Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study

INTRODUCTION

Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP.

METHODS

This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital.

RESULTS

Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay.

CONCLUSION

Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.

Kaposi’s sarcoma associated with chronic myeloid leukemia and imatinib mesylate therapy

Kaposi's sarcoma is associated with immunosuppression and human herpesvirus 8 infection, while rarely described in myeloid malignancies. Here, we illustrate a rare case of chronic myeloid leukemia treated with imatinib, a tyrosine kinase inhibitor, who developed a human herpesvirus 8‐related Kaposi's sarcoma.

POS0871 DIAGNOSTIC ACCURACY OF POWER DOPPLER ULTRASONOGRAPHY FOR THE DIAGNOSIS OF IDIOPATHIC INFLAMMATORY MYOPATHIES

Background

No clear-cut guidelines exist about the use of imaging procedures for the diagnosis of idiopathic inflammatory myopathies (IIM). Similarly, conflicting, and scanty data exist about Power Doppler Ultrasonography (PDUS) in this subset of patients. In this regard, we recently proposed (1) a 0-3 grey scale (GS) and Power Doppler (PD) score in a cohort of patients affected by IIM, evidencing a positive, statistically significant, correlation for PD and oedema and disease activity.

Objectives

The aim of this study was to assess the diagnostic accuracy of our score in IIM patients compared to a control group.

Methods

We prospectively collected, since July 2020 to December 2021, all patients evaluated in Vasculitis and Myositis clinic, Rheumatology Unit, University of Siena, with a recent diagnosis of IIM, as well as patients with a previous, definite diagnosis of IIM and evaluated during follow-up or referred from other centres for a second opinion. As control group, we collected all patients affected by amyopathic dermatomyositis (DM) or who underwent myositis immunoblot or muscle biopsy for proximal limbs weakness but eventually received a diagnosis other than IIM. All patients underwent US examination of both thighs in axial and longitudinal scans.

Results

Forty-five IIM patients (11 anti-synthetase syndrome, 20 DM, 12 PM, 2 scleromyositis) and twenty-six controls were included. During the observational period, 7, 8, 1 and 1 patients underwent PDUS twice, three, four and five times, respectively

Assessing area under the receiver operating characteristic (AUROC) curve analysis, IIM patients and control group were distinguished according to PD sum, Oedema sum, atrophy sum and CRP values (Figure 1a). The best cut-off value for PD sum values was 0.5 (70.2% SE and 83.3% SP), for Oedema sum 1.5 (74.5% SE and 79.2% SP), atrophy sum 0.5 (63.4% SE and 65.4% SP) and CRP was 0.22 mg/dL (61.5% SE and 75% SP).

Figure 1.

Stratifying IIM population into two groups according to disease activity (PhGA≥2), AUROC curve analysis allow to distinguish these groups according to PD and oedema sum and CRP values (Figure 1b) and the best cut-off values was 1.5 (69.6% SE and 76.9% SP), 2.5 (52.2% SE and 92.3% SP) and 0.55 mg/dL (66.7% SE and 88.9% SP), respectively.

Testing the IIM group versus control as dependent variable by logistic regression, with PD sum, oedema sum, atrophy sum, CRP, CPK and myoglobin as independent variables, the AUROC was 0.976. From the probability associated with the Chi-square tests, the Type II analysis showed the variable that most influences the IIM diagnosis was PD sum and oedema sum (p=0.017 and p=0.013, respectively) (Figure 1c).

Conclusion

GS and PDUS have proven an overall good diagnostic accuracy in distinguishing between IIM and myositis mimicker. In particular, even low values of PD (sum 1.5) display a good sensitivity and specificity and, together with oedema, elevated CRP values and myositis-specific and associated antibodies, may be considered a reliable tool for a definite diagnosis of IIM.

References

[1]Conticini E, Falsetti P, Al Khayyat SG et al. A novel grey scale and Power Doppler ultrasonographic score for idiopathic inflammatory myopathies: Siena Myositis Ultrasound Grading Scale. Rheumatology (Oxford). 2021 Dec 24;61(1):185-194.

Disclosure of Interests

None declared

P97 VALIDATION OF THE ACADEMIC RESEARCH CONSORTIUM HIGH BLEEDING RISK CRITERIA IN PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: A SYSTEMATIC REVIEW AND METANALYSIS OF 10 STUDIES AND 67,862 PATIENTS

Background

The Academic Research Consortium for High Bleeding Risk (ARC–HBR) has recently proposed, by consensus, twenty clinical criteria for the assessment of the bleeding risk after percutaneous coronary intervention (PCI). A major criterion was defined as any individual clinical condition conferring in isolation a risk for major bleeding ≥4% up to 1 year after PCI; instead, a minor criterion was considered to confer a bleeding risk of < 4%. The aim of this meta–analysis was to assess the performance of the ARC–HBR criteria in stratifying the risk of bleeding and ischemic events after PCI.

Methods

MEDLINE, COCHRANE, Web of Sciences, and SCOPUS were searched for studies aimed at validating the ARC–HBR criteria in patients treated with PCI. The primary outcome measure of this meta–analysis was major bleeding.

Results

The analysis included 10 studies encompassing 67,862 patients undergoing PCI; the HBR definition was fulfilled in 44.7% of the cases. The risk of major bleeding was significantly higher in HBR vs. Non–HBR group (RR, 2.56, 95% CI 2.28–2.89). The average C–statistic was 0.64 (95% CI 0.60–0.68), indicating modest discrimination. The risk of intracranial hemorrhage, gastrointestinal bleeding, fatal bleeding, ischaemic stroke, cardiac death and all–cause death was higher in HBR vs. Non–HBR group. Despite a higher incidence of myocardial infarction and stent thrombosis in patients deemed at HBR, the rate of target lesion revascularization was comparable between groups (RR, 1.01, 95% CI 0.88–1.16). When assessed in isolation, the mean cumulative incidence of major bleeding at 1 year exceeded the cut–off value of 4% for all the major criteria and for two out of six minor criteria, including age ≥75 years and moderate chronic kidney disease (CKD) (Figure).

Conclusion

The ARC–HBR definition identifies patients at higher risk of major bleeding and other adverse cardiovascular events after PCI. Almost all major criteria, but also two of the minor criteria, were individually associated with rates of major bleeding above 4% thus fulfilling the definition of major HBR criteria. These findings corroborate the ability of ARC–HBR major criteria in identifying PCI patients who are more likely to develop adverse events, but also suggest caution in the decision making of patients with isolated minor criteria, including age≥75 years and moderate CKD.

P192 LONG TERM PROGNOSTIC EFFECT OF LIPROTEIN(A) IN PATIENTS WITH AND WITHOUT DIABETES MELLITUS AFTER MYOCARDIAL INFARCTION

Aims

To describe the baseline clinical, laboratory and angiographic characteristics of patients with acute myocardial infarction (MI) according to the presence or not of diabetes mellitus (DM), and to evaluate if DM may influence the effect of lipoprotein(a) [Lp(a)] serum level on long–term outcome in this very high–risk population.

Methods

This was a retrospective, single–center, study including consecutive patients admitted with MI diagnosis between January 1, 2017, and December 31, 2020. The availability of data on baseline Lp(a) serum level was considered as an inclusion criterion. The study population was divided into two groups according to the presence or not of DM. The Lp(a) value of 50 mg/dL was used to test the hypothesis of a different effect of Lp(a) on the clinical outcome of patients with or without DM. The primary study outcome was all–cause death at 3–year follow–up.

Results

The study population included 997 patients (mean age 63.7±13.5 years; 75.7% were males). Diabetes was reported in 280 (28.1%) patients. DM patients were older than those without DM (67.8±12.1 vs. 62.0±13.7 years, p < 0.001) and showed a significantly higher prevalence of dyslipidemia, hypertension, obesity, prior MI and prior coronary revascularization (p < 0.001). DM patients showed higher SYNTAX score value (19.8 vs. 15.1, p < 0.001) and a higher prevalence of left main involvement (6.3 vs. 3.1, p = 0.023). At Kaplan–Meier analysis, in the group without DM, patients with Lp(a)≥50 mg/dL showed a significantly lower long–term survival compared with those with Lp(a)<50 mg/dL (Log–Rank=0.004). In DM patients DM, conversely, no survival difference was found between patients with Lp(a)≥50 mg/dL vs. those with Lp(a)<50 mg/dL. At multivariable Cox regression analysis, in patients without DM, Lp(a) serum level (HR: 2.68, 95% CI 1.23–5.83; p = 0.013) and age (HR: 1.06, 95% CI 1.04–1.09; p < 0.001) were independent predictors of mortality at 3–year follow–up. Among DM patients, only age was independently associated with 3–year mortality (HR: 1.07, 95% CI 1.03–1.10; p < 0.001) (Table).

Conclusion

In this MI population, Lp(a) was independently associated with long–term mortality in patients without DM, but not in patients with DM. Whether DM can modify the effect of Lp(a) on clinical outcome after MI requires confirmation by larger prospective studies.

Negative prognostic impact of right ventricular free wall strain in patients with functional mitral regurgitation undergoing transcatheter edge-to-edge repair

Funding Acknowledgements

Type of funding sources: None.

Backgrounds

although right ventricular (RV) systolic dysfunction seems to be associated with adverse outcome after transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system, the prognostic value of RV free wall strain in this setting has not been yet investigated. 

Purpose

aim of this study is to evaluate RV free wall strain as predictor of outcome in patients with severe or moderate-to-severe functional MR undergoing TEER and its prognostic role compared with tricuspid annular plane systolic excursion (TAPSE).

Methods

102 patients [73 (IQR 66.8-77.0) years, 73 males (71.6%)] were retrospectively selected from March 2012 to February 2021. Echocardiograms were performed by using General Electric machines. RV free wall strain was assessed through RV modified apical 4-chamber view, setting the region of interest to minimum size (Figure 1). Values of RV free wall strain >-20% were recognized as abnormal. We considered a composite endpoint including rehospitalization for heart failure (HF) and overall death as primary outcome. Secondary outcomes were overall death, cardiac death and rehospitalization for HF. All patients were assessed at the longest available follow-up [median 22.1 (IQR 9.7-49.3) months].

Results

primary outcome was found in 60 (58.8%) patients, while secondary outcomes, i.e. overall death, cardiac death and rehospitalization for HF, were found respectively in 50 (50.0%), 31 (30.4%) and 36 (35.3%) patients. Mean TAPSE was 16.7 ± 4.0 mm and mean RV free wall strain was -16.9 ± 6.0%. At univariable analysis both TAPSE (HR 0.907, CI 0.848-0.970, p value 0.004) and RV free wall strain (HR 0.937, CI 0.897-0.979, p value 0.004) were significantly associated with the primary outcome. Kaplan-Meier survival curves showed that patients with TAPSE <17 mm had a lower survival free from the composite outcome compared with those with TAPSE ≥17 mm (Log-Rank = 0.030); patients with RV free wall strain value > -20% also showed a lower survival free from the composite outcome compared with patients with RV free wall strain ≤-20% (Log Rank 0.004). Among patients with preserved RV systolic longitudinal function as indicated by TAPSE ≥17 mm, subjects with RV free wall strain >-20% had a significantly higher incidence of the composite outcome compare with those with RV free wall strain ≤-20% (Log-Rank = 0.008, Figure 2). Conversely, no difference was found among patients with TAPSE <17 mm. 

Conclusions

RV dysfunction assessed either by TAPSE and RV free wall strain is associated with poorer outcome in patients with severe or moderate-to-severe functional MR undergoing TEER. Compared with TAPSE, RV free wall strain seems to be superior in identifying patients at higher risk of adverse events during follow-up. Our data encourage the use of this speckle tracking-derived echocardiographic parameter in routinely evaluation of patients with functional MR candidate for TEER. Abstract Figure.  Abstract Figure 2

Mitral regurgitation and in-hospital mortality in patients with heart failure and low flow low gradient aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Aim

this study sought to determine the prevalence, clinical impact, and in-hospital outcome of moderate to severe mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) hospitalized for heart failure (HF).

Methods

Patients with aortic valve thickness and aortic velocities >2.5 m/s hospitalized for heart failure in a single referral center were prospectively enrolled from 2013 to 2021.

LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient <40 mmHg and stroke volume index <36 ml/m2. Complete demographic, clinical characteristics and echocardiographic data were collected. Mitral regurgitation severity was graded according to current guidelines. Patients were divided into two subgroups according to MR severity: no/mild MR vs moderate/severe MR. In hospital all cause death has been considered as the primary outcome.

Results

A total of 136 patients  (78 ± 9 yy; 68 (50%) male) hospitalized for HF with a new diagnosis of LFLG-AS were included in the study.

The most frequent comorbidities were hypertension (121, 89%), dyslipidemia (106, 78%), chronic kidney disease (85, 63%), diabetes (56, 41%) and obesity (44, 32%). Atrial fibrillation/flutter was detected in 61 (45%) patients. Moderate to severe MR was detected in 33%. Mean functional NYHA class was 2,8 ± 0,8.

Concerning echocardiographic evaluation, the mean gradient of the aortic valve was 26 ± 7 mmHg and the mean iAVA was 0.42 ± 0.10 cm2/m2. The mean left ventricular ejection fraction (LV EF) was 46 ± 13%. Paradoxical LFLG-AS with a preserved LV EF was detected in 73 patients (54%) and the LFLG-AS with a low LV EF was detected in 63 (46%).

In this population, 26 patients (19%) underwent surgical valvular replacement, 15 patients (11%) had aortic percutaneous valvuloplasty and 33 patients (24%) underwent TAVI. The remaining patients (45%, n = 62) were maintained under optimized medical therapy.

In-hospital death occurred in 17 (12,5%) patients (just 1 for non-cardiovascular causes).

Moderate/severe MR was detected in 44 (33%) patients.

When comparing the two subgroups statistically significant differences between age (p = 0,035), male sex (p = 0,028), atrial fibrillation/flutter (p = 0,003), obesity (p = 0,040) and in-hospital mortality (p = 0,013) were detected. In the overall population the multivariate regression analysis showed that only the presence of moderate /severe MR was a significant independent predictor of all-cause in-hospital death (p = 0.017 ; OR 3.571 ; IC  1.257-10.151).

Conclusion. Moderate to severe MR is frequently detected in patients with LFLG AS and HF. In this peculiar cohort significant MR has a negative impact on outcome and is independently associated with in-hospital mortality.

AB0450 PERIPHERAL MACROVASCULAR INVOLVEMENT IN SYSTEMIC SCLEROSIS AS COMPARED WITH HEALTHY CONTROLS: A SMALL COHORT STUDY BY COLOR AND SPECTRAL DOPPLER ULTRASONOGRAPHY

Background:

Together with autoimmune-inflammation and fibrosis, microvasculopathy is a hallmark of SSc. However, also macrovascular changes may occur including peripheral proliferative vasculopathy. Whether this changes may represent a specific SSc marker with a predictive value remains a matter of debate.[1,2,3]

Objectives:

To study peripheral macrovascular involvement by color doppler ultrasound (CDUS) with spectral wave analysis (SWA) in a cohort of 40 SSc patients as compared to healthy controls. To further analyze any differences among the SSc population.

Methods:

Forty SSc patients and 36 healthy controls were examined by CDUS with SWA of both hands. Macrovascular involvement was assessed by measuring the resistivity index (RI) of distal ulnar and radial arteries. Examinations were performed with an Esaote MyLab Twice machine equipped with a linear 10-22 MHz probe. Ultrasound examination was carried out by two independent rheumatologists blinded to clinical conditions of the patients. Statistical analysis was performed by using MaxStat software.

Results:

The RI index resulted increased in the SSc cohort as compared with healthy controls (left ulnar RI 0.977 vs 0.715; right ulnar RI 0.996 vs 0.699; left radial RI 0.988 vs 0.706; right radial RI 0.999 vs 0.688; p<0.001). SSc patients with an increased RI in one artery were more probable to have an increased RI in the other vessels too (r 2 = 0.35; p<0.01). In addition, 8 out of 40 SSc patients presented left ulnar artery occlusion (UAO) and 7 out of 40 SSc patients presented right UAO, of which 6 presented bilateral UAO. Awaiting to enlarge the cohort for further analysis, descriptive data regarding increased RI at CDUS/SWA and clinical features, including years from onset of the disease, subtype of SSc, mRSS, history of digital ulcers, interstitial lung disease and PAH are described in Table 1.

Conclusion:

Peripheral macrovascular involvement was observed in SSc patients as compared with healthy controls. Further studies will determine whether this feature may have specificity for diagnosis/prognosis in SSc.

References:

[1]Lescoat A, Yelnik CM, Coiffier G et al. Ulnar Artery Occlusion and Severity Markers of Vasculopathy in Systemic Sclerosis: A Multicenter Cross-Sectional Study. Arthritis Rheumatol. 2019;71:983-990.

[2]Lescoat A, Coiffier G, Rouil A et al. Vascular Evaluation of the Hand by Power Doppler Ultrasonography and New Predictive Markers of Ischemic Digital Ulcers in Systemic Sclerosis: Results of a Prospective Pilot Study. Arthritis Care Res (Hoboken). 2017;69:543-551.

[3]Schioppo T, Orenti A, Boracchi P, De Lucia O, Murgo A, Ingegnoli F. Evidence of macro- and micro-angiopathy in scleroderma: An integrated approach combining 22-MHz power Doppler ultrasonography and video-capillaroscopy. Microvasc Res. 2019;122:125-130.

Table 1.

Main clinical features of the SSc cohort (n=40) studied by CDUS for macrovascular involvement.

SSc cohort (n = 40)Years from onsetrange (35 y – 0 y)mean = 10.5 yAutoantibodiesACA 13/40Anti-TopoI 14/40Other 13/40mRSSrange (0 -30)mean = 3ILD17/40PAH7/40Capillaroscopy patternEarly 10/40Active 11/40Late 6/40History of digital ulcers16/40Left ulnar IR0.977Left radial IR0.988Right ulnar IR0.996Right radial IR0.999

Disclosure of Interests:

None declared.

POS0832 A NOVEL GREY SCALE AND POWER DOPPLER ULTRASONOGRAPHIC SCORE FOR IDIOPATHIC INFLAMMATORY MYOPATHIES: SIENA MYOSITIS ULTRASOUND GRADING SCALE

Background:

No clear-cut guidelines exist about the use of diagnostic procedures for idiopathic inflammatory myopathies (IIM) and only scanty and conflicting data report the use of ultrasound (US).

Objectives:

We aimed to assess if grey-scale (GS) and Power Doppler (PD) US, graded with a 0-3-points-scale, may be a reliable tool in a cohort of patients affected by IIM.

Methods:

We prospectively collected, since July to October 2020, all patients referred to Vasculitis and Myositis clinic, Rheumatology Unit, University of Siena, for suspected IIM, as well as patients with a previous, definite diagnosis of IIM and evaluated during follow-up or referred from other centers for a second opinion. All patients underwent US examination of both thighs in axial and longitudinal scans. Edema and atrophy, both assessed in GS, and PD, were graded with a 0-3-points-scale. Spearman test was used to identify the correlations between US and clinical and serological variables.

Results:

A total of 18 patients was included. Four of them were evaluated twice, at baseline and within 3 months of therapy. Muscle edema was found to be directly correlated with physician global assessment (PhGA), serum myoglobin and PD and negatively with disease duration. PD score was positively correlated to PhGA and negatively to disease duration. Muscle atrophy directly correlated with Myositis Damage Index and patients’ age. The single-thigh sub-analysis evidenced a direct correlation between PD score and Manual Muscle Test.

Conclusion:

In our cohort, we found that edema and PD are strictly related to early, active myositis, suggesting that an inflamed muscle should appear swollen, thickened and with Doppler signal. Conversely, muscle atrophy reflects the age of the patient and the overall severity of the disease. Such findings shed a new, promising, light in the role of US in diagnosis and monitoring of IIMs.

Table 1.

Siena Myositis Ultrasound Grading Scale (SMUGS).

Grey-scale edemaGrey-scale atrophyPower Doppler0Normal muscle echotexture with hyperechoic septa and hypoechoic muscle fibers, conserved thickness.Normal muscle echotexture, with hyperechoic septa and hypoechoic muscle fibers, conserved thickness.No PD signal.1Focal hypoechoic areas, where septa are less evident. Conserved thickness.Focal heterogeneously hyperechoic areas, where septa are thicker and more evident, and muscle fibers are thinner. Conserved muscle thickness.One or two PD signals in at least one muscle (PD vascular spots, small vessels of homogenous diameters, vessel diameters approximately not superior to fibrous intramuscular septa)2Diffuse and heterogeneous hypo echogenicity (rectus femoris as hypoechoic or more than vastus intermedius), septa diffusely less evident. Conserved thickness.Diffuse and heterogeneously hyperechoic muscle, with thicker septa and thinner muscle fibers. Conserved muscle thickness.More than 2 PD signals for each muscle (as vascular spots, small vessels of homogenous diameters, vessel diameters approximately not superior to fibrous intramuscular septa).3Diffuse and heterogeneous hypo echogenicity (rectus femoris as hypoechoic or more than vastus intermedius), septa diffusely less evident. Increased thickness (rectus femoris became thicker than vastus intermedius).Diffuse and heterogeneously hyperechoic muscle, with thicker septa and thinner muscle fibers. Reduced muscle thickness.More than 2 PD signals for each muscle with larger diameter of the vessel (at least superior to fibrous intramuscular septa), or vessels with different diameters or branched vessels.Figure 1.

Different PD findings (clockwise) in longitudinal anterior scans of the thigh: PD 3 in a patient with a recent diagnosis of anti-Mi2 DM; PD 2 in the same patient after one month of treatment with steroids and Methotrexate; PD 1 in a patient affected by anti-SAE DM, with a suspected disease flare; PD 0 in a patient affected by an advanced polymyositis diagnosed in 2000, currently not in treatment.

Disclosure of Interests:

None declared

POS0963 POWER AND SPECTRAL DOPPLER ULTRASOUND AS A SCREENING TOOL IN THE DIAGNOSTIC COURSE OF SUSPECTED AXIAL SPONDYLOARTHRITIS: PRELIMINARY DATA FROM A LARGE MONOCENTRIC COHORT

Background:

Sacroiliac joints (SIJs) involvement is a characteristic feature of Spondylarthritis (SpA). Magnetic resonance imaging (MRI) has been included in the new Assessment of SpA International Society (ASAS) criteria for the classification of non-radiographic axial SpA. Power Doppler ultrasound (PDUS) and spectral Doppler US have been used in few works, also from our group, to evaluate the inflammatory activity of the SIJs, in comparison with MRI, with different results.

Objectives:

We aimed to evaluate the value of PDUS with spectral wave analysis (SWA) in the assessment of suspected active sacroiliitis (SI). PDUS of SIJs was used as a screening tool alongside the routine PDUS assessment of peripheral joints.

Methods:

143 patients (114 females and 29 males, mean age 46,2 years, mean BMI 25.9) with new onset of inflammatory back pain (IBP), were included. Peripheral symptoms were allowed. Every patient underwent a PDUS examination of SIJs as previously reported. The sonographer was blinded to the clinical data. An Esaote Twice US machine, with convex 1-8 MHz and linear 6-18 MHz probes, was used, with standardized parameters. PD signals detected in the SIJs, were scored with a 3-points scale: 0= absence of signals, 1= isolate vessels, 2= more than one vessel. The signals were also classified as intra-articular (vascularity from deep joint and inter-osseous ligament) or peri-articular (vascularity along posterior sacroiliac ligament). SWA was applied to the same vessels calculating the Resistive Index (RI) (Figure 1). A PDUS diagnosis of active SI was made with a grade 1 of vascularity and RI<0,60, or grade 2 of vascularity and RI<0,70. PDUS multi-site examination of peripheral joints and entheses was also performed; entheseal involvement was scored with Belgrade Ultrasound Enthesitis Score (BUSES) and as global enthesitic charge (GEC). Every patient underwent MRI of SIJs within 2 weeks, and before to start pharmacologic treatment. The non-parametric Spearman rank test and univariate linear regression analysis was applied using InStat GraphPad statistical package.

Results:

A time of 5-8 minutes was sufficient to set and to complete PDUS/SWA examination on both SJJs. All patients considered this examination quick, not painful and substantially comfortable. PD signals were detected in 124 patients (mean RI 0,56). Bone marrow edema (BME) lesions (active SI on MRI) were detected in 94 patients. A final diagnosis of SpA was made in 103 patients (81 females, 22 males). Among SpA patients 24 had psoriasis, 3 inflammatory bowel disease, 3 uveitis, 5 were B27+, and they had mean BUSES of 4,1 and GEC of 1,2. The mean SIJs PDUS score was 1,3 in SpA and 0,52 in not-SpA patients. The mean SIJs RI was 0,53 in SpA and 0,68 in not-SpA patients. A significant correlation was demonstrated between MRI and PDUS diagnosis of SI (r=0,6486, p<0,0001), between MRI diagnosis and PD grading (r=0,4937, p<0,0001). The split analysis of peculiar parameters of imaging between the two methods also showed significant correlation: periarticular vascularity showed correlation with post-contrast MRI evidence of posterior capsulitis and enthesitis (p=0,001), as SIJs BME correlated with intra-articular PD signals (p<0,001). RI from SWA analysis was inversely correlated with MRI diagnosis of active SI (p<0.0001). SIJs PD demonstrated a significant correlation with SIJs pain (p<0,001), but not with inflammatory reactants, GEC, peripheral synovitis, and a weak correlation with BUSES (p=0,038).

Conclusion:

SIJs PDUS/SWA may be an optional method for preliminary screening of active SI, as a feasible, cheap and an accurate diagnostic tool, compared with MRI as a gold standard for nr-Axial SpA. PD US in SI. Right SI joint with a PD signal within inter-osseous ligament (curved arrow), where spectral PD analysis shows a RI of 0,62. Normal vessels (with high RI, unshowed) can be observed into the first sacral foramen (arrowhead). The first sacral apophysis (arrow) protrudes from the sacrum profile.

Disclosure of Interests:

None declared.

POS0661 RAPID RESPONSE TO BARICITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS AND AN INADEQUATE RESPONSE TO METHOTREXATE AND AT LEAST ONE BIOLOGIC DMARD: A CLINICAL AND POWER DOPPLER ULTRASOUND STUDY

Background:

Baricitinib, an oral Janus kinase (JAK) 1-2 inhibitor, is currently used among biologic DMARDs (bDMARDs) after the failure of methotrexate (MTX) in rheumatoid arthritis (RA). Power Doppler ultrasound (PDUS) is a promising, non-invasive imaging method to assess synovitis in RA: results from numerous studies suggest that it provides additional information to clinical and conventional radiographic examinations.

Objectives:

The main objective of our study was to evaluate short-term efficacy of Baricitinib in reducing synovitis, using the composite semi quantitative scale (0–3 grades) PDUS synovitis score, developed by the Outcome Measures in Rheumatology– European League Against Rheumatism (OMERACT– EULAR)-Ultrasound Task Force. Moreover both synovial hyperplasia and intrasynovial power Doppler (PD) signal were also scored as single components/parameters on 0-3 scales. Secondary objective was to assess the concordance between patient reported outcomes (PROs), markers of inflammation, physical examination and US.

Methods:

We enrolled 30 patients fulfilling 2010 ACR and EULAR criteria for RA. All patients had failed at least one anti-TNF. Each patient was prescribed Baricitinib 4 mg/daily at T0, in addition to MTX and/or oral steroids at a dosage ≤ 7, 5 mg/day of Prednisone or equivalent, at T’. All patients were evaluated at baseline (T0) and then after one month (T1), 3 months (T2) and 6 months (T3) of treatment. Swollen and tender joints (out of 28)were evaluated and recorded, as well as patient (PGA) and physician global assessment (PhGA) and pain, expressed in a visual analog scale (VAS). Disease activity was evaluated at each visit using DAS28 (Disease activity score 28), CDAI (Clinical disease activity index)and SDAI(Simplified disease activity index), accompanied by a complete blood count, Erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) collection. Statistical analysis was performed using GraphPad version 9.0.0. PDUS examination, was carried out by two rheumatologists (PF and CB) blinded to clinical conditions of the patients, using an Esaote Mylab Twice (Genoa, Italy), equipped with a high-frequency (6-18 MHz) linear probe. With standardised Doppler parameters (pulse repetition frequency between 500-750 Hz; Doppler frequency between 7–11.1 MHz). PDUS was performed at each visit bilaterally for 22 joint sites [MCPs 1–5, proximal interphalangeal joints (PIPs) 1–5, wrist, elbow, glenohumeral, knee, tibiotalar, talonavicular and calcaneocuboidal and metatarsophalangeal joints (MTPs) 1–5] for a total of 44 joints for each patient.

Results:

we observed a reduction of VAS pain (T0 vs, T6<0,0001) PDUS composite score (T0 vs. T6 p<0,0001), Power Doppler (T0 vs. T6 p<0,0001) synovial hyperplasia (T0 vs. T6 p=0,0002), CRP (T0 vs. T6 p<0,0001) and ESR (T0 vs. T6 p <0,0001) was observed in our patients. Accordingly, DAS-28, CDAI and SDAI displayed a significant reduction too (DAS-28: T0 vs. T6 p< 0, 0001; CDAI: T0 vs. T6 p< <0, 0001; SDAI: T0 vs. T6 p= 0, 0003).

Conclusion:

We investigated the efficacy of Baricitinib in real life, evaluating both from a clinimetric and ultrasound point of view. Baricitinib, demonstrated a significant parallel and fast improvement in VAS, PDUS and CRP was found at follow up assessment as early as one month of therapy. In conclusion, these results demonstrated the short term efficacy of Baricitinib 4mg for up to 6 months and providing a prompt improvement of PROs within the first weeks of treatment.

Figure 1.

The difference between the means of PD and of the VAS pain over time (T0, T1, T3 and T6). Power Doppler (T0 vs. T6** p<0,0001), VAS: (T0 vs. T1 *p<0,0098;T0 vs. T3 **** p<0,0001; T0 vs. T6 ****p<0,0001)

Disclosure of Interests:

None declared

Hepatic Presentation of Late-Onset Multiple Acyl-CoA Dehydrogenase Deficiency (MADD): Case Report and Systematic Review

Diagnosis of pediatric steatohepatitis is a challenging issue due to a vast number of established and novel causes. Here, we report a child with Multiple Acyl-CoA Dehydrogenase Deficiency (MADD) presenting with an underrated muscle weakness, exercise intolerance and an atypically severe steatotic liver involvement. A systematic literature review of liver involvement in MADD was performed as well. Our patient is a 11-year-old otherwise healthy, non-obese, male child admitted for some weakness/asthenia, vomiting and recurrent severe hypertransaminasemia (aspartate and alanine aminotransferases up to ×20 times upper limit of normal). Hepatic ultrasound showed a bright liver. MRI detected mild lipid storage of thighs muscles. A liver biopsy showed a micro-macrovacuolar steatohepatitis with minimal fibrosis. Main causes of hypertransaminasemia were ruled out. Serum aminoacids (increased proline), acylcarnitines (increased C4-C18) and a large excretion of urinary glutaric acid, ethylmalonic, butyric, isobutyric, 2-methyl-butyric and isovaleric acids suggested a diagnosis of MADD. Serum acylcarnitines and urinary organic acids fluctuated overtime paralleling serum transaminases during periods of illness/catabolic stress, confirming their recurrent nature. Genetic testing confirmed the diagnosis [homozygous c.1658A > G (p.Tyr553Cys) in exon 12 of the ETFDH gene]. Lipid-restricted diet and riboflavin treatment rapidly ameliorated symptoms, hepatic ultrasonography/enzymes, and metabolic profiles. Literature review (37 retrieved eligible studies, 283 patients) showed that liver is an extramuscular organ rarely involved in late-onset MADD (70 patients), and that amongst 45 patients who had fatty liver only nine had severe presentation. Conclusion: MADD is a disorder with a clinically heterogeneous phenotype. Our study suggests that MADD warrants consideration in the work-up of obesity-unrelated severe steatohepatitis.

Observations about subcalcaneal adventitial bursitis (heel fat pad inflammatory lesion) in rheumatoid arthritis. Comment on the article of Suzuki and Shirai

Not available

Clinical profile and in-hospital course of patients with primary and secondary takotsubo syndrome: single center experience

Background

Takotsubo syndrome (TTS) is an acute cardiac disease increasingly recognized in a variety of clinical scenarios. Heart Failure Association of the ESC classified TTS in primary (occurring in the setting of psychological or emotional trigger or without clear identifiable stressors) and secondary (triggered by physical stressors or other critical illnesses). However, the clinical profile and outcome of these different subtypes is still controversial.

Aim of the study

To compare baseline features, clinical presentation and in-hospital outcomes in patients with primary or secondary TTS in a single referral center.

Methods

Overall study population included 210 patients (mean age 66.1±12.2 years, 14 male); 165 and 45 with primary and secondary TTS, respectively; consecutively enrolled from 2012 to 2019 in our center. Clinical, instrumental and laboratory data and in-hospital events were also recorded in both groups.

Results

Compared to patients with primary TTS, patients with secondary form were older (70.6±14.6 vs 64.9±11.2 years; p=0.006) and more frequently man (13.3% vs 4.8%; p=0.043). Several comorbidities such as diabetes (23.8% vs 8.9%; p=0.008); pulmonary (45.2% vs 12.9%; p&lt;0.001); neurologic (23.8% vs 9.7%; p=0.015); nephro-urologic (31% vs 13.5%; p=0.008); psychiatric (42.9% vs 26.5%; p=0.039) and orthopedic (28.6% vs 13.5%; p=0.020) diseases were prevalent in secondary TTS patients. Atypical presentation with higher incidence of dyspnea was significantly prevalent (42.2% vs 19.4%; p=0.002) in secondary group. The number of patients with ST-T elevation on admission was similar (80% vs 77%; p=0.5) in both groups. Prolonged QT interval in a majority of secondary TTS patients (46.3% vs 28.4%; p=0.029) was detected. Peak levels of troponin, creatine-kinase and myoglobin did not differ between the two groups. Echocardiography revealed larger left ventricular end-diastolic and end-systolic volumes (62.7±25.3 vs 50.6±14.3 ml/mq; p=0.024 and 35.1±14.5 vs 28.7±9 ml/mq; p=0.048) at presentation in secondary TTS, however no differences in baseline left ventricular ejection fraction were detected. Furthermore, the prevalence of apical ballooning was similar between the two groups. Of note, secondary TTS patients experienced more frequently acute heart failure (40.5% vs 23.1%; p=0.024), hyperkinetic arrhythmia (9.1% vs 1.9%; p=0.022), cardiogenic shock (15.9% vs 3.2%; p=0.002), and mechanical ventilation use (9.3% vs 1.3%; p=0.006) during the acute phase. In-hospital stay (10.8±6.9 vs 7.4±6.2 days, p=0.004) was longer in this cohort.

Conclusion

Our results demonstrate that to classify TTS patients in primary or secondary form is clinically relevant. Secondary form generally is associated to higher rate of comorbidities and to atypical presentation. Owing to the worse in-hospital outcome of the secondary TTS patients a tailored and more intensive treatment should be adopted in this cohort.

Funding Acknowledgement

Type of funding source: None

Clinical outcome of patients with ST-elevation myocardial infarction and angiographic evidence of coronary artery ectasia

Background

Coronary artery ectasia (CAE) is a relatively frequent finding in patient with ST-elevation myocardial infarction (STEMI) who undergo emergent coronary angiography. However, the long-term outcome of STEMI patients with CAE as compared to Non-CAE has been poorly investigated.

Purpose

To compare the baseline features and outcome of patients with and without CAE in the clinical setting of STEMI.

Methods

All patients with STEMI who underwent emergent coronary angiography from January 2012 to December 2017 at our Institution were retrospectively enrolled. Baseline demographic, clinical, instrumental, angiographic and percutaneous coronary intervention (PCI) findings were collected for patients with and without CAE. The study outcome measures were recurrent myocardial infarction (MI) and all-cause death. The propensity score weighting (PSW) technique was used to take into account for potential selection bias in treatment assignment between CAE and Non-CAE groups.

Results

The study included 534 patients with STEMI (mean age 62.9±12.0 years), 154 were CAE and 380 Non-CAE. The two groups were significantly different in terms of sex (90.9% in CAE vs 72,6% in Non-CAE, p&lt;0.001), diabetes (11.7% vs. 25.8%; p=0.009) and smoking status (72.1% vs. 62.4%; p=0.042). The right coronary artery was more commonly treated in CAE patients (41.6% vs. 30.8%, p=0.023) and, as expected, the stent diameter (p&lt;0.001) and the TIMI frame count (p&lt;0.001) were significantly higher in CAE group. The myocardial blush grade was higher in Non-CAE (p&lt;0.001). The Kaplan-Meyer analysis showed a comparable rate of all-cause death among the two groups (3.4/100 person/years in CAE vs. 3.5 per 100 person/years in Non-CAE, Log-Rank = 0.86).

The survival free from recurrent MI was lower, although not statistically significant, in CAE vs. Non-CAE patients (3.1/100 person/years vs. 4.8/100 person/years; Log-Rank = 0.068).

After PSW, an optimal balance was obtained as demonstrated by a standardized mean difference &lt;0.1 for all the variables included in the model. The adjusted Cox regression analysis showed a significantly higher risk of recurrent MI in CAE vs. Non-CAE groups (HR = 1.93; p=0.009). No difference in the risk of all-cause death was observed (HR = 0.83, p=0.501).

Conclusions

Patient with STEMI and angiographic evidence of CAE have a different clinical profile compared to Non-CAE. In this analysis focused on STEMI patients, CAE was associated with a higher risk of recurrent MI at long-term follow-up.

Funding Acknowledgement

Type of funding source: None

AB0939 POLYMYALGIA RHEUMATICA FOLLOWING INFECTIVE TRIGGERS OR VACCINATIONS: A DIFFERENT SUBSET OF DISEASE?

Background:

Polymyalgia rheumatica (PMR) is the most common inflammatory disorder of elderly; an association with environmental triggers and deregulated immune response has been described.

Objectives:

The aim of this study was to investigate the presence of environmental triggers before the onset of PMR and its association to a particular subset of disease.

Methods:

The database of 58 consecutive PMR patients recruited from a single rheumatology secondary care setting was retrospectively analyzed to investigate the frequency of environmental triggers and correlations with clinical characteristics. Patients underwent multidistrict ultrasound examination of both proximal and distal sites. Laboratory tests were repeated after one month from first visit, when steroids were started, and about every three months during follow-up (for at least 24 months)

Results:

Fifteen PMR patients (26%) described a connection with environmental agents: six PMR patients reported a vaccination, 3 an upper respiratory tract infection and 1 pneumonia before the onset of disease. Five patients reported seasonal influenza as trigger of PMR. The model of multivariate linear regression which better predicted a shorter time to normalize inflammatory reactants (R squared 27,46%, p=0,0042) comprised the presence of an environmental trigger and a higher CRP. A linear regression analysis confirmed an inverse correlation between CRP at onset ant time to normalize inflammatory reactant (r= -0,3031, p=0,0208). A significant correlation was demonstrated between presence of environmental trigger and shorter time to normalize inflammation (r=-0,5215, p<0,0001), lesser frequency of gleno-humeral synovitis on US (r=-0,3774, p=0,0038).

Conclusion:

Our work describes a correlation between environmental triggers in PMR and higher CRP at diagnosis and faster response to therapy. We may suppose that these patients belong to a more specific subtype of PMR, in whom external stimuli, such as vaccinations or infections, may lead to a deregulated response within the context of an impaired immune and endocrine system. We recommend a systematic research of previous infections or vaccination in recent onset PMR

Disclosure of Interests:

None declared

THU0520 DIFFUSE ENTHESITIS AND LOW-GRADE INFLAMMATION IN PATIENTS WITH METABOLIC SYNDROME: A CLINICAL AND ULTRASOUND STUDY

Background:

Metabolic syndrome (MS) is a clinical condition characterized by central obesity and additional factors such dyslipidemia, hypertension, raised fasting plasma. Scanty observations describe the association of MS with musculoskeletal conditions, such as enthesopathies and diffuse idiopathic hyperostosis syndrome (DISH). Musculoskeletal ultrasound (US) has been applied to the study of entheses, but the real prevalence and characteristics of entheseal involvement in MS has yet to be clarified.

Objectives:

The aim of our work was to study the US-defined entheseal changes in MS, to correlates the US enthesitis scores to clinical characteristics, and to define a relation between MS-related enthesitis and the presence of concurrent DISH

Methods:

Sixty consecutive outpatients (24 males, 36 females, mean age 60 years), all fullfilling International Diabetes Foundation (IDF) criteria for MS, were also evaluated with multi-site bilateral US entheseal examination. Each patient underwent power Doppler (PD) US examination of twelve entheseal sites, using Esaote MyLab Twice with 6–18 MHz transducer. Enthesitis was defined on the basis of OMERACT’s filter. Inflammatory and structural changes were scored as a whole when present (score 1) or absent (score 0). The sum of entheses with inflammatory and structural damage was defined as “global inflammatory score” (GIs) and “global structural damage score” (GSDs) for each patient. The Leeds Enthesitis Index (LEI) was also applied, and a spinal radiography was obtained for each patient to research concurrent signs of DISH satisfying Resnick and Niwayama criteria.

Results:

Patients showed moderate overweight (mean BMI 29) and a diagnosis of type 2 diabetes was present in 24 (40%). A low-grade inflammatory state was demonstrated in MS (mean CRP 0,58 md/dL, mean ESR 21,9 mm/h). A high prevalence of US-defined enthesitis was noted in 52 patients (86%) and 127/720 entheses (17,6%). PD signals, were reported in 11 patients (18%) and 11/720 entheses (1,52%), and they were associated to clinical symptoms expressed as LEI (p=0,0138). Erosions, although rare (0.3% of entheses), were more frequent in males (p= 0.001). Moreover, in 57 patients (95%) and 217 entheses (30%) structural damages were found. A correlation was found between GIs and GSDs and both BMI (p=0.0233 and p=0.0068 respectively), LEI (p=0.03 and p=0.0099 respectively), and type 2 diabetes (p=0.0248 and p=0.0156 respectively). In 28 patients (46%) a concurrent diagnosis of DISH was made. In multivariate regression analysis the best predictors for DISH were higher levels of CRP (p=0,038) and older age (p<0,0001). DISH correlated with older age (p<0,0001), CRP and ESR (p= 0,0428 p=0,0069 respectively) and US global scores for enthesitis (p=0,0312 for GIs, p=0,0071 for GSDs).

Conclusion:

This is the first study where diffuse enthesitis and entheseal structural damage are demonstrated with high prevalences in MS, comparable or also higher than those reported for SpA-related enthesitis. Our data, obtained using the most recent OMERACT’s definition for US-detected enthesitis (proposed for SpA), also suggest a low specificity of this definition, in consideration of the high prevalence of MS-associated enthesitis. Moreover PD was associated to entheseal pain expressed as LEI. Both GIs and GSDs showed a correlation with overweight and type 2 diabetes. As secondary result, this study demonstrated that almost half of patients with MS could have a concurrent diagnosis of DISH. Patients with DISH were older, with higher levels of inflammation, and higher scores of US-defined enthesitis. Our results suggest that MS and DISH could be strictly related; diffuse enthesitis with a low-grade inflammatory state should be regarded as potential factor of progression from MS towards a conclamed DISH.

Disclosure of Interests:

None declared

AB0281 SAFETY AND RETENTION RATE AFTER SWITCHING FROM ETANERCEPT ORIGINATOR (ETN) TO ETANERCEPT BIOSIMILAR (SB4) IN INFLAMMATORY JOINT DISEASES: DATA FROM REAL LIFE

Background:

SB4 in now commonly used in the treatment of inflammatory joint diseases, with evidence of efficacy and persistence up to 12 months from switching in both randomized controlled trials in Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) and Ankylosing Spondylitis (AS).

Objectives:

we investigated the safety and retention rate of SB4 at 6, 12 and 18 months after switching from ETN in two rheumatology departments in our region.

Methods:

adult patients with RA, PsA, AS, Juvenile Idiopathic Arthritis (JIA) and other rheumatic diseases treated with ETN for at least 6 months, switched to SB4 in stable clinical conditions, were eligible for this retrospective evaluation. Data on adverse events (in particular infectious events), loss of efficacy (articular, cutaneous, ocular or intestinal disease re-activation) and persistence on treatment were collected since latest available follow-up. Retention rate, reason for discontinuation and subsequent management data were collected at 6, 12, 18 months.

Results:

220 patients (142 females, mean age 58+-7 years, disease duration 12+-4 years, ETN duration 7+-4 years) were enrolled, with median follow up of 12.1 (9.7-15.8) months duration; ETN was used in different biologic DMARDs treatment lines (first 76.8%, second 17.7%, third 3.2 %, fourth 2.3%). Study population was composed of 85 RA, 81 PsA, 33 AS, 14 JIA and 7 other conditions (mostly scleroderma). In the follow-up, 50 patients (22.7%) presented with at least one non-serious adverse event, with 36 (16,4%) disease re-activation (mostly articular) and 30 (13,6% - 11 for safety and 19 loss of efficacy) SB4 interruptions. Retention rates were 99.1 (210/212) at 6, 90.9% (150/165) at 12 and 81.5% (53/65) at 18 months respectively. Back-switch to ETN was performed in 17/30 cases, the remaining cases were managed with change of bDMARD or csDMARD). Age was the only significant predictor of SB4 interruption at 6 months (OR 1.058, 95%CI 1.007-1.112, p=0.026), while disease, bDMARD line, csDMARD combination, gender, disease duration or ETN duration did not influence retention rates at 6, 12 or 18 months.

Conclusion:

our real-life data confirm the safety profile of switching from ETN to SB4. In our patients, the data show a higher retention rate, when compared to other-real life registries data (1,2)

References:

[1]Ebbers HC et al. Real-World evidence on Etanercept Biosimilar SB4 in Etanercept-Naïve or Switching Patients: A Systematic Review. Rheumatol Ther. 2019 Sep;6(3):317-338.

Disclosure of Interests:

Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Stefano Gentileschi: None declared, Marco Capassoni: None declared, Giovanni Pacini: None declared, Marco Bardelli: None declared, Caterina Baldi: None declared, Lorenzo Tofani: None declared, Laura Cometi: None declared, Francesca Nacci: None declared, Francesca Bartoli: None declared, Ginevra Fiori: None declared, Luca Cantarini: None declared, Serena Guiducci: None declared, Bruno Frediani: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

AB1086 POWER DOPPLER AND SPECTRAL DOPPLER ULTRASOUND IN SUSPECTED ACTIVE SACROILIITIS: A COMPARISON WITH MAGNETIC RESONANCE IMAGING AS GOLD STANDARD

Background:

SIJ involvement is a characteristic feature of Spondylarthritis (SpA). Magnetic Resonance imaging (MRI) has been included in the new Assessment of SpA International Society (ASAS) criteria for the classification of Axial SpA. Gray scale US, Color Doppler ultrasound (CDUS), contrast-enhanced CDUS, and spectral Doppler (SD) US has been used in few works to evaluate the inflammatory activity of the SIJ with not conclusive results. Power Doppler ultrasound (PDUS) was not yet applied to the study of SIJ with active SI.

Objectives:

The aim of this work was to study with PDUS and SD US the SIJ of patients with suspected active SI, to describe inflammatory flows with spectral wave analysis (SWA) in duplex Doppler US, and to correlate US data with clinical characteristics and the presence of bone marrow edema (BME) in MRI.

Methods:

22 patients (18 females and 4 males, mean age 35 years) with new onset of inflammatory back pain (IBP), were included. Every patient underwent an US examination in prone position. The sonographers were blinded to the clinical data of the patient. A Esaote Twice US machine, equipped with a convex multifrequency 1-8 MHz probe, was used, with standardized parameters: 1-5 MHz for gray scale, 1.9-2.3 MHz frequency for Doppler with Pulse Repetition Frequency (PRF) of 1.0 KHz and a color gain just under the artifact limit. SIJ was located as the hypoechoic triangle delimited between the sacrum and iliac bone, and the posterior SI ligament as the upper margin. The first sacral foramen was always localized to avoid measurement of the normal pre-sacral arteries. The PDUS was applied, and if any signals were detected in the SIJ, they were scored with a 3-points scale: 0= absence of signals, 1= isolate vessels, 2= more than one vessel. The signals were also classified as intra-articular or peri-articular. The same vessels were also evaluated using quantitative SD calculating the Resistive Index (RI=peak of systolic flow- end diastolic flow/peak systolic flow), ranging between 0 and 1. Every patient underwent MRI of SIJ within the same week, before treatment. A statistical analysis was performed, estimating the sensitivity and specificity against the gold standard (presence of BME in the same SIJ according to ASAS criteria). The Spearman rank not-parametric test was applied to correlate the presence and grading of BME with PDUS grading and RI. A regression analysis was applied between PDUS results and clinical characteristics.

Results:

In 14/22 SIJ MRI revealed BME. In 13 of them, PDUS confirmed abnormal hypervascularisation in the intrarticular portion of SI, and in 3 in the periarticular site too. Two SIJ showed hypervascularisation at PD with no BME in MRI. A significant correlation was demonstrated between positivity and grading of PD and presence of BME in MRI (p=0.0005). SD analysis demonstrated low Resistance Index (RI) values in 14 SIJ (mean 0.57). An inverse correlation was demonstrated between RI and grading of BME in MRI (r= -0,6229, p= 0,044). The diagnostic accuracy of SD for detection of active SI varied on the basis of RI cut-off value. The best values of sensitivity (62,5%) and specificity (61,5%) were obtained with a RI cut-off values of 0.60. A multiple regression model demonstrated a significant relationship between PDUS signals and ASDAS (p=0.0382), but not with inflammatory reactants.

Conclusion:

PDUS and SD US of SIJ can be useful as first imaging assessment in suspected active SI, demonstrating a good diagnostic accuracy compared with MRI. Intra-articular low RI values (<0.60) on SD indicate active SI with good accuracy. Moreover, PDUS signals into the SIJ correlate with clinical symptoms but not with inflammation reactants.

Figure 1.

Doppler US in SI.Right SIJ with a Doppler signal along the posterior SIJ ligament, and another Doppler signal into the joint, where SD analysis gave a RI of 0,62.

Disclosure of Interests:

None declared

P322 Dynamic changes of left ventricular cardiac mechanics in takotsubo syndrome: a preliminary study

Background

Takotsubo syndrome (TTS) is a transient left ventricular (LV) heart failure due to a reversible systolic dysfunction, usually recovering within days or weeks.

Purpose

To assess the dynamic changes of LV cardiac mechanics in a small cohort of TTS patients through the estimation of myocardial work, a newly developed non-invasive approach which allows correction of global longitudinal strain (GLS) for systolic blood pressure.

Methods

Twenty-four patients (mean age, 63.8 ± 8.4 yy; all female) with TTS diagnosis were retrospectively enrolled. Data from transthoracic two-dimensional and speckle-tracking echocardiography on admission and at 3 months follow-up were collected. Global myocardial work index (GWI, mmHg%) was calculated as the area of the LV pressure (LVP)-strain loop, where LVP was estimated noninvasively using a standard waveform fitted to valvular events and scaled to systolic blood pressure. From GWI we also assessed: global constructive work (GCW, mmHg%: work performed during shortening in systole + negative work during lenghtening in isovolumetric relaxation, IVR), global wasted work (GWW, mmHg%: negative workperformed by a segment during lengthening in systole + work performed during shortening in IVR) and global work efficiency (GWE, %: constructive work divided by the sum of constructive and wasted work). Baseline demographic and clinical features, including in-hospital adverse events as acute heart failure, cardiogenic shock and cardiac death, were also assessed.

Results

On overall population, a reduced ejection fraction (EF) and GLS were detected at hospital admission, with a substantial improvement at discharge and at follow-up (from 41.7 ± 8.3% to 54.5 ± 6.5% to 60.2 ± 4.6% for EF and from -11.7 ± 4.5% to -16.2 ± 4.2 to -21.3 ± 2.8% for GLS, respectively). Similarly, global MWI and MWE both showed a positive trend during the hospital course and at follow-up: MWI increased from 1048.8 ± 580.5 to 1522.4 ± 695.4 to 2021.1 ± 388.6 mmHg% and MWE from 78.7 ± 10.2 to 91.1 ± 4.6 to 94.5 ± 3.8 %. Increasing in MWE has been obtained through an improvement of GCW (from 1195.9 ± 537.2 to 1651.3 ± 700.3 to 2316.8 ± 490.6 mmHg%) and a contemporary decreasing in GWW (from 237.9 ± 137.2 to 106 ± 37.2 to 131.8 ± 150.8 mmHg%).

In-hospital adverse events occurred in 8 (50%) patients. Of note, despite EF and GLS at admission showed no significant differences, patients experiencing in-hospital adverse events showed lower value of acute MWI (725.6 ± 289.6 vs 1371.9 ± 632.1 mmHg%; p= 0.02) and MWE (73.6 ± 3.4 vs 83.8 ± 12.4%; p= 0.04) compared to patients without in-hospital complications.

Conclusion

Non-invasive assessment of myocardial work through echocardiographic strain-based technique could be useful to demonstrate the peculiar dynamic changes of cardiac mechanics and for a better risk stratification in TTS patients.

Abstract P322 Figure.

5037Drug treatment with beta-blockers and long-term outcome in patients with takotsubo syndrome: results from the takotsubo Italian network

Background

Although generally considered a benign disease, Takotsubo syndrome (TTS) has recently been associated to a substantially comparable long-term outcome than acute coronary syndrome (ACS). The use of beta-blockers (BB) has been advocated in these patients for secondary prevention after the index event, considering the presumed role of catecholamine in TTS pathophysiology. However, the effect of BB on long-term outcome remains controversial due to the paucity of data and the lack of evidence from randomized studies.

Purpose

To investigate the impact of BB therapy on long-term outcome in patients with TTS.

Methods

The study included all TTS patients enrolled in the Takotsubo Italian Network multicenter registry. Patients were divided in two study groups according to the BB therapy after discharge. The following major adverse cardiac events (MACE) were assessed at the longest available follow-up: cardiac death, TTS recurrence, rehospitalization for cardiac cause, acute or worsening heart failure (HF) and ACS. Also, the composite of cardiac death and rehospitalization as well as the overall MACE were analyzed

Results

The study population included 548 patients (mean age 68.7±11.4 years; 44 males, 8%). Among them, BB treatment was reported in 368 (BB group, 67.2%) and 180 (no-BB group, 32.8%) patients, respectively. The baseline clinical characteristics were substantially comparable among groups with the only exception of COPD, which was prevalent in the no-BB group (10.3% vs 21.7%, p=0.001).

During follow-up (median 18 months 25–75% c.i. 6–29), TTS recurrence was reported in 26 patients (4.7%), ACS in 10 (1.8%), acute or worsening HF in 39 (7.1%), cardiac hospitalization in 71 (13.0%) and cardiac death in 18 (3.3%). The rate of TTS recurrence and ACS was comparable between groups. Conversely, no-BB patients experienced more frequently acute or worsening HF (5.4% vs 10.6%, p=0.034), cardiac rehospitalization (10.9% vs 17.2%, p=0.042) and cardiac death (1.9% vs 6.1, p=0.018) than BB patients. Therefore, the MACE composite endpoint was significantly prevalent in the no-BB group (12.0% vs 20.6%, p=0.010).

Kaplan-Meier curves for the composite of cardiac death and rehospitalization showed a statistically lower survival in the no-BB patients compared to the BB group (p=0.006). Moreover, landmark analysis showed a wider survival benefit in the BB patients after 2 years.

Conclusions

Although in absence of a secondary preventive effect on TTS recurrence, BB may improve the long-term cardiac outcome in patients with TTS. Prospective randomized studies are advisable to confirm these findings.

Expanding the clinical and genetic spectra of NKX6-2-related disorder

Hypomyelinating leukodystrophies (HLDs) affect the white matter of the central nervous system and manifest as neurological disorders. They are genetically heterogeneous. Very recently, biallelic variants in NKX6-2 have been suggested to cause a novel form of autosomal recessive HLD. Using whole-exome or whole-genome sequencing, we identified the previously reported c.196delC and c.487C>G variants in NKX6-2 in 3 and 2 unrelated index cases, respectively; the novel c.608G>A variant was identified in a sixth patient. All variants were homozygous in affected family members only. Our patients share a primary diagnosis of psychomotor delay, and they show spastic quadriparesis, nystagmus and hypotonia. Seizures and dysmorphic features (observed in 2 families each) represent an addition to the phenotype, while developmental regression (observed in 3 families) appears to be a notable and previously underestimated clinical feature. Our findings extend the clinical and mutational spectra associated with this novel form of HLD. Comparative analysis of our 10 patients and the 15 reported previously did, however, not reveal clear evidence for a genotype-phenotype correlation.

Obstructive sleep apnea: neurocognitive and behavioral functions before and after treatment

Obstructive sleep apnea syndrome (OSAS) is a sleep disorder characterized by repetitive episodes of upper airway obstruction. The aim of this study was to evaluate whether continuous positive airway pressure (CPAP) treatment is linked to improvements in cognitive abilities and emotional functions of patients with OSAS. Following the exclusion of four subjects for non-adherence to CPAP treatment, the final study sample was composed of 16 patients with moderate-to-severe OSAS, who were assessed both prior to and after 3 months of CPAP treatment, using a neuropsychological battery and questionnaires to assess mood and anxiety disorders, irritability, quality of life, quality of sleep and daytime sleepiness. We observed significant improvements in Digit Span Backward, Short Story and Corsi Span performances after 3 months of CPAP treatment. Questionnaires showed a significant reduction in daytime sleepiness and improvements in the subjective perception of sleep quality and sleep efficiency, and reduced daytime dysfunction. CPAP treatment has significant effects on different cognitive domains in patients with OSAS, especially working memory, long-term verbal memory, and short-term visuospatial memory.

Optimizing Efficacy of Quick Parathyroid Hormone Determination in the Operating Theater

The usefulness of intraoperative parathyroid hormone (PTH) monitoring has been extensively documented in primary hyperparathyroidism (HPT), whereas few data have been published on its use in reoperations or in secondary and tertiary HPT. We report our initial experience with a rapid (12 min response) PTH immunochemiluminometric assay performed in the operating room during surgery in 12 patients with primary HPT, 16 end-stage renal disease patients with secondary HPT and five kidney transplanted subjects with tertiary HPT. Blood samples were taken at baseline, within 10 min after resection and subsequently at various intervals whenever needed. The mean PTH levels before and after parathyroidectomy were 230.5 pg/mL (range 69–842) and 47.3 pg/mL (range 5–184), respectively, in primary HPT, 855.0 pg/mL (416–1655) and 202.2 pg/mL (53–440) in secondary HPT, and 205.6 pg/mL (116–301) and 45.4 pg/mL (18–97) in tertiary HPT. All patients but one had a significant percentage decline from pre-excision values (mean 76.9%, 76.0%, and 76.1% in primary, secondary and tertiary HPT, respectively). While a reduction of more than 50% was observed in 30 out of 33 patients after the first intraoperative sampling, additional measurements were performed in 10 cases. On-site PTH monitoring with this user-friendly and reliable system has proved helpful in targeting PTH tests to give the surgeon a rapid and accurate assessment of the intervention. The development of optimal PTH sequence strategies with decision-focused analytical and clinical limits will improve the efficacy of “point-of-care” PTH assay and resource utilization.

A rare case of squamous cell carcinoma of a proliferating trichilemmal tumour

INTRODUCTION

Squamous Cell Carcinoma (SCC) includes several subtypes and these can be classified according to their clinical behaviours from the least invasive to the most aggressive. Moreover, it is appropriate to analyse their clinicalpathological patterns 1. In light of its wide histopathological variability, we encountered a rare malignant cutaneous lesion: a SCC of a proliferating trichilemmal tumour (PTT) nature.

CASE REPORT

We describe the clinical and pathologic findings of an 82-year-old woman, who developed a SCC with areas of trichilemmal differentiation. It has a surprising thickness of 25 mm, which passes through the dermis, infiltrates the hypodermis and evolves quickly.

CONCLUSION

Considering its exophytic growth and the negative results of the post operative tests (ultrasounds confirmed absence of metastasis), the tumour was eradicated thanks to the surgical approach (a 1 cm border wide excision, including the periosteum in the central part of the lesion, followed by its reconstruction using a full-thickness skin graft) and the prompt intervention, without need for further complimentary treatments. The overall aesthetic results were pleasing.

KEY WORDS

Adnexal tumour, PPT, SCC, Surgery.

Prolonged complete hematologic response in relapsed/refractory T-large granular lymphocyte leukemia after bendamustine treatment

T-large granular lymphocyte leukemia (T-LGLL) is a chronic clonal proliferation of effector memory cytotoxic CD3⁺CD57⁺CD56^- T cells and the current guidelines suggest immunosuppressive therapy as first-line therapy, but the treatment of refractory/relapsed patients is still challenging due to the lack of prospective studies. We describe a series of two refractory/relapsed T-LGLL patients successfully treated with bendamustine, a chemotherapeutic agent largely used for B-cell neoplasms, but poorly investigated for the treatment of T-cell diseases. Complete remission (CR) was achieved in 3 and 6 months, respectively, and maintained for at least 20 months. One patient relapsed after a 20-month CR, but she was responsive to bendamustine therapy again, obtaining a further prolonged CR. Bendamustine as single agent or in combination could be a feasible therapeutic option in refractory/relapsed T-LGLL, especially for elderly patients because of its safety profile.

The first case of benign multicystic mesothelioma presenting as a splenic mass

Multicystic mesothelioma (MM) is a relatively rare tumour arising in the pelvic peritoneum of the tuboovarian region of young woman. Exceptionally, MM occurs on the serosal surfaces of various organs including kidney, bladder, lymph nodes, and liver. We report here the first case of MM wherein a 58-year-old woman with a previous history of endometriosis of the right ovary presented with a large multicystic mass of the spleen. The diagnosis of MM was made on a surgical specimen after splenectomy. A histopathologic examination is always necessary for the diagnosis of MM which should be differentiated from other lesions particularly from cystic lymphangioma. At one year follow-up, the patient had no evidence of recurrence. Despite the high frequency of local recurrences, MM is a benign lesion and ‘en bloc’ surgical excision with prolonged follow-ups is the treatment of choice.

Melanoma and immunotherapy bridge 2015 : Naples, Italy. 1-5 December 2015

MELANOMA BRIDGE 2015

KEYNOTE SPEAKER PRESENTATIONS

Molecular and immuno-advances

K1 Immunologic and metabolic consequences of PI3K/AKT/mTOR activation in melanoma

Vashisht G. Y. Nanda, Weiyi Peng, Patrick Hwu, Michael A. Davies

K2 Non-mutational adaptive changes in melanoma cells exposed to BRAF and MEK inhibitors help the establishment of drug resistance

Gennaro Ciliberto, Luigi Fattore, Debora Malpicci, Luigi Aurisicchio, Paolo Antonio Ascierto, Carlo M. Croce, Rita Mancini

K3 Tumor-intrinsic beta-catenin signaling mediates tumor-immune avoidance

Stefani Spranger, Thomas F. Gajewski

K4 Intracellular tumor antigens as a source of targets of antibody-based immunotherapy of melanoma

Yangyang Wang, Soldano Ferrone

Combination therapies

K5 Harnessing radiotherapy to improve responses to immunotherapy in cancer

Claire Vanpouille-Box, Erik Wennerberg, Karsten A. Pilones, Silvia C. Formenti, Sandra Demaria

K6 Creating a T cell-inflamed tumor microenvironment overcomes resistance to checkpoint blockade

Haidong Tang, Yang Wang, Yang-Xin Fu

K7 Biomarkers for treatment decisions?

Reinhard Dummer

K8 Combining oncolytic therapies in the era of checkpoint inhibitors

Igor Puzanov

K9 Immune checkpoint blockade for melanoma: should we combine or sequence ipilimumab and PD-1 antibody therapy?

Michael A. Postow

News in immunotherapy

K10 An update on adjuvant and neoadjuvant therapy for melanom

Ahmad Tarhini

K11 Targeting multiple inhibitory receptors in melanoma

Joe-Marc Chauvin, Ornella Pagliano, Julien Fourcade, Zhaojun Sun, Hong Wang, Cindy Sanders, John M. Kirkwood, Tseng-hui Timothy Chen, Mark Maurer, Alan J. Korman, Hassane M. Zarour

K12 Improving adoptive immune therapy using genetically engineered T cells

David F. Stroncek

Tumor microenvironment and biomarkers

K13 Myeloid cells and tumor exosomes: a crosstalk for assessing immunosuppression?

Veronica Huber, Licia Rivoltini

K14 Update on the SITC biomarker taskforce: progress and challenges

Magdalena Thurin

World-wide immunoscore task force: an update

K15 The immunoscore in colorectal cancer highlights the importance of digital scoring systems in surgical pathology

Tilman Rau, Alessandro Lugli

K16 The immunoscore: toward an integrated immunomonitoring from the diagnosis to the follow up of cancer’s patients

Franck Pagès

Economic sustainability of melanoma treatments: regulatory, health technology assessment and market access issues

K17 Nivolumab, the regulatory experience in immunotherapy

Jorge Camarero, Arantxa Sancho

K18 Evidence to optimize access for immunotherapies

Claudio Jommi

ORAL PRESENTATIONS

Molecular and immuno-advances

O1 Ipilimumab treatment results in CD4 T cell activation that is concomitant with a reduction in Tregs and MDSCs

Yago Pico de Coaña, Maria Wolodarski, Yuya Yoshimoto, Giusy Gentilcore, Isabel Poschke, Giuseppe V. Masucci, Johan Hansson, Rolf Kiessling

O2 Evaluation of prognostic and therapeutic potential of COX-2 and PD-L1 in primary and metastatic melanoma

Giosuè Scognamiglio, Francesco Sabbatino, Federica Zito Marino, Anna Maria Anniciello, Monica Cantile, Margherita Cerrone, Stefania Scala, Crescenzo D’alterio, Angela Ianaro, Giuseppe Cirino, Paolo Antonio Ascierto, Giuseppina Liguori, Gerardo Botti

O3 Vemurafenib in patients with BRAFV600 mutation–positive metastatic melanoma: final overall survival results of the BRIM-3 study

Paul B. Chapman, Caroline Robert, James Larkin, John B. Haanen, Antoni Ribas, David Hogg, Omid Hamid, Paolo Antonio Ascierto, Alessandro Testori, Paul Lorigan, Reinhard Dummer, Jeffrey A. Sosman, Keith T. Flaherty, Huibin Yue, Shelley Coleman, Ivor Caro, Axel Hauschild, Grant A. McArthur

O4 Updated survival, response and safety data in a phase 1 dose-finding study (CA209-004) of concurrent nivolumab (NIVO) and ipilimumab (IPI) in advanced melanoma

Mario Sznol, Margaret K. Callahan, Harriet Kluger, Michael A. Postow, RuthAnn Gordan, Neil H. Segal, Naiyer A. Rizvi, Alexander Lesokhin, Michael B. Atkins, John M. Kirkwood, Matthew M. Burke, Amanda Ralabate, Angel Rivera, Stephanie A. Kronenberg, Blessing Agunwamba, Mary Ruisi, Christine Horak, Joel Jiang, Jedd Wolchok

Combination therapies

O5 Efficacy and correlative biomarker analysis of the coBRIM study comparing cobimetinib (COBI) + vemurafenib (VEM) vs placebo (PBO) + VEM in advanced BRAF-mutated melanoma patients (pts)

Paolo A. Ascierto, Grant A. McArthur, James Larkin, Gabriella Liszkay, Michele Maio, Mario Mandalà, Lev Demidov, Daniil Stoyakovskiy, Luc Thomas, Luis de la Cruz-Merino, Victoria Atkinson, Caroline Dutriaux, Claus Garbe, Matthew Wongchenko, Ilsung Chang, Daniel O. Koralek, Isabelle Rooney, Yibing Yan, Antoni Ribas, Brigitte Dréno

O6 Preliminary clinical safety, tolerability and activity results from a Phase Ib study of atezolizumab (anti-PDL1) combined with vemurafenib in BRAFV600-mutant metastatic melanoma

Ryan Sullivan, Omid Hamid, Manish Patel, Stephen Hodi, Rodabe Amaria, Peter Boasberg, Jeffrey Wallin, Xian He, Edward Cha, Nicole Richie, Marcus Ballinger, Patrick Hwu

O7 Preliminary safety and efficacy data from a phase 1/2 study of epacadostat (INCB024360) in combination with pembrolizumab in patients with advanced/metastatic melanoma

Thomas F. Gajewski, Omid Hamid, David C. Smith, Todd M. Bauer, Jeffrey S. Wasser, Jason J. Luke, Ani S. Balmanoukian, David R. Kaufman, Yufan Zhao, Janet Maleski, Lance Leopold, Tara C. Gangadhar

O8 Primary analysis of MASTERKEY-265 phase 1b study of talimogene laherparepvec (T-VEC) and pembrolizumab (pembro) for unresectable stage IIIB-IV melanoma

Reinhard Dummer, Georgina V. Long, Antoni Ribas, Igor Puzanov, Olivier Michielin, Ari VanderWalde, Robert H.I. Andtbacka, Jonathan Cebon, Eugenio Fernandez, Josep Malvehy, Anthony J. Olszanski, Thomas F. Gajewski, John M. Kirkwood, Christine Gause, Lisa Chen, David R. Kaufman, Jeffrey Chou, F. Stephen Hodi

News in immunotherapy

O9 Two-year survival and safety update in patients (pts) with treatment-naïve advanced melanoma (MEL) receiving nivolumab (NIVO) or dacarbazine (DTIC) in CheckMate 066

Victoria Atkinson, Paolo A. Ascierto, Georgina V. Long, Benjamin Brady, Caroline Dutriaux, Michele Maio, Laurent Mortier, Jessica C. Hassel, Piotr Rutkowski, Catriona McNeil, Ewa Kalinka-Warzocha, Celeste Lebbé, Lars Ny, Matias Chacon, Paola Queirolo, Carmen Loquai, Parneet Cheema, Alfonso Berrocal, Karmele Mujika Eizmendi, Luis De La Cruz-Merino, Gil Bar-Sela, Christine Horak, Joel Jiang, Helene Hardy, Caroline Robert

O10 Efficacy and safety of nivolumab (NIVO) in patients (pts) with advanced melanoma (MEL) who were treated beyond progression in CheckMate 066/067

Georgina V. Long, Jeffrey S. Weber, James Larkin, Victoria Atkinson, Jean-Jacques Grob, Reinhard Dummer, Caroline Robert, Ivan Marquez-Rodas, Catriona McNeil, Henrik Schmidt, Karen Briscoe, Jean-François Baurain, F. Stephen Hodi, Jedd D. Wolchok

Tumor microenvironment and biomarkers

O11 New biomarkers for response/resistance to BRAF inhibitor therapy in metastatic melanoma

Rosamaria Pinto, Simona De Summa, Vito Michele Garrisi, Sabino Strippoli, Amalia Azzariti, Gabriella Guida, Michele Guida, Stefania Tommasi

O12 Chemokine receptor patterns in lymphocytes mirror metastatic spreading in melanoma and response to ipilimumab

Nicolas Jacquelot, David Enot, Caroline Flament, Jonathan M. Pitt, Nadège Vimond, Carolin Blattner, Takahiro Yamazaki, Maria-Paula Roberti, Marie Vetizou, Romain Daillere, Vichnou Poirier-Colame, Michaëla Semeraro, Anne Caignard, Craig L Slingluff Jr, Federica Sallusto, Sylvie Rusakiewicz, Benjamin Weide, Aurélien Marabelle, Holbrook Kohrt, Stéphane Dalle, Andréa Cavalcanti, Guido Kroemer, Anna Maria Di Giacomo, Michaele Maio, Phillip Wong, Jianda Yuan, Jedd Wolchok, Viktor Umansky, Alexander Eggermont, Laurence Zitvogel

O13 Serum levels of PD1- and CD28-positive exosomes before Ipilimumab correlate with therapeutic response in metastatic melanoma patients

Passarelli Anna, Tucci Marco, Stucci Stefania, Mannavola Francesco, Capone Mariaelena, Madonna Gabriele, Ascierto Paolo Antonio, Silvestris Franco

O14 Immunological prognostic factors in stage III melanomas

María Paula Roberti, Nicolas Jacquelot, David P Enot, Sylvie Rusakiewicz, Michaela Semeraro, Sarah Jégou, Camila Flores, Lieping Chen, Byoung S. Kwon, Ana Carrizossa Anderson, Caroline Robert, Christophe Borg, Benjamin Weide, François Aubin, Stéphane Dalle, Michele Maio, Jedd D. Wolchok, Holbrook Kohrt, Maha Ayyoub, Guido Kroemer, Aurélien Marabelle, Andréa Cavalcanti, Alexander Eggermont, Laurence Zitvogel

POSTER PRESENTATIONS

Molecular and immuno-advances

P1 Human melanoma cells resistant to B-RAF and MEK inhibition exhibit mesenchymal-like features

Anna Lisa De Presbiteris, Fabiola Gilda Cordaro, Rosa Camerlingo, Federica Fratangelo, Nicola Mozzillo, Giuseppe Pirozzi, Eduardo J. Patriarca, Paolo A. Ascierto, Emilia Caputo

P2 Anti-proliferative and pro-apoptotic effect of ABT888 on melanoma cell lines and its potential role in the treatment of melanoma resistant to B-RAF inhibitors

Federica Fratangelo, Rosa Camerlingo, Emilia Caputo, Maria Letizia Motti, Rosaria Falcone, Roberta Miceli, Mariaelena Capone, Gabriele Madonna, Domenico Mallardo, Maria Vincenza Carriero, Giuseppe Pirozzi and Paolo Antonio Ascierto

P3 Involvement of the L-cysteine/CSE/H2S pathway in human melanoma progression

Elisabetta Panza, Paola De Cicco, Chiara Armogida, Giuseppe Ercolano, Rosa Camerlingo, Giuseppe Pirozzi, Giosuè Scognamiglio, Gerardo Botti, Giuseppe Cirino, Angela Ianaro

P4 Cancer stem cell antigen revealing pattern of antibody variable region genes were defined by immunoglobulin repertoire analysis in patients with malignant melanoma

Beatrix Kotlan, Gabriella Liszkay, Miri Blank, Timea Balatoni, Judit Olasz, Emil Farkas, Andras Szollar, Akos Savolt, Maria Godeny, Orsolya Csuka, Szabolcs Horvath, Klara Eles, Yehuda Shoenfeld and Miklos Kasler

P5 Upregulation of Neuregulin-1 expression is a hallmark of adaptive response to BRAF/MEK inhibitors in melanoma

Debora Malpicci, Luigi Fattore, Susan Costantini, Francesca Capone, Paolo Antonio Ascierto, Rita Mancini, Gennaro Ciliberto

P6 HuR positively regulates migration of HTB63 melanoma cells

Farnaz Moradi, Pontus Berglund, Karin Leandersson, Rickard Linnskog, Tommy Andersson, Chandra Prakash Prasad

P7 Prolyl 4- (C-P4H) hydroxylases have opposing effects in malignant melanoma: implication in prognosis and therapy

Cristiana Lo Nigro, Laura Lattanzio, Hexiao Wang, Charlotte Proby, Nelofer Syed, Marcella Occelli, Carolina Cauchi, Marco Merlano, Catherine Harwood, Alastair Thompson, Tim Crook

P8 Urokinase receptor antagonists: novel agents for the treatment of melanoma

Maria Letizia Motti, Katia Bifulco, Vincenzo Ingangi, Michele Minopoli, Concetta Ragone, Federica Fratangelo, Antonello Pessi, Gennaro Ciliberto, Paolo Antonio Ascierto, Maria Vincenza Carriero

P9 Exosomes released by melanoma cell lines enhance chemotaxis of primary tumor cells

Francesco Mannavola, Stella D’Oronzo, Claudia Felici, Marco Tucci, Antonio Doronzo, Franco Silvestris

P10 New insights in mitochondrial metabolic reprogramming in melanoma

Anna Ferretta, Gabriella Guida, Stefania Guida, Imma Maida, Tiziana Cocco, Sabino Strippoli, Stefania Tommasi, Amalia Azzariti, Michele Guida

P11 Lenalidomide restrains the proliferation in melanoma cells through a negative regulation of their cell cycle

Stella D’Oronzo, Anna Passarelli, Claudia Felici, Marco Tucci, Davide Quaresmini, Franco Silvestris

Combination therapies

P12 Chemoimmunotherapy elicits polyfunctional anti-tumor CD8 + T cells depending on the activation of an AKT pathway sustained by ICOS

Ornella Franzese, Belinda Palermo, Cosmo Di Donna, Isabella Sperduti, MariaLaura Foddai, Helena Stabile, Angela Gismondi, Angela Santoni, Paola Nisticò

P13 Favourable toxicity profile of combined BRAF and MEK inhibitors in metastatic melanoma patients

Andrea P. Sponghini, Francesca Platini, Elena Marra, David Rondonotti, Oscar Alabiso, Maria T. Fierro, Paola Savoia, Florian Stratica, Pietro Quaglino

P14 Electrothermal bipolar vessel sealing system dissection reduces seroma output or time to drain removal following axillary and ilio-inguinal node dissection in melanoma patients: a pilot study

Di Monta Gianluca, Caracò Corrado, Di Marzo Massimiliano, Marone Ugo, Di Cecilia Maria Luisa, Mozzillo Nicola

News in immunotherapy

P15 Clinical and immunological response to ipilimumab in a metastatic melanoma patient with HIV infection

Francesco Sabbatino, Celeste Fusciello1, Antonio Marra, Rosario Guarrasi, Carlo Baldi, Rosa Russo, Di Giulio Giovanni, Vincenzo Faiola, Pio Zeppa, Stefano Pepe

P16 Immunotherapy and hypophysitis: a case report

Elisabetta Gambale, Consiglia Carella, Alessandra Di Paolo, Michele De Tursi

Tumor microenvironment and biomarkers

P17 New immuno- histochemical markers for the differential diagnosis of atypical melanocytic lesions with uncertain malignant potential

Laura Marra, Giosuè Scognamiglio, Monica Cantile, Margherita Cerrone, Fara De Murtas, Valeria Sorrentino, Anna Maria Anniciello, Gerardo Botti

P18 Utility of simultaneous measurement of three serum tumor markers in melanoma patients

Angela Sandru, Silviu Voinea, Eugenia Panaitescu, Madalina Bolovan, Adina Stanciu, Sabin Cinca

P19 The significance of various cut-off levels of melanoma inhibitory activity in evaluation of cutaneous melanoma patients

Angela Sandru, Silviu Voinea, Eugenia Panaitescu, Madalina Bolovan, Adina Stanciu, Sabin Cinca

P20 The long noncoding RNA HOTAIR is associated to metastatic progression of melanoma and it can be identified in the blood of patients with advanced disease

Chiara Botti, Giosuè Scognamiglio, Laura Marra, Gabriella Aquino, Rosaria Falcone, Annamaria Anniciello, Paolo Antonio Ascierto, Gerardo Botti, Monica Cantile

Other

P21 The effect of Sentinel Lymph Node Biopsy in melanoma mortality: timing of dissection

Cristina Fortes, Simona Mastroeni, Alessio Caggiati, Francesca Passarelli, Alba Zappalà, Maria Capuano, Riccardo Bono, Maurizio Nudo, Claudia Marino, Paola Michelozzi

P22 Epidemiological survey on related psychopathology in melanoma

Valeria De Biasio, Vincenzo C. Battarra

IMMUNOTHERAPY BRIDGE

KEYNOTE SPEAKER PRESENTATIONS

Immunotherapy beyond melanoma

K19 Predictor of response to radiation and immunotherapy

Silvia Formenti

K20 Response and resistance to PD-1 pathway blockade: clues from the tumor microenvironment

Maria Libera Ascierto, Tracee L. McMiller, Alan E. Berger, Ludmila Danilova, Robert A. Anders, George J. Netto, Haiying Xu, Theresa S. Pritchard, Jinshui Fan, Chris Cheadle, Leslie Cope, Charles G. Drake, Drew M. Pardoll, Janis M. Taube and Suzanne L. Topalian

K21 Combination immunotherapy with autologous stem cell transplantation, protein immunization, and PBMC reinfusion in myeloma patients

Sacha Gnjatic, Sarah Nataraj, Naoko Imai, Adeeb Rahman, Achim A. Jungbluth, Linda Pan, Ralph Venhaus, Andrew Park, Frédéric F. Lehmann, Nikoletta Lendvai, Adam D. Cohen, and Hearn J. Cho

K22 Anti-cancer immunity despite T cell “exhaustion”

Speiser Daniel

Immunotherapy in oncology (I-O): data from clinical trial

K23 The Checkpoint Inhibitors for the Treatment of Metastatic Non-small Cell Lung Cancer (NSCLC)

Vera Hirsh

Improvement of Clinical Response in Allergic Rhinitis Patients Treated with an Oral Immunostimulating Bacterial Lysate: In Vivo Immunological Effects

Allergic rhinitis is known to be one of the most common chronic diseases in the industrialized world. According to the concept that allergic rhinitis patients generally suffer from an immune deficit, in order to stimulate specifically or aspecifically their immune system, immunomodulating agents from various sources, such as synthetic compounds, tissue extracts or a mixture of bacterial extracts, have been used. The aim of the present trial is to evaluate the efficacy of the treatment with an immunostimulating vaccine consisting of a polyvalent mechanical bacterial lysate (PMBL) in the prophylaxis of allergic rhinitis and subsequently to analyze its in vivo effects on immune responses. 41 allergic rhinitis patients were enrolled: 26 patients were randomly assigned to the group for PMBL sublingual treatment and 15 others to the group for placebo treatment. For all 26 patients blood samples were drawn just before (T0) and after 3 months of PMBL treatment (T3) to evaluate plasma IgE levels (total and allergen-specific) and the cytokine production involved in the allergic response (IL-4, IFN-γ). The results of our study indicate that PMBL is effective in vivo in the reduction or in the elimination of the symptoms in rhinitis subjects during the treatment period in comparison to a non-immunostimulating treatment. A significant and clinically relevant improvement was found in 61.5%, a stationary clinical response was registered in 38.4% and no negative side effects associated with the medication or worsening were recorded. At the end of a 3-month follow up period the clinical picture remained the same as that observed at T3. PMBL treatment did not affect the serum IgE levels (either total or allergen-specific) and did not induce significant changes in IFN-γ concentration. In contrast, PMBL therapy may be accompanied, in some patients, by a potential immunomodulating activity by decreasing IL-4 cytokine expression.

CD10, BCL6, and MUM1 expression in diffuse large B-cell lymphoma on FNA samples

BACKGROUND

Gene expression profiling has divided diffuse large B-cell lymphoma (DLBCL) into 2 main subgroups: germinal center B (GCB) and non-GCB type. This classification is reproducible by immunohistochemistry using specific antibodies such as CD10, B-cell lymphoma 6 (BCL6), and multiple myeloma oncogene 1 (MUM1). Fine-needle aspiration (FNA) plays an important role in the diagnosis of non-Hodgkin lymphoma, and in some cases FNA may be the only available pathological specimen. The objectives of the current study were to evaluate CD10, BCL6, and MUM1 immunostaining on FNA samples by testing the CD10, BCL6, and MUM1 algorithm on both FNA cell blocks (CB) and conventional smears (CS), evaluating differences in CB and CS immunocytochemical (ICC) performance, and comparing results with histological data.

METHODS

Thirty-eight consecutive DLBCL cases diagnosed by FNA were studied. Additional passes were used to prepare CB in 22 cases and CS in 16 cases; the corresponding sections and smears were immunostained using CD10, BCL6, and MUM1 in all cases. The data obtained were compared with histological immunostaining in 24 cases.

RESULTS

ICC was successful in 33 cases (18 CB and 15 CS) and not evaluable in 5 cases (4 CB and 1 CS). The CD10-BCL6-MUM1 algorithm subclassified DLBCL as GCB (9 cases) and non-GCB (24 cases). ICC data were confirmed on histologic staining in 24 cases.

CONCLUSIONS

CD10, BCL6, and MUM1 ICC staining can be performed on FNA samples. The results herein prove it is reliable both on CB and CS, and is equally effective and comparable to immunohistochemistry data.

Effects of limiting fluid intake on clinical and laboratory outcomes in patients with heart failure. Results of a meta-analysis of randomized controlled trials

BACKGROUND

The guidelines of the Scientific Societies of Cardiology recommend limiting fluid intake as a nonpharmacological measure for the management of chronic heart failure (HF). However, many patients with HF may suffer from severe thirst. A meta-analysis was performed to evaluate the effect of limiting fluid consumption based on various clinical and laboratory outcomes in patients with chronic HF.

METHODS

Only randomized controlled trials comparing liberal and restricted fluid oral intake in patients with HF were included. Primary outcomes were HF hospitalizations and all-cause mortality. Secondary outcomes were the sensation of thirst, the duration of therapy with intravenous diuretics, and the serum levels of creatinine, sodium, and B-type natriuretic peptide (BNP).

RESULTS

Six studies met the inclusion criteria. Significant heterogeneity was detected for the majority of outcomes. In 5 studies, patients with restricted fluid intake compared to patients with free consumption of beverages had similar rehospitalization and mortality rates. There were no differences regarding patients' sense of thirst (4 studies), duration of intravenous diuretic treatment (2 studies), serum creatinine levels (5 studies), and serum sodium levels (5 studies). Serum BNP levels were significantly higher in the group with free fluid intake (4 studies).

CONCLUSION

In patients with HF, liberal fluid consumption does not seem to exert an unfavorable impact on HF rehospitalizations or all-cause mortality. Further randomized controlled trials are warranted to definitively confirm the present findings.

Cardiovascular risk associated with celecoxib or etoricoxib: a meta-analysis of randomized controlled trials which adopted comparison with placebo or naproxen

AIM

The present meta-analysis attempted to assess whether an unfavourable cardiovascular risk profile could be identified in the case of two COX2 selective inhibitors (COXIBs), namely celecoxib and etoricoxib. Based on the data from the literature, our meta-analysis aimed to assess the probability of major cardiovascular events reported with the use of celecoxib or etoricoxib and compare this with the results seen in patients assigned to the placebo group. Furthermore, the risk of cardiovascular events found by using celecoxib or etoricoxib was also compared with that associated with the use of naproxen, a nonselective non-steroidal anti-inflammatory drug (NSAID) chosen as our reference drug.

METHODS

The studies had to be randomized controlled trials with at least 4-week duration. Studies were included if they compared celecoxib or etoricoxib against placebo or naproxen. Moreover, the selected studies had to have determined the risk, odds or incidence of myocardial infarction, stroke or cardiovascular death. For the comparisons versus placebo, the endpoints of interest were "serious vascular events", "non-fatal myocardial infarction", "non-fatal stroke" and "death from cardiovascular causes", whereas "myocardial infarction" and "stroke" were the endpoints of interest concerning the comparison versus naproxen.

RESULTS

From the evaluation of 41 studies comparing celecoxib with placebo, we found a significantly higher incidence of serious vascular events in the celecoxib group compared to controls treated with placebo (rate ratio 1.598, 95% CI: 1.048 to 2.438; P=0.029). Furthermore, in patients allocated to treatment with celecoxib, we found an incidence rate of non-fatal acute myocardial infarction that was three times higher compared with the placebo group (rate ratio 3.074, 95% CI: 1.375-6.873, P=0.006). In contrast, we did not find any significant difference with regard to the incidence of nonfatal stroke and that of death from cardiovascular causes by comparing celecoxib and placebo. In addition, by examining cardiovascular outcomes that emerged from the 17 trials which compared etoricoxib with placebo, it was not possible to demonstrate statistically significant differences in incidence for each of the explored endpoints. With regard to the comparison of each coxib with the non-selective COX2 inhibitor naproxen, we did not find any significant difference for either the odds of myocardial infarction or that of stroke.

CONCLUSION

On the basis of our meta-analysis, we can state that symptomatic benefits induced by the prolonged administration of celecoxib may be partially invalidated by a concomitant increase in vascular risk, particularly the increased risk of myocardial infarction found in celecoxib-treated patients, compared to controls taking placebo. In contrast, treatment with etoricoxib proved not to result in an increased risk of serious vascular events when compared with both the placebo and naproxen. Our meta-analysis also denotes that the alternative to COXIBs, represented by naproxen, does not show significant benefit in terms of reduced cardiovascular risk. Therefore, considering that the increase in incidence rate of cardiovascular events associated with treatment with celecoxib is small in absolute terms, it is reasonable to state that celecoxib is still a drug whose benefits outweigh the potential adverse effects on the cardiovascular system.

Ultrasound-guided fine needle aspiration cytology of a primary lymph node leiomyoma: a flexible procedure for a complex case

BACKGROUND

A primary lymph node leiomyoma diagnosed by fine needle aspiration cytology (FNAC) is reported.

CASE

A 22-year-old male complained of right groin swelling; ultrasound examination (US) showed a lymph node containing a 20-mm hypoechoic nodule. The residual lymph node was oval, with a well-characterized cortex and hilum. US-FNAC of the nodule showed oval spindle cells embedded in fibrillar matrix. Nuclei were naked and oval with dispersed chromatin but without nucleoli. Immunocytochemistry showed positivity for vimentin and actin, and negativity for cytokeratin, S100, CD23 and CD31. A smear of the residual lymph node showed a reactive lymphoid cell population. FNAC diagnosis was mesenchymal cell proliferation with smooth muscle phenotype; a lymph node is part of the lesion. A CT scan did not detect any inguinal or abdominal mass. The surgical sample was a lymph node containing a spindle cell tumor, which was actin and desmin positive, and S100, CD21, HMB45, CD23 and CD31 negative; MIB1 was positive in <5% of the cells. The residual lymph node was normal.

CONCLUSION

The final diagnosis was primary benign leiomyoma in a lymph node. US-FNAC may frame complex lymph node lesions and provide treatment options.