Abstract P1-08-29: Current status of clinical and pathological characteristics of breast cancer patients in Brazil: Results of the AMAZONA III study (GBECAM 0115)

BACKGROUND

Breast cancer (BC) is the most common tumor in women in Brazil with about 60 thousand new cases estimated per year. In low and middle-income countries, patients with BC are diagnosed with more advanced stages as compared with high-income countries. In Brazil, disparities in access to new therapies are recognized; previous data suggests worse survival of BC patients treated in the public system. The aim of AMAZONA III study (GBECAM 0115) is to describe the current status of BC care in Brazil. Here we report patients data at baseline.

METHODS

The AMAZONA III is a prospective BC registry that included women 18 years or older with newly diagnosed stage I to IV BC from 22 sites in Brazil in the period of January 2016 to March 2018. All patients provided written informed consent; data was collected from interview and medical charts, comprising clinical-demographic variables, initial treatment and a planned follow-up for 5 years. BC subtypes were defined by hormone receptor (HR) expression, HER2 status and grade according to von Minckwitz G. et al 2012. Here we present a descriptive analysis of the patients' baseline characteristics. Continuous variables are shown as mean (standard-deviation) and categorical variables by its absolute and relative frequencies. The study is registered in clinicaltrials.gov NCT02663973.

RESULTS

A total of 2950 patients were included in the study. Median age at diagnosis was 53 years old (8.4% <= 35 years, 34.8% 36-50 years, 56.8% > 50 years), 58.6% were white, 34.4% had brown skin-color, 83% had children before BC diagnosis (median of 1 child/patient) and 63.1% had public health insurance. In terms of method of detection 34% were screen-detected whereas 66% were symptomatic, the last was even higher (70%) in patients in younger than 50 years. The distribution of BC stage at diagnosis was I (26.4%), II (41.6%), III (27%) and IV (5%). The most common histologies were ductal (80.9%) and lobular carcinoma (6.9%). The pathological characteristics were HR positive in 78.0%, HER-2 positive in 23.4% and grade 2 in 51%. BC subtypes were as follows: Luminal A 48%, Luminal B 12%, Luminal HER2 positive 17%, Non-luminal HER2 positive 7.3% and Triple negative 15.5%.

DISCUSSION

Breast cancer is diagnosed at an earlier age among Brazilian patients. The majority of patients were detected through symptomatic BC and therefore a significant proportion is still diagnosed in stages III and IV. Among other factors, these findings could have a significant impact in treatment outcomes. Further analysis of this large cohort of patients will help to identify other important elements and direct future strategies for breast cancer control.

TRIAL REGISTRY: NCT02663973

KEYWORDS: Breast Cancer; Epidemiology; Treatment; Brazil

Citation Format: Rosa D, Barrios C, Bines J, Werustky G, Cronemberger E, Queiroz GS, Lima VC, Freitas-Júnior R, Couto J, Emerenciano K, Resende H, Crocamo S, Reinert T, Van Eyil B, Néron Y, Dybal V, Lazaretti N, Costamilan RC, Andrade DA, Mathias C, Vacaro GZ, Borges G, Torres KL, Morelle A, Sampaio Filho CA, Mano M, Zaffaroni F, Simon S. Current status of clinical and pathological characteristics of breast cancer patients in Brazil: Results of the AMAZONA III study (GBECAM 0115) [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 P1-08-29.

Factors associated with topographic changes of the optic nerve head induced by acute intraocular pressure reduction in glaucoma patients

PURPOSE

To investigate factors associated with changes in optic nerve head (ONH) topography after acute intraocular pressure (IOP) reduction in patients with primary open-angle glaucoma (POAG).

METHODS

Untreated POAG patients (IOP >21 mm Hg) were prospectively enrolled. Systemic and ocular information were collected, including central corneal thickness (CCT) and corneal hysteresis (CH). All patients underwent confocal scanning laser ophthalmoscopy and tonometry (Goldmann) before and 1 h after pharmacological IOP reduction. The mean of three measurements was considered for analysis. Changes in each ONH topographic parameter were assessed (one eye was randomly selected), and those that changed significantly were correlated with patient's systemic and ocular characteristics.

RESULTS

A total of 42 patients were included (mean age, 66.7 ± 11.8 years). After a mean IOP reduction of 47.3 ± 11.9%, significant changes were observed in cup area and volume, and in rim area and volume (P < 0.01), but not in mean cup depth (P = 0.80). Multiple regression analysis (controlling for baseline IOP and magnitude of IOP reduction) showed that CH (r(2) = 0.17, P < 0.01) and diabetes diagnosis (r(2) ≥ 0.21, P < 0.01) were negatively correlated with the magnitude of changes in ONH parameters, whereas the cup-to-disc ratio was positively correlated (r(2) = 0.30, P < 0.01). Age, race, disc area, and CCT were not significant (P ≥ 0.12). Including all significant factors in a multivariable model, only the presence of diabetes remained significantly associated with all ONH parameters evaluated (P < 0.01).

CONCLUSIONS

Different systemic and ocular factors, such as diabetes, CH, and the relative size of the cup, seem to be associated with the magnitude of changes in ONH topography after acute IOP reduction in POAG patients. These associations partially explain the ONH changes observed in these patients and suggest that other factors are possibly implicated in an individual susceptibility to IOP.

Influence of autonomic neuropathy upon left ventricular dysfunction in insulin-dependent diabetic patients

BACKGROUND

Diabetic cardiomyopathy is a well-defined complication of diabetes that occurs in the absence of ischemic, vascular, and hypertensive disease.

HYPOTHESIS

The study was undertaken to test the relationship among autonomic neuropathy (AN), 24-h blood pressure (BP) profile, and left ventricular function.

METHODS

Nineteen type-1 diabetic patients underwent autonomic tests and echocardiographic examination. Patients were divided according to the presence (AN+) or absence (AN-) of AN.

RESULTS

In the AN+ group (n = 8), the E/A ratio at echo was lower than in the AN- group (n = 11) (1.1 +/- 0.3 vs. 1.6 +/- 0.3; p < 0.005). Systolic and diastolic BP reductions during sleep were smaller in the AN+ than in the AN- group (6.6 +/- 6.6 vs. 13.0 +/- 4.3%; p < 0.03 for systolic and 12.8 +/- 6.8 vs. 20.0 +/- 4.0% for diastolic BP reduction; p < 0.03, respectively). Considering all patients, the E/A ratio correlated inversely with awake diastolic BP (r - 0.63; p = 0.005); sleep systolic BP (r - 0.48; p = 0.04), and sleep diastolic BP (r - 0.67; p = 0.002). The AN correlated with diastolic interventricular septum thickness (r 0.57; p = 0.01), sleep systolic BP (r 0.45; p = 0.05), sleep diastolic BP (r 0.54; p = 0.02), and correlated inversely with systolic and diastolic sleep BP reduction (r - 0.49; p = 0.03 and r - 0.67; p = 0.002, respectively). Finally, E/A ratio and AN score correlated between themselves (r - 0.6; p = 0.005).

CONCLUSION

Our results suggest that left ventricular diastolic dysfunction may be detected very early in type-1 diabetic patients with AN. Parasympathetic lesion and nocturnal elevations in BP could be the link between AN and diastolic ventricular dysfunction.

Primary mediastinal large B-cell lymphoma: Treatment outcomes in 43 patients

17556

Objectives: Primary mediastinal B-cell Lymphoma (PMBL) is recognized as a separate entity in the WHO classification. Treatment for PMBL is based on a combination of conventional dose chemotherapy, high dose chemotherapy and radiation therapy. The best strategy is still undefined. We conducted a retrospective analysis of patients with PBML to identify clinical prognostic factors. Methods: A retrospective analysis of 43 patients treated at Hospital do Cancer AC Camargo, Sao Paulo, Brazil, between 1989 and 2004. All patients had previous diagnosis of diffuse large B-cell lymphoma, with positive CD20 on neoplastic cells. A predominant anterior mediastinal lesion should be present. Induction chemotherapy regimens were grouped in first generation (CHOP/CHOP-like), third generation (PromaceCytabon/MACOP) and other (pediatric regimens, COP). Results: Age ranged from 16 to 82 years-old, 30 females and 13 male. Age < 35 yo was associated with a better prognosis (5 years OS - 56% × 34%, p = 0.048). Among clinical variables, female gender, stage IA-IIB, IPI 0–1, normal LDH, absence of mediastinal bulky disease were associated with better prognosis, although not statistically significant. Response rate to first generation regimens was: 37% CR (11/29), 24% PR (7/29) and 24% PD (7/29). Four patients were treated with Third generation regimens with 2 CR and 2 PR. 20 out of 25 patients with PR or CR to first line chemotherapy received mediastinal radiation therapy. More than 65% of patients had a follow up of 5 years or more. With a median follow up of 22.3 months, projected 5 year OS was 47% and for the responders the median PFS was 8,4 months. No difference in OS and PFS was observed among the three chemotherapy groups. Conclusion: Our analysis showed that response rate to first line regimens was around 60% and 25% of patients were primarily refractory to CHOP regimen. Age younger than 35 years old was associated with a better prognosis. 5 years overall survival was 45% and is in accordance with the literature. Although recent studies have demonstrated biological similarities between PMBL and Hodgkin’s Lymphoma, the prognosis of PMBL is less favorable than HL. Better understanding of the disease will help in developing more appropriate therapeutic strategies for PMBL.

No significant financial relationships to disclose.

Safety and efficacy of sirolimus in kidney transplant patients and in patients with coronary artery disease undergoing angioplasty

We show the key results of our 4-year experience with sirolimus in kidney transplant patients and in nontransplanted patients undergoing coronary angioplasty.

METHODS

Recipients of one-haplotype living-related kidney allografts were randomized to receive sirolimus (2 mg/d, n = 35) or azathioprine (2 mg/kg per day, n = 35). Recipients of fully mismatched living kidney allografts (n = 55) received sirolimus (2 mg/day). High-risk recipients of black ethnicity (n = 68) were randomized to target whole-blood trough sirolimus concentrations between 8 and 12 ng/mL or 15 to 20 ng/mL. All kidney transplant patients received cyclosporine and prednisone. Sirolimus/cyclosporine pharmacokinetic studies were performed in 40 patients receiving 2 mg (n = 20) or 5 mg (n = 20) of sirolimus 7 days after transplantation. In the coronary intervention study, 12 patients at high risk for in-stent restenosis received sirolimus for 28 days after angioplasty.

RESULTS

The incidence of biopsy-confirmed acute rejection was 11.4% in recipients of one-haplotype living-related kidney allografts, 16.4% in recipients of fully mismatched living kidney allografts, and 15% (8 to 12 ng/mL) and 4% (15 to 20 ng/mL) in high-risk recipients of black ethnicity. Cyclosporine exposure was higher after morning administration compared to evening administration. There were poor correlations between sirolimus and cyclosporine exposures. The 4-month follow-up angiography revealed no restenosis (stenosis diameter > 50%), a late loss of 0.56 +/- 0.40 mm, and a loss index of 0.33 +/- 0.30. The follow-up 3D-intravascular ultrasound restudy showed an in-stent relative volumetric obstruction of 9.9 +/- 5.5%. Sirolimus in highly effective in preventing kidney allograft acute rejection and in-stent coronary restenosis.

Non-invasive determination of the systolic peak-to-peak gradient in children with aortic stenosis: validation of a mathematical model

Doppler derived systolic pressure gradients have become widely applied as noninvasively obtained estimates of the severity of aortic valvar stenosis. There is little correlation, however, between the Doppler derived peak instantaneous gradient and the peak-to-peak gradient obtained at catheterisation, the latter being the most applied variable to determine severity in children. The purpose of this study was to validate a mathematical model based on data from catheterisation which estimates the peak-to-peak gradient from variables which can be obtained by noninvasive means (Doppler derived mean gradient and pulse pressure), according to the formula: peak-to-peak systolic gradient = 6.02+/-1.49*(mean gradient)-0.44*(pulse pressure). Simultaneous cardiac catheterization and Doppler studies were performed on 10 patients with congenital aortic valvar stenosis. Correlations between the gradients measured at catheter measured, and those derived by Doppler, were performed using linear regression analysis. The mean gradients correlated well (y = 0.67 x +11.11, r = 0.87, SEE = 6 mm Hg, p = 0.001). The gradients predicted by the formula also correlated well with the peak-to-peak gradients measured at catheter (y = 0.66 x +14.44, r = 0.84, SEE = 9 mm Hg, p = 0.002). The data support the application of the model, allowing noninvasive prediction of the peak-to-peak gradient across the aortic valvar stenosis.

Long-term endothelial dysfunction after coronary artery stenting

OBJECTIVES

We assessed the endothelial-dependent vasomotor function in nonrestenotic coronary arteries more than six months following stent implantation, balloon angioplasty (BA), and directional atherectomy (DCA).

BACKGROUND

Catheter-based coronary interventions are associated with extensive arterial injury. Endothelial function has been shown to remain chronically abnormal after vascular injury. The long-term effects of different percutaneous coronary interventions on endothelial function are not known.

METHODS

Thirty-nine patients treated at least six months earlier with a coronary intervention for isolated proximal left anterior descending (LAD) stenosis, with no evidence of restenosis, were studied. Twelve patients had been stented, 15 had been treated with BA, and 12 had undergone DCA. Changes in diameter of the intervened LAD, and the unintervened circumflex coronary artery (Cx), in response to intracoronary acetylcholine infusions were assessed by quantitative angiography.

RESULTS

The groups had similar angiographic characteristics and risk factors for endothelial dysfunction. The LAD constricted significantly more (p = 0.02) in previously stented patients (-21.8+/-4.3%), as compared to patients previously treated with BA (-9.5+/-2.8%) or with DCA (-9.1+/-3.6%). In contrast, acetylcholine infusion resulted in mild constriction in the Cx, which was similar in the three groups (p = 0.47). By multiple regression analysis, previous implant of a stent was the only significant predictor of LAD constriction (p = 0.008).

CONCLUSIONS

More severe endothelial dysfunction was observed long term after stenting as compared to BA or DCA. These findings may have implications with respect to the progression of atherosclerosis in coronary arteries subjected to percutaneous interventions.

Cardiac sympathetic activity in response to acute myocardial ischemia

Although experimental evidence has demonstrated that brief periods of myocardial ischemia are not associated with norepinephrine overflow from the heart, cardiac sympathetic responses to myocardial ischemia in humans remain unclear. Eleven patients undergoing angioplasty of the left anterior descending coronary artery had cardiac norepinephrine spillover measured immediately before inflation, during the final minute of a 5-min balloon inflation, and 1 min after deflation. Angioplasty caused significant S-T segment elevation and a reduction in the transcardiac lactate extraction ratio. Cardiac norepinephrine spillover was reduced from a mean value of 58 +/- 14 pmol/min at control to 41 +/- 15 pmol/min during balloon inflation and 38 +/- 14 pmol/min after deflation (P < 0.05 vs. control for both inflation and deflation values). In contrast, during balloon inflation, there were significant increases in arterial norepinephrine and epinephrine concentrations. Therefore, a brief period of myocardial ischemia caused by angioplasty of the left anterior descending coronary artery does not result in cardiac sympathetic activation, despite evidence of generalized sympathoadrenal activation.

Analysis of atherosclerotic plaques obtained by coronary atherectomy: Foam cells correlated positively with subsequent restenosis

Restenosis following coronary intervention is a complex process the mechanisms of which remains mostly unknown. Tissue obtained by atherectomy is an important means to study restenosis. Previous studies on atherectomy-retrieved tissue have not identified histologic features that correlate with restenosis. We performed an histopathologic evaluation on atherosclerotic plaque tissue obtained by atherectomy from 58 patients, all of whom had a 6-month angiographic follow-up. We identified macrophages and lymphocytes and localized tumor necrosis factor-α expression in the tissue by immunohistochemistry. Histopathology was correlated with late angiographic outcomes. Of 10 histologic features evaluated in the plaque tissue, only the presence of foam cells, identified in paraffin sections, correlated positively with restenosis (p = 0.04). Immunohistochemistry showed that macrophages (p = .07), tumor necrosis factor-α (p = .07), and lymphocytes (p = .14) were more prominent, but not significantly so, in lesions from patients with foam cells and restenosis than in lesions from patients without foam cells or restenosis. Thus the presence of foam cells in primary lesions obtained by atherectomy as identified in paraffin-embedded tissue appears to be a marker for restenosis.

Stenting for pulmonary artery stenosis following the Ross procedure

A 34-year-old woman showed the development of significant main pulmonary artery obstruction along the supravalvar suture line 18 months following a Ross procedure. The patient underwent unsuccessful balloon angioplasty, followed by successful stent implantation. The angiographic narrowing disappeared postprocedure, and the excellent hemodynamic result maintained at 4 month follow-up.

Contrast echocardiography during cardiac catheterization in patients with congenital heart diseases

Contrast echocardiography performed during cardiac catheterization has mostly been limited to a few published case reports. We studied 37 patients with congenital heart disease to assess the capability of the method to diagnose cardiac shunts and valve regurgitation. Injections of 5% dextrose in water through an angiographic catheter were made to evaluate septal integrity and valve competence compared with conventional contrast angiography. An overall sensitivity of 93% and specificity of 78% were found. In four cases of atrial septal defect and seven of mitral regurgitation, the sensitivity was 100%. It was slightly lower for eleven cases of ventricular septal defect (91%) and four of patent ductus arteriosus (75%). When assessing aortic, tricuspid and pulmonary valve competence, the method proved to be more sensitive than conventional angiography to detect mild regurgitation. Contrast echocardiography is a sensitive and safe technique that may be used in association with conventional angiography reducing the need for radiographic contrast and ionizing radiation time.

Cardiopulmonary exercise testing early after catheter-balloon mitral valvuloplasty in patients with mitral stenosis

Seven female patients (age 27 to 53 yr) with significant mitral stenosis performed continuous, incremental, maximal treadmill exercise tests the day before and within 3-5 days after catheter-balloon valvuloplasty. Mitral valve area determined by the echo-Doppler method increased from 0.9 +/- 0.3 cm2 to 1.9 +/- 0.7 cm2 (p < 0.02). Mean left atrial pressure was reduced from 24 +/- 8 to 13 +/- 7 mmHg (p < 0.01) and mean pulmonary artery pressure from 36 +/- 13 to 28 +/- 10 mmHg (p < 0.02) with a non-significant increase in cardiac output from 3.6 +/- 1.2 to 4.0 +/- 1.7 l/min. After catheter-balloon valvuloplasty all patients reached a higher maximal workload during exercise, and mean value of oxygen consumption and pulmonary ventilation were significantly lower in submaximal workloads. The calculated ventilatory equivalent for oxygen was significantly reduced in submaximal and in maximal workloads after catheter-balloon valvuloplasty. Peak oxygen consumption and the ventilatory anaerobic threshold were not changed after catheter-balloon valvuloplasty (pre 15.59 +/- 2.72 vs post 16.90 +/- 3.44 and pre 12.10 +/- 2.55 vs post 12.62 +/- 2.71 ml/kg/min, respectively). We concluded that after catheter-balloon valvuloplasty the cost of breathing was reduced and the oxygen consumed was more effectively utilized during exercise. Increases in peak oxygen consumption and in ventilatory anaerobic threshold would require circulatory and metabolic adaptations in response to increased physical activity and were not observed when cardiopulmonary tests were performed early after catheter-balloon valvuloplasty.

Absence of an aortic valve cusp, a cause of severe aortic regurgitation in infancy

Congenital aortic regurgitation is an extremely rare cardiac lesion. This is a case report of an infant with a severe degree of valve regurgitation due to absence of the noncoronary aortic cusp. We show the echocardiographic, angiographic, and surgical aspects of the case, emphasizing the importance of a precise anatomical diagnosis and the problems of early valve replacement.

Dipyridamole-thallium tests are predictive of severe cardiac arrhythmias in patients with left ventricular hypertrophy

In a population of patients with chronic renal failure (CRF) and a high prevalence of left ventricular hypertrophy (LVH) undergoing chronic hemodialysis, we investigated the association between the results of dipyridamole-thallium tests (DTTs) and the occurrence of ventricular arrhythmias. We observed a positive significant association between positive DTTs and the occurrence of severe forms of ventricular arrhythmias. A significant association was also observed between the presence of severe LVH and the occurrence of severe ventricular arrhythmias. However, no association was found between the presence of LVH and the positivity of the DTT. As most of our patients with positive DTTs had unimpaired coronary circulations, we conclude that positive DTTs, although falsely indicative of impaired myocardial blood supply, does have an important clinical relevance, indicating increased risk of morbidity (and, possibly, mortality) due to ventricular arrhythmias in a population of CRF patients submitted to chronic renal function replacement program.