[Severe complications of systemic treatment in thoracic oncology]

Primary thoracic cancers affect a large number of patients, mainly those with lung cancer and to a lesser extent those with pleural mesothelioma and thymic tumours. Given their frequency and associated comorbidities, in patients whose mean age is high, these diseases are associated with multiple complications. This article, the last of a series dedicated to emergencies in onco-haematological patients, aims to present a clinical picture of the severe complications (side effects, immune-related adverse events) associated with systemic treatments, excluding infections and respiratory emergencies, with which general practitioners and specialists can be confronted. New toxicities are to be expected with the implementation of innovative therapeutic approaches, such as CAR-T cells, along with immunomodulators and antibody-drug conjugates.

Replacing Plastics with Alternatives Is Worse for Greenhouse Gas Emissions in Most Cases

Plastics are controversial due to their production from fossil fuels, emissions during production and disposal, potential toxicity, and leakage to the environment. In light of these concerns, calls to use less plastic products and move toward nonplastic alternatives are common. However, these calls often overlook the environmental impacts of alternative materials. This article examines the greenhouse gas (GHG) emission impact of plastic products versus their alternatives. We assess 16 applications where plastics are used across five key sectors: packaging, building and construction, automotive, textiles, and consumer durables. These sectors account for about 90% of the global plastic volume. Our results show that in 15 of the 16 applications a plastic product incurs fewer GHG emissions than their alternatives. In these applications, plastic products release 10% to 90% fewer emissions across the product life cycle. Furthermore, in some applications, such as food packaging, no suitable alternatives to plastics exist. These results demonstrate that care must be taken when formulating policies or interventions to reduce plastic use so that we do not inadvertently drive a shift to nonplastic alternatives with higher GHG emissions. For most plastic products, increasing the efficiency of plastic use, extending the lifetime, boosting recycling rates, and improving waste collection would be more effective for reducing emissions.

Is tree planting an effective strategy for climate change mitigation?

The world's forests store large amounts of carbon (C), and growing forests can reduce atmospheric CO2 by storing C in their biomass. This has provided the impetus for world-wide tree planting initiatives to offset fossil-fuel emissions. However, forests interact with their environment in complex and multifaceted ways that must be considered for a balanced assessment of the value of planting trees. First, one needs to consider the potential reversibility of C sequestration in trees through either harvesting or tree death from natural factors. If carbon storage is only temporary, future temperatures will actually be higher than without tree plantings, but cumulative warming will be reduced, contributing both positively and negatively to future climate-change impacts. Alternatively, forests could be used for bioenergy or wood products to replace fossil-fuel use which would obviate the need to consider the possible reversibility of any benefits. Forests also affect the Earth's energy balance through either absorbing or reflecting incoming solar radiation. As forests generally absorb more incoming radiation than bare ground or grasslands, this constitutes an important warming effect that substantially reduces the benefit of C storage, especially in snow-covered regions. Forests also affect other local ecosystem services, such as conserving biodiversity, modifying water and nutrient cycles, and preventing erosion that could be either beneficial or harmful depending on specific circumstances. Considering all these factors, tree plantings may be beneficial or detrimental for mitigating climate-change impacts, but the range of possibilities makes generalisations difficult. Their net benefit depends on many factors that differ between specific circumstances. One can, therefore, neither uncritically endorse tree planting everywhere, nor condemn it as counter-productive. Our aim is to provide key information to enable appropriate assessments to be made under specific circumstances. We conclude our discussion by providing a step-by-step guide for assessing the merit of tree plantings under specific circumstances.

Unsupervised clustering to differentiate rheumatoid arthritis patients based on proteomic signatures

OBJECTIVE

Patients with rheumatoid arthritis (RA) have different presentations and prognoses. Cluster analysis based on proteomic signatures creates independent phenogroups of patients with different pathophysiological backgrounds. We aimed to identify distinct pathophysiological clusters of RA patients based on circulating proteomic biomarkers.

METHOD

This was a cohort study including 399 RA patients. Clustering was performed on 94 circulating proteins (92 CVDII Olink®, high-sensitivity troponin T, and C-reactive protein). Unsupervised clustering was performed using a partitioning cluster algorithm.

RESULTS

The clustering algorithm identified two distinct clusters: cluster 1 (n = 223) and cluster 2 (n = 176). Compared with cluster 1, cluster 2 included older patients with a higher burden of comorbidities (cardiovascular and RA related), more erosive and longer RA duration, more dyspnoea and fatigue, walking a shorter distance in the Six-Minute Walk Test, with more severe diastolic dysfunction, and a 4.5-fold higher risk of death or hospitalization for cardiovascular reasons. Tumour necrosis factor (TNF) receptor superfamily-related pathways were mainly responsible for the model's discriminative ability.

CONCLUSION

Using unsupervised cluster analysis based on proteomic phenotypes, we identified two clusters of RA patients with distinct biomarkers profiles, clinical characteristics, and different outcomes that could reflect different pathophysiological backgrounds. TNF receptor superfamily-related proteins may be used to distinguish subgroups.

[Olimetastatic disease: Current status and perspectives in non-small cell lung cancer]

The concept of oligometastatic disease was first introduced in the late 1990s to describe an situation more or less midway between locally advanced tumours and multifocal metastatic cancer. Four concepts are currently used: synchronous oligometastatic disease, metachronous oligometastatic disease (or oligo-recurrence), oligo-persistence and oligo-progression. Some phase II studies, randomised or not, have validated this concept in non-small cell lung cancer (NSCLC) and suggest the interest of adding local ablative therapy to systemic treatment. That said, numerous questions remain, and the impact of this therapeutic approach in the framework of immunotherapies and targeted therapies has yet to be assessed. Which of these new treatments offer hope of significantly improved long-term survival in stage IV NSCLC? This article appraises current knowledge and therapeutic regarding oligometastatic NSCLC.

Development of bioenergy technologies: A scientometric analysis

Bioenergy has the potential to substitute the current demand for fossil fuels in various applications. Recovering energy from bio-based materials due to environmental considerations has been adopted as a policy objective by governments and international organizations, which led to both vast financial investment and scientific research, especially in the last two decades. So far, various feedstocks and technologies have been scrutinised by the research community, although not all of them are commercially adopted due to sustainability considerations. This study employs scientometric analysis to survey the progress of scientific development in the field of bioenergy from 1966 to 2022, using ten parameters including publication year, type of document, categories, countries, affiliations, document citations, co-authorship, author citation networks, journal citation networks, and keywords. A total of 51,905 scientific documents were collected from the Web of Science, involving more than 96,000 authors from 162 countries. The dispersion of studies followed an ascending distribution with a sharp increase in the second half of the 2000s. The evolution of keywords in terms of burst strength confirmed the advancements of technologies from primary first-generation to advanced fourth-generation bioenergies. Based on the evolution of science in this area, it is concluded that integrated sustainability assessment studies, covering technical, economical, environmental, and social aspects, are needed to bridge the gap between abundant theoretical endeavours and limited commercial use of this energy source.

Evaluating the environmental profiles of winter wheat rotation systems under different management strategies

Climate change poses a remarkable challenge to global food security, for which wheat is one of the main staple agricultural commodities. The cultivation of different varieties of winter wheat in Galicia (commercial and native) under rotation systems with potato, maize and oilseed rape was evaluated from an environmental point of view. The general approach of this study included the gathering of the inventory data of the different crops, the quantification of their environmental impacts and economic benefits, to identify the best land management system. Life Cycle Assessment (LCA) was used as environmental tool. The environmental profiles of each rotation system were reported in terms of nine impact categories. Crop rotations were analysed both per hectare and per € of gross margin, so that the information can be relevant to land-management decisions. Preference ranks were established based on an environmental normalized score for both units. The results suggest that arable operations contribute decisively to the environmental profile of the rotations. The avoided mineral fertilization processes, the carbon storage in the soil when returning straw to the field, as well as the electricity production clearly influence the environmental impact of the rotations. Scenarios that include native wheat under organic management are always the environmentally preferred ones while the preferred alternate crop depends on the reference unit. Concerning the margin gross, scenarios including the native variety report the highest profits, being the potato the preferred alternate crop. Further assessment needs to be undertaken to identify differences in the results of different ways of conducting LCA, i.e. attributional vs consequential approaches.

AB0406 HUMAN PAPILLOMA VIRUS (HPV) VACCINATION SAFETY IN SYSTEMIC LUPUS ERYTHEMATOSUS COHORT - PORTUGUESE UNIVERSITY HOSPITAL SINGLE-CENTER COHORT STUDY

Background:

Cervical cancer is a potentially preventable consequence of Human Papillomavirus (HPV). HPV vaccination is recommended in most countries for all young women, preferentially before sexual activity begins. In Portugal, HPV vaccination is available in either bivalent (genotypes 6, 18) or tetravalent (6, 11, 16 e 18) vaccines. Both have aluminum as an adjuvant, a substance arguably capable of inducing inflammatory adjuvant syndromes. Systemic Lupus Erythematosus (SLE) mostly afflicts women of childbearing age, the very target population for HPV vaccination. There are conflicting reports in the literature regarding both the efficacy and safety of this vaccine in SLE patients. This question is particularly pressing as HPV infection prevalence seems to be increased in SLE patients.

Objectives:

To analyze the safety of HPV vaccination in a SLE patient cohort followed at a university hospital.

Methods:

Retrospective single-center (35 year long, 436 SLE patient cohort) review of all female SLE patients’ local and online national records on HPV vaccination and cervical cancer screening. Data on activity (using SLEDAI-2K scoring) and concomitant drug use were reviewed for the two years before and after vaccination date.

Results:

Of the 463 SLE patients, 420 were women (91%), of which 322 had clinical information about yes/no HPV vaccination. Twenty-seven of the patients (8%) had one of HPV vaccines, but only 13 (4%) had full information on activity before and after vaccination. Mean current age was 33,8 years and a minimum of 8,4 years of follow-up after HPV vaccination. Twenty-there (85%) were vaccinated with the tetravalent vaccine. Pre-vaccination mean SLEDAI score of was 5.9: due to arthritis (n= 5; 38,5%), low complement (n=4; 31%), dsDNA (n=4; 31%); with a medium dose of 10mg prednisolone/day and 265mg/day of hydroxychloroquine. Post-vaccination mean SLEDAI was 5.8: due to arthritis (n=6; 46%), rash (n= 5; 38,5%) and low complement (n=6; 46%); with a medium dose of 8mg prednisolone/day and 288mg/day of hydroxychloroquine. There was not a difference in organ involvement before and after vaccination, but rash was slightly more prevalent after vaccination.

Conclusion:

In our population, HPV vaccination didn’t significantly change disease activity and organ involvement or mean dose need of prednisolone or hydroxychloroquine. Although it is a small size SLE sample, it suggests that is safe to administer HPV vaccination to SLE patients.

References:

[1]eularSegal Yahel, Zabludowicz Center for Autoimmune Diseases, Tel Aviv (2017), “HPV and systemic lupus erythematosus: a mosai of potential crossreaction”, SLE Research and Clinical Update, 23 January 2017

[2]Geier David Institute of Chronic Illnesses, USA, (2016), “Quadrivalent human pappilomavirus vaccine and autoimmune adverse events: a case-control assessment of the vaccine adverse event reporting system (VAERS) database, Environment and Autoimmunity, 13 July 2016

Disclosure of Interests: :

None declared

AB0407 HUMAN PAPILLOMA VIRUS (HPV) INFECTION AND CERVICAL CANCER PREVALENCE IN A PORTUGUESE UNIVERSITY HOSPITAL SINGLE-CENTER SYSTEMIC LUPUS ERYTHEMATOSUS COHORT

Background:

About 12% of women worldwide are infected with Human Papillomavirus (HPV), the most frequent cause of cervical cancer (CC) - very prevalent (~ 7,5%) and preventable. National screening efforts are in use in several countries, including Portugal. Patients with Systemic Lupus Erythematosus (SLE) are at increased risk of HPV infection and CC when compared to the healthy population.

Objectives:

To evaluate the prevalence of HPV infection and rate of incidence of cervical neoplastic lesions in a SLE patient cohort followed at a university hospital.

Methods:

Retrospective single-center (35 year long, 463 SLE patient cohort) review of all female SLE patients’ local and online national health care records on HPV vaccination and CC screening.

Results:

Of the 463 SLE patients, 420 were women (91%), of which 322 had records on of HPV infection or CC developed. Mean patients’ current age was 48 years and all had screening for cervical pathology in the last 3 years. Thirty-three patients (11%) had HPV infection diagnosed at a mean age of 44 years. Twenty-seven (8%) of SLE patients were vaccinated for HPV: 8 (22%) of the infected patients had the vaccine, half after the HPV infection. Despite HPV infection, 49 patients (15%) had developed some cervical lesion, of which 41 (84% of cervical lesion) were suggestive of malignancy, and ultimately CC was diagnosed in 20 women (41%; 6% of total women), with a mean age at diagnosis of 45 years. All CC patients had history of HPV infection, but only 3 women (15%; 0,9% of total women) had been vaccinated against HPV, 2 after the diagnoses of CC and 1 before.

Conclusion:

In our population the prevalence of HPV was higher than reported for the general population using the World Health Organization database, conforming the higher risk of HPV infection in SLE patients. The prevalence of cervical cancer, however, was similar to the healthy population.

References:

[1]https://www.who.int/immunization/diseases/hpv/en/

[2]Forman David (2012); “Global Burden of Human Papillomavirus and Related Diseases”, Vaccine, Elsevier Volume 30, Supplement 5, 20 November 2012

[3]Grein Ingrid (2016), Department of Pediatric Immunology and Rheumatology, Netherland (2016), HPV infection and vaccination in Systemic Lupus Erythematosus patients: what we really should know, Pediatric Rheumatology, 2016

Disclosure of Interests: :

None declared

Biomarkers of response and resistance to PI3K inhibitors in estrogen receptor-positive breast cancer patients and combination therapies involving PI3K inhibitors

In this review, we discuss biomarkers of response and resistance to PI3K inhibitors (PI3Ki) in estrogen receptor-positive breast cancer, both in the early and advanced settings. We analyse data regarding PIK3CA mutations, PI3K pathway activation, PTEN expression loss, Akt signalling, insulin levels, 18FFDG-PET/CT imaging, FGFR1/2 amplification, KRAS and TP53 mutations. Most of the discussed data comprise retrospective and exploratory studies, hence many results are not conclusive. Therefore, among all of these biomarkers, only PIK3CA mutations have proved to have a predictive value for treatment with the α-selective PI3Ki alpelisib (SOLAR-1 trial) and the β-sparing PI3Ki taselisib (SANDPIPER trial) in the advanced setting. Since the accuracy of current individual biomarkers is not optimal, a composite biomarker, including DNA, RNA and protein expression data, to more precisely assess the PI3K/AKT/mTOR pathway activation status, may arise as a promising approach. Finally, we describe the rational for new combination therapies involving PI3Ki and anti-HER2 agents, chemotherapy, CDK4/6 inhibitors, mTOR inhibitors or new endocrine treatments and discuss the ongoing trials in this field.

Environmental footprint family to address local to planetary sustainability and deliver on the SDGs

The number of publications on environmental footprint indicators has been growing rapidly, but with limited efforts to integrate different footprints into a coherent framework. Such integration is important for comprehensive understanding of environmental issues, policy formulation and assessment of trade-offs between different environmental concerns. Here, we systematize published footprint studies and define a family of footprints that can be used for the assessment of environmental sustainability. We identify overlaps between different footprints and analyse how they relate to the nine planetary boundaries and visualize the crucial information they provide for local and planetary sustainability. In addition, we assess how the footprint family delivers on measuring progress towards Sustainable Development Goals (SDGs), considering its ability to quantify environmental pressures along the supply chain and relating them to the water-energy-food-ecosystem (WEFE) nexus and ecosystem services. We argue that the footprint family is a flexible framework where particular members can be included or excluded according to the context or area of concern. Our paper is based upon a recent workshop bringing together global leading experts on existing environmental footprint indicators.

Upper Airway Video Endoscopy: Assessment of the response to positive pressure ventilation and mechanical in-exsufflation

Upper airways (UA) include the nasal cavities, pharynx, and larynx, and its main function is to warm and filter the inspired air. UA dysfunction is in the pathogenesis of various disorders, such as obstructive sleep apnea syndrome (OSAS) and vocal cord dysfunction. In addition, in some neurodegenerative diseases (e.g. Amyotrophic Lateral Sclerosis - ALS), UA dysfunction may also compromise the effective use of ventilatory support (VS). In this context, the endoscopic evaluation of UA may be useful in understanding the OSAS mechanisms, in determining the causes for treatment-induced airway obstruction and even in helping to titrate noninvasive ventilation (NIV) in ALS patients with bulbar or pseudo-bulbar (spastic) dysfunction. Specifically, in OSAS patients, when residual obstructive events persist, although an optimal ventilatory mode has been apparently achieved, along with interface and equipment, the endoscopic evaluation of UA seems to be a valuable tool in understanding its mechanisms, even assisting adjustments to NIV parameters. In addition, it has also been described as being useful in laryngeal response to mechanical in-exsufflation (MI-E) and Exercise-Induced Laryngeal Obstruction (EILO). However, no protocol has yet been published or validated for this. For this reason, a literature review was conducted on UA function and its response to positive pressure and MI-E. Special emphasis has also been given to the current indication for video endoscopy in chronically ventilated patients.

Estimating 20-year land-use change and derived CO2 emissions associated with crops, pasture and forestry in Brazil and each of its 27 states

Land-use change (LUC) in Brazil has important implications on global climate change, ecosystem services and biodiversity, and agricultural expansion plays a critical role in this process. Concerns over these issues have led to the need for estimating the magnitude and impacts associated with that, which are increasingly reported in the environmental assessment of products. Currently, there is an extensive debate on which methods are more appropriate for estimating LUC and related emissions and regionalized estimates are lacking for Brazil, which is a world leader in agricultural production (e.g. food, fibres and bioenergy). We developed a method for estimating scenarios of past 20-year LUC and derived CO₂ emission rates associated with 64 crops, pasture and forestry in Brazil as whole and in each of its 27 states, based on time-series statistics and in accordance with most used carbon-footprinting standards. The scenarios adopted provide a range between minimum and maximum rates of CO₂ emissions from LUC according to different possibilities of land-use transitions, which can have large impacts in the results. Specificities of Brazil, like multiple cropping and highly heterogeneous carbon stocks, are also addressed. The highest CO₂ emission rates are observed in the Amazon biome states and crops with the highest rates are those that have undergone expansion in this region. Some states and crops showing large agricultural areas have low emissions associated, especially in southern and eastern Brazil. Native carbon stocks and time of agricultural expansion are the most decisive factors to the patterns of emissions. Some implications on LUC estimation methods and standards and on agri-environmental policies are discussed.

GUIDELINE FOR THE MANAGEMENT OF BILE DUCT CANCERS BY THE BRAZILIAN GASTROINTESTINAL TUMOR GROUP

The Brazilian Gastrointestinal Tumor Group developed guidelines for the surgical and clinical management of patients with billiary cancers. The multidisciplinary panel was composed of experts in the field of radiology, medical oncology, surgical oncology, radiotherapy, endoscopy and pathology. The panel utilized the most recent literature to develop a series of evidence-based recommendations on different treatment and diagnostic strategies for cholangiocarcinomas and gallbladder cancers.

Absence of Tumor-Infiltrating Lymphocyte Is a Reproducible Predictive Factor for Sentinel Lymph Node Metastasis: A Multicenter Database Study by the Brazilian Melanoma Group

Aims

The aim of this study is to confirm the function of tumor-infiltrating lymphocytes (TILs) in sentinel lymph node (SLN) metastasis.

Materials and Methods

This retrospective study included 633 patients with invasive melanoma who underwent sentinel lymph node biopsy in 7 referral centers certified by the Brazilian Melanoma Group. Independent risk factors of sentinel node metastasis (SNL) were identified by multiple logistic regression.

Results

SLN metastasis was detected in 101 of 633 cases (16.1%) and in 93 of 428 patients (21.7%) when melanomas ≤ 1mm were excluded. By multiple logistic regression, the absence of TILs was as an independent risk factor of SLN metastasis (OR = 1.8; 95%CI: 1.1–3.0), in addition to Breslow index (greater than 2.00 mm), lymph vascular invasion, and presence of mitosis.

Conclusion

SLNB can identify patients who might benefit from immunotherapy, and the determination of predictors of SLNB positivity can help select the proper population for this type of therapy. The absence of TILs is a reproducible parameter that can predict SLNB positivity in melanoma patients, since this study was made with several centers with different dermatopathologists.

Biological screening of Brazilian medicinal plants

In this study, we screened sixty medicinal plant species from the Brazilian savanna ("cerrado") that could contain useful compounds for the control of tropical diseases. The plant selection was based on existing ethnobotanic information and interviews with local healers. Plant extracts were screened for: (a) molluscicidal activity against Biomphalaria glabrata, (b) toxicity to brine shrimp (Artemia salina L.), (c) antifungal activity in the bioautographic assay with Cladosporium sphaerospermum and (d) antibacterial activity in the agar diffusion assay against Staphylococcus aureus, Escherichia coli, Bacillus cereus and Pseudomonas aeruginosa. Forty-two species afforded extracts that showed some degree of activity in one or more of these bioassays.

Methotrexate hepatotoxicity in psoriatic patients submitted to long-term therapy

Eighty-four patients with severe psoriasis who required methotrexate (MTX) therapy have been reviewed. A total of 134 liver biopsies were performed. The lack of correlation between alcohol intake and the use of potential hepatotoxic drugs with pretreatment liver biopsies is noted. A review of 30 patients who had liver biopsies performed before and after MTX treatment showed no statistically significant difference between the histological grades before and after treatment. Nor was there any absolute correlation between the cumulative MTX doses and the histological changes of follow-up biopsies. In this group of patients, 15 (50%) developed fibrosis, which was severe in 2 patients, after 3,431 mg MTX average dose. Cirrhosis was observed in 3 patients (10%) after 1,667 mg MTX average dose. Follow-up liver biopsies are recommended for patients treated with MTX.

Paraganglioma of the spermatic cord. Report of a case with immunohistochemical and ultrastructural studies

We describe a case of paraganglioma arising in the spermatic cord, which is an extremely rare location. Immunohistochemical studies characterized two types of cells: (1) polygonal cells expressing neuron-specific enolase, chromogranin A, and synaptophysin and (2) S100 protein-positive sustentacular cells. Electron microscopy revealed that within the cytoplasm of the polygonal cells, there were electron-dense granules whose morphological appearance was consistent with that of neurosecretory granules. Paraganglioma of the spermatic cord may originate from embryonic chromaffin cells that have followed the testis into the scrotum.

Carcinoid tumour of male breast diagnosed by fine needle aspiration

A primary carcinoid tumour of the breast in a 66-year-old man was diagnosed by fine-needle aspiration cytology. The nature of the lesion was proved by histochemical and immunocytochemical studies. The importance of a conclusive diagnosis is discussed and the value of immunocytochemical analysis as an aid to cytomorphologic diagnosis is demonstrated.

Flight behavior induced by microinjection of GABA antagonists into periventricular structures in detelencephalated rats

Behavioral effects of unilateral microinjections into periventricular structures of bicuculline, a classic GABA-A antagonist, and semicarbazide, a glutamic acid decarboxylase blocker, were studied in detelencephalated rats. These drugs produced a behavioral activation together with jumps. However, the characteristics of this behavioral activation differed as the injections were made in dorsal periaqueductal gray matter or medial hypothalamus. These data show close similarities to those observed with intact animals suggesting that GABA-A receptors are involved in the neural control of expression of flight behavior and functions in an intact manner and possibly independent of influences from forebrain structures. At variance with intact animals, these drugs produced contralateral turning behavior when locally injected into MH, pointing to some kind of inhibitory control exerted by telencephalic structures on the expression of circling behavior from diencephalic regions.

Contact dermatitis to Hirudoid cream

31 patients allergic to Hirudoid cream were patch tested with the ingredients. 29 were allergic to the cream base and 16 to one or more components. The most common allergens were myristyl alcohol, cetostearyl alcohol and parabens. 14 patients reacted only to the base. The results are discussed.