[Incidence and risk factors of congenital ventricular septal defect in Qingdao]

Objective: To analyze the incidence and risk factors of ventricular septal defect (VSD) in Qingdao. Methods: A prospective cohort study design was used to include pregnant women who underwent prenatal screening in Qingdao between August 2018 and June 2020 (the whole population coverage). VSD was diagnosed according to the pulse oxygen saturation and heart auscultation, and the final diagnosis was made according to the echocardiography of VSD positive newborns within postnatal day 7. Results: The study included 115 238 live births, among which 388 were diagnosed as VSD, with an incidence of 3.37‰. The results of multivariate logistic regression analysis showed that mother with postgraduate level (OR=1.61, 95%CI: 1.00-2.58, P=0.049) (compared with junior high school and below), preterm birth history (OR=2.90, 95%CI: 1.47-5.70, P=0.002), and pregnancy history of congenital heart disease (OR=5.98, 95%CI: 2.63-14.73, P<0.001) were risk factors for VSD. Compared with female infants, the overall risk of VSD in male infants was relatively low (OR=0.74, 95%CI: 0.60-0.91, P=0.005). Conclusions: The incidence of VSD in Qingdao is 3.37‰. The risk factors of VSD include higher maternal education level, pregnancy history of congenital heart disease and preterm birth history. Moreover, the overall risk of VSD in male infants is low.

Topological data analysis identified prognostically-distinct phenotypes in MitraClip patients

Background

Topological data analysis (TDA) is the state-of-the-art unsupervised machine learning framework that can provide insight into the dataset and visualize condensed information via the topological network graph. This robust approach was never used to assess the heterogeneous MitraClip population.

Purpose

We aim to develop a TDA model that will identify prognostically-distinct phenogroups in MitraClip patients without a priori knowledge of the population and their outcomes.

Method

Patients who underwent MitraClip (June 2014-September 2020) at Mayo Clinic sites were identified from the institutional database for baseline and follow-up data. Thirteen variables were used for TDA. The topological network graph was created using the Python Scikit-TDA Kepler-Mapper package (v. 2.0.1), and clustering was performed at the graph level with Louvain's modularity method. Kaplan-Meier survival analysis was used to assess the all-cause mortality endpoint of each cluster identified in an unsupervised manner. The dataset with cluster labels was also used to train a Light Gradient Boosted Machine model, and SHapley Additive exPlanations (SHAP) analysis was applied to determine the feature importance.

Results

A total of 389 consecutive patients were included in the final analysis and two major clusters consisting of 384 patients were identified. The mean age was 80.3±8.7 years; 256 (65.8%) were male. The mean Society of Thoracic Surgeons Mitral Valve Replacement risk score was 9.6±6.9%. Fifty-five (14.5%) patients died during the mean follow duration (185 days). Kaplan-Meier analysis showed significant survival differences among the two clusters (HR: 2.38; 95% CI: 1.39–4.06, p=0.001; Figure 1). Clusters 1 (n=195) was associated with &gt; mild residual mitral regurgitation and worse survival performance and was characterized with worse tricuspid regurgitation severity, a higher proportion of patients with atrial fibrillation/flutter, anterior leaflet prolapse, and mitral annular/leaflet calcification, as summarized in Table 1.

Conclusion

TDA can identify distinct phenotype clusters with prognostic significance in MitraClip patients based on mitral valve morphology and clinical risk factors. This simple model can facilitate clinical risk stratification for MitraClip patients regarding procedural success and survival performance.

Funding Acknowledgement

Type of funding sources: None.

AB1521 IgG4-RD AND SLE: COEXISTENCE IN THE KIDNEYS

Background

IgG4 related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition that can mimic malignant, infectious and inflammatory diseases (1). Systemic lupus erythematosus (SLE) is a chronic autoimmune condition characterized by multisystem inflammation and autoantibody generation (2). Overlap of IgG4-RD and SLE is not frequent, however there have been few cases reported with kidney involvement secondary to both conditions (2,3). We present a case of an elderly male with a new diagnosis of IgG4-RD and SLE with kidney involvement.

Objectives

To present a case with a new concomitant diagnosis of IgG4-RD and SLE.

Methods

Case report.

Results

A 67-year-old man with longstanding history of cervical lymphadenopathy (LAD) presented to the Rheumatology Clinic due to intermittent lower extremity rash, anemia, worsening fatigue for the past 2 years. Prior history includes controlled DM type 2 and HTN treated with amlodipine. Denied photosensitivity, oral ulcers, sicca symptoms, Raynaud’s phenomenon, weight loss, fever, chills, joint pain. Physical examination revealed bilateral cervical LAD and a non-blanching purpuric rash on lower extremities consistent with leukocytoclastic vasculitis, later confirmed with biopsy. Further workup revealed, normocytic anemia (Hgb 9.9 mg/dl), positive ANA (>1:2560, homogeneous pattern), positive dsDNA (211 IU/ml), positive histone Ab (413 IU/ml), low C3 (28 mg/dl), low C4 (1 mg/dl), increased IgG4 level (2787 mg/dl) and proteinuria 1100 mg/g with microalbuminuria, no urine casts. ANCA serologies were negative. Pan-CT showed mild cervical, retroperitoneal, pelvic LAD bilaterally. Kidney biopsy was performed and revealed severe diffuse tubulointerstitial nephritis, plasma cell rich (more than 40 IgG4 + cells seen per 40X hpf), with moderate to severe chronicity in addition to diffuse mesangial IgG and IgM staining with focal tubular basement membrane IgG and C1 staining consistent with mesangial proliferative class II lupus nephritis. Patient was started on moderate dose steroids (due to DM), hydroxychloroquine and azathioprine with resolution of LCV rash, anemia, LAD, improvement in dsDNA, proteinuria, complement levels.

Conclusion

SLE and IgG4-RDs are autoimmune diseases that cause damage to several organs, including lymph nodes and kidneys. Both are associated with hypocomplementemia and involvement of autoantibody-producing B cells and plasma cells. Patients with SLE present with positive antibodies such as anti-dsDNA and anti-Sm antibodies. On the other hand, IgG4-RD lack a specific antibody and the IgG4 is thought to be the result of the pathogenic process and not pathogenic by itself (1,2). Histologically, SLE presents with inflammatory cell infiltration in organs, whereas IgG4-RD is associated with fibrosis and organ enlargement (1-3). Lupus nephritis causes wide spectrum renal involvement whereas IgG4-RD most common presentation is tubulointerstitial nephritis (TIN), although other glomerular lesions, such as membranous nephropathy, have been reported (1-2). Our patient presented with proteinuria, positive antibodies for SLE, low complements and high levels of IgG4 which makes us consider that both diseases were active at time of diagnosis. This was confirmed by renal biopsy showing chronicity of IgG4-RD and lupus nephritis as a consenquence of progression of autoimmunity. The treatment of both conditions is immunosupression with medium to high doses of steroids and a steroid sparing agent. Due to patient preference he was started on azatioprine along with medium dose steroids with adequate clinical response. This case highlights the fact that SLE and IgG4-RD can coexist and it should be supected in elderly patients with lympadenopathy and renal disease.

References

[1]Kamisawa T, et. al. IgG4-related disease. Lancet. 2015;385(9976):1460-1471.

[2]Zaarour M, et.al. An Overlapping Case of Lupus Nephritis and IgG4-Related Kidney Disease. J Clin Med Res. 2015;7(7):575-581.

[3]Naramala S, et al. An Overlapping Case of IgG4-Related Disease and Systemic Lupus Erythematosus. J Investig Med High Impact Case Rep. 2019;7:1-4

Disclosure of Interests

None declared

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Society for Cardiovascular Magnetic Resonance 2019 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). The SCMR web site ( https://www.scmr.org ) hosts a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. In this publication, we provide a digital archive of the 2019 Case of the Week series as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.

[Comparison of islet autoantigen-specific T cell response detected by direct enzyme-linked immunospot (ELISPOT) assay and accelerated co-cultured dendritic cells (acDCs) assay]

Objective: To investigate the effect of enzyme-linked immunospot (ELISPOT) on accelerated co-cultured dendritic cells (acDCs) and direct detection of islet full-length antigen-specific T cell response in peripheral blood of patients with type 1 diabetes mellitus (T1DM). Methods: Sixteen patients with T1DM[9 males, 7 females, mean age(28.5±9.4)years] and 12 age-and sex-matched healthy controls were selected in the Department of Metabolism and Endocrinology, the Second Xiangya Hospital between March 2012 and August 2014. The numbers of IFN-γ secreting CD4(+)T cells responding to glutamic acid decarboxylase 65 (GAD(65)), C-peptide (CP) and insulin (INS) were detected by ELISPOT-acDCs and ELISPOT-direct assays, respectively. The positive rate of islet autoantigen and associated antigen reactive T cells under different detection assays were compared. Results: The positive rate for GAD(65), INS, and CP antigen reactive T cells detected by ELISPOT-acDCs was 1/16, 6/16 and 4/16, respectively, and T cells positive for INS in T1DM patients were higher than that in the controls (0/12) (P=0.024). Combining GAD(65), CP and INS-ELISPOT-acDCs detection, the positive rate for CD4(+) T cells in T1DM patients was higher than that in the controls (9/16 vs 1/12, P=0.016). The positive rate for GAD(65), INS, and CP antigen reactive T cells detected by ELISPOT-direct detection was 2/16, 1/16 and 7/16, respectively, and T cells positive for CP was higher than that in the controls (1/12), but the difference was not statistically significant (P=0.088). Likewise, the positive rate for CD4(+) T cells was higher in T1DM patients than that in the controls by combined GAD(65), CP and INS-ELISPOT-direct detection (8/16 vs 1/12, P=0.039). Compared with the ELISPOT-direct assay, the positive rate of INS antigen specific T cell response detected by ELISPOT-acDCs was higher (P=0.041). No statistical differences of other antigens were found between the two groups (all P>0.05). Conclusions: Both multiple islet antigens-combined CD4(+)-ELISPOT-acDCs and direct assays could provide diagnostic value of cellular immunology for T1DM patients. The ELISPOT-acDCs assay is superior to the ELISPOT-direct assay in the detection of INS antigen-specific T cell response.

Abstract P1-06-06: No age-related outcome disparities according to 21-gene recurrence score groups in early breast cancer patients treated by adjuvant chemotherapy in the prospective WSG PlanB trial

Background: Elderly breast cancer (BC) patients (pts) have been reported to have worse BC-related outcome than younger pts, even within clinical trials such as TEAM. Shak et al. recently showed in a large SEER data analysis that in the high 21-gene recurrence score (RS) group, older pts (&gt;70y) receive less chemotherapy (CT) and have a worse BC-specific mortality than younger pts. Here, we therefore aimed to see whether there are age-related outcome disparities according to RS groups in pts receiving state-of-the-art CT in the prospective WSG PlanB trial.

Material and Methods: PlanB compared 6 cycles of anthracycline-free TC vs. standard anthracycline-taxane based CT (4xECà4xDoc) in patients with high risk pN0 (T2-4, G2-3, &lt;35 years, or high uPA/PAI-1) or pN+ HER2- early BC. 21-gene assay was performed in all HR+ tumors and omission of chemotherapy (CT) recommended in RS≤11 HR+ pN0-1 BC. Final analysis for the CT randomization for RS 12-25 after 60 months median follow-up revealed similar 5-year DFS and OS outcomes for both CT arms (ASCO 2017).

Results: In all pts with luminal cancer and RS results (n=2577), there was an age-related significant difference in RS risk group assignment (p&lt;0.0001): in young pts (&lt;40y), 9.1% had RS≤11, 52.7% RS 12-25, and 38.2% RS&gt;25; in pts 40-69 years, 18.3% had RS≤11, 61% RS 12-25, and 20.7%% RS&gt;25; in elderly pts (&gt;70y), 19.5% had RS≤11, 55.3% RS 12-25, and 25.2% RS&gt;25. Among patients receiving chemotherapy, RS&gt;25 vs. RS&lt;25 was associated with significantly poorer DFS separately within the elderly subgroup (HR=3.03, 95%-CI [1.15-7.96]) and in those aged 40-69 years (HR=3.14, 95%-CI [2.18-4.52]); there were only nine events among patients &lt;40y. In particular, among pts receiving CT with RS&gt;25, there were no significant differences in DFS between any two of these three age groups.

Conclusion: A substantial percentage of elderly patients (&gt; 70y) presents with high-risk luminal disease; these patients are candidates for CT. In PlanB, about 25% of elderly luminal BC patients had high-risk (RS&gt;25) tumors. Nevertheless, after receiving modern adjuvant CT, their DFS was comparable to that of non-elderly pts with high-risk RS tumors. Consequently, older BC pts with high-risk luminal tumors who are fit enough to receive adjuvant CT should be treated according to guidelines in order to overcome age-dependent survival disparities which have been observed in registries for high-RS tumors.

Citation Format: Harbeck N, Gluz O, Wuerstlein R, Clemens M, Malter W, Reimer T, Nuding B, Stefek A, Pollmanns A, Augustin D, Uleer C, Lorenz-Salehi F, Shak S, Chao C, Christgen M, Kates R, Kreipe H, Nitz U. No age-related outcome disparities according to 21-gene recurrence score groups in early breast cancer patients treated by adjuvant chemotherapy in the prospective WSG PlanB trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-06-06.

Abstract PD5-03: TransNEOS: Validation of the oncotype DX recurrence score (RS) testing core needle biopsy samples from NEOS as predictor of clinical response to neoadjuvant endocrine therapy for postmenopausal estrogen receptor positive (ER+), HER2 negative (HER2-) breast cancer patients

Background: Neoadjuvant therapy for locally advanced breast cancer has the potential to improve surgical therapeutic outcomes without sacrificing the survival advantages of adjuvant therapy. However, determining whether ER+ patients (pts) will respond to neoadjuvant (NA) chemotherapy (CT) or hormone therapy (HT) can be difficult. Not all ER+ pts respond to NACT, while response to NAHT can vary across ER+ pts. Thus, the ability to select pts more likely to benefit from NAHT would represent progress in clinical management of breast cancer. NEOS is a randomized phase III study assessinglong-term prognosis of ER+ primary breast cancer with/without adjuvant CT following NAHT (UMIN 000001090, http://www.umin.ac.jp/). We used archived core biopsy tumor samples from the NEOS study to validate the RS result as a predictor of clinical response and its association with successful breast conserving surgery (BCS) in pts treated with 6 months of NAHT.

Methods: NEOS enrolled 904 postmenopausal pts with ER+, HER2-, clinically node negative (cN0) breast cancer to evaluate whether adjuvant CT was necessary for pts who responded to NAHT. In this current study, we enrolled pts with tumors ≥2cm from the NEOS study. Biopsy samples of 333 pts were assessed for the Oncotype DX assay. Response to NAHT was recorded as complete/partial response (CR/PR), or stable/progressive disease (SD/PD).

Primary endpoint of this study was to evaluate clinical response (CR/PR) to NA letrozole between pts with low (&lt;18) and high (≥31) RS result. Secondary endpoints include evaluating the relationships between clinical response and continuous RS results, and other covariates including age, tumor size, grade, Ki67 by IHC, ER and PR single gene scores, and ER and proliferation gene group scores by RT-PCR.

Results: The analysis included 294 pts with median age of 63 yrs, median tumor size of 25mm, and 66% were nuclear grade 1. 156 (53.0%), 83 (28.6%) and 54(18.4%) cases were low, intermediate, and high RS groups by Oncotype DX, respectively. Six (2%), 126 (42.8%), 149 (50.3%), 13 (4.4%) cases experienced CR, PR, SD, PD as clinical response, respectively, similar to that of all NEOS pts. Clinical response rate was 54%, 42% and 22% in low, intermediate, and high RS groups, respectively. The proportion of pts with clinical response was significantly higher in the low RS group vs the high RS group (p&lt;0.001). In univariate analyses, continuous RS was significantly associated with clinical response (p&lt;0.001), along with ER (p=.02), PR (p&lt;0.001), and ER gene group score (p&lt;0.001). Other covariates were not associated with clinical response.

Conclusion: The Oncotype DX RS test in core biopsy samples is validated as a predictive assay for clinical response of NAHT in postmenopausal, ER+/HER2-, cN0, primary early breast cancer pts. Further results on the association of RS results with BCS outcomes following NAHT will be presented. These results when combined with previously published data on RS in NACT studies help guide pts with ER+, HER2- breast cancer with NAHT vs NACT treatment options to maximize clinical response.

Citation Format: Yamamoto Y, Iwata H, Masuda N, Fujisawa T, Toyama T, Kashiwaba M, Ohtani S, Taira N, Sakai T, Hasegawa Y, Nakamura R, Akabane H, Shibahara Y, Sasano H, Yamaguchi T, Sakamaki K, Chao C, McCullough D, Sugiyama N, Ohashi Y. TransNEOS: Validation of the oncotype DX recurrence score (RS) testing core needle biopsy samples from NEOS as predictor of clinical response to neoadjuvant endocrine therapy for postmenopausal estrogen receptor positive (ER+), HER2 negative (HER2-) breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD5-03.

Abstract OT3-04-03: The impact of the 21 gene recurrence score (RS) on chemotherapy prescribing in estrogen receptor (ER) positive, lymph node positive early stage breast cancer in Ireland

BACKGROUND

For Estrogen Receptor (ER) positive, early stage breast cancer, the 21 gene Recurrence Score (RS) has clinical use both as a prognostic tool and to predict chemotherapy benefit. The availability of this tool in Ireland has led to a reduction in the use of adjuvant chemotherapy for women with lymph node (LN) negative disease. However, the RS is not routinely funded for patients with LN positive (LN+) breast cancer in Ireland. In addition, there are limited international data on the use of this tool in the preoperative setting. In this prospective observational study, we are investigating whether access to the 21 gene RS leads to a reduction in the receipt of chemotherapy for patients with ER+, LN+ breast cancer, and to correlate the 21 gene RS with response to preoperative systemic therapy.

TRIAL DESIGN

This is a national, multi-site, prospective, observational study that will examine the impact of the 21 gene RS on chemotherapy recommendations in both the neoadjuvant and adjuvant setting. Prior to and following tumor testing with the 21 gene RS, Physicians will complete a questionnaire which details type and strength of systemic therapy recommendations.

ELIGIBILITY

Cohort 1 (postoperative) will include patients with ER+ tumors of any size with involvement of 1-3 lymph nodes (N1 including micrometastases). Cohort 2 (preoperative) will include patients with ER+, T2-T4 tumors with biopsy proven nodal metastases. Both cohorts will have ECOG PS 0 or 1 and be fit for consideration of chemotherapy as determined by the Investigator.

SPECIFIC AIMS

The primary endpoint is the percentage reduction in the number of patients for whom treating physicians recommend chemotherapy after testing with 21 gene RS. Secondary endpoints include the correlation between the 21 gene RS and residual cancer burden score, as well as pathological, clinical and radiological response rates. The economic impact of the 21 gene RS in ER+, LN+ will also be assessed.

STATISTICAL METHODS

The sample size is based on similar decision impact studies conducted in other countries. Physician recommendations for chemotherapy pre 21-gene RS and recommendations post 21-gene RS testing will be compared and percentage change estimated with 95% confidence intervals. For secondary endpoints, the Pearson correlation coefficient (rho) will be used to examine the strength of the correlation between the 21 gene RS category and response. A budget impact model will be used to estimate the cost reduction in adjuvant chemotherapy as a result of 21-gene RS testing.

PRESENT ACCRUAL AND TARGET ACCRUAL

Target accrual is 75 in each of the neoadjuvant and adjuvant cohorts to total 150 patients.

Supported by Genomic Health.

Citation Format: Keegan NM, Milewski M, Kelly CM, Murphy V, Chao C, Walsh J, Kennedy MJ, O'Connor M, Murphy C, O'Reilly S, Keane M, Duffy K, Hennessy B, Morris PG. The impact of the 21 gene recurrence score (RS) on chemotherapy prescribing in estrogen receptor (ER) positive, lymph node positive early stage breast cancer in Ireland [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-04-03.

History of chronic comorbidity and risk of chemotherapy-induced febrile neutropenia in cancer patients not receiving G-CSF prophylaxis

BACKGROUND

Chemotherapy-induced febrile neutropenia (FN) is a clinically important complication that affects patient outcome by delaying chemotherapy doses or reducing dose intensity. Risk of FN depends on chemotherapy- and patient-level factors. We sought to determine the effects of chronic comorbidities on risk of FN.

DESIGN

We conducted a cohort study to examine the association between a variety of chronic comorbidities and risk of FN in patients diagnosed with six types of cancer (non-Hodgkin lymphoma and breast, colorectal, lung, ovary, and gastric cancer) from 2000 to 2009 who were treated with chemotherapy at Kaiser Permanente Southern California, a large managed care organization. We excluded those patients who received primary prophylactic granulocyte colony-stimulating factor. History of comorbidities and FN events were identified using electronic medical records. Cox models adjusting for propensity score, stratified by cancer type, were used to determine the association between comorbid conditions and FN. Models that additionally adjusted for cancer stage, baseline neutrophil count, chemotherapy regimen, and dose reduction were also evaluated.

RESULTS

A total of 19 160 patients with mean age of 60 years were included; 963 (5.0%) developed FN in the first chemotherapy cycle. Chronic obstructive pulmonary disease [hazard ratio (HR) = 1.30 (1.07-1.57)], congestive heart failure [HR = 1.43 (1.00-1.98)], HIV infection [HR = 3.40 (1.90-5.63)], autoimmune disease [HR = 2.01 (1.10-3.33)], peptic ulcer disease [HR = 1.57 (1.05-2.26)], renal disease [HR = 1.60 (1.21-2.09)], and thyroid disorder [HR = 1.32 (1.06-1.64)] were all associated with a significantly increased FN risk.

CONCLUSIONS

These results provide evidence that history of several chronic comorbidities increases risk of FN, which should be considered when managing patients during chemotherapy.