochondrial ultrastructural abnormalities and improved mitochondrial activity (P < 0.05), while lipid content was again elevated. The in vitro developmental capacity of the oocytes was improved but did not reach the levels of the CTRL_CTRL mice. HF_CR mice completely restored cholesterol concentrations and insulin sensitivity already after 2 weeks. Other metabolic health parameters were only restored after 4 weeks of intervention with clear signs of fasting hypoglycemia. Although all mitochondrial parameters in HF_CR oocytes stayed aberrant, oocyte developmental competence in vitro was completely restored already after 2 weeks of intervention.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

In this study, we applied a relevant HF/HS Western-type diet to induce obesity in an outbred mouse model. Nevertheless, physiological differences should be considered when translating these results to the human setting. However, the in-depth study and follow-up of the metabolic health changes together with the strategic implementation of specific PCCI intervals (2 and 4 weeks) related to the duration of the mouse folliculogenesis (3 weeks), should aid in the extrapolation of our findings to the human setting.

WIDER IMPLICATIONS OF THE FINDINGS

Our study results with a specific focus on oocyte quality provide important fundamental insights to be considered when developing preconception care guidelines for obese metabolically compromised women wishing to become pregnant.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Flemish Research Fund (FWO-SB grant 1S25020N and FWO project G038619N). The authors declare there are no conflicts of interest.

Developing regenerative therapies targeting cardiomyocytes using organotypic slice culture from human adult ventricular myocardium

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Regenerative Medicine Across Borders (RegMedXB) Foundation

Introduction

Cardiovascular diseases (CVDs) are the number one cause of mortality among non-communicable diseases. Two mechanisms of cardiac remodelling after injury have been hypothesized. In the early phases, remodelling is caused by cardiomyocytes (CMs) death, while later it is due to the attempts at reconstruction from the surviving myocardium. Due to the inability of cardiomyocytes to divide, the adult mammalian heart has negligible endogenous regenerative capacity, and the injured myocardium heals through formation of a scar, while surviving CMs become hypertrophic. These mechanisms can lead to progressive left ventricular dilatation, loss of contractility and transition to heart failure. With significant effort from the research community, new therapies to treat cardiac injury are being investigated, with particular attention to regenerative cellular therapies.

Purpose

The aim of this study is to devise therapies able to target CMs to eventually replenish the heart of contractile units by inducing CMs proliferation.

Methods

Atrial appendage or ventricle wall samples were derived from the surgical waste material of adult patients who underwent heart surgery for heart valve disease and/or Morrow myectomy. Cardiac-resident mesenchymal progenitor cells and endothelial cells were derived and amplified from the atrial samples, while organotypic cardiac slices (thickness 300 um) were obtained by cutting the ventricular samples with a vibratome and then cultured at a liquid-air interface. Functionality was proven by viability staining and biochemical assays. Cells and slices were treated with compounds aimed to improve cell health (dexamethasone or SB-431542) and/or vectors carrying reporters (Fiber-modified HAdV vectors or nanoparticles enveloped in a lipid membrane).

Results

Human myocardial slices were viable up to 7 days in culture without electrical or mechanical stimulation. During this time in control conditions there was collagen deposition and onset of fibrosis. Treatment with dexamethasone (100 nM) prevented loss of collagen structure and activation of markers of cardiac remodelling. The specific inhibition of the remodelling marker Smad-3 with SB-431542 didn’t have any evident effect on the viability and structural integrity of the slices. Vectors HadV-5 and HadV-11 had highly efficient transduction in monolayers of human cells peaking around 48h, but low efficiency in myocardial slices. Nanoparticles had efficient transduction in monolayers of cells and myocardial slices, but shorter particle lifespan (&lt;48h).

Conclusions

We established a quick and simple method for the preparation of vital tissue slices from human adult ventricular myocardium as well as their preservation in culture. This model represents a novel platform for testing vectors targeting CMs in a 3-D environment, highlighting the differences in transduction efficiency when compared to standard monolayer culture techniques.

P11.06 Health-related quality of life and emotional wellbeing connected to glioblastoma; a longitudinal follow-up of patients and relatives

BACKGROUND

Glioblastoma is the most common malignant brain tumor in adults and also the most aggressive one. At present, there is only palliative treatment available. The aim of this study is to investigate the HRQoL and emotional well-being of patients with glioblastoma by surveying them and their relatives from a time point before surgery until 2 years later.

MATERIAL AND METHODS

Patients and their relatives answered the validated questionnaires SF-36 and HADS at several time points: preoperatively, at 3 weeks postoperatively, at 12 weeks postoperatively, at 6 months postoperatively, at 1 year postoperatively, at 1.5 years postoperatively, and at 2 years postoperatively. At baseline, the paired patients and their relatives came to consist of 63 patients and 63 relatives. Descriptive statistics and the Wilcoxon signed-rank test were used.

RESULTS

Relatives scored more symptoms of anxiety than patients on all occasions except at 1.5 years postoperatively, with the largest significance preoperatively with p&lt;0.001 and at 3 weeks postoperatively with p&lt;0.001. 50% or more of the relatives reported the presence of symptoms of anxiety on all measured occasions. Furthermore, relatives scored worse for the SF-36 mental component summary (MCS) on all occasions except at 1.5 years postoperatively. Patients scored the SF-36 physical component summary (PCS) worse than the relatives on all measured occasions e.g., preoperatively p&lt;0.001, at 3 weeks postoperatively p&lt;0.001, at 12 weeks postoperatively p&lt;0.001 and at 6 months postoperatively p&lt;0.001. A comparison was also made between patients’ PCS and MCS with an age and gender matched population, patients scored MCS significantly worse than the general population preoperatively p&lt;0.001 with effect size r=0.5, at 3 weeks postoperatively p&lt;0.001with effect size r=0.5 and at 1.5 years postoperatively p=0.013 with effect size r=0.6.

CONCLUSION

The comparison between the HRQoL and emotional well-being of patients with glioblastoma and their relatives from presurgery to one and a half years postsurgery shows that patients on most occasions scored worse physical HRQoL and that relatives mostly scored worse mental HRQoL and emotional well-being. When comparing the patients in the present study with an age and gender matched reference population, it was found that the patients with glioblastoma scored worse HRQoL than the reference population.

O-155 Dietary caloric normalization or restriction as preconception care strategies: impact on oocyte developmental competence and quality in high fat/high sugar-induced obese outbred mice

Study question

Can diet normalization or caloric restriction (CR) for two weeks be used as a preconception care intervention in obese Swiss mice to restore oocyte development and quality

Summary answer

Diet normalization or CR as short-term preconception care interventions in obese mice only partially restored oocyte quality but did improve overall developmental competence.

What is known already

Maternal metabolic disorders like obesity and metabolic syndrome may result in decreased oocyte and embryo quality, and thus reproductive failure. Overweight and obese patients are advised to lose weight before conception to increase the chance of a healthy pregnancy. However, as human studies show no univocal guidelines, more fundamental research might provide additional answers. In order to avoid interference with increased maternal age, the question remains if oocyte quality can be restored after only a short preconception care intervention (PCCI).

Study design, size, duration

Outbred mice were fed a control (CTRL) or high-fat/high-sugar (HF) diet for seven weeks. Afterwards, HF-mice were put on different PCCIs for two weeks, resulting in four treatment groups: control diet (9w; CTRL_CTRL), HF diet (9w; HF_HF), switch from HF (7w) to an ad libitum control diet for 2w (HF_CTRL) or to a 30% CR diet for 2w (HF_CR). Oocyte developmental competence (n = 357) and quality (12-16 oocytes /treatment, scored blinded) were determined, using 6-8 mice/treatment.

Participants/materials, setting, methods

Body weight changes were recorded. In vivo matured oocytes were collected after superovulation and analysed for quality or in vitro fertilized and cultured. Oocyte quality was determined by staining for lipid content (Bodipy) and mitochondrial inner membrane potential and active mitochondria localization (JC-1). Oocyte developmental competence [cleavage (24h p.i.) and blastocyst rates (5 days p.i.)] was scored. Categorical and numerical data were analysed using binary logistic regression and ANOVA, respectively and corrected for multiple testing.

Main results and the role of chance

Compared to the CTRL group, HF diet increased body weight after 7 weeks by 24.19% (P &lt; 0.001). After the start of the PCCI, both HF_CTRL and HF_CR mice progressively lost weight and reached values similar to control mice after two weeks. HF_HF diet increased the intracellular lipid content in oocytes with 54.3% compared to the CTRL_CTRL group (P &lt; 0.05). This increased content was (partially) normalized in both preconception care intervention groups, even similar to the control levels in the HF_CTRL group. Both HF_HF and HF_CR oocytes showed a tendency to an increased ratio of active/total mitochondria when compared to the CTRL_CTRL group (P = 0.081, P = 0.083 respectively). In addition, active oocyte mitochondria in the HF_HF group were less pericortically distributed compared to controls. This was also the case in both preconception care intervention groups (P &lt; 0.05). After two weeks of PCCI, oocytes from HF_HF mice displayed lower cleavage rates than those from CTRL_CTRL mice (36.26% vs. 64.52%, P &lt; 0.05) but blastocyst rates (26.37% vs. 35.48%, P &gt; 0.1) were not different. HF_CR, but not HF_CTRL, oocytes showed higher cleavage rates (68.48%, P &lt; 0.001) compared with HF_HF oocytes. Moreover, both HF_CTRL (44.64%, P &lt; 0.05) and HF_CR (59.78%, P &lt; 0.001) oocytes showed improved blastocyst rates when compared to the HF_HF group (26.37%).

Limitations, reasons for caution

Although using a mouse model has several advantages, translating these results to the human setting is a limitation of this study. However, to improve this translatability, an outbred mouse model was used. Additional data will be collected to gain more information regarding the best preconception care intervention advice.

Wider implications of the findings

This research aims to provide fundamental insights in order to be able to formulate clear preconception guidelines to obese women planning for pregnancy. In addition, we aim to find the shortest possible intervention period to improve fertility.

Trial registration number

Not applicable

Ontogeny of Hepatic Transporters and Drug-Metabolizing Enzymes in Humans and in Nonclinical Species

The liver represents a major eliminating and detoxifying organ, determining exposure to endogenous compounds, drugs, and other xenobiotics. Drug transporters (DTs) and drug-metabolizing enzymes (DMEs) are key determinants of disposition, efficacy, and toxicity of drugs. Changes in their mRNA and protein expression levels and associated functional activity between the perinatal period until adulthood impact drug disposition. However, high-resolution ontogeny profiles for hepatic DTs and DMEs in nonclinical species and humans are lacking. Meanwhile, increasing use of physiologically based pharmacokinetic (PBPK) models necessitates availability of underlying ontogeny profiles to reliably predict drug exposure in children. In addition, understanding of species similarities and differences in DT/DME ontogeny is crucial for selecting the most appropriate animal species when studying the impact of development on pharmacokinetics. Cross-species ontogeny mapping is also required for adequate translation of drug disposition data in developing nonclinical species to humans. This review presents a quantitative cross-species compilation of the ontogeny of DTs and DMEs relevant to hepatic drug disposition. A comprehensive literature search was conducted on PubMed Central: Tables and graphs (often after digitization) in original manuscripts were used to extract ontogeny data. Data from independent studies were standardized and normalized before being compiled in graphs and tables for further interpretation. New insights gained from these high-resolution ontogeny profiles will be indispensable to understand cross-species differences in maturation of hepatic DTs and DMEs. Integration of these ontogeny data into PBPK models will support improved predictions of pediatric hepatic drug disposition processes. SIGNIFICANCE STATEMENT: Hepatic drug transporters (DTs) and drug-metabolizing enzymes (DMEs) play pivotal roles in hepatic drug disposition. Developmental changes in expression levels and activities of these proteins drive age-dependent pharmacokinetics. This review compiles the currently available ontogeny profiles of DTs and DMEs expressed in livers of humans and nonclinical species, enabling robust interpretation of age-related changes in drug disposition and ultimately optimization of pediatric drug therapy.

[Lithium use in women with bipolar disorder during peripartum]

BACKGROUND

Lithium use during peripartum requires careful consideration due to a risk of teratogenic effects, adverse side effects and risk of neonatal complications. However, given the effectiveness of lithium, use during the peripartum period may be indicated.

AIM

To provide an overview of the current evidence regarding the clinical use of lithium during peripartum, including risk of relapse in case of (dis)continuation and evolution of lithium levels.

METHOD

A review was performed in the Medline and ScienceDirect database.

RESULTS

Ten studies were included. Six studies concerned the risk of relapse in case of (dis)continuation of lithium during the peripartum. Four studies concerned the evolution of lithium levels throughout the peripartum. Lithium discontinuation during pregnancy leads to an increased risk of relapse during pregnancy and postpartum. At the same dose, lithium levels are lower than preconceptual in all trimesters.

CONCLUSION

Risk and benefits of lithium use during the peripartum should be carefully considered, if possible prior to conception. Close monitoring of maternal lithium levels and renal function is necessary due to significant fluctuations during peripartum.

Capacity of Trolox to improve the development and quality of metabolically compromised bovine oocytes and embryos invitro during different windows of development

Trials to improve oocyte developmental competence under metabolic stress by using antioxidants may start before or after oocyte maturation. In the present conceptual study, we aimed to identify the most efficient timing of antioxidant application in relation to a metabolic insult using a bovine invitro embryo production model. Pathophysiological concentrations of palmitic acid (PA) were used to induce metabolic stress during oocyte maturation or embryo development. Trolox (TR; antioxidant) treatment prior to, during or after the PA insult was tested to evaluate the protective, neutralising and rescuing capacity of TR respectively. Changes in embryo developmental competence, mitochondrial activity, reactive oxygen species (ROS) concentrations, blastocyst cell allocation and apoptosis and cell stress-related gene expression were monitored. The improvement in developmental capacity was most obvious when oocytes were preloaded with TR before the PA insult. This protective effect could be explained by the observed combination of increased mitochondrial activity with reduced ROS production. This resulted in blastocysts with normal cell counts and apoptosis, as well as increased nuclear factor erythroid 2-related factor 2 (NRF2) expression (a marker for redox regulatory processes) and normalised the expression of the mitochondrial transcription factor A (TFAM), a marker of mitochondrial biogenesis. These results indicate that 'pretreatment' of oocytes with antioxidants produces embryos that seem to be more resilient to a metabolic stress insult.

EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort†: Under the Auspices of the EAU-ESMO Guidelines Committees

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts prior to voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), and 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these statements, 33 (28%) achieved level 1 consensus and 49 (42%) achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease, and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time when further evidence is available to guide our approach.

PATIENT SUMMARY

This report summarises findings from an international, multistakeholder project organised by the EAU and ESMO. In this project, a steering committee identified areas of bladder cancer management where there is currently no good-quality evidence to guide treatment decisions. From this, they developed a series of proposed statements, 71 of which achieved consensus by a large group of experts in the field of bladder cancer. It is anticipated that these statements will provide further guidance to health care professionals and could help improve patient outcomes until a time when good-quality evidence is available.

Monitoring of Brain Hemodynamics Coupling in Neonates using Updated Tensor Decompositions

In this paper we explore the use of updated tensor decompositions for the monitoring of brain hemodynamics in neonates. For this study, we used concomitant measurements of heart rate, mean arterial blood pressure, arterial oxygen saturation, EEG, and brain oxygenation - measured using near-infrared spectroscopy. These measurements were obtained from 22 neonates undergoing an INSURE procedure (INtubation, SURfactant and Extubation) and sedation using propofol. To develop the monitoring framework using tensors, we used radial basis kernel function (RBF) to construct a similarity matrix for consecutive segments of the signals. These matrices were concatenated forming a tensor. Updating canonical polyadic decomposition was used to evaluate the impact of propofol in the coupling between the different signals. Results indicate, as previously reported, a drop in the interaction between signals due to propofol administration. This shows that tensor decompositions can be useful in order to monitor the coupling between different physiological signals.

3 Dietary caloric normalization or restriction as preconception care strategies: Impact on metabolic health and fertility in high fat-induced obese outbred mice

Maternal metabolic disorders such as obesity and metabolic syndrome are linked to decreased oocyte and embryo quality and thus reproductive failure. Overweight and obese patients are advised to lose weight before conception to increase the chance of a healthy pregnancy. Human studies show conflicting results and are often underpowered, leading to a lack of scientifically substantiated advice. Furthermore, the effects of significant weight loss, due to caloric restriction, on oocyte quality are not known. Therefore, we aimed to feed a normal control or low-calorie diet as a preconception care strategy in high-fat-fed obese Swiss mice to improve their metabolic health and oocyte quality. Five-week-old female outbred Swiss mice (as a model for human physiology) were fed a control (CTRL; 10% fat) or a high-fat (HF; 60% fat) diet for seven weeks. Afterward, HF mice were switched to different preconception care interventions (PCCI) for six weeks, resulting in four treatment groups: (1) control diet for 13 weeks (CTRL_CTRL), (2) high fat diet for 13 weeks (HF_HF), (3) switch from a HF to an ad libitum CTRL diet (HF_CTRL), and (4) switch to a 30% caloric restriction diet (HF_CR). Change in bodyweight (twice a week, n=156 mice), metabolic health (glucose and insulin tolerance tests; n=32 mice), oocyte quality and pregnancy rates (n=32 mice) were studied. To assess oocyte quality, mature oocytes were collected after hormonal stimulation (10IU equine chorionic gonadotrophin followed by 10IU human chorionic gonadotrophin 48h later, IP injected) to evaluate oocyte lipid content (Bodipy staining; 11-12 oocytes/group) and to examine mitochondrial ultrastructure by transmission electron microscopy (4-5 oocytes/group). All data were analysed using analysis of variance and Bonferroni corrected. In comparison with the CTRL group, HF diet increased bodyweight after seven weeks (40.01±0.54g vs. 32.01±0.47 g; P&lt;0.05). After 2 weeks of PCCI, both HF_CTRL and HF_CR mice had lost weight, reaching similar weights as control mice. Overall, the deteriorated glucose tolerance and insulin sensitivity in the HF_HF group were normalized to levels similar to the CTRL_CTRL group in both PCCI. Transmission electron microscopy of HF_HF oocytes showed higher proportions of mitochondrial ultrastructural abnormalities, e.g. low electron density and rose petal appearance (Boudoures et al. 2016 Reproduction 151(3):261-270) compared with CTRL_CTRL (54.70% vs. 30.52%; P&lt;0.05). After six weeks of PCCI, the proportions of mitochondrial abnormalities were partially reduced in both HF_CTRL (39.64%) and HF_CR (44.47%) groups. The HF_HF diet increased the intracellular lipid content in oocytes with 84.41% compared with the CTRL_CTRL group (P&lt;0.05). However, both PCCI strategies failed to alleviate this effect. The HF_HF-fed mice displayed lower pregnancy rates compared with those on the CTRL_CTRL diet (12.5% vs. 100%; P&lt;0.05). Pregnancy rates were completely restored in the HF_CTRL and HF_CR group. In conclusion, both PCCI improved metabolic health (reduced weight, restored glucose tolerance and insulin sensitivity), partially improved oocyte quality, and restored pregnancy rates in HF-induced obese mice.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

P11.43 Deletions on Y chromosome are associated with shorter survival in glioblastoma

BACKGROUND

Apart from few exceptions, men are more likely to be diagnosed with cancer during their lifetime, including glioblastoma (GBM), but the gender-related differences in GBM are poorly understood. Loss of chromosome Y (LOY) in peripheral blood cells is associated with physiological ageing, but also with disorders like cardiovascular disease, Alzheimer’s disease and different cancer types. In this study, we determined deletions on Y chromosome in tumor tissue of male patients with GBM, and studied the impact of LOY on survival.

MATERIAL AND METHODS

Ten genes, serving as markers, were selected on both arms of chromosome Y for copy number analysis with droplet digital PCR (ddPCR), enabling detection of loss of a marker in a fraction of the tumor cells used for DNA extraction. A total of 114 tumor samples from male patients were used, derived from a cohort of IDH wild type GBM patients treated with standard radio-chemo therapy. For 61 of these 114 patients, corresponding blood samples were available and analyzed. Different cut-off values were tested for each marker and Kaplan-Meier log-rank analysis was used to estimate overall survival. The mRNA expression for nine of the ten tested genes was available in TCGA, and 225 IDH wild type male GBM were included in a separate survival analysis, where median value of expression was used as group separator.

RESULTS

Fractional loss, as well as gain of markers was detected. Decreased copy number of the following markers was associated with significantly shorter survival; amelogenin Y-linked (AMELY) (13.5 vs. 19.3 months, p=0.017), neuroligin 4 Y-linked (NLGN4Y) (11.8 vs. 18.9 months, p=0.03) and sex determining region Y (SRY) (10.3 vs. 18.7 months, p=0.002). Additional analysis of SRY in the blood samples verified that copy number alterations were predominantly present in tumors. Survival analysis using mRNA expression data from TCGA showed that reduced expression of SRY was associated with significantly shorter OS (13.8 vs. 19.8 months, p=0.008), but no significant correlation with OS for any of the other markers.

CONCLUSION

Our data suggests a clonal or at least sporadic occurrence of fractional loss of Y chromosome markers in GBM, as detected with ddPCR. Interestingly, such dosage changes may contribute to shorter survival in men and explain some of the sex disparity seen in GBM. More research is needed to elucidate the molecular mechanisms of LOY and the role of specific Y-linked genes in GBM but also other diseases.

The Use of Hemodynamic and Cerebral Monitoring to Study Pharmacodynamics in Neonates

BACKGROUND

Drugs acting on the cardiovascular and central nervous system often display relatively fast clinical responses, which may differ in neonates compared to children and adults. Introduction of bedside monitoring tools might be of additional value in the pharmacodynamic (PD) assessment of such drugs in neonates.

METHODS

We aim to provide an overview of the frequently used monitoring tools to assess drug effects on the hemodynamic status as well as the cerebral circulation, oxygenation and cerebral metabolism in neonates.

RESULTS

The use of blood pressure measurements, heart rate variability, functional echocardiography, nearinfrared spectroscopy and (amplitude-integrated) electroencephalography in neonates is discussed, as well as new parameters introduced by these tools. Based on the 'brain circulation model', the hemodynamic effects on the brain and their interplay are summarized. In this model, 3 processes (i.e. blood processes, vascular smooth muscle processes and tissue processes) and 3 mechanisms (i.e. autoregulation, blood flow metabolism coupling and cerebral oxygen balance) are distinguished, which all may be influenced by drug administration. Finally, propofol, sevoflurane, midazolam and inotropes are used as examples of which PD has been studied using the available hemodynamic and/or cerebral monitoring tools.

CONCLUSION

The implementation of (non-)invasive monitoring tools to document hemodynamic and cerebral PD effects in neonates is of relevance both in a neonatal research and intensive clinical care setting. We highlight the need to integrate these tools in future PD research. Furthermore, besides short-term drug effects, long-term outcome of drug therapy in neonates also warrants further attention.

47 Effect of a long-term, high-fat diet on metabolic health and oocyte quality of an outbred (Swiss) versus inbred (C57BL/6N) mouse strain

Maternal metabolic disorders like obesity and diabetes type II are known to affect reproductive physiology, ultimately leading to poor fertility. The oocyte and embryo are extremely vulnerable during the periconceptional period to metabolic stressors, leading to disappointing fertility results. Most mouse model research regarding obesity and Western type diets has been performed on the inbred C57BL/6 strain. However, inbred strains are often linked with decreased fertility. Relying only on inbred strains might also limit translation to human (outbred) physiology. To further explore this, we compared the inbred C57BL/6N to an outbred Swiss strain. Five-week-old Swiss (N=30) and C57BL/6N (B6) (N=29) mice were fed a control (CTRL) or a high-fat (HF) diet for 13 weeks. Diets differed in percentage of fat (10% v. 60%). Body weight gain, serum profile (nonesterified fatty acids, cholesterol, and triglycerides), and oocyte quality were studied. Mature oocytes were collected after hormonal stimulation (IP injection of 10IU of pregnant mare serum gonadotropin followed by 10IU of hCG 48h later). To study oocyte quality, Bodipy (lipid droplets), JC-1 (mitochondrial membrane potential), and Cell-Rox Deep Red stainings were performed, as well as transmission electron microscopy to examine mitochondrial structures. All data were analysed using the t-test. In comparison with the CTRL group, the HF diet increased body weight by 18.09 and 27.87% in Swiss and B6, respectively. The HF significantly increased blood cholesterol levels (103.5v. 143.1 mg/dL in Swiss mice, 141.8v. 185.4 mg/dL in B6 mice) in both strains, and tended to increase blood nonesterified fatty acids (P=0.053) and triglycerides (P=0.075) only in Swiss but not in B6 mice. Oocytes collected from the HF diet group contained a larger total volume of lipid droplets (P&lt;0.05) in both strains compared with controls. The mitochondrial membrane potential and Cell-Rox Deep Red were significantly increased (P&lt;0.05) in oocytes of Swiss mice, but not B6 mice, fed a HF diet. Transmission electron microscopy images from HF oocytes showed mitochondria with abnormal morphology, low electron density, and rose petal appearance, resulting in significantly increased mitochondrial abnormalities in Swiss mice on the HF diet (P&lt;0.05). In B6 mice, both CTRL and HF oocytes contained high proportions of abnormal mitochondria compared with the CTRL group of the Swiss mice, explaining the lack of HF diet effects in B6 oocyte ultrastructure. We conclude that a HF diet has a significant effect on both metabolic health and oocyte quality. However, the Swiss model seems more sensitive to a Western type diet insult, making it more suitable for research focusing on metabolic health and oocyte quality than the B6 strain. The HF diet-exposed Swiss mice showed differences (compared with CTRL) in their serum profile. Alterations in mitochondrial activity, structures, and oxidative stress were induced by HF diet in the Swiss mice and not the B6, although B6 oocytes also showed higher lipid droplet accumulation. Furthermore, even the B6 mice that were fed a normal control diet showed deviant oocyte quality, clearly shown by morphological signs of lower quality and mitochondrial abnormalities.

Can sidestream dark field (SDF) imaging identify subtle microvascular changes of the bowel during colorectal surgery?

BACKGROUND

Recognition of a non-viable bowel during colorectal surgery is a challenging task for surgeons. Identifying the turning point in serosal microcirculatory deterioration leading up to a non-viable bowel is crucial. The aim of the present study was to determine whether sidestream darkfield (SDF) imaging can detect subtle changes in serosal microcirculation of the sigmoid after vascular transection during colorectal surgery.

METHODS

A prospective observational clinical study was performed at a single medical centre. All eligible participants underwent laparoscopic sigmoid resection and measurements were taken during the extra-abdominal phase. Microcirculation was measured at the transected bowel and 20 cm proximal to this point. Microcirculatory parameters such as Microvascular Flow Index (MFI), proportion of perfused vessels (PPV), perfused vessel density (PVD), total vessel density (TVD) and the Heterogeneity Index were determined. Data are presented as median (interquartile range) or mean ± standard deviation.

RESULTS

A total of 60 SDF images were acquired for 10 patients. Perfusion parameters and perfused vessel density were significantly lower at the transected bowel compared with the non-transected measurements [MFI 2.29 (1.96-2.63) vs 2.96 (2.73-3.00), p = 0.007; PPV 74% (55-83) vs 94% (86-97), p = 0.007; and PVD 7.61 ± 2.99 mm/mm² versus 10.67 ± 1.48 mm/mm², p = 0.009]. Total vessel density was similar between the measurement locations.

CONCLUSIONS

SDF imaging can identify changes of the bowel serosal microcirculation. Significantly lower serosal microcirculatory parameters of the vascular transected bowel was seen compared with the non-transected bowel. The ability of SDF imaging to detect subtle differences holds promise for future research on microvascular cut-off values leading to a non-viable bowel.

Age and surgical outcome of low-grade glioma in Sweden

BACKGROUND

Low-grade gliomas (LGG) are slow-growing primary brain tumors that typically affect young adults. Advanced age is widely recognized as a poor prognostic factor in LGG. The impact of age on postoperative outcome in this patient group has not been systemically studied.

METHODS

We performed a nationwide register-based study with data from the Swedish Brain Tumor Registry (SBTR) for all adults diagnosed with a supratentorial LGG (WHO grade II astrocytoma, oligoastrocytoma, or oligodendroglioma) during 2005-2015. Patient- and tumor-related characteristics, postoperative complications, and survival were compared between three different age groups (18-39 years, 40-59 years, and ≥60 years).

RESULTS

We identified 548 patients; 204 patients (37.2%) aged 18-39 years, 227 patients (41.4%) aged 40-59 years, and 117 patients (21.4%) ≥60 years of age. Unfavorable preoperative prognostic factors (eg, functional status and neurological deficit) were more common with increased age (P < .001). In addition, overall survival was significantly impaired in those 60 years and above (P < .001). We observed a clear dose-response for age with separation of survival curves at 50 years. Biopsy was more common in patients ≥60 years (P < .001). Subgroup analysis of patients with resection revealed a higher amount of postoperative neurological deficits in older patients (P = .029).

CONCLUSION

In general, older patients with LGG have several unfavorable prognostic factors compared with younger patients but seem to tolerate surgery in a comparable fashion. However, more neurological deficits were observed following resections in elderly. Our data further support a cutoff at 50 years rather than 40 years for selection of high-risk patients.