Executive summary of the consensus document on the management of perioperative anemia in Spain

Perioperative anemia is an independent risk factor for postoperative morbidity and mortality. However, conceptual, logistical and administrative barriers persist that hinder the widespread implementation of protocols for their management. The project coordinator convened a multidisciplinary group of 8 experienced professionals to develop perioperative anemia management algorithms, based on a series of key points (KPs) related to its prevalence, consequences, diagnosis and treatment. These KPs were assessed using a 5-point Likert scale, from "strongly disagree [1]" to "strongly agree [5]". For each KP, consensus was reached when receiving a score of 4 or 5 from at least 7 participants (>75%). Based on the 36 KPs agreed upon, diagnostic-therapeutic algorithms were developed that we believe can facilitate the implementation of programs for early identification and adequate management of perioperative anemia, adapted to the characteristics of the different institutions in our country.

Abstract P4-04-05: Primary endocrine therapy (PETx) induces PAM50 intrinsic subtype migration with prognostic implications

Backgorund: ER activation is a major ruler of cell biology in ER+ve breast cancer. Hence, ER dependent gene expression at diagnosis, may unveil most of the oncogenic mechanisms responsible of potential tumour relapse and metastasis. Thus, we hypothesized that oestrogen deprivation through PETx may unveil underlying tumour biology with deeper prognostic implications. To explore this, we studied changes in PAM50 intrinsic subtyping and Risk of Recurrence score throughout PETx and their correlation with known prognostic factors.

Methods: Clinical-pathological data were evaluated in a series of patients with stage I-III ER-positive/HER2-negative breast cancer treated in 6 centers in Spain with PETx during more than two months with available baseline and surgical samples. The expressions of 50 genes were measured in baseline samples and surgical specimens using the nCounter platform. Intrinsic subtypes and Risk of Recurrence score (ROR) were determined by the research-based PAM50 predictor. Response by ultrasonography (US) and magnetic resonance (RMI) between diagnosis and before surgery and PEPI score in surgical samples were used as the endpoints. Association between two variables was evaluated using χ2 test or Pearson correlation. All statistical tests were two-sided and considered significant when P≤0.05.

Results: Gene expression profile was feasible in 58 pre/post sample pairs with a median of 7.8 months (range 2.5-40.6) of PETx with AIs (98.3%) or tamoxifen (1.7%). At baseline, 68.9%(n=40) were classified as Luminal A, followed by Luminal B (24.1%; n=14), HER2 enriched (HER2-E) (5.2%; n=3) and Normal-like (1.8%; n=1). Radiologic response did not change significantly according to intrinsic subtype either by MRI or US (P>0.05). Instead, PEPI score varied according to intrinsic subtype (P=0.024).Thirteen (32%) of LumA, while neither of LumB or HER2-E tumours showed a PEPI score Group 1. PETx resulted in changes in the intrinsic subtype in 29 (50%) of tumours

Table 1 Her2-E postLumA postLumB postNormal postHer2 pre2 (66.7%)1 (33.33%)00LumA pre1 (2.5%)21 (52.5%)3 (7.5%)15 (37.5%)LumB pre06 (42.86%)5 (35.71%)3 (21.43%)Normal pre0001 (100%)

. Of note, 2 of 3 (66.7%) HER2 tumors, and 5 of 14 (35.7%) LumB tumors did not change their profile. Forty-eight (83%) tumours showed a decrease in ROR score after PETx (P<0.001). ROR was over 30 in 29 tumours (49.1%) at baseline and 16 (27%) at surgery. Change in ROR was moderately correlated with percentage of change in Ki-67 [correlation: 0.417 (P<0.01)]. Correlation of surgical tumour subtype with IHC markers of cell-viability/apoptosis will be presented.

Conclusion: Oestrogen deprivation of luminal tumours through PETx results in profound changes in tumour biology including a migration in intrinsic subtype in 50% of tumours.

Correlation of the largely decreased ROR with changes in Ki67 reveals the potential prognostic additional information generated by profiling tumours after PETx. ER-blockade may unveil underlying tumour oncogenic capabilities for relapse, survival and metastasis.

Hence, the post-PETx gene expression profile, molecular subtype and ROR may bear incremental prognostic and predictive information generating a novel scenario for optimal clinical decision making.

Citation Format: Larburu L, Paré L, Rezola R, Carrera M, Buch E, Gimenez J, Quiroga V, Fernandez M, Aragón S, Pascual T, Prat A, Urruticoechea A. Primary endocrine therapy (PETx) induces PAM50 intrinsic subtype migration with prognostic implications [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-04-05.

Oral versus vaginal misoprostol for cervical priming in first-trimester abortion: a randomized trial

The objective of this study was to compare the oral and vaginal administration of misoprostol for cervical priming before surgical abortion up to 63 days' gestation. A total of 900 pregnant women, with ages ranging from 18 to 42 years, who asked for pregnancy termination, were included in this study. Women were randomly allocated to one of the following groups: oral administration of 400 microg misoprostol, 8 h before aspiration; and vaginal self-administration of 400 microg misoprostol, 4 h before aspiration. During admission, all subjects were checked on a 15-min basis. The preoperative cervical dilatation achieved was the main outcome assessed. The cervix was dilated (Hegar > or = 8) in 348 (78%) subjects from the oral treatment group and in 391 (87%) women from the vaginal treatment group; this difference was statistically significant (p = 0.0004). The mean dilatation achieved in the oral treatment group was 8.1 mm (SD 1.6 mm) and it was 8.5 mm (SD 1.5 mm) in the vaginal treatment group; this difference was statistically significant (p = 0.0001). The frequencies of side-effects such as nausea, vomiting, diarrhea and chills reported by women from the vaginal misoprostol group were 10, 8, 18 and 4 times lower, respectively, than those reported by subjects from the oral misoprostol group. In conclusion, vaginal self-administration of misoprostol was the best administration route, as it obtained the same or greater priming effectiveness of the cervix in half the time with a much lower frequency of side-effects.

Misoprostol for abortion at 9-12 weeks' gestation in adolescents

The objectives of the present clinical study were to evaluate the safety and efficacy of misoprostol (Cytotec), self-administered into the vagina for medical abortion, in adolescents under 18 years ofage. A group of 150 adolescents with gestations between 63 and 84 days, with previous written consent from the patient and parents or guardians, received 800 microg of vaginal misoprostol every 24 h, up to a maximum of three main doses, for abortion. Outcomes assessed included successful abortion (complete abortion without surgery), side-effects, decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time for the return of menses. Complete abortion occurred in 126/150 (84.0%, 95% confidence interval 77-89) patients. The frequencies of nausea and vomiting were statistically significantly higher when compared to those obtained for adult females. Vaginal bleeding lasted for 13.2 +/- 3.8 days (median 13 days, range 1-22 days). The mean expulsion time was 8.0 +/- 3.4 h (median 8 h, range 1-14 h) for all subjects who aborted after the first misoprostol dose. The mean drop in hemoglobin was statistically significant (p = 0.001), but without clinical relevance. From the high abortion rate obtained, we concluded that misoprostol alone is a valid method for terminating unwanted pregnancies at 10-13 weeks' gestation in adolescents under 18 years of age in the absence of mifepristone.

Vaginal misoprostol 1000 μg for early abortion

The objective of this study was to evaluate the safety and efficacy of 1000 microg misoprostol vaginally (Cytotec) self-administered into the vagina for medical abortion. Three-hundred women with gestations between 42 and 63 days, with previous written consent, received vaginal misoprostol every 24 h up to a maximum of three doses for abortion. Outcome measures assessed included: successful abortion (complete abortion without surgery), side effects, decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time of returning of menses. Complete abortion occurred in 279/300 (93.0%, 95% CI 90, 96) patients. Medication to relieve symptoms was administered to all subjects after every misoprostol dose. Vaginal bleeding lasted 14.7 +/- 5.4 days. Mean expulsion time was 8.1 +/- 3.0 h for those who aborted after the first misoprostol dose. The mean drop in hemoglobin was statistically significant (p = 0.0001) but without clinical relevance. The frequencies of nausea and diarrhea were high. According to the observed outcomes, 1000-microg misoprostol vaginally could be a valid method to terminate pregnancies up to nine weeks gestation.

Misoprostol for abortion up to 9 weeks' gestation in adolescents

The objectives of the present clinical study were to evaluate the safety and efficacy of misoprostol (Cytotec) self-administered into the vagina for medical abortion in adolescents under the age of 18 years. After obtaining written consent from the patients and parents or guardians, a group of 150 adolescents with gestations between 35 and 63 days received 800 microg of vaginal misoprostol every 24 h, up to a maximum of three main doses, for abortion. Outcomes assessed included successful abortion (complete abortion without surgery), side-effects, decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time for the return of menses. Complete abortion occurred in 133/150 (88.7%, 95% confidence interval 82-93) patients. The frequencies of nausea, vomiting and diarrhea were statistically significantly higher when compared to those obtained for adult females. Vaginal bleeding lasted for 12.7 +/- 5.7 days (median 12 days, range 1-23 days). The mean expulsion time was 6.8 +/- 2.4 h (median 6 h, range 3-14 h) for those who aborted after the first misoprostol dose. The mean time for the return of menses, for those who aborted with misoprostol, was 34.7 +/- 3.4 days. The mean decrease in hemoglobin was statistically significant (p = 0.001), but had no clinical relevance. Taking into account the high abortion rate obtained, we could conclude that misoprostol alone is a valid method for terminating unwanted pregnancies in adolescents under the age of 18 years.

The effect of age and experience on the reproductive performance and prenatal expenditure of resources in female fallow deer (Dama dama)

In this paper we tested whether prenatal expenditure of resources in fallow deer (Dama dama) is affected by the age and reproductive experience of mothers. The study was carried out on the wild fallow deer population in Doñana National Park in southwestern Spain. Between 1985 and 1996 a total of 60 different females were monitored by direct observation during the fawning season. The exact age of 22 of these females was known, and 59 fawns born of these females were captured. The mother's age had more influence on the fawn's birth mass than the mother's experience did. Fallow deer fawns born of adult multiparous mothers (5-8 years old) were heavier than fawns born of young multiparous mothers (3-4 years old), whereas birth masses of fawns born of primiparous mothers (2-3 years) and young multiparous mothers showed no significant difference. Fawns were born earlier in the breeding season as the mother's age increased. The trade-off required between resources allocated to reproduction and resources available for growth and maintenance may limit reproduction and the possibility of increasing prenatal expenditure by both young primiparous and young multiparous female fallow deer. Sexual dimorphism in birth mass was detected, males being heavier than females, independently of the age and parity of the mothers. This confirms the finding that fallow deer mothers are selected to expend more resources on their male offspring.