Endovascular treatment of a mycotic aneurysm in an immunocompromised child with acute leukemia-case report and review of the literature

Mycotic aneurysms are dilatations of an artery, a rare but severe complication arising from infectious obliteration of the vessel wall. Thoracic aneurysms often present with unspecific symptoms and multiple diagnostic and therapeutic challenges. In an advanced state, they have an increased risk of perforation and a high mortality rate. The surgical therapeutic approach has a high perioperative complication rate. In this study, we report a case of a thoracic mycotic aortic aneurysm in an immunocompromised pediatric patient caused by Klebsiella pneumoniae bacteremia. A combination of prompt antibacterial treatment and minimally invasive stent implantation showed a good outcome, avoiding possible severe surgical problems.

Case report: Beneficial long-term effect of the atrial-flow-regulator device in a pediatric patient with idiopathic pulmonary arterial hypertension and recurring syncope

We report the long-term effect after successfully implanting an 8 mm Atrial-flow-regulator (AFR) device in a 7-year-old girl with idiopathic pulmonary hypertension with persistent syncope under triple therapy with significant improvement after implantation and absence of any further syncope. Early Implantation of the AFR device (Occlutech, Germany) can be efficient and safe interventional therapy option for pulmonary arterial hypertension with a history of syncope.

Case report: Central venous catheter thrombosis complicated by chronic thromboembolic disease/pulmonary hypertension in two children requiring parenteral nutrition

Chronic thromboembolic pulmonary hypertension is a rare but life-threatening complication of long-term central venous catheters (CVC) in children. However, evidence in terms of potential treatment strategies and outcome data remains scarce. We describe two cases of CVC-related thrombosis (Hickman-catheter) complicated by recurrent pulmonary emboli. One patient experienced a complete thromboembolic obstruction of the right pulmonary artery with normal pulmonary pressures and the second patient suffered from a central thromboembolic obstruction of both pulmonary arteries associated with severe pulmonary hypertension. Both patients successfully underwent surgical thromboendarterectomy with deep hypothermic circulatory arrest.

Tricuspid Annular Plane Systolic Excursion (TAPSE) correlates with mean pulmonary artery pressure especially 10 years after pediatric heart transplantation

Tricuspid annular plane systolic excursion (TAPSE) is important in the noninvasive echocardiographic assessment of right heart function. This retrospective observational study shows correlations of TAPSE with invasive right heart catheterization parameters after pediatric heart transplantation (HTx). The study included patients after pediatric HTx with cardiac catheterizations in 2018/2019 and measurement of TAPSE (n = 52 patients with 57 examinations; 50.9% adults, 52.6% female, median age: 18.54 years). TAPSE was compared with normal values. Stepwise, linear and multiple regression were used to show influencing variables on TAPSE. Mean TAPSE z-score was -3.48 (SD: 2.25) and 68.4% of HTx-recipients showed abnormally reduced TAPSE (z-score ←2) compared to normal values. Multiple regression (p-value <0.001; corrected R² = 0.338) showed significant correlations of time since HTx (p-value <0.001) and mPAP (p-value: 0.008) with TAPSE z-scores. Divided into subgroups (time since HTx <10 and ≥10 years), TAPSE and mPAP correlated only ≥10 years after HTx (p-value = 0.002). This study provides data of TAPSE even ≥10 years after pediatric HTx. Most patients showed a decreased TAPSE early after HTx, which improved over time. TAPSE z-scores correlated significantly with time since HTx and mPAP, especially ≥10 years post-HTx. Therefore, TAPSE must be used carefully in the early follow-up.

Case report: Heart Mate III for systemic right ventricular support in a patient with hypoplastic left heart syndrome

Ventricular assist device implantation presents a possible bridge to heart transplantation for patients with failing Fontan physiology. However, evidence regarding outcome and possible pitfalls associated with the Fontan circulation is still insufficient. We describe the course of a 13-year-old male, who was born with hypoplastic left heart syndrome and underwent HeartMate III implantation due to refractory failure of the systemic right ventricle.

3D-printed heart models for hands-on training in pediatric cardiology - the future of modern learning and teaching?

BACKGROUND

This project aims to develop a new concept in training pediatric cardiologists to meet the requirements of interventional cardiac catheterizations today in terms of complexity and importance. This newly developed hands-on training program is supposed to enable the acquisition of certain skills which are necessary when investigating and treating patients in a catheter laboratory.

METHODS

Based on anonymous CT-scans of pediatric patients' digital 3D heart models with or without cardiac defects were developed and printed three-dimensionally in a flexible material visible under X-ray. Hands-on training courses were offered using models of a healthy heart and the most common congenital heart defects (CHD). An evaluation was performed by quantifying fluoroscopy times (FL-time) and a questionnaire.

RESULTS

The acceptance of theoretical and practical contents within the hands-on training was very positive. It was demonstrated that it is possible to master various steps of a diagnostic procedure and an intervention as well as to practice and repeat them independently which significantly reduced FL-time. The participants stated that the hands-on training led to more confidence in interventions on real patients.

CONCLUSION

With the development of a training module using 3D-printed heart models, basic and advanced training in the field of diagnostic cardiac examinations as well as interventional therapies of CHD is possible. The learning effect for both, practical skills and theoretical understanding, was significant which underlines the importance of integrating such hands-on trainings on 3D heart models in education and practical training.

Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.

Quality of life and patient satisfaction with outpatient care after heart transplantation in adult and pediatric patients - room for improvement?

Reduced adherence after heart transplantation increases the risk for acute rejection. Therefore, the aim of this study was to evaluate the patient's satisfaction with outpatient care and quality of life (QOL) after pediatric and adult heart transplantation. Observational study after pediatric (n = 22) and adult (n = 65) heart transplantation and the parents of the pediatric patients (n = 22) to evaluate the patients' satisfaction with outpatient care and QOL. Established standardized questionnaires were used for patient satisfaction (ZAP survey) and QOL (SF36); the latter was compared with the cohort of the BGS98 survey (BGS98 cohort). ZAP score: excellent results with almost all values >80. QOL: pediatric cohort showed significantly higher values in physical functioning (P = 0.041) and role physical (P = 0.003) but significantly lower values in the sub-scale general health (P = 0.02) compared to adult cohort. In comparison with BGS98 cohort, children showed almost similar results, whereas adult cohort showed worse values in physical and emotional functioning, but higher values regarding general health. The QOL of patients after pediatric heart transplantation is comparable to a standardized reference population in Germany, whereas adult patients show reduced physical and emotional functioning, but better values regarding general health. The patients' satisfaction with the outpatient care is very high.

Design and 3D printing of variant pediatric heart models for training based on a single patient scan

Background

3D printed models of pediatric hearts with congenital heart disease have been proven helpful in simulation training of diagnostic and interventional catheterization. However, anatomically accurate 3D printed models are traditionally based on real scans of clinical patients requiring specific imaging techniques, i.e., CT or MRI. In small children both imaging technologies are rare as minimization of radiation and sedation is key. 3D sonography does not (yet) allow adequate imaging of the entire heart for 3D printing. Therefore, an alternative solution to create variant 3D printed heart models for teaching and hands-on training has been established.

Methods

In this study different methods utilizing image processing and computer aided design software have been established to overcome this shortage and to allow unlimited variations of 3D heart models based on single patient scans. Patient-specific models based on a CT or MRI image stack were digitally modified to alter the original shape and structure of the heart. Thereby, 3D hearts showing various pathologies were created. Training models were adapted to training level and aims of hands-on workshops, particularly for interventional cardiology.

Results

By changing the shape and structure of the original anatomy, various training models were created of which four examples are presented in this paper: 1. Design of perimembranous and muscular ventricular septal defect on a heart model with patent ductus arteriosus, 2. Series of heart models with atrial septal defect showing the long-term hemodynamic effect of the congenital heart defect on the right atrial and ventricular wall, 3. Implementation of simplified heart valves and addition of the myocardium to a right heart model with pulmonary valve stenosis, 4. Integration of a constructed 3D model of the aortic valve into a pulsatile left heart model with coarctation of the aorta. All presented models have been successfully utilized and evaluated in teaching or hands-on training courses.

Conclusions

It has been demonstrated that non-patient-specific anatomical variants can be created by modifying existing patient-specific 3D heart models. This way, a range of pathologies can be modeled based on a single CT or MRI dataset. Benefits of designed 3D models for education and training purposes have been successfully applied in pediatric cardiology but can potentially be transferred to simulation training in other medical fields as well.

Conversion to everolimus in pediatric heart transplant recipients is a safe treatment option with an impact on cardiac allograft vasculopathy and renal function

BACKGROUND

Cardiac allograft vasculopathy (CAV) and nephrotoxicity affect long-term survival after heart transplantation (HTX). Studies, mostly conducted in adults, showed a positive effect of everolimus (EVL) on these problems. We describe the effects of conversion of the immunosuppressive therapy to an everolimus including regime on CAV, renal function, and safety in heart transplanted children/adolescents.

METHODS

This retrospective single-center study included 36 participants (mean time after HTX 6.3 ± 4.7 years). Descriptive pre/post-comparisons were performed with an observation period partially up to 4 years. Impact on CAV was assessed based on intravascular imaging and Stanford grading. Safety analysis included cytomegalovirus (CMV)-infection and acute rejection.

RESULTS

In terms of CAV (9 out of 36 patients) four showed no progression, three an improvement, one a worsening; one new diagnosis. The average CrCl showed a significant improvement 6, 12, and 24 months after conversion regarding all patients (n = 29). There was no acute rejection or CMV-infection.

CONCLUSION

Conversion to an EVL-based therapy after pediatric HTX is a safe immunosuppressive regime without increasing risk of acute rejection or CMV-infection. There was some evidence of reduction in progression of CAV and a significant improvement of the renal function.

Cardiac allograft vasculopathy: Differences of absolute and relative intimal hyperplasia in children versus adults in optical coherence tomography

BACKGROUND

Intracoronary imaging enables an early detection of intimal changes. To what extend the development of absolute and relative intimal hyperplasia in intracoronary imaging differs depending on age and post-transplant time is not known.

METHODS

Aim of our retrospective study was to compare findings between 24 pediatric (cohort P) and 21 adult HTx patients (cohort A) using optical coherence tomography (OCT) at corresponding post-transplant intervals (≤5 years: P1 (n = 11) and A1 (n = 10); >5 and ≤ 10 years: P2 (n = 13) and A2 (n = 11),. Coronary intima thickness (IT), media thickness (MT) and intima to media ratio (I/M) were assessed per quadrant. Maximal IT >0.3 mm was considered absolute, I/M > 1 relative intimal hyperplasia.

RESULTS

Compared to A1, I/M was significantly higher in P1 (maximal I/M: P1: 5.41 [2.81-13.39] vs. A1: 2.30 [1.55-3.62], p = 0.005), whereas absolute IT values were comparable. In contrast, I/M was comparable between P2 and A2, but absolute IT were significantly higher in A2 (maximal IT: P2: 0.16 mm [0.11-0.25] vs. A2: 0.40 mm [0.30-0.71], p < 0.001). A2 presented with higher absolute IT (maximal: A1: 0.16 mm [0.12-0.44] vs. A2: 0.40 mm [0.30-0.71], p = 0.02) and I/M (maximal I/M A1: 2.30 [1.55-3.62] vs. A2: 3.79 [3.01-5.62], p = 0.04).

CONCLUSION

Our results suggest an age- and time-dependent difference in the prevalence of absolute and relative intimal hyperplasia in OCT, with an early peak in children and a progressive increase in adults.

Intermediate outcomes of transcatheter pulmonary valve replacement with the Edwards Sapien 3 valve - German experience

Background: After encouraging results with the Edwards Sapien and XT valves, this study aimed to review procedural data and early outcomes for the Sapien 3 valves for transcatheter pulmonary valve replacement (TPVR). Methods: We performed a multicenter, retrospective analysis of cases who underwent a Sapien 3 TPVR between 2015 and 2017 in 7 centers in Germany with a follow-up of up to 2 years. Results: 56 patients could be enrolled (weight 58,5 ± 25,0 kg; 53% Tetralogy of Fallot, 45% native RVOT). Most procedures were two-stage procedures (82,1%) with 100% prestenting. Valve sizes were 20 mm (n = 1), 23 mm (n = 15), 26 mm (n = 27), 29 mm (n = 13). Procedural success rate was 96.4%. Two patients underwent surgical valve implantation after balloon rupture during TPVR. Follow-up data were available up to 24-month post TPVR. The rate of patients with ? moderate and severe pulmonary regurgitation decreased to 0% after TPVR, peak systolic gradient decreased from 24,2 (SD±20,9) mmHg to 7,1 mmHg (SD±5,0). There were no endocarditis, severe tricuspid valve impairment or stent fractures. Conclusions: With the Edwards Sapien 3 valve, the patient pool for TPVR can be substantially extended. Continued data collection is necessary to verify long-term results.

Microcatheter-assisted stenting of the tortuous vertical ductus arteriosus via femoral access in a duct-dependent pulmonary circulation

BACKGROUND

Stenting of the patent ductus arteriosus (PDA) has been accepted as alternative option to surgical shunting to enable additional pulmonary blood flow or for palliation of patients with a truly duct-dependent pulmonary circulation. The procedure can be challenging given the variable and often tortuous anatomy of the PDA and various technical approaches are reported.

OBJECTIVE

To report an alternative technique to treat tortuous ducts with microcatheter assistance and by transfemoral approach.

METHODS

We applied this technique of PDA stenting in 5 consecutive patients (4/5 age < 1 week, weight 2,7-3,2 kg; 1/5 re-do PDA stenting at 6,5 month and 5,9 kg). A soft coronary guidewire was advanced by microcatheter assistance into the branch pulmonary arteries and thereafter replaced by an extrastiff guidewire to enable the placement of long coronary stents.

RESULTS

Successful PDA stenting with this stepwise approach and with femoral access only could be achieved in all patients (n = 5/5). A single stent was used in 2 patients (one with re-do stenting and previous stents). 3/5 patients had 2 stents implanted by telescopic technique. Stent sizes used were 4,5 × 15 mm (n = 2) and 4,5 × 18 mm (n = 6). No guide wire or stent dislodgement appeared through all procedures with microcatheter assistance.

CONCLUSIONS

This technique enables PDA stenting via transfemoral approach in complex and tortuous ducts and thereby offers an attractive addition to the interventional management of truly duct-dependent pulmonary circulation.

Breastfeeding and vitamin D supplementation reduce the risk of Kawasaki disease in a German population-based case-control study

Background

In Kawasaki disease (KD), a vasculitis of unknown etiology, the most serious complication is the development of coronary artery aneurysm (CAA). To date, the exact pathomechanism of KD is unknown. Both environmental and genetic factors seem to be associated with the development of the disease.

Methods

Data on KD patients recruited from the population-based German Pediatric Surveillance Study during 2012–2014 were used to evaluate the impact of various factors from the perinatal and infancy period on the development of KD. The study design was a matched case-control study with respect to age, sex and place of residence (n = 308 KD cases, n = 326 controls). All KD patients were individually re-evaluated; all fulfilled the international diagnostic KD criteria. A standardized questionnaire was used to review breastfeeding practices, vitamin D supplementation and birth characteristics. Logistic regression analyses were performed to obtain odds ratios (OR) for various risk factors among the case-control pairs. Simple measures of association were used to assess the impact of these factors on the clinical course.

Results

There was no difference in lengths of gestation, birth weight or parturition between KD patients and controls, but independently from each other vitamin D supplementation and breastfeeding were negatively associated with KD, even when adjusted for age, place of residence and sex. The duration of vitamin D was significantly shorter among children with KD than among children without KD (p = 0.039, OR = 0.964, 95% CI: 0.931–0.998), as was the duration of breastfeeding (p = 0.013, OR = 0.471, 95% CI: 0.260–0.853). Comparing KD patients with and without breastfeeding and/or vitamin D supplementation, there were no differences regarding developing CAA, being refractory to intravenous immunoglobulin treatment, age at onset of the disease and levels of inflammatory laboratory values.

Conclusion

Our findings indicate breastfeeding and vitamin D supplementation to have protective effects in association with KD in our study population; however, these seem not to influence the natural course of the disease. Although the overall effects were relatively small, they nevertheless underline the overall benefit of both interventions.

Trial registration

Clinical Trial Registration: German clinical trial registration, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00010071. Date of registration was 26. February 2016. The trial was registered retrospectively.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1438-2) contains supplementary material, which is available to authorized users.

Heparin Coating of the Extracorporeal Circuit Combined with Leukocyte Filtration Reduces Coagulation Activity, Blood Loss and Blood Product Substitution

Background

Cardiopulmonary bypass is associated with activation of the coagulation cascade. Occasionally, this results in postoperative hemorrhage and consequently the need for blood products associated with increasing costs and risk of infection. Contact activation of the intrinsic coagulation pathway, and damage to cellular blood components with the release of proteolytic substances from neutrophil granulocytes have been linked to these coagulation disorders.

Methods

Eighteen routine CABG-patients were randomly assigned to totally heparin coated circuits (Bioline coating) combined with leukocyte filtration in a double blind protocol (group I), 34 patients served as controls (group II). Leukocyte filters were activated before release of the aortic crossclamp. Coagulation activity, postoperative blood loss, and substitution with blood products were assessed.

Results

Blood loss in the first 24h after surgery was significantly lower with combined application of heparin coating and leukocyte filters (group I) vs. controls (group II) (526±78ml vs. 786±88ml; p<0.05). Thrombin formation represented by prothrombin fragments 1+2 was significantly lower in group I vs. group II after declamping of the aorta (2.1±0.3nmol/L vs. 4.0±0.3nmol/L; p<0.05). Group I showed higher AT III plasma than group II (48.8±3.2% vs. 41.5±1.7%; p<0.05).

Conclusions

Leukocyte filtration during reperfusion in heparin coated cardiopulmonary bypass circuits is associated with lower coagulation activation, decreased blood loss and reduced transfusion of packed red cells in elective CABG patients.

Abstract P1-11-01: Effectiveness, safety and quality of life (QoL) results from the German multicenter AVANTI study of 1st-line bevacizumab (BEV)-containing therapy in &gt;2000 patients (pts) with advanced breast cancer (aBC)

Background: In Europe, BEV is approved with either paclitaxel (PAC) or capecitabine (CAP) as 1st-line therapy for HER2-negative aBC. These regimens are being evaluated in routine oncology practice in the German AVANTI (ML22452) observational study.

Methods: Eligible pts had received no prior chemotherapy (CT) for aBC and had no BEV contraindications. CT schedule, diagnostics and frequency of follow-up are at the physician's discretion. Data are collected for 1 y after starting BEV, with 6-monthly follow-up for 1.5 y thereafter. QoL is assessed using EORTC QLQ-C30. Data cutoff for the 3rd interim analysis was Dec 1, 2016.

Results: Between Oct 2009 and Feb 2015, 2056 eligible pts at &gt;300 centers began treatment with BEV+PAC (n=1658) or BEV+CAP (n=398). Median follow-up was 12.7 (range &lt;0.1–50.9) mo. Median treatment duration was 4.4 (95% CI 4.2–4.6) mo for CT and 6.0 (95% CI 5.8–6.5) mo for BEV. Table 1 summarizes PFS. In the overall population, grade 3/4 AEs were reported in 20% of pts (20% BEV+PAC; 22% BEV+CAP) and led to treatment discontinuation in 5% (5% and 5%, respectively). Mean QLQ-C30 scores were relatively stable over time both overall and in subgroups aged &lt;65 vs ≥65 y, indicating maintained QoL during therapy; no relevant QoL differences between age groups were seen (Table 2). To characterize 'long responders', we identified 459 pts with PFS ≥15 mo (410 BEV+PAC; 49 BEV+CAP). Of these, 33% were aged ≥65 y, 15% had triple-negative aBC (TNBC) and 25% had ≥3 metastatic sites. Median treatment duration was 5.1 mo for CT and 10.8 mo for BEV.

Table 1. PFS by subgroupPtsNo. of events/pts (%)Median PFS (95% CI), moAll1121/2042 (55)14.2 (13.5–15.3)BEV+PAC902/1646 (55)15.2 (14.0–16.2)BEV+CAP219/396 (55)10.9 (10.1–13.4)TNBC187/429 (44)12.6 (10.7–14.3)Non-TNBC677/1486 (46)14.7 (13.6–16.1)&lt;65 y577/1325 (44)15.1 (13.6–16.2)≥65 y344/717 (48)13.5 (12.5–14.9)&lt;3 metastatic sites678/1522 (45)14.4 (13.6–15.8)≥3 metastatic sites254/534 (48)13.5 (11.7–15.5)

Table 2. Mean QoL scores over time, selected scalesScaleTimepointAll pts&lt;65 y≥65 y  nMean scorenMean scorenMean scoreGlobal health statusaBL84046.555747.128345.4 Wk 986744.057044.229743.7 Wk 3352043.335543.716542.4 Wk 5434244.622845.111443.6Physical functioningaBL83668.555570.328164.7 Wk 986360.956864.329554.4 Wk 3351360.335263.316153.8 Wk 5434161.622862.411359.9Social functioningaBL82761.455559.727264.8 Wk 985654.456655.429052.5 Wk 3351455.435156.516353.2 Wk 5433758.122555.811262.8FatiguebBL83548.955548.128050.6 Wk 986059.156756.329364.6 Wk 3351656.135254.516459.7 Wk 5434055.822855.711255.9PainbBL83537.855638.027937.2 Wk 986438.556937.029541.3 Wk 3351746.935345.616449.8 Wk 5434046.922848.111244.5BL=baseline. aHigher score=better QoL/functioning. bHigher score=greater symptom burden.

Conclusions: More mature results from AVANTI show median PFS of 14.2 mo, favorable tolerability and maintained QoL, supporting 1st-line use of BEV for aBC. The subgroup with prolonged disease control (PFS &gt;15 mo) was heterogeneous; further analyses of these pts are ongoing.

Citation Format: Müller V, Jakob A, Aktas B, Grafe A, März W, Fett W, Bruch H-R, Klare P, Hoefflin S, Schneeweiss A. Effectiveness, safety and quality of life (QoL) results from the German multicenter AVANTI study of 1st-line bevacizumab (BEV)-containing therapy in &gt;2000 patients (pts) with advanced breast cancer (aBC) [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 P1-11-01.

Abstract P6-13-02: Efficacy of first-line bevacizumab (BEV)-containing therapy for poor-prognosis advanced breast cancer (aBC): Subgroup analyses of the German AVANTI observational study

Background: The multicenter AVANTI observational study is evaluating the safety and effectiveness of EU-approved BEV-containing regimens (BEV + paclitaxel [PAC] or BEV + capecitabine [CAP]) as first-line therapy for HER2-negative aBC in German routine oncology practice.

Methods: Eligible patients (pts) had received no prior chemotherapy (CT) for aBC and had no BEV contraindications. CT schedule, diagnostics, and frequency of follow-up visits are at the physician's discretion. Data are collected for 1 year after starting BEV, with 6-monthly follow-up for 1.5 years thereafter. We explored treatment outcomes in pts with triple-negative aBC (TNBC), pts considered at high risk according to a simple prognostic index for OS in BEV-treated pts [Llombart, 2014], and subgroups defined by timing of BEV+CT initiation.

Results: Between Oct 2009 and Feb 2015, 2168 pts treated at 331 centers received BEV+PAC (n=1774) or BEV+CAP (n=394). Of these, 445 (21%) had TNBC and 306 (14%) met the high-risk criteria. Within the hormone receptor-positive (HR+) subgroup, pts receiving endocrine therapy (ET) before BEV+CT were older than pts starting BEV+CT immediately (median age 65 vs 60 years, respectively) and included a smaller proportion with ECOG performance status 0 (39% vs 47%), visceral metastases (70% vs 77%), or prior (neo)adjuvant CT exposure (46% vs 57%). In all subgroups, median BEV treatment duration was longer than median CT duration. At the data cutoff for this interim analysis (Mar 1, 2015), median duration of observation was 10.8 (range &lt;0.1–47.5) months. The table shows treatment exposure and efficacy overall and in selected subgroups.

table 1 All pts (n=2168)TNBC (n=445)aHR+ with immediate BEV+CT (n=1260)a,bHR+ with ET before BEV+CT (n=309)a,bHigh riskc (n=306)bBEV+PAC, n (%)1774 (82)352 (79)b1062 (84)238 (77)229 (75)Treated until PD, n (%)b,d640 (30)180 (40)314 (25)104 (34)125 (41)BEV+CT until PD449 (21)143 (32)210 (17)61 (20)99 (32)Single-agent BEV until PD191 (9)37 (8)104 (8)43 (14)26 (8)Median BEV duration, months (95% CI)5.9 (5.6–6.3)5.1 (4.9–5.6)6.4 (5.9–7.0)5.6 (5.1–6.5)5.1 (4.6–5.6)Median CT duration, months4.6 (4.4–4.9)3.9 (3.5–4.2)4.9 (4.6–5.1)4.6 (4.2–5.1)3.9 (3.3–4.4)No. of PFS events/pts (%)e1238/2154 (57)302/441 (68)667/1255 (53)187/307 (61)210/306 (69)Median PFS, months (95% CI)10.1 (9.7–10.7)7.2 (6.2–8.0)11.5 (10.8–12.3)9.0 (8.3–10.0)6.4 (5.9–7.4)a154 pts could not be classified as TNBC or HR+ because of missing HR status information. bPost hoc analysis. c≥3 of the 5 risk factors (disease-free interval ≤24 months; ECOG performance status ≥2; liver metastases and/or ≥3 metastatic organ sites; TNBC; prior (neo)adjuvant anthracycline and/or taxane). dData available only in pts with documented end of treatment. ePFS data missing in 14 pts.

Conclusions: Interim results from this large observational study indicate that first-line BEV+CT is an effective therapy in all risk subgroups of a general population of pts with HER2-negative aBC treated in routine oncology practice, including pts with a particularly poor prognosis. Results of these exploratory subgroup analyses suggest that BEV+CT could be considered irrespective of HR status.

Citation Format: Mueller V, Jakob A, Aktas B, Pott D, Grafe A, Jungberg P, Maerz W, Fett W, Bruch H-R, Klare P, Boller E, Hoefflin S, Schneeweiss A. Efficacy of first-line bevacizumab (BEV)-containing therapy for poor-prognosis advanced breast cancer (aBC): Subgroup analyses of the German AVANTI observational study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-13-02.

Long-term behavior of (90)Sr and (137)Cs in the environment: Case studies in Switzerland

We present long-term records of the (137)Cs and (90)Sr activity concentrations in soil, grass and milk from two lowland and two alpine pastures of Switzerland. The data is used for better understanding the long-term behavior of these radionuclides in the environment. Transfer factors between compartments are used as qualitative indicators of the magnitude of transfer and as a way to compare different elements (e.g. Cs and Sr) in similar conditions. The long-term behavior was quantified by means of the effective half-life which integrates all processes that cause a decrease of activity in a given medium such as leaching, fixation, erosion and radioactive decay. Our study shows that (90)Sr is more likely transferred from alpine soil to grass than (137)Cs. This is explained by a stronger fixation of Cs in the soils. We observed higher transfers of (90)Sr to grass in soils with lower Ca concentrations, and vice versa. In contrast, the transfer of (137)Cs to grass was not affected by the variations of the K content in the soil. We provide evidence that shows that (137)Cs, after intake by dairy cattle, is more likely transferred to milk than (90)Sr. However, as the (90)Sr and Ca transfers to milk are influenced by parameters/processes that were not taken into account in our study, our result cannot be entirely validated. The effective half-lives of (137)Cs and (90)Sr in soil, grass and milk corresponded with previous estimates in alpine soils. We have found that processes other than radioactive decay are responsible for a major decrease of the (90)Sr activity in soil. For (137)Cs, on the other hand, radioactive decay is among the most relevant process. Our data shows to be of interest in studying the trends of behavior of radionuclides in alpine regions.

Abstract P4-13-26: Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC)

Background: In Europe, BEV is approved as first-line therapy for metastatic breast cancer in combination with either paclitaxel (PAC) or capecitabine (CAP).

Methods: The ongoing multicenter non-interventional AVANTI study aims to determine the safety and efficacy of first-line BEV–PAC or BEV–CAP in the context of routine oncology practice in Germany and to assess selection criteria that influence therapy choice. Eligible patients (pts) have previously untreated aBC and no contraindications for BEV. Chemotherapy schedule, diagnostics, and frequency of follow-up visits are at the physician's discretion. Data are collected for 1 year after the start of BEV, with 6-monthly follow-up for 1.5 years after the end of documented observation or BEV discontinuation, whichever occurs first.

Results: Between Oct 2009 and Feb 2015, 2168 pts treated at 331 German centers received BEV–PAC (N=1774) or BEV–CAP (N=394). The most common reasons driving treatment choice were efficacy (66% BEV–PAC, 60% BEV–CAP), guidelines (55% BEV–PAC, 50% BEV–CAP), and tolerability (40% BEV–PAC, 45% BEV–CAP). Compared with pts receiving BEV–PAC, the BEV–CAP subgroup included relatively fewer pts with ≥3 metastatic sites, visceral metastases, and stage IV disease at diagnosis, and relatively more pts with triple-negative aBC (TNBC) and prior (neo)adjuvant chemotherapy. At the time of data cut-off for this interim analysis (Mar 1, 2015), median duration of observation was 10.8 months (range &lt;0.1–47.5). BEV was typically continued for longer than chemotherapy (median 5.9 months [95% CI 5.6–6.3] vs 4.6 months [95% CI 4.4–4.9], respectively). Among pts with hormone receptor-positive disease, only 9% received concurrent endocrine therapy with BEV. The most common reason for stopping treatment was disease progression (483 of 1529 [32%] who had stopped BEV–PAC; 157/345 [46%] who had stopped BEV–CAP). At data cut-off, 1245 pts (57%) had experienced a PFS event. Median PFS was 10.1 months (95% CI 9.6–10.7) overall, 10.7 months (95% CI 10.1–11.3) for BEV–PAC, and 8.1 months (95% CI 6.6–9.0) for BEV–CAP. Median PFS in clinically important subgroups was: TNBC 7.1 months (95% CI 6.2–8.0); ≥3 metastatic sites 9.7 months (8.7–11.2); anthracycline- and/or taxane-pretreated 9.2 months (8.5–9.9); ≥65 years old 9.9 months (9.1–10.7). Safety was consistent with the well-established safety profiles of the two regimens. Grade ≥3 adverse events occurred in 17% of pts (16% BEV–PAC, 18% BEV–CAP). There were no new safety signals.

Conclusions: Interim results of this large non-interventional study indicate that first-line BEV-containing regimens represent an active and well-tolerated therapy option for aBC. Data collection in non-inferiority studies based on routine clinical practice typically differs from that in prospective clinical trials. Nevertheless, these results from AVANTI suggest that the efficacy and tolerability of BEV–PAC and BEV–CAP seen in the E2100, RIBBON-1, and TURANDOT trials can be replicated in routine oncology practice. Further analyses focusing on the incidence, management, and potential risk factors for elevation of blood pressure are ongoing.

Citation Format: Müller V, Jakob A, Aktas B, Grafe A, Fett W, März W, Bruch H, Pott D, Klare P, Boller E, Kiewitz C, Schneeweiss A. Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC). [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 P4-13-26.

Bis(β-diketonato)- and allyl-(β-diketonato)-palladium(ii) complexes: synthesis, characterization and MOCVD application

Halogen-free allyl- and β-diketonate-functionalized Pd(ii) compounds were synthesized and successfully applied as MOVCD precursors for Pd and PdO thin film formation.

Radioactive and chemical contamination of the water resources in the former uranium mining and milling sites of Mailuu Suu (Kyrgyzstan)

An assessment of the radioactive and chemical contamination of the water resources at the former uranium mines and processing sites of Mailuu-Suu, in Kyrgyzstan, was carried out. A large number of water samples were collected from the drinking water distribution system (DWDS), rivers, shallow aquifers and drainage water from the mine tailings. Radionuclides and trace metal contents in water from the DWDS were low in general, but were extremely high for Fe, Al and Mn. These elements were associated with the particle fractions in the water and strongly correlated with high turbidity levels. Overall, these results suggest that water from the DWDS does not represent a serious radiological hazard to the Mailuu Suu population. However, due to the high turbidities and contents of some elements, this water is not good quality drinking water. Water from artesian and dug wells were characterized by elevated levels of U (up to 10 μg/L) and some trace elements (e.g. As, Se, Cr, V and F) and anions (e.g. Cl(-), NO3(-), SO4(2-)). In two artesian wells, the WHO guideline value of 10 μg/L for As in water was exceeded. As the artesian wells are used as a source of drinking water by a large number of households, special care should be taken in order to stay within the WHO recommended guidelines. Drainage water from the mine tailings was as expected highly contaminated with many chemicals (e.g. As) and radioactive contaminants (e.g. U). The concentrations of U were more than 200 times the WHO guideline value of 30 μg/L for U in drinking water. A large variation in (234)U/(238)U isotopic ratios in water was observed, with values near equilibrium at the mine tailings and far from equilibrium outside this area (reaching ratios of 2.3 in the artesian well). This result highlights the potential use of this ratio as an indicator of the origin of U contamination in Mailuu Suu.

Abstract P4-14-04: AVANTI: A non-interventional study examining the combination of bevacizumab with paclitaxel or capecitabine in metastatic breast cancer

Background: We initiated a large, multicentre, non-interventional study (NIS) to determine the safety and efficacy of treatment, as well as the selection criteria that influence choice of therapy (bevacizumab plus paclitaxel or capecitabine), for patients with metastatic breast cancer (MBC) treated in the context of routine oncology practice in Germany. The study also aimed to gather information on patient-reported quality of life and treatment satisfaction. Here we present an interim analysis of the safety and efficacy data.

Methods: Pre- or postmenopausal female patients aged ≥18 years with previously untreated locally advanced, recurrent, or MBC were enrolled if they were considered eligible for treatment with a combination of bevacizumab and either paclitaxel or capecitabine. Endocrine pretreatment was allowed. Patients with contraindications to bevacizumab were excluded. Kaplan-Meier estimates and Cox-regression were used to model survival data.

Results: Since October 2009, 1,807 patients have been recruited; this analysis includes data for 1,464 patients with a median age of 60.4 years (range: 23.6–86.4). Most patients had a performance status of 1 (43.1%) and HER2-negative (83.5%), hormone receptor-positive (70.2%) disease. The most common sites of metastasis were bone (52.3%), liver (39.3%) and lungs (33.4%); 736 patients (50.3%) had at least two documented metastatic sites. Bevacizumab plus paclitaxel (68.5% of patients) and bevacizumab plus capecitabine (12.0%) were the most frequently prescribed therapies. Other bevacizumab-containing combination regimens were prescribed to the remaining 19.5% of patients. The treatment decision factors cited most often were efficacy of therapy (62.4%), therapy guidelines (49.7%), tolerability of therapy (40.6%) and HER2 status (38.1%). The overall response rate (complete response [CR] + partial response [PR]) was 48.5% with 5.9% of patients achieving a CR. The disease control rate (CR + PR + stable disease) was 72.7%. At the time of data cut-off, 414 patients (28.3%) had experienced a progression-free survival (PFS) event. Median PFS was 9.5 months (95% CI: 8.8–10.1). Adverse events (AEs) and serious AEs were reported in 457 (31.2%) and 109 patients (7.4%), respectively. The most frequently reported AEs were hypertension (6.1% of patients), fatigue (5.5%), sensory neuropathy (4.6%), leukopenia (4.0%), nausea (4.2%) and diarrhoea (3.6%). Treatment was discontinued due to AEs in 72 patients (4.9%).

Conclusions: Interim results of this large NIS demonstrate that bevacizumab plus either paclitaxel or capecitabine combination therapy is well tolerated and active in patients with MBC representative of those treated in routine oncology practice. Follow-up is ongoing and final results of this interim analysis, as well as subgroup analyses, will be reported at the meeting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-14-04.