A phase II study of pembrolizumab plus carboplatin in BRCA-related metastatic breast cancer (PEMBRACA)

BACKGROUND

BRCA1/2-related metastatic breast cancers (mBC) are sensitive to DNA-damage agents and show high tumor-infiltrated lymphocytes. We hypothesized that the association between pembrolizumab and carboplatin could be active in BRCA-related mBC.

PATIENTS AND METHODS

In this phase II Simon's design multicenter single-arm study, BRCA1/2-related mBC patients received carboplatin at area under the curve 6 every 3 weeks for six courses associated with 200 mg pembrolizumab every 3 weeks until disease progression or unacceptable toxicity. The primary aim at first stage was overall response rate (ORR) ≥70%. Disease control rate (DCR), time to progression (TTP), duration of response (DOR), and overall survival (OS) were the secondary aims.

RESULTS

Among 22 patients enrolled at the first stage, 5 BRCA1 and 17 BRCA2, 16 (76%) were luminal tumors and 6 (24%) triple-negative BC (TNBC). In 21 patients, ORR and DCR were 43% and 76% (47% and 87% in luminal, 33% and 50% in TNBC), respectively. TTP was 7.1 months, DOR was 6.3 months, and median OS was not reached. Grade ≥3 adverse events (AEs) or serious AEs occurred in 5/22 patients (22.7%). Since the primary aim was not met, the study was terminated at the first stage.

CONCLUSIONS

Although the primary aim was not reached, data on efficacy and safety of pembrolizumab plus carboplatin in first-line visceral disease BRCA-related luminal mBC were provided and they need to be further investigated.

Background rates of 41 adverse events of special interest for COVID-19 vaccines in 10 European healthcare databases - an ACCESS cohort study

BACKGROUND

In May 2020, the ACCESS (The vACCine covid-19 monitoring readinESS) project was launched to prepare real-world monitoring of COVID-19 vaccines. Within this project, this study aimed to generate background incidence rates of 41 adverse events of special interest (AESI) to contextualize potential safety signals detected following administration of COVID-19 vaccines.

METHODS

A dynamic cohort study was conducted using a distributed data network of 10 healthcare databases from 7 European countries (Italy, Spain, Denmark, The Netherlands, Germany, France and United Kingdom) over the period 2017 to 2020. A common protocol (EUPAS37273), common data model, and common analytics programs were applied for syntactic, semantic and analytical harmonization. Incidence rates (IR) for each AESI and each database were calculated by age and sex by dividing the number of incident cases by the total person-time at risk. Age-standardized rates were pooled using random effect models according to the provenance of the events.

FINDINGS

A total number of 63,456,074 individuals were included in the study, contributing to 211.7 million person-years. A clear age pattern was observed for most AESIs, rates also varied by provenance of disease diagnosis (primary care, specialist care). Thrombosis with thrombocytopenia rates were extremely low ranging from 0.06 to 4.53/100,000 person-years for cerebral venous sinus thrombosis (CVST) with thrombocytopenia (TP) and mixed venous and arterial thrombosis with TP, respectively.

INTERPRETATION

Given the nature of the AESIs and the setting (general practitioners or hospital-based databases or both), background rates from databases that show the highest level of completeness (primary care and specialist care) should be preferred, others can be used for sensitivity. The study was designed to ensure representativeness to the European population and generalizability of the background incidence rates.

FUNDING

The project has received support from the European Medicines Agency under the Framework service contract nr EMA/2018/28/PE.

Two-month stop in mammographic screening significantly impacts on breast cancer stage at diagnosis and upfront treatment in the COVID era

Introduction

The present analysis aims to evaluate the consequences of a 2-month interruption of mammographic screening on breast cancer (BC) stage at diagnosis and upfront treatments in a region of Northern Italy highly affected by the severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) virus.

Methods

This retrospective single-institution analysis compared the clinical pathological characteristics of BC diagnosed between May 2020 and July 2020, after a 2-month screening interruption, with BC diagnosed in the same trimester of 2019 when mammographic screening was regularly carried out.

Results

The 2-month stop in mammographic screening produced a significant decrease in in situ BC diagnosis (−10.4%) and an increase in node-positive (+11.2%) and stage III BC (+10.3%). A major impact was on the subgroup of patients with BC at high proliferation rates. Among these, the rate of node-positive BC increased by 18.5% and stage III by 11.4%. In the subgroup of patients with low proliferation rates, a 9.3% increase in stage III tumors was observed, although node-positive tumors remained stable. Despite screening interruption, procedures to establish a definitive diagnosis and treatment start were subsequently carried out without delay.

Conclusion

Our data showed an increase in node-positive and stage III BC after a 2-month stop in BC screening. These findings support recommendations for a quick restoration of BC screening at full capacity, with adequate prioritization strategies to mitigate harm and meet infection prevention requirements.

•

Due to the COVID19 pandemic, several mammographic screening services were disrupted.

•

A 2-month stop in BC screening led to decreased in situ BC and increased node-positive and stage III BC diagnosis.

•

A major impact was on the subgroup of patients with BC at high proliferation rates.

•

Despite screening interruption, procedures to start treatments were subsequently carried out without delay.

•

Restoration of BC screening at full capacity with infection prevention requirements is recommended.

A retrospective database analysis of burden of IPD and pneumonia in children <15y in Veneto region

Background

IPD and pneumonia are associated with high mortality and healthcare resource utilization (HCRU). This analysis assessed incidence, HCRU and costs of IPD and pneumonia following PCV13 introduction in 2010 in Veneto.

Methods

IPD, unspecified invasive disease episodes, outpatient pneumococcal and unspecified pneumonia episodes were identified in Pedianet, a pediatric primary care database from 2010-2017. HCRU includes primary care and specialist visits, antibiotic prescriptions, diagnostics, ER visits and hospitalizations. Incidence rates (IRs) were numbers of episodes/1,000 person-years. Standardized regional incidence rates (SRIRs) were calculated by standardizing IRs with regional population data by age and year. Regional expenditures (€/1,000 person-years) were calculated by multiplying SRIRs with average costs per episode. Interrupted time series (ITS) analyses assessed trends in annual IRs in the early and late PCV13 (2010-2013, 2014-2017) periods.

Results

During 2010-2017, IPD and unspecified invasive disease incidence decreased from 0.40 to 0.31/1,000 person-years. While incidence was numerically lower in 2017 than in 2010, ITS analysis did not detect a significant trend in the early (coef=1.97; p = 0.63) or late PCV13 (coef=0.50; p = 0.90) periods. Average cost per episode was €4206 and average regional expenditure was €171/1,000 person-year. SRIR for outpatient pneumonia decreased from 13.35 to 5.48/1,000 person-year during 2010 to 2017. Pneumonia episodes were associated with 0.29 ER visits and 0.15 short stay and 0.06 long stay hospitalization. Average cost per episode was €345, majority of which was associated with ER visits (€50.8) and hospitalizations (€243.9). Regional expenditures decreased from €12852.31 to €5351.98/1,000 person-year.

Conclusions

IPD and unspecified invasive disease burden did not change significantly following PCV13 introduction, while disease burden declined for outpatient pneumococcal and unspecified pneumonia.

Key messages

IPD and unspecified invasive disease burden did not change significantly following PCV13 introduction. Disease burden declined for outpatient pneumococcal and unspecified pneumonia following PCV13.

Scientific literature response in Pubmed for the novel Coronavirus outbreak: a literature analysis

Background

Recent events highlight how emerging and re-emerging pathogens are actually becoming global challenges for public health. In December 2019, a novel coronavirus (SARS-CoV-2) has emerged. This has suddenly turned out into a global health concern which has led to a very high number of papers published in the scientific literature. Aim of this research is to focus on the bibliometric aspects in order to give researchers a glimpse on what is published in the first 30-days of a global epidemic outbreak.

Methods

We searched MEDLINE (PubMed) electronic database in order to find all relevant studies in the first 30-days from the first publication (which appeared on Pubmed at 14/01/2020), meaning the period 15/01/2020-13/02/2020. We used the following search string: coronavirus* OR Pneumonia of Unknown Etiology OR Covid-19 OR nCoV. We placed a language restriction for English, but no publication status or study design limit was put in place for our search.

Results

From the initial 462 identified articles, 234 articles were found as pertinent and read in extenso in order to classify them. The vast majority of papers come from China, UK and USA. 66.2% of the papers were Editorials, comments, letters or other kind of mainly reported data. 10.7% of papers were secondary literature papers (mainly narrative reviews). The remaining 23.1% were original primary studies. Only 17.5% of the sources used data which were directly collected on the field.

Conclusions

Almost all of data came from China. Even if some preferential channels were guaranteed for publishing those results in the most important journals, it appears that the vast majority of publication in scientific literature in the first 30-days of an epidemic outbreak is based more on reported data and comments, and only a small fraction of the papers have primary data collected in the field. Nevertheless the whole international literature depends on that type of data sources in the early days of the epidemic.

Key messages

This is the first bibliometric research in Pubmed Database on the first 30 days of publications regarding the novel Coronavirus (2019-nCoV) outbreak of 2019.

The vast majority of publication in the first 30-days of an epidemic outbreak are reported data or comments, and only a small fraction of the papers has directly collected data.

A retrospective database analysis to estimate the burden of AOM in children <15y in Veneto region

Background

Acute Otitis Media (AOM) causes substantial healthcare resource utilization (HCRU) in children. This analysis assessed AOM HCRU and costs following PCV13 introduction in 2010 in Veneto.

Methods

AOM episodes in children <15 years residing in Veneto were identified in Pedianet, a pediatric primary care, database from 2010-2017. Recurrent AOM was defined as at least three episodes in 6 months, or four or more episodes in 12 months. HCRU includes primary care visits, antibiotic prescriptions, diagnostic tests, specialist visits, emergency room (ER) visits and hospitalizations. Incidence rates (IRs) were numbers of episodes/1,000 person-years. Standardized regional incidence rates (SRIRs) were calculated by standardizing IRs with regional population data by age and year. Regional expenditures (€/1,000 person-years) were calculated by multiplying SRIRs with average cost per episode.

Results

Simple AOM episodes were associated with 1.03 primary care visits and 1.52 antibiotic prescriptions on average. Only 2.4% and 0.18% of simple AOM episodes included an ER visit, and a hospitalization respectively. Recurrent AOM episodes were associated with 1.06 primary care visits and 1.62 antibiotic prescriptions. Annual costs per episode were €50 for simple AOM and €54.2 for recurrent AOM, majority of which were associated with primary care visits and antibiotic prescriptions. Average antibiotic prescription costs were €14.2 for simple AOM and €16 for recurrent AOM. During 2010 and 2017, SRIRs declined from 100 to 72/1000 person-year for simple AOM and from 13 to 11/1,000 person-year for recurrent AOM. Regional expenditures decreased from €4702.7 to €3358.5/1,000 person-year for simple AOM and from €672.4 to €572.6/1000 person-year for recurrent AOM.

Conclusions

SRIRs and regional expenditures declined for simple and recurrent AOM after PCV13 introduction. Primary care visits and antibiotic prescriptions account for the majority of expenditures.

Key messages

SRIRs and regional expenditures declined for simple and recurrent AOM after PCV13 introduction. Primary care visits and antibiotic prescriptions account for the majority of expenditures.

Microbiological quality of shellfish and evaluation of compact dry EC for detecting total coliforms and Escherichia coli

The objective of this study was to evaluate the microbiological quality of oysters and mussels grown in Cananéia, Brazil, by analysing mesophiles, psychrothophic bacteria, moulds and yeasts, Staphylococcus aureus, and Salmonella spp., and to compare the efficiency of Compact Dry EC method and the conventional method for counting of total coliforms and Escherichia coli. The microbial analysis showed that the mean values of mesophilic counts were 3.14±0.81 log CFU g−1 for oysters and 3.92±0.90 for mussels; the mean values of psychrophilic counts were 2.78±0.75 log CFU g−1 for oysters and 3.22±0.75 log CFU g−1 for mussels; the mean values of mould and yeast counts were 3.70±0.58 log CFU g−1 for oysters and 3.33±0.81 log CFU g−1 for mussels. Salmonella spp. did not present positive results, and the maximal count of Staphylococcus aureus was 1.7 log CFU g−1, therefore, within the limits established in the legislation. The correlation coefficients between the Compact Dry EC method and conventional method were >0.87 for total coliform and E. coli counts for both types of shellfish. The data in this study show that the Compact Dry EC method is an acceptable alternative to conventional methods for enumeration of total coliforms and E. coli in shellfish.

Reduction of fibrillar strain-rate sensitivity in steroid-induced osteoporosis linked to changes in mineralized fibrillar nanostructure

As bone is used in a dynamic mechanical environment, understanding the structural origins of its time-dependent mechanical behaviour - and the alterations in metabolic bone disease - is of interest. However, at the scale of the mineralized fibrillar matrix (nanometre-level), the nature of the strain-rate dependent mechanics is incompletely understood. Here, we investigate the fibrillar- and mineral-deformation behaviour in a murine model of Cushing's syndrome, used to understand steroid induced osteoporosis, using synchrotron small- and wide-angle scattering/diffraction combined with in situ tensile testing at three strain rates ranging from 10-4 to 10-1 s-1. We find that the effective fibril- and mineral-modulus and fibrillar-reorientation show no significant increase with strain-rate in osteoporotic bone, but increase significantly in normal (wild-type) bone. By applying a fibril-lamellar two-level structural model of bone matrix deformation to fit the results, we obtain indications that altered collagen-mineral interactions at the nanoscale - along with altered fibrillar orientation distributions - may be the underlying reason for this altered strain-rate sensitivity. Our results suggest that an altered strain-rate sensitivity of the bone matrix in osteoporosis may be one of the contributing factors to reduced mechanical competence in such metabolic bone disorders, and that increasing this sensitivity may improve biomechanical performance.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

P231 Cardiac metastasis mimicking a myocardial infarction

We present the case of a 79 years old male patient affected by a lung squamous cell carcinoma (T4 N0 M1a) diagnosed in december 2018 with a 5x5 cm mass in the inferior lobe of the left lung close to the pericardium and a second 5 cm mass in the apical lobe of the right lung. TT echocardiography at that time was normal. Treatment with gemcitabine was scheduled with slight progression of the disease at the CT scan control in april 2019 when initial invasion of the left inferior pulmonary vein was detected. An ECG performed during routine control revealed the presence of q waves and ST segment elevation in the inferior leads. The patient was asymptomatic about the heart but the blood tests revealed a slight increase of HS Troponin I. We decided to repeat the TT echo, which showed the presence of a rounded mobile mass of about 3x2.5 cm in the left atrium close to the upper left pulmonary vein and another formation of about 5x2 cm infiltrating the inferior wall of the left ventricle that appeared akynetic. Both metastatic and thrombotic origins were debated and anticoagulant therapy with LMWH was started. We chose to perform a TE echocardiography, which confirmed the presence of the rounded mass in the left atrium, enlarged as compared to the TT evaluation. At the 3D reconstruction, it appeared to come from the left inferior pulmonary vein, completely occluding it, and expanding to the left superior vein, narrowing but not closing its orifice. The mass was well delimitated, disomogenous and vacuolated, thus confirming its likely neoplastic origin. From the trans-gastric view, we confirmed the large infiltration of the inferior wall of the left ventricle. General conditions of the patients quickly deteriorated and he experienced an ischemic stroke. At the TT echo re-evaluation the mass in the left atrium was greatly reduced as compared to the previous control. Cardiac metastases are a rare and frequently clinically silent occurrence; However, in a minority of cases they may present with ECG alterations such as ST-T segment modifications. In neoplastic patients an ischaemic ECG pattern not following its typical progression, without typical symptoms of ischaemia should rise the suspicion of a cardiac metastasis. In our case the abnormalities could be caused by a loss of viable myocardium secondary to the infiltrating mass or by a compression of the right coronary artery. In this context the echocardiography, both TT and especially TE, is a valuable tool that allow to recognize the real cause of these abnormalities and provides useful informations that enable to distinguish neoplastic mass from a thrombus. The ischaemic stroke was probably due to an embolization of the mass from the left atrium, as confirmed by its important reduction at the last echo control.

Abstract P231 Figure. ECG abnormalities and TE echo alteration

Environmental impact of biogenic silver nanoparticles in soil and aquatic organisms

Synthetic silver nanoparticles (AgNPs) are being extensively used in our daily lives; however, they may also pose a risk to public health and environment. Nowadays, biological AgNPs are considered an excellent alternative, since their synthesis occurs by a green technology of low cost and easy scaling. However, studies with these biological nanomaterials (NM) are still limited. Thus, a more careful assessment of their industrial application, economic feasibility and ecotoxicological impacts is crucial. The aim of this study was to investigate the effects of different concentrations of mangrove fungus Aspergillus tubingensis AgNPs on the aerobic heterotrophs soil microorganisms, rice seeds (Oryza sativa) and zebrafish (Danio rerio). Biogenic AgNPs were less harmful for soil microbiota compared to AgNO₃. On rice seeds, the AgNPs displayed a dose-dependent inhibitory effect on germination and their subsequent growth and development. The percentage of inhibition of rice seed germination was 30, 69 and 80% for 0.01, 0.1 and 0.5 mM AgNPs, respectively. After 24 h of AgNPs exposition at a limit concentration of 0.2 mM, it did not induce mortality of the zebrafish D. rerio. Overall, A. tubingensis AgNPs can be considered as a suitable alternative to synthetic nanoparticles.

P1345 Tumors metastatic to the heart :Echo, CT, CMR Imaging

Background

The frequency of secondary metastatic tumors has increased over years attributable to increased life expectancy in oncologic patients. Imaging with different methods: echo, CMR, CT and PET can provide noninvasive characterization of cardiac masses. We present 3 cases of cardiac metastasis, different for localization in the heart, pathways of dissemination and relation with neighboring structures.

Case 1: a 62-years-old male was admitted to Cardiology department for chest pain and epistaxis. Patient’s medical history was negative for cardiovascular disease. The routine TTE detected a rounded,immobile,intra-myocardial mass (Panel A, fig.1) a the level of the interventricular septum protruding in the LV cavity. The mass was characterized by several anecogenic cavities and echo-contrast showed slight late hyperenhancement of the mass confirming vascularity (fig. 2).CMR gadolinium imaging confirmed late enhancement at the level of the edges of the cavities and in the external border (fig.4). In the suspicion of neuroendocrine tumor, a Gallium-68 dotatate PET/CT was performed with detection of pathological uptake at the abdominal and cardiac level (fig.3).

Case 2: a 64-years-old woman presented with shortness of breath, fatigue and weight loss in the past three months. History of smoke was present and diagnosis of non-small cell lung cancer was made. PET-CT demonstrated pathological uptake at pulmonary, limph-nodes, adrenal, hepatic, bone, muscular and pericardial level (Panel B, fig.1).CMR clearly revealed a massive lesion (7x3x3.5 cm) at the level of the LV antero-lateral wall (fig.2) and TTE SAX view (fig.3) confirmed the presence of a large infiltrative immobile mass in the antero-lateral wall. In the same region the pericardium was irregular and thickened suggestive of pericardial tumor involvement. Some degree of pericardial effusion was also present. The ECG was consistent with ST-T elevation in D1 and aVL in absence of ischemic symptoms (fig.4).Case 3: a 78-years-old man known for non-small cell lung cancer underwent transthoracic echo for monitoring cardiotoxicity.Two–chamber TTE showed a intra-myocardial mass in the inferior wall of LV and another rounded mass at the left atrial level (Panel C, fig.1). Chest CT showed the pulmonary mass with irregular borders, intravascular invasion of left lower pulmonary vein (LLPV) and extension into the left atrium (fig.2).2D/3D TEE well demonstrated the atrial invasion by the mass composed by one more echogenic part inside the llpv and outside in the left atrium a rounded head with several region of cystic colliquation (fig.3). Attached to the rounded head irregular protuberances was noted (thrombus?, fig.4). Conclusion: metastasis to the heart and pericardium are much more common than primary cardiac tumors and occur late in the course of malignant disease. Echo is the initial diagnostic test to evaluate for the presence of cardiac metastases.

Abstract P1345 Figure. Different cases of cardiac metastasis

Antibiotic prescriptions in acute otitis media and pharyngitis in Italian pediatric outpatients

Background

Acute otitis media (AOM) and pharyngitis are very common infections in children and adolescents. Italy is one of the European countries with the highest rate of antibiotic prescriptions. The aim of this study is to describe first-line treatment approaches for AOM and pharyngitis in primary care settings in Italy over six years, including the prevalence of ‘wait and see’ for AOM, where prescription of antibiotics is delayed 48 h from presentation, and differences in prescribing for pharyngitis when diagnostic tests are used.

Methods

The study is a secondary data analysis using Pedianet, a database including data at outpatient level from children aged 0–14 in Italy. Prescriptions per antibiotic group, per age group and per calendar year were described as percentages. “Wait and see” approach rate was described for AOM and pharyngitis prescriptions were further grouped according to the diagnostic test performed and test results.

Results

We identified 120,338 children followed by 125 family pediatricians between January 2010 and December 2015 for a total of 923,780 person-years of follow-up. Among them 30,394 (mean age 44 months) had at least one AOM diagnosis (n = 54,943) and 52,341 (mean age 5 years) had at least one pharyngitis diagnosis (n = 126,098). 82.5% of AOM diagnoses were treated with an antibiotic within 48 h (mainly amoxicillin and amoxicillin/clavulanate) and the “wait and see” approach was adopted only in 17.5% of cases. The trend over time shows an increase in broad spectrum antibiotic prescriptions in the last year (2015). 79,620 (63%) cases of pharyngitis were treated and among GABHS pharyngitis confirmed by rapid test 56% were treated with amoxicillin. The ones not test confirmed were treated mainly with broad spectrum antibiotics.

Conclusions

Despite guidance to use the ‘wait and see’ approach in the age group analyzed, this strategy is not often used for AOM, as previously noted in other studies in hospital settings. Broad-spectrum antibiotic prescription was more frequent when pharyngitis was not confirmed by rapid test, in keeping with evidence from other studies that diagnostic uncertainty leads to overuse of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0696-9) contains supplementary material, which is available to authorized users.

Abstract P1-18-06: First-line treatment for endocrine sensitive bone-only metastatic breast cancer: Is more always better?

The standard first-line for endocrine sensitive metastatic breast cancer (BC) is represented by endocrine therapy. Several phase III clinical trials searched for more effective endocrine strategies. Nevertheless, the use of combinations for the first-line treatment of bone-only disease (BoD) is widely discussed, due to its indolent course. Our meta-analysis aims to explore the role of new endocrine strategies in BoD.

A systematic review of electronic databases was conducted to identify the phase III clinical trials comparing the standard AI to novel experimental strategies. The hazard ratios (HR) for PFS were pooled in a meta-analysis. The heterogeneity of the data was evaluated by Chi-square Q test and I2 statistic.

8 studies were included in the analyses. 4 trials explored the role of CDK4/6 inhibitors (Monaleesa2 and 7, Monarch3 and Paloma2), 2 trials analyzed Fulvestrant + AI (SWOG and FACT), one trial studied Fulvestrant monotherapy (FALCON), while one trial evaluated the association between Bevacizumab and Letrozole (ALLIANCE). 6 trials reported data regarding the BoD, while 2 trials included the BoD in the non-visceral disease. Overall, the meta-analyses showed a PFS advantage for the experimental arms [HR 0.70 p 0.012], with a significant moderate/high heterogeneity [I2 66.48% p 0.004]. Only the FALCON and Paloma2 showed a significant improvement in PFS, respectively for Fulvestrant and Palbociclib + Letrozole. Considering only trials reporting data for BoD, the experimental arms significantly improved the PFS [HR 0.66 p 0.005], with a low/moderate non-significant heterogeneity [I2 44.95% p 0.106].

The novel strategies showed to be able to improve the PFS of BoD. Nonetheless, only Palbociclib + Letrozole provided statistically significant data of advantage in this setting. In clinical trials, BoD is often included in the non-visceral disease subgroup. Future clinical trials should take into account the differences in natural history and better prognosis of BoD, in order to define the best approach to these patients.

Citation Format: Toss A, Venturelli M, Sperduti I, Isca C, Molinaro E, Barbieri E, Piacentini F, Omarini C, Cortesi L, Cascinu S, Moscetti L. First-line treatment for endocrine sensitive bone-only metastatic breast cancer: Is more always better? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-18-06.

Cep Regimen (Ccnu, Etoposide, Prednimustine) for Relapsed/Refractory Hodgkin's Disease

Aims and background

Although initial treatment of Hodgkin's disease induces a complete remission in most patients, approximately 50% of patients with advanced disease will not achieve a complete remission or will relapse following the first complete remission.

Patients and methods

Twenty-three patients with relapsed/resistant Hodgkin's disease, observed between January 1991 and October 1993, underwent CEP combination chemotherapy (CCNU, etoposide, prednimustine). All patients had previously received MOPP and ABVD regimens, in combination at diagnosis or sequentially (at diagnosis and at the first relapse).

Results

Thirteen (56%) patients achieved complete responses and 4 (18%) had partial responses. Two partial responders obtained a complete remission after a successive autologous bone marrow transplantation. The complete remission was not influenced by the timing of MOPP and ABVD treatments, presence of extranodal involvement or presence of bulky disease, but was affected by the presence of a primary disease refractory to the first standard programs. All the complete responders but 2 were alive and relapse-free at a median follow-up of 15 months; no major toxic effects were recorded.

Conclusions

These data suggest, as did those of other studies, that CEP is an effective regimen in patients with Hodgkin's disease in first or second relapse, also to reduce the tumor burden and to determine chemosensitivity before contingent bone marrow or peripheral blood stem cell support.

Bone matrix development in steroid-induced osteoporosis is associated with a consistently reduced fibrillar stiffness linked to altered bone mineral quality

Glucocorticoid-induced osteoporosis (GIOP) is a major secondary form of osteoporosis, with the fracture risk significantly elevated - at similar levels of bone mineral density - in patients taking glucocorticoids compared with non-users. The adverse bone structural changes at multiple hierarchical levels in GIOP, and their mechanistic consequences leading to reduced load-bearing capacity, are not clearly understood. Here we combine experimental X-ray nanoscale mechanical imaging with analytical modelling of the bone matrix mechanics to determine mechanisms causing bone material quality deterioration during development of GIOP. In situ synchrotron small-angle X-ray diffraction combined with tensile testing was used to measure nanoscale deformation mechanisms in a murine model of GIOP, due to a corticotrophin-releasing hormone promoter mutation, at multiple ages (8-, 12-, 24- and 36 weeks), complemented by quantitative micro-computed tomography and backscattered electron imaging to determine mineral concentrations. We develop a two-level hierarchical model of the bone matrix (mineralized fibril and lamella) to predict fibrillar mechanical response as a function of architectural parameters of the mineralized matrix. The fibrillar elastic modulus of GIOP-bone is lower than healthy bone throughout development, and nearly constant in time, in contrast to the progressively increasing stiffness in healthy bone. The lower mineral platelet aspect ratio value for GIOP compared to healthy bone in the multiscale model can explain the fibrillar deformation. Consistent with this result, independent measurement of mineral platelet lengths from wide-angle X-ray diffraction finds a shorter mineral platelet length in GIOP. Our results show how lowered mineralization combined with altered mineral nanostructure in GIOP leads to lowered mechanical competence.

SIGNIFICANCE STATEMENT

Increased fragility in musculoskeletal disorders like osteoporosis are believed to arise due to alterations in bone structure at multiple length-scales from the organ down to the supramolecular-level, where collagen molecules and elongated mineral nanoparticles form stiff fibrils. However, the nature of these molecular-level alterations are not known. Here we used X-ray scattering to determine both how bone fibrils deform in secondary osteoporosis, as well as how the fibril orientation and mineral nanoparticle structure changes. We found that osteoporotic fibrils become less stiff both because the mineral nanoparticles became shorter and less efficient at transferring load from collagen, and because the fibrils are more randomly oriented. These results will help in the design of new composite musculoskeletal implants for bone repair.

Non Conventional Fractionation in Radiotherapy of the Musculo-Skeletal Sarcomas

In 1989 we started an accelerated hyperfractionated schedule of radiotherapy (two 1.6 Gy daily fractions) in standard risk localized Ewing's sarcoma of bone, with the aim at reducing late effects in young patients and at improving disease control through a better integration of treatment modalities. From 1991, the same schedule was used in preoperative radiotherapy of adult soft tissue sarcomas of the extremities: the main purpose was to reduce the time to surgery and to evaluate surgical complications in comparison with a previous experience of hypofractionated radiotherapy (one 3 Gy daily fraction). From 1991 to 1997, 76 patients with Ewing's sarcoma and 24 patients with soft tissue sarcoma were treated at our Institution. Results and complication rates are analyzed in comparison with historical data. In Ewing's sarcoma, a correct evaluation of improvement in local control was difficult because of changing treatment policy (bulky disease was not included in the present series). Late effects, as evaluated in patients with a minimum follow-up of 3 years, occurred with similar incidence, but at higher total dose levels in patients treated with accelerated hyperfractionation. In patients with soft tissue sarcomas, incidence of surgical complications is reduced as compared to historical experience. Major problems of wound healing were seen in association with intraoperative brachitherapy boost.

Neoadjuvant Chemotherapy for Localized Ewing's Sarcoma of the Extremities: Preliminary Results of a Protocol Which uses Surgery (Alone or Followed by Radiotherapy) for Local Control

From June 1983 to December 1985, thirty-eight paients with localized Ewing's sarcoma of the extremities were treated with a protocol that consisted of an initial nine week period of polychemotherapy (vincristine, adriamycin and cyclophosphamide) followed by local therapy and additional chemotherapy (vincristine, adriamycin, cyclophosphamide and dactino-mycln) for one year. As local treatment all patients were offered surgery; thirty-two accepted and six refused. These six patients were locally treated with radiotherapy alone (50 Gy). In the remaining patients an amputation was performed in one case and a resection in thirty-one. In resected patients when a wide margin was achieved (24 cases) no further local treatment was performed; when it was marginal (5 cases) or intralesional (2 cases) radiotherapy at lower doses (40 Gy) followed. At mean follow-up of thirty-seven months the percentage of continuously disease-free patients was 50 % for those treated with radiotherapy, 76 % with surgery, and 85 % with surgery and radiotherapy. Eight patients developed metastatic disease and two patients had local recurrence and metastases. The local recurrences were seen in one patient locally treated with surgery and in one locally treated with radiotherapy. Nine major local complications were observed: three in patients treated with radiotherapy, five in patients treated with surgery, and one in a patient treated with surgery and radiotherapy. These results indicate that after induction chemotherapy conservative surgery is possible in almost all cases of Ewing's sarcoma of the extremities and that such treatment is better than radiotherapy alone as local therapy.

Radio-induced Sarcomas in Survivors of Ewing's Sarcoma

Of 255 cases of Ewing's sarcoma recorded at the Bone Tumor Center of the Rizzoli Orthopaedic Institute, 78 patients (irradiated and with a follow-up of longer than 3 years) were considered « at risk » for the development of a second radio-induced sarcoma (RIS). Three of the 78 patients developed an RIS in the irradiated field. Theoretical and statistical analyses were carried out considering different modalities of local treatment. Statistically, the only significant factor was related to the irradiation dose. Surgical resection seems to prevent RIS.

Combination Chemotherapy with Methotrexate, Endoxan, and Vincristine (M.E.V.) in the Treatment of non-Hodgkin's Lymphoma

Twelve patients with lymphocytic lymphoma (L.L.), and 9 patients with histiocytic lymphoma (H.L.), stage III and IV, were treated as outpatients with combination chemotherapy including six courses of cyclophosphamide (Endoxan), Methotrexate, and vincristine (M.E.V. regimen). Marrow depression and side-effects were moderate. In the 12 patients with L.L., there were 6 complete remissions (C.R.), 3 incomplete remission (I.R.), and 3 partial failures (P.F.). In the 9 patients with H.L., there were 7 C.R., 1 I.R. and 1 P.F. Median survival from the end of the therapy is 7 + mos. for the L.L. patients, and 10 + mos. for H.L. patients, all patients being alive but one.

Prognostic impact of interval breast cancer detection in women with pT1a N0M0 breast cancer with HER2-positive status: Results from a multicentre population-based cancer registry study

BACKGROUND

Although human epidermal growth factor receptor 2 (HER2) overexpression is associated with poor prognosis, patients (pts) with pT1a N0M0 breast cancers (BCs) have an excellent outcome across all subtypes. Interval cancers (ICs) have poorer survival than screen-detected (SD) tumours, and an association has been reported between ICs and HER2 overexpression. We aimed to determine, in a general population of pT1a N0M0 BCs with known screening status, whether HER2-positive ICs have a poorer outcome than HER2-positive SD cancers.

METHODS

We evaluated all incident pT1a N0M0 BCs (n = 874) collected in the Emilia-Romagna region (Italy) from 2003 to 2009 and diagnosed in women aged 50-69. Pts unexposed to screening, with unknown HER2 status and/or treated with adjuvant trastuzumab were excluded from analysis.

RESULTS

Sixty-one percent of the BCs were SD, whereas 19% were ICs. BCs with high histologic grade, hormone receptor-negative or HER2-positive status (odds ratio=1.7; 95% confidence interval [CI]: 1.1-2.7) were more likely ICs. Median follow-up was 115 months. The 10-year invasive disease-free survival (iDFS) for HER2-positive ICs was lower than that for HER2-positive SD cancers: 75.0% (95% CI: 55.5%-94.5%) versus 93.8% (95% CI: 86.5%-100%). An interaction between ICs and HER2-positive status was found for poorer iDFS after adjusting for prognostic variables (HR = 5.3; 95% CI: 1.6-16.7).

CONCLUSIONS

IC detection may identify pts with HER2-positive pT1a N0M0 tumours in whom the rate of recurrence justifies consideration for conventional, anti-HER2, adjuvant treatment.

Towards in situ determination of 3D strain and reorientation in the interpenetrating nanofibre networks of cuticle

Determining the in situ 3D nano- and microscale strain and reorientation fields in hierarchical nanocomposite materials is technically very challenging. Such a determination is important to understand the mechanisms enabling their functional optimization. An example of functional specialization to high dynamic mechanical resistance is the crustacean stomatopod cuticle. Here we develop a new 3D X-ray nanostrain reconstruction method combining analytical modelling of the diffraction signal, fibre-composite theory and in situ deformation, to determine the hitherto unknown nano- and microscale deformation mechanisms in stomatopod tergite cuticle. Stomatopod cuticle at the nanoscale consists of mineralized chitin fibres and calcified protein matrix, which form (at the microscale) plywood (Bouligand) layers with interpenetrating pore-canal fibres. We uncover anisotropic deformation patterns inside Bouligand lamellae, accompanied by load-induced fibre reorientation and pore-canal fibre compression. Lamination theory was used to decouple in-plane fibre reorientation from diffraction intensity changes induced by 3D lamellae tilting. Our method enables separation of deformation dynamics at multiple hierarchical levels, a critical consideration in the cooperative mechanics characteristic of biological and bioinspired materials. The nanostrain reconstruction technique is general, depending only on molecular-level fibre symmetry and can be applied to the in situ dynamics of advanced nanostructured materials with 3D hierarchical design.

Abstract OT3-05-01: Three-monthly dynamic evaluation of CEA and CA15-3 (followed by 18-FDG PET) vs usual practice in the follow-up of early breast cancer (BC) patients (pts): A prospective randomized trial (KRONOS-patient-oriented new surveillance study, Italy)

Background: Current guidelines for BC surveillance in asymptomatic pts recommend annual mammography and periodical physical examination. These recommendations arise from two trials conducted in the 1980's: since then no other randomized controlled trials (RCTs) have been conducted on BC follow-up. However our knowledge on BC biology, diagnosis of metastases and treatment has improved. The aim of this prospective RCT is to verify if the serial measurement of CEA and CA15.3 (followed by 18-FDG PET) can anticipate the diagnosis of breast cancer recurrence compared to control arm. If this intermediate end-point will be met a subsequent extension trial will investigate the impact of the earlier diagnosis of distant metastases on survival. Methods: Pts diagnosed with stage I-III BC, who underwent adequate surgery are eligible. Special histologies and low-risk cases according to St. Gallen criteria are excluded. We will include pts at the beginning of the follow-up after the conclusion of primary treatment (cohort 1), and pts that have concluded without relapse the first 5 years of follow-up (cohort 2). Eligible pts will be randomized in a 1:1 ratio to follow-up according to local practice (control arm) or to three-monthly serial dosing of CEA and CA15.3 and subsequent imaging studies (18-FDG PET) only in case of an increase of CEA and/or CA 15.3 greater than a critical difference (CEA +100% and/or CA15.3 +75%) compared to baseline (experimental arm). The following stratification factors will be used: node negative vs positive, HER2 negative vs positive, ER positive vs negative. Eight-hundred pts will be enrolled over 3 years. For such a calculation, we made the assumption of a 20% 5-year incidence of relapse. The target reduction of 3 months in restricted mean survival time (RMST) between the two arms implies a median time of diagnostic anticipation, conditional on having breast cancer recurrence, of 10 months. The follow-up will continue until 10 years from surgery. The first patient was enrolled on 23rd October 2014, up to now 434 pts have been enrolled. The present trial was approved by the Ethical Commitee of S. Orsola-Malpighi Hospital and is registered on clinicaltrials.gov (NCT02261389).

Citation Format: Zamagni C, Gion M, Mariani L, Stieber P, Quercia S, Rubino D, Bernardi A, Cacciari N, Fini A, Lenzi M, Minichillo S, Pizzirani C, Pagliaro M, Tomasini S, Barbieri E. Three-monthly dynamic evaluation of CEA and CA15-3 (followed by 18-FDG PET) vs usual practice in the follow-up of early breast cancer (BC) patients (pts): A prospective randomized trial (KRONOS-patient-oriented new surveillance study, Italy) [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 OT3-05-01.

Abstract P1-07-23: Prognostic impact of HER2 overexpression/amplification in women with pT1a N0 M0 breast cancer with known screening status: Results from a multicenter population-based cancer registry study

Introduction: Outcomes for women with pT1aN0M0 breast cancers (BC) may vary by biologic subtype. A higher proportion of HER2-positive BCs diagnosed in the interval between scheduled screening rounds has been proposed to account for the more aggressive behaviour of interval cancers (IC) compared with screen-detected (SD) tumors. No data are available on the prognostic role of HER2-positive status in a general population of pT1aN0M0 breast tumors with known screening status.

Methods: All incident pT1aN0M0 BCs (n=874), systematically collected by the Cancer Registries of Emilia Romagna Region (northern Italy) and diagnosed in women aged 50-69 from 2003 to 2009 were evaluated. Screening status was ascertained by reference to the Emilia Romagna Breast Cancer Screening Program (ERBSP) database. Patients unexposed to screening, with HER2 unknown primary tumor and/or who received adjuvant chemotherapy or trastuzumab were excluded from analysis.

Results: Twenty percent of patients had HER2-positive tumors. Fifty-three percent of the entire study population were SD cancers, while 18% were ICs. Tumors with high histologic grade, high proliferative rate, negative estrogen receptor status, or HER2-positive status were more likely to be diagnosed in the interval between screening. At a median follow-up of 84 months, the 5-year invasive disease-free survival (IDFS) rates were 89% and 95% in patients with HER2-positive and HER2-negative tumors, respectively (P = 0.025). Notably, HER2-positive ICs showed poorer IDFS than HER2-positive SD tumors (84% vs. 95%, respectively; P = 0.04). No difference in IDFS rates were observed between HER2-positive SD cancers and HER2-negative SD cancers. Multivariable analysis of candidate prognostic factors for IDFS will be reported.

Conclusions: In a general population of pT1aN0M0 early BCs with known screening status, IC detection may identify patients with HER2-positive pT1aN0M0 tumors in whom the rate of recurrence justifies consideration for systemic, anti-HER2, adjuvant therapy.

Citation Format: Musolino A, Michiara M, Boggiani D, Sikokis A, Rimanti A, Pellegrino B, Silini EM, Campanini N, Barbieri E, Sgargi P, Falcini F, Pinto C. Prognostic impact of HER2 overexpression/amplification in women with pT1a N0 M0 breast cancer with known screening status: Results from a multicenter population-based cancer registry study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-07-23.