P5684Left ventricular wall thickness measured with computed tomography stratifies the response to cardiac resynchronization therapy in patients with non-ischemic cardiomyopathy

Background

Cardiac resynchronization therapy (CRT) has provided benefit in selected heart failure (HF) patients. Unfortunately, up to 30% of device recipients do not benefit clinically from CRT. Left ventricular (LV) wall geometry analyzed using computed tomography (CT) has not been evaluated in the response to CRT. The objective of this study was to examine the association of LV wall thickness (WT) and the ability for reverse LV remodeling after CRT in non ischemic cardiomyopathy (NICM) patients.

Methods

In this prospective study, a total 54 patients (33 NICM) scheduled for CRT, underwent pre procedural CT. Reduced LV WT was defined as WT≤6mm and was quantified as a percentage of total LV area. End points were 6-month clinical and echocardiographic response to CRT (NYHA functional class, LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVEDV)) and 2-year major adverse cardiac events (MACE). Of note, positive reduction was defined as in reduction LVESV and LVEDV by ≥15% and ≥10% respectively and ≥5% absolute increase in LVEF.

Results

The 33 NICM enrolled patients were divided in 3 groups according to the percentage of LV WT<6mm area: ≤20% (low LV WT area); 20–50% (moderate LV WT area) and ≥50% (high LV WT area). At 6 months, 78%, 67% and 25% of the patients experienced NYHA class improvement by ≥1 in the ≤20%, 20–50% and ≥50% group respectively. Furthermore, majority of patients in the ≤20% and 20–50% groups (92% and 75% respectively) had a significant improvement of their global assessment compared to only 38% in the ≥50% group. Additionally, low LV WT area group presented a significant LVEF, LVEDV and LVESV positive response rate (92%, 69% and 85% respectively). Patients included in the moderate and high groups exhibited gradually lower LVEF, LVEDV and LVESV positive response rate (42% and 50%; 67% and 50%; 75% and 50%, respectively). Notably, patients with the least LV WT (i.e ≥50% group) experienced significantly lower 2-years MACE survival free probability than other groups.

Left ventriculat segmentation

Conclusion

LV WT evaluated using CT could help to stratify the response to CRT in NICM patients.

P3804Left ventricular wall thickness measured with computed tomography predicts mitral regurgitation improvement in patients implanted with cardiac resynchronization therapy

Background

Secondary mitral regurgitation (MR) is common in heart failure (HF) patients and results in progressive left ventricular (LV) dilatation, papillary muscle (PM) displacement and mitral valve leaflet tethering. In selected HF patients, cardiac resynchronization therapy (CRT) has been proved to reduce MR by LV reverse remodeling, resynchronization of PM insertion site contraction and reduction in MV tenting area and inter PM distance. However, data regarding the impact of LV wall thickness (WT) on MR improvement are scarce.

Methods

In this prospective study, a total 54 patients scheduled for CRT, underwent pre procedural CT. Reduced LV WT was defined as WT<6mm and was quantified as a percentage of total LV area. LV was segmented in 17 segments to assess the number of LV segments with reduced WT. End point was 6-month echocardiographic MR improvement by ≥1 class. For this analysis, we focused on patient with mild (class 2) to severe (class 4) MR.

Results

Among the 54 patients, 38 (70.4%) had mild to severe MR at baseline and a total of 16 (42.1%) experienced MR improvement by ≥1 class at 6 months. there was no difference regarding the co-morbidities, electrocardiogram and echocardiographic parameters between patients with or without MR improvement. However, patients without MR improvement had significant higher NT-pro BNP level at baseline. Interestingly, patients without MR improvement had larger LVWT <6mm area (41.541.5±19.4 vs. 22.4±16.1%, p=0.003) associated with higher number of papillary muscle (PM) inserted in reduced LV WT area. In multivariate analysis, an area ≥25% of LVWT<6mm including at least 1 PM insertion was the only predictor of no MR improvement at 6 months (HR 18.4 (1.25–271.75), p=0.034). Lastly, patients with MR improvement had significant lower rate of basal segments with reduced WT, especially in the lateral location. Of note, patients with MR improvement exhibited fewer rate of postero-lateral WT <6mm segments.

Left ventriculat segmentation

Conclusion

LV WT evaluated using CT is a strong predictor of no MR improvement in HF patients with mild to severe MR and who scheduled for CRT implantation.

Phase I/II study of neoadjuvant bevacizumab, erlotinib and 5-fluorouracil with concurrent external beam radiation therapy in locally advanced rectal cancer

BACKGROUND

To determine the maximal tolerated dose of erlotinib when added to 5-fluorouracil (5-FU) chemoradiation and bevacizumab and safety and efficacy of this combination in patients with locally advanced rectal cancer.

PATIENTS AND METHODS

Patients with Magnetic resonance imaging (MRI) or ultrasound defined T3 or T4 adenocarcinoma of the rectum and without evidence of metastatic disease were enrolled. Patients received infusional 5-FU 225 mg/M2/day continuously, along with bevacizumab 5 mg/kg days 14, 1, 15 and 29. Standard radiotherapy was administered to 50.4 Gy in 28 fractions. Erlotinib started at a dose of 50 mg orally daily and advanced by 50 mg increments in the subsequent cohort. Open total mesorectal excision was carried out 6-9 weeks following the completion of chemoradiation.

RESULTS

Thirty-two patients received one of three dose levels of erlotinib. Erlotinib dose level of 100 mg was determined to be the maximally tolerated dose. Thirty-one patients underwent resection of the primary tumor, one refused resection. Twenty-seven patients completed study therapy, all of whom underwent resection. At least one grade 3-4 toxicity occurred in 46.9% of patients. Grade 3-4 diarrhea occurred in 18.8%. The pathologic complete response (pCR) for all patients completing study therapy was 33%. With a median follow-up of 2.9 years, there are no documented local recurrences. Disease-free survival at 3 years is 75.5% (confidence interval: 55.1-87.6%).

CONCLUSIONS

Erlotinib added to infusional 5-FU, bevacizumab and radiation in patients with locally advanced rectal cancer is relatively well tolerated and associated with an encouraging pCR.

P1-08-17: Pregnancy-Associated Breast Cancer Does Not Have a Worse Outcome in the 4912 Women with Breast Cancer of the AMAZONA Project

Introduction: Pregnancy traditionally is considered a protective factor for breast cancer. Recent data suggests that pregnancy-associated breast cancer (PABC), a distinct biologic variant possibly related to breast involution, can occur up to 10 years post-partum and may carry a worse prognosis than that of age matched sporadic or nulliparous breast cancer. The Amazona project is a retrospective cohort of 4,912 Brazilian women with breast cancer that has previously reported on worse outcomes of patients according to type of institution where treatment was received (San Antonio 2009 abstr. 3082). We have assessed the outcomes of PABC in the Amazona cohort.

Objectives: 1- To identify whether women who were diagnosed with breast cancer up to 10 years after their first pregnancy had worse disease free survival (DFS) and overall survival (OS) than nulliparous women (NW); 2- to assess if age at first pregnancy is related to age of breast cancer diagnosis and worse DFS or OS; 3- to assess whether number of pregnancies is associated with worse DFS or OS; 4- to assess whether time from first pregnancy to diagnosis or age of first pregnancy are associated with histological grade, clinical stage or tumor expression of ER, PR, and HER2.

Methods: We analyzed 4836 women for whom parous history was available, in respect to DFS, OS, tumor clinical stage, histological grade, expression of ER, PR and HER2, according to age of first pregnancy, diagnosis up to 5 and 10 years after first pregnancy, and number of pregnancies, using NW as controls. Analysis of DFS and OS was done by Cox regression modeling adjusted for institution type, stage, ER, PR, HER2 and grade.

Results: Our cohort had 1996 nulliparous women and 2840 parous women. The median follow up was 28 months and there were 318 deaths and 735 recurrences. We did not find any correlation between PABC with DFS (5 year interval HR 1.15, 95%CI 0.43−3.07; 10 year interval HR 1.01, 95%CI 0.57−1.81) or OS (5 year interval HR 1.88, 95%CI 0.6−5.94; 10 year interval HR 0.5, 95%CI 0.73−3.09), nor was there a correlation between age at first pregnancy with age of breast cancer diagnosis. We also did not see any difference between age of first pregnancy and DFS or OS.

Women with 3 or more pregnancies had worse OS (HR 0.71, 95%CI 0.54−0.93) but not worse DFS (HR 0.93, 95%CI 0.76−1.13).Tumors diagnosed within 5 or 10 years from first pregnancy did not differ by grade, ER, PR, HER2, and clinical stage from those of NW. Women who had their first pregnancy after age 20 tended to have more ER positive (OR 1.99, 95%CI 1.49−2.65), PR positive (OR 1.40, 95%CI 1.06−1.87), and HER2 positive (OR 1.85, 95%CI 1.22−2.79) tumors than NW.

Conclusions: In this large cohort of breast cancer patients from the diverse geographic and socioeconomic spectrum of Brazil we did not find any association between PABC or age of first pregnancy to DFS or OS. The association with worse OS but not DFS for women with 3 or more pregnancies might be due to confounding factors. PABC was not associated with worse clinical prognostic factors. Women who had their first pregnancy after age 20 were more likely to have ER+, PR+ and HER2 + tumors than nulliparous patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-17.

Benefit of thalidomide (THAL) in total therapy 2 (TT2) of multiple myeloma (MM) exhibiting both cytogenetic abnormalities (CA) and low-risk (LR) by gene expression profiling (GEP)

8590

Background: We recently reported an update of TT2 and observed an unexpected preferential benefit from THAL for OS in the subgroup of patients with CA (Blood, 2008). We now re-examined these results with further follow-up of 81 months in the context of GEP-defined risk. Methods: OS and EFS were examined in the 668 patients enrolled in TT2 according to treatment arm, CA status and by GEP risk status. Results: Median overall and event-free survival (OS, EFS) are 9yr and 5yr, with a significant benefit from THAL v the control arm (p=0.04, p=0.0004). We confirmed the ongoing unique survival benefit of THAL in the CA group with 6-yr OS estimates of 53% v 35% (p<0.001), while patients not exhibiting CA had similar OS of 70% and 68%. EFS was superior with THAL regardless of CA status, 56% v 45% without CA (p=0.02) and 38% v 20% with CA (p=0.008). With respect to GEP, THAL benefited the LR group with 6-yr OS/EFS rates of 73%/56% v 63%/36% without THAL (p=0.10/p=0.002); the corresponding data for high-risk (HR) patients showed OS/EFS with THAL of 35%/19% v 15%/10% without THAL (p=0.36/p=0.43). When examined in the context of both GEP and CA, THAL only benefited the 33 patients with both CA and LR with 6-yr OS of 72% v 37% among the 47 without THAL (p=0.003). For the remaining subgroups (CA/HR; no CA/LR, no CA/HR), the addition of THAL did not impact OS. Conclusions: The unique benefit of THAL to the CA/LR subgroup may be linked to its greater efficacy in proliferative MM (enabling CA detection) that can only be sustained in the LR (lacking amplification of 1q21?) but not in the HR subset. The concomitant examinations of MM genetics by both GEP and cytogenetics enabled the discovery of this subgroup-specific treatment benefit. Data on TT3 with the addition of bortezomib will be presented in the context of the CA/GEP-risk scenario.

[Table: see text]

VTD combination therapy with bortezomib-thalidomide-dexamethasone is highly effective in advanced and refractory multiple myeloma

Bortezomib (V) was combined with thalidomide (T) and dexamethasone (D) in a phase I/II trial to determine dose-limiting toxicities (DLT's) and clinical activity of the VTD regimen in 85 patients with advanced and refractory myeloma. The starting dose of V was 1.0 mg/m(2) (days 1, 4, 8, 11, every 21 day) with T added from cycle 2 at 50 mg/day, with 50 mg increments per 10 patient cohorts, to a maximum dose of 200 mg. In the absence of DLT's, the same reiteration of T dose increases was applied with a higher dose of V=1.3 mg/m(2). D was added with cycle 4 in the absence of partial response (PR). Ninety-two percent had prior autotransplants, 74% had prior T and 76% abnormal cytogenetics. MTD was reached at V=1.3 mg/m(2) and T=150 mg. Minor response (MR) was recorded in 79%, and 63% achieved PR including 22% who qualified for near-complete remission. At 4 years, 6% remain event-free and 23% alive. Both OS and EFS were significantly longer in the absence of prior T exposure and when at least MR status was attained. The MMSET/FGFR3 molecular subtype was prognostically favorable, a finding since reported for a VTD-incorporating tandem transplant trial (Total Therapy 3) for untreated patients with myeloma (BJH 2008).