Robotic-assisted versus laparoscopic incisional hernia repair: a systematic review and meta-analysis

PURPOSE

This study aimed to perform a systematic review and meta-analysis comparing the efficacy and safety outcomes of robotic-assisted and laparoscopic techniques for incisional hernia repair.

METHODS

PubMed, Embase, Scopus, Cochrane databases, and conference abstracts were systematically searched for studies that directly compared robot-assisted versus laparoscopy for incisional hernia repair and reported safety or efficacy outcomes in a follow-up of ≥ 1 month. The primary endpoints of interest were postoperative complications and the length of hospital stay.

RESULTS

The search strategy yielded 2104 results, of which four studies met the inclusion criteria. The studies included 1293 patients with incisional hernia repairs, 440 (34%) of whom underwent robot-assisted repair. Study follow-up ranged from 1 to 24 months. There was no significant difference between groups in the incidence of postoperative complications (OR 0.65; 95% CI 0.35-1.21; p = 0.17). The recurrence rate of incisional hernias (OR 0.34; 95% CI 0.05-2.29; p = 0.27) was also similar between robotic and laparoscopic surgeries. Hospital length of stay (MD - 1.05 days; 95% CI - 2.06, - 0.04; p = 0.04) was significantly reduced in the robotic-assisted repair. However, the robot-assisted repair had a significantly longer operative time (MD 69.6 min; 95% CI 59.0-80.1; p < 0.001).

CONCLUSION

The robotic approach for incisional hernia repair was associated with a significant difference between the two groups in complications and recurrence rates, a longer operative time than laparoscopic repair, but with a shorter length of stay.

Correction: A Machine Learning Model to Predict Patients' Adherence Behavior and a Decision Support System for Patients With Metastatic Breast Cancer: Protocol for a Randomized Controlled Trial

[This corrects the article DOI: 10.2196/48852.].

The Post-conditioning Acute Strength Exercise Facilitates Contextual Fear Memory Consolidation Via Hippocampal N-methyl-D-aspartate-receptors

The benefits of aerobic exercises for memory are known, but studies of strength training on memory consolidation are still scarce. Exercise stimulates the release of metabolites and myokines that reaching the brain stimulate the activation of NMDA-receptors and associated pathways related to cognition and synaptic plasticity. The aim of the present study was to investigate whether the acute strength exercise could promote the consolidation of a weak memory. We also investigated whether the effects of strength exercise on memory consolidation and on the BDNF and synapsin I levels depends on the activation of NMDA-receptors. Male Wistar rats were submitted to strength exercise session after a weak training in contextual fear conditioning paradigm to investigate the induction of memory consolidation. To investigate the participation of NMDA-receptors animals were submitted to contextual fear training and strength exercise and infused with MK801 or saline immediately after exercise. To investigate the participation of NMDA-receptors in BDNF and synapsin I levels the animals were submitted to acute strength exercise and infused with MK801 or saline immediately after exercise (in absence of behavior experiment). Results showed that exercise induced the consolidation of a weak memory and this effect was dependent on the activation of NMDA-receptors. The hippocampal overexpression of BDNF and Synapsin I through exercise where NMDA-receptors dependent. Our findings showed that strength exercise strengthened fear memory consolidation and modulates the overexpression of BDNF and synapsin I through the activation of NMDA-receptors dependent signaling pathways.

A Machine Learning Model to Predict Patients' Adherence Behavior and a Decision Support System for Patients With Metastatic Breast Cancer: Protocol for a Randomized Controlled Trial

BACKGROUND

Adherence to oral anticancer treatments is critical in the disease trajectory of patients with breast cancer. Given the impact of nonadherence on clinical outcomes and the associated economic burden for the health care system, finding ways to increase treatment adherence is particularly relevant.

OBJECTIVE

The primary end point is to evaluate the effectiveness of a decision support system (DSS) and a machine learning web application in promoting adherence to oral anticancer treatments among patients with metastatic breast cancer. The secondary end point is to collect a set of new physical, psychological, social, behavioral, and quality of life predictive variables that could be used to refine the preliminary version of the machine learning model to predict patients' adherence behavior.

METHODS

This prospective, randomized controlled study is nested in a large-scale international project named "Enhancing therapy adherence among metastatic breast cancer patients" (Pfizer 65080791), aimed to develop a predictive model of nonadherence and associated DSS and guidelines to foster patients' engagement and therapy adherence. A web-based DSS named TREAT (treatment adherence support) was developed using a patient-driven approach, with 4 sections, that is, Section A: Metastatic Breast Cancer; Section B: Adherence to Cancer Therapies; Section C: Promoting Adherence; and Section D: My Adherence Diary. Moreover, a machine learning-based web application was developed to predict patients' risk factors of adherence to anticancer treatment, specifically pertaining to physical status and comorbid conditions, as well as short and long-term side effects. Overall, 100 patients consecutively admitted at the European Institute of Oncology (IEO) at the Division of Medical Senology will be enrolled; 50 patients with metastatic breast cancer will be exposed to the DSS and machine learning web application for 3 months (experimental group), and 50 patients will not be exposed to the intervention (control group). Each participant will fill a weekly medication diary and a set of standardized self-reports evaluating psychological and quality of life variables (Adherence Attitude Inventory, Beck Depression Inventory-II, Brief Pain Inventory, 13-item Sense of Coherence scale, Brief Italian version of Cancer Behavior Inventory, European Organization for Research and Treatment of Cancer Quality of Life 23-item Breast Cancer-specific Questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, 8-item Morisky Medication Adherence Scale, State-Trait Anxiety Inventory forms I and II, Big Five Inventory, and visual analogue scales evaluating risk perception). The 3 assessment time points are T0 (baseline), T1 (1 month), T2 (2 months), and T3 (3 months). This study was approved by the IEO ethics committee (R1786/22-IEO 1907).

RESULTS

The recruitment process started in May 2023 and is expected to conclude on December 2023.

CONCLUSIONS

The contribution of machine learning techniques through risk-predictive models integrated into DSS will enable medication adherence by patients with cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06161181; https://clinicaltrials.gov/study/NCT06161181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48852.

Glycogen synthase kinase 3 inhibition enhances mineral nodule formation by cementoblasts in vitro

This study aimed to investigate whether GSK-3 inhibition (CHIR99021) effectively promoted mineralization by cementoblasts (OCCM-30). OCCM-30 cells were used and treated with different concentrations of CHIR99021 (2.5, 5, and 10 mM). Experiments included proliferation and viability, cellular metabolic activity, gene expression, and mineral nodule formation by Xylene Orange at the experimental time points. In general, CHIR99021 did not significantly affect OCCM-30 viability and cell metabolism (MTT assay) (p > 0.05), but increased OCCM-30 proliferation at 2.5 mM on days 2 and 4 (p < 0.05). Data analysis further showed that inhibition of GSK-3 resulted in increased transcript levels of Axin2 in OCCM-30 cells starting as early as 4 h, and regulated the expression of key bone markers including alkaline phosphatase (Alp), runt-related transcription factor 2 (Runx-2), osteocalcin (Ocn), and osterix (Osx). In addition, CHIR99021 led to an enhanced mineral nodule formation in vitro under both osteogenic and non-osteogenic conditions as early as 5 days after treatment. Altogether, the results of the current study suggest that inhibition of GSK-3 has the potential to promote cementoblast differentiation leading to increased mineral deposition in vitro.

From transabdominal to totally extra-peritoneal robotic ventral hernia repair: observations and outcomes

PURPOSE

While robotic-assisted hernia repair has increased the popularity of minimally invasive hernia surgery, selecting between the types of approaches is a challenge for both experts and novices alike. In this study, we compared a single surgeon's early experience transitioning from transabdominal hernia repair with sublay mesh in either the pre-peritoneal or retrorectus space (TA-SM) and enhanced-view totally extra-peritoneal (eTEP) ventral hernia repair in the peri-operative and long-term post-operative time periods.

METHODS

We conducted a retrospective review of 50 eTEP and 108 TA-SM procedures to collect demographics, intraoperative details, and 30-day and 1-year post-operative outcomes. Statistical analysis was performed utilizing Chi-square analysis, Fisher's test, and two sample t-tests with equal variances.

RESULTS

There were no significant differences in patient demographics or comorbidities. eTEP patients had larger defects (109.1 cm² vs. 31.8 cm², p = 0.043) and mesh used (432.8 cm² vs. 137.9 cm², p = 0.001). Operative times were equivalent (158.3 ± 90.6 min eTEP and 155.8 ± 65.2 min TA-SM, p = 0.84), but conversion to alternate procedure type was higher for the transabdominal approach (4% eTEP vs. 22% TA-SM, p < 0.05). Hospital stay was less in the eTEP cohort (1.3 days vs. 2.2 days, p < 0.05). Within 30 days, there were no significant differences in emergency visits or hospital readmissions. There was a greater propensity for eTEP patients to develop seromas (12.0% vs. 1.9%, p < 0.05). At 1 year, there was no statistically significant difference in recurrence rate (4.56% eTEP vs. 12.2% TA-SM, p = 0.28) respective to average time to recurrence (9.17 months eTEP vs. 11.05 months TA-SM).

CONCLUSION

The eTEP approach can be adopted safely and efficiently, and may have superior peri-operative outcomes including fewer conversions and reduced hospital stay.

Dupilumab for atopic dermatitis: a real-world portuguese multicenter retrospective study

Introduction: Atopic dermatitis (AD) is a difficult-to-treat inflammatory skin disease with a high impact on patients' quality of life. Dupilumab, an IL-4 and IL-13 inhibitor, was the first monoclonal antibody approved for the treatment of moderate-to-severe AD and is currently approved in patients aged 6 or older.Methods: This is a nationwide, multicenter, retrospective, 48-week study designed by the Portuguese Group of AD to assess real-world efficacy and safety of dupilumab for the treatment of AD.Results: A total of 169 patients were enrolled, with a mean disease duration of 22.75 (±11.98) years. The percentage of patients achieving an improvement of at least 75% in Eczema Area and Severity Index (EASI) compared to baseline (EASI75 response) at weeks 12 and 48 was 67.6% and 74.1%, respectively. In the same timepoints, 25.0% and 44.1% achieved an EASI90 response. Patient-reported outcome measures also improved throughout the study period. Regarding safety, 32.0% of the patients developed adverse events, with conjunctivitis (26.6%), persistent facial erythema (4.7%), and arthritis/arthralgia (3.6%) as the more frequently reported.Conclusion: Data from real-world populations are crucial to guide clinicians in their daily decisions. This study provides data demonstrating that dupilumab is an effective and safe therapeutic option for AD.

Safety of assisted reproductive techniques in young women harboring germline pathogenic variants in BRCA1/2 with a pregnancy after prior history of breast cancer

BACKGROUND

Knowledge is growing on the safety of assisted reproductive techniques (ART) in cancer survivors. No data exist, however, for the specific population of breast cancer patients harboring germline BRCA1/2 pathogenic variants.

PATIENTS AND METHODS

This is a multicenter retrospective cohort study across 30 centers worldwide including women diagnosed at ≤40 years with stage I-III breast cancer, between January 2000 and December 2012, harboring known germline BRCA1/2 pathogenic variants. Patients included in this analysis had a post-treatment pregnancy either achieved through use of ART (ART group) or naturally (non-ART group). ART procedures included ovulation induction, ovarian stimulation for in vitro fertilization or intracytoplasmic sperm injection, and embryo transfer under hormonal replacement therapy.

RESULTS

Among the 1424 patients registered in the study, 168 were eligible for inclusion in the present analysis, of whom 22 were in the ART group and 146 in the non-ART group. Survivors in the ART group conceived at an older age compared with those in the non-ART group (median age: 39.7 versus 35.4 years, respectively). Women in the ART group experienced more delivery complications compared with those in the non-ART group (22.1% versus 4.1%, respectively). No other apparent differences in obstetrical outcomes were observed between cohorts. The median follow-up from pregnancy was 3.4 years (range: 0.8-8.6 years) in the ART group and 5.0 years (range: 0.8-17.6 years) in the non-ART group. Two patients (9.1%) in the ART group experienced a disease-free survival event (specifically, a locoregional recurrence) compared with 40 patients (27.4%) in the non-ART group. In the ART group, no patients deceased compared with 10 patients (6.9%) in the non-ART group.

CONCLUSION

This study provides encouraging safety data on the use of ART in breast cancer survivors harboring germline pathogenic variants in BRCA1/2, when natural conception fails or when they opt for ART in order to carry out preimplantation genetic testing.

Linking human and ecological components to understand human-wildlife conflicts across landscapes and species

Human-wildlife conflicts (HWC) are complex conservation challenges that impair both wildlife populations and human livelihood. Research on HWC, however, has traditionally approached ecological and human components separately, hampering a broader understanding of connections between ecological drivers and human dimensions of conflicts. We developed a model that integrates ecological and human components of HWC to investigate how the amount of remaining native forest (forest cover, a key ecological variable known to influence species occurrence and abundance) affects human experiences with wildlife (contact with species and attacks on livestock) and how such experiences influence tolerance via beliefs, emotions, and attitudes. We tested the model with piecewise structural equation modeling and data on human interactions with 3 mammals with different rarity and body size: opossum (Didelphis aurita), crab-eating fox (Cerdocyon thous), and puma (Puma concolor). Data were obtained by interviewing 114 landowners across 13 Atlantic Forest landscapes (10-50% forest cover). Forest cover was associated with high chance of attacks on livestock, and thus with low tolerance, only in the case of the puma. Effects of distinct experiences with wildlife on beliefs and emotions varied across species. Beliefs and emotions toward wildlife influenced tolerance toward all species, but negative emotions affected tolerance toward only with the puma. Conflicts with large carnivores, such as pumas, can then be understood as disservices provided by forests, indicating the relevance of framing HWC more broadly to consider trade-offs with ecosystems services. For some species, positive experiences with wildlife may counteract the negative effects of attacks on livestock in shaping tolerance. Models such as ours-that link ecological and human dimensions-can help identify more effective leverage points to improve HWC mitigation.

Abstract P5-17-05: Outcome of triple negative inflammatory breast cancer (TNIBC) treated with dose-dense dose intense neoadjuvant chemotherapy (NAC), prognostic impact of post NAC lymphovascular invasion and tumor infiltrating lymphocytes (TIL)

Background

Inflammatory breast cancers (IBC) particularly triple negative (TN) subtype have poor prognosis. There are few series reporting IBC outcome according to their immunohistochemical profile. We have already shown the efficiency of dose dense dose intense chemotherapy in triple negative breast cancer (1). We report a series of TNIBC treated with dose dense anthracycline cyclophosphamide followed with taxane and analyzed the correlation between pathological complete response (pCR), pre and post NAC TIL, post NAC LVI and disease free survival (DFS).

Methods

Between January 2010 and December 2016, all patients with TNIBC seen at breast cancer disease center, St Louis hospital, Paris, France, were treated with neoadjuvant dose dense dose intense Cyclophophamide (1.2g/m2 d1) - Epirubicin (75mg/m2 d1) q2w (SIM regimen) followed with 12 injections of paclitaxel (80 mg/m2) qw or 4 injections of docetaxel (100 mg/m2) q3w. All patients have histologically proven TN tumors and no evidence of metastases assessed by initial FDG PET Scanner. Mastectomy and axillary clearance was performed after chemotherapy. pCR was defined as no residual invasive tumor in breast and lymph nodes. TIL and lymphovascular invasion were evaluated pre and post NAC by 2 independent anatomopathologists dedicated to breast cancer. Delta TILS was defined as the difference between post chemotherapy and pre chemotherapy TIL.

Results

Thirty TNIBC pts were treated, 28 underwent surgery and 2 progressed during chemotherapy. Median follow-up was 39 months (8 – 86). 9/30 patients (30%) achieved pCR. Median disease free survival (DFS) was 41 months (2 – 86). Median TIL infiltration at diagnosis was 11% (0-60) and dropped to 1% after chemotherapy (0 – 80). Median delta TIL was - 9% (-50% – +40%). TIL increase after chemotherapy was associated with a decrease of DFS (14 months vs not reached ; p = 0,0009). LVI was present on surgical specimens in 12 cases (12/30, 43%; 12/21 non pCR pts 57 %). Presence of LVI after chemotherapy was significantly associated with a decrease of DFS in the whole population (21 months vs not reached ; p = 0.008) and no significantly among the patients without pCR (23 months vs not reached; p = 0.07).

Conclusion

To the best of our knowledge, it is the best pCR rate reported in TNIBC (2). We showed in this retrospective series of 30 TNIBC that dose dense dose intense chemotherapy is efficient in this population. Presence of lymphovascular invasion and TIL after neoadjuvant chemotherapy in TNIBC are strong prognostic factors associated with DFS. Systematic determination of post NAC TIL and LIV could be a surrogate to propose adjuvant treatment after NAC in TNIBC.

References

1. Giacchetti S, et al. Long-term survival of advanced triple-negative breast cancers with a dose-intense cyclophosphamide/anthracycline neoadjuvant regimen. Br J Cancer. 2014;110:1413.

2. Masuda H, Brewer TM, Liu DD, Iwamoto T, Shen Y, Hsu L, et al. Long-term treatment efficacy in primary inflammatory breast cancer by hormonal receptor- and HER2-defined subtypes. Ann Oncol. 2014;25:384–91.

Citation Format: Campedel L, Binasker A, Blanc-Durand P, Becourt S, Ledoux F, Cuvier C, Gardnair C, Teixeira L, de Roquancourt A, Espie M, Giacchetti S. Outcome of triple negative inflammatory breast cancer (TNIBC) treated with dose-dense dose intense neoadjuvant chemotherapy (NAC), prognostic impact of post NAC lymphovascular invasion and tumor infiltrating lymphocytes (TIL) [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 P5-17-05.

Toxicités sévères des immunothérapies du cancer

L’immunothérapie représente une avancée récente et importante en cancérologie. Les inhibiteurs de checkpoints immunitaires, ciblant les protéines PD-1, PD-L1 et CTLA-4, sont les thérapies les plus prometteuses et sont utilisés dans la prise en charge de plusieurs cancers. Les toxicités associées à ces traitements sont généralement moins fréquentes et moins graves que celles associées aux chimiothérapies et à la plupart des thérapies ciblées. Cependant, il existe un certain nombre de toxicités spécifiques de ce type de traitement, qui peuvent parfois être sévères et dont les plus fréquentes sont les toxicités pulmonaire, digestive, endocrinienne et cutanée. Dans cette mise au point, nous reviendrons sur la fréquence, le mécanisme et les principes de traitement des différentes toxicités sévères associées à l’immunothérapie.

Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update

BACKGROUND

Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007.

METHODS

SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey.

RESULTS

The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Effect of Comedication With Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Retention of Tumor Necrosis Factor Inhibitors in Patients With Spondyloarthritis: A Prospective Cohort Study

OBJECTIVE

To evaluate whether use of comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) influences the retention of tumor necrosis factor inhibitors (TNFi) in patients with spondyloarthritis (SpA).

METHODS

Patients with SpA from the Rheumatic Diseases Portuguese Register who started treatment with their first TNFi between 2001 and 2014 were included in this study. Cox regression analysis was used to estimate the effect of comedication with csDMARDs on TNFi retention in 2 types of models: a model in which baseline (time-fixed) variables were included, and a second model incorporating time-varying variables, including sociodemographic features, measures of disease activity, measures of physical function, and cotreatment with other drugs (nonsteroidal antiinflammatory drugs and oral steroids). To control for possible confounding by indication, the effect of csDMARD comedication on TNFi retention was also tested after adjustment for the treatment propensity score.

RESULTS

In total, 954 patients were included in the study, of whom 289 (30.3%) discontinued treatment with their first TNFi after a median follow-up time of 2.5 years (range 0.08-13 years). Inefficacy was the most common reason for TNFi discontinuation (55.7% of patients). In the multivariable analyses, comedication with csDMARDs had no measurable effect on TNFi retention, neither in the baseline model (hazard ratio [HR] 0.83, 95% confidence interval [95% CI] 0.59-1.16) nor during follow-up in the model adjusted for time-varying covariates (HR 1.07, 95% CI 0.68-1.68). The effect of csDMARD comedication remained nonsignificant after propensity score adjustment.

CONCLUSION

Comedication with csDMARDs does not prolong TNFi retention in patients with SpA in clinical practice, suggesting that there is no benefit conferred by the concomitant use of these drugs.

Positron emission tomography response evaluation from a randomized phase III trial of weekly nab-paclitaxel plus gemcitabine versus gemcitabine alone for patients with metastatic adenocarcinoma of the pancreas

BACKGROUND

In the phase III MPACT trial, nab-paclitaxel plus gemcitabine (nab-P + Gem) demonstrated superior efficacy versus Gem alone for patients with metastatic pancreatic cancer. We sought to examine the feasibility of positron emission tomography (PET) and to compare metabolic response rates and associated correlations with efficacy in the MPACT trial.

PATIENTS AND METHODS

Patients with previously untreated metastatic adenocarcinoma of the pancreas were randomized 1:1 to receive nab-P + Gem or Gem alone. Treatment continued until disease progression by RECIST or unacceptable toxicity.

RESULTS

PET scans were carried out on the first 257 patients enrolled at PET-equipped centers (PET cohort). Most patients (252 of 257) had ≥2 PET-avid lesions, and median maximum standardized uptake values at baseline were 4.6 and 4.5 in the nab-P + Gem and Gem-alone arms, respectively. In a pooled treatment arm analysis, a metabolic response by PET (best response at any time during study) was associated with longer overall survival (OS) (median 11.3 versus 6.9 months; HR, 0.56; P < 0.001). Efficacy results within each treatment arm appeared better for patients with a metabolic response. The metabolic response rate (best response and week 8 response) was higher for nab-P + Gem (best response: 72% versus 53%, P = 0.002; week 8: 67% versus 51%; P = 0.014). Efficacy in the PET cohort was greater for nab-P + Gem versus Gem alone, including for OS (median 10.5 versus 8.4 months; hazard ratio [HR], 0.71; P = 0.009) and ORR by RECIST (31% versus 11%; P < 0.001).

CONCLUSION

Pancreatic lesions were PET avid at baseline, and the rate of metabolic response was significantly higher for nab-P + Gem versus Gem alone at week 8 and for best response during study. Having a metabolic response was associated with longer survival, and more patients experienced a metabolic response than a RECIST-defined response.

CLINICALTRIALSGOV

NCT00844649.

Abstract P1-14-08: Prediction of pathological response (pCR) to neoadjuvant dose dense and intense cyclophosphamide and anthracycline in a prospective series of triple negative locally advanced breast cancers (TNLABC)

Background: Stage II-III TNBC retains a poor outcome despite high chemosensitivity. Patients (pts) with pCR after neoadjuvant chemotherapy have a good prognosis whereas non-responding pts have a 25-40% risk of distant relapse at 5 years. pCR is thus a major goal in TNBC. We previously reported that TNLABC benefit the most of dose dense dose intense cyclophosphamide (C)-epirubicin (E) (S.Giacchetti; BJC, 2014)

Aim: To confirm these results prospectively and analyze the predictive factors of response to high dose chemotherapy in TNBC.

Patients and methods: From january 2009 to april 2015 non inflammatory TNLABC received high dose C (1200 mg/m2 d1 qw 2) with E (75 mg/m2/ d1 qw2) for 6 cycles. The pts had a breast biopsy with frozen tissue. We performed molecular studies: qRT-PCR for AR, FOXA1, PI3K and FASAY technic for p53 mutation.The percentage of stromal Tumor-infiltrating lymphocytes (TILs) was also evaluated by two independent pathologists and assessed as a continuous variable. A18F-FDG PET/CT was performed initially and after 2 courses of chemotherapy and the metabolic answer assessed as a variation of the tumor uptake (ΔSUVmax). We report here the pathological complete response (pCR) (absence of infiltrative carcinomas in the breast and in the lymph nodes) and the factors associated with pCR.

Results: The characteristics of the 74 pts are listed in table 1. The median age is 48 years old, 48 pts (65.8%) are premenopausal and 79% did not have any family history of breast cancers. TIL was divided in 3 groups &lt; 10 % (26 pts, 40 %); 10-50 % (30 pts, 46 %) &gt; 50% (9 pts, 14 %). Pathological response was assessed in 66 pts, one pt progressed during chemotherapy and 6 pts did not undergo surgery yet. 28 pts were in pCR (42.4 %). With a median follow up of 25 months, 13 pts (17.8 %) progressed and 8 (11%) died.

Table 1: Patients characteristics and pCR according to tumor features and metabolic responseCharacteristicsNumber of pts (%)N of pts evaluated for pCRpCR (%)OR [IC 95%]p-valueTumor size T2363519 (54)10.04T337319 (29)0.34 [0.12 ; 0.96]Nodal status N0363315 (46)10.62N1/N2/N3 24/11/33313 (39)0.78 [0.29 ; 2.07]Histological grade: 2660 (0) 0.04*3676028 (47)TILs &lt;10 %26 (40)2510 (40)10.02610-50 %30 (46)267 (27)0.55 [0.17 ; 1.80]≥ 509 (14)9 7 (78)5.25 [0.90 ; 30.62]P53 Mutated54 (89)5121 (41)10.43WT7 (12)53 (60)2.14 [0.33; 13.96]AR Negative43 (83)4318 (42)10.46Positive 9 (17)95 (56)1.74 [0.41 ; 7.38]FOXA1 Negative40 (77)4015 (38)10.08Positive 12 (23)128 (60) 3.33 [0.86 ; 12.99]Molecular Apocrine8 (17)85 (63)10.19TN38 (83)3814 (37)0.35 [0.07 ; 1.69]PI3K Non mutated44 (88)4419 (43)10.75Mutated6 (12)63 (50)1.31 [0.24 ; 7.26]SUVmax at 2 courses0.0001&lt; 70 %27 (53)221 (5)1≥ 70 %24 (47)2318 (78)79.2 [8.48 ; 739.82]* Measured with a Fisher Test

Tumor size, tumor grade, percentage of TILs, the change in 18F-fluorodeoxyglucose tumor uptake (ΔSUVmax) were significantly associated with pCR at univariate analysis. Only one factor remained significant at multivariate analysis, the ΔSUVmax, OR: 0.04 [0.007- 0.27], p = 0.0008.

Conclusion: In this prospective phase III trial we confirm the efficacy of a dose dense EC in TNBC. The metabolic response evaluated with 18 F-FDG PET/CT is a strong and reliable predictor of pCR and could allow an early change of treatment for the non responders. A clinical trial is planned to test this strategy.

Citation Format: Giacchetti S, De Roquancourt A, Groheux D, Piron P, Lehmann-che J, Cuvier C, Resche-rigon M, Albiter M, Roche B, Frank S, Hamy A-S, Teixeira L, Marty M, Lalloum M, Espié M. Prediction of pathological response (pCR) to neoadjuvant dose dense and intense cyclophosphamide and anthracycline in a prospective series of triple negative locally advanced breast cancers (TNLABC). [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 P1-14-08.

[New targeted therapies in breast cancer]

Trastuzumab improves care of patients with HER2+ breast cancer and allows a major gain in terms of survival. T-DM1 and pertuzumab are two new treatments, which give very encouraging results in metastatic breast cancer. Their place in neo-adjuvant and adjuvant setting still remains to be defined. Bevacizumab have its place in metastatic breast cancer. In adjuvant setting, results are disappointing and in neo-adjuvant setting, we need more studies on subgroups, which can benefit more. Development of the PARP inhibitors was slowed down by recent negative results in metastatic breast cancer but studies continue with more targeted patient's. Finally, everolimus, inhibitor of mTOR, allows to by pass the hormono-resistance in metastatic phase. Its toxicity must be taken into account in particular in adjuvant setting.

Organ Donation European Quality System: ODEQUS project methodology

Differences in the number of organ donors among hospitals cannot be explained only by the number of intensive care unit beds used or neurologic patients treated. The figures obtained are influenced by the organizational structure of the donation process and how efficient it is. The Organ Donation European Quality System (ODEQUS) is a 3-year project (from October 2010 to September 2013) co-financed by the European Agency for Health and Consumers (EAHC20091108) which aims to define a methodology to evaluate organ procurement performance at the hospital level. ODEQUS's specific objectives are to identify quality criteria and to develop quality indicators in three types of organ donation (after brain death, after cardiac death, and living donation). Those tools will be useful for hospitals' self-assessment as well as for developing an international auditing model. A consortium has been established involving 14 associated partners from Austria, Croatia, France, Germany, Italy, Poland, Portugal, Romania, Spain, Sweden, and the United Kingdom, as well as five collaborating partners from Greece, Hungary, Malta, Slovenia, and Turkey. The project has been established in three steps: 1) Design of a survey about the use of quality tools in a wide sample of European hospitals; 2) Development of quality criteria and quality indicators by the project experts. The main fields considered have been organizational structures, clinical procedures, and outcomes; and 3) Elaboration of an evaluation system to test the quality indicators in 11 European hospitals. Two types of training have been designed and performed: one concerns the development of quality criteria and quality indicators, whereas another is focused on how to use evaluation tools. Following this methodology, the project has so far identified 131 quality criteria and developed 31 quality indicators. Currently, the quality indicators are being tested in 11 selected hospitals.

Better outcomes of peritoneal dialysis in diabetic patients in spite of risk of loss of autonomy for home dialysis

INTRODUCTION

Diabetes mellitus is a leading cause of chronic renal failure, challenging therapy strategies. Patients with diabetes may benefit from peritoneal dialysis (PD) but higher technique failure is feared. Our purpose was to critically evaluate clinical outcomes of this modality in diabetics, in order to find quality improvement strategies in these risk patients.

METHODS

A registry-based study of 432 incident patients, 23% with diabetes, from a university hospital PD program was performed. Traditional methods (Kaplan-Meier, Cox models) and innovative survival analysis, taking competing risks into account, were performed, as well as exploring the trends in cohorts according to the decade of PD start.

RESULTS

In spite of the detrimental effect of diabetes in patient survival compared to non-diabetics (77%, 52% vs 86%, 71%, at 2 and 4 years, respectively; p < 0.0001) the hazard ratio (HR) for death decreased in the more contemporary cohort (0.303, 95% confidence interval (CI) 0.150 - 0.614, p < 0.001). It is noteworthy that diabetes was not associated with lower technique survival: 74%, 51% vs 79%, 57%, at 2 and 4 years, respectively (p = not significant (NS)). On multivariate analysis, diabetes was an independent predictor for mortality, but not for technique failure. The hazard ratio (HR) for technique failure also decreased in the more recent cohort (0.566, 95% CI 0.348 - 0.919, p = 0.021). Among reasons for transfer to hemodialysis, proportion of ultrafiltration failure was similar between groups (26% vs 22%, p = NS), but drop-out due to loss of autonomy occurred more in the group with diabetes (23% vs 5%, p = 0.004), mainly due to ischemic stroke. The hospitalization rate was also higher in diabetic patients (1.39 vs 0.84 episodes per patient-year (E/PY), p = 0.004) but the peritonitis rate was not increased (0.53 vs 0.61 E/PY, p = NS).

CONCLUSION

PD was an effective long-term renal replacement therapy in diabetics, without higher rates of technique failure, ultrafiltration failure or peritonitis. Better outcomes were achieved in the contemporary cohort. The menace of autonomy loss due to stroke and higher hospitalization rates enhance the need for assisted PD strategies and better control of comorbidities.