Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.

QRS dispersion using 252-leads Body Surface Mapping (BSM) – an explorative study of a novel diagnostic tool for Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Background

The diagnosis of ARVC is complex and challenging requiring multiple investigational tools, most of which include the demonstration of depolarization/conduction abnormalities, described in recent HRS consensus documents 2019. A simple and user friendly diagnostic tool is warranted.

Purpose

The purpose of our study was therefore to explore whether the analysis of QRS dispersion obtained from 252-leads recorded by a Body Surface Mapping (BSM) system can be used to identify ARVC patients as compared to the traditional ECG criteria including QRS dispersion measured by conventional 12 lead surface ECG.

Methods

12 definite ARVC patients (10/12 with known pathogenic mutation) (Group 1) and 8 healthy family members tested negative for the family mutation served as controls (Group 0), were included. All patients underwent 12-lead ECG (50mm/sec), Signal-averaged ECG for late potentials and 252 lead BSM recordings. The QRS duration was measured in each of the 12 ECG leads manually with digital caliper. The QRS duration from the BSM leads were manually analyzed in Matlab by two observers unaware of the diagnosis. For each lead, the mean value of three randomly chosen beats was calculated. The QRS dispersion was calculated as the difference between the minimum and maximum value for both the 12 lead ECG and the BSM recordings.

Results

The mean age was 49,6 and 38,8 years in ARVC patients and controls, respectively. The number of males in the two groups were 8/12 and 5/8, respectively. Epsilon waves and Terminal Activation Duration (TAD) >55msec were detected in 6/12 and 8/12 ARVC patients, respectively, but in no controls. Late potentials were detected in 11/12 ARVC patients and in 2 controls. The QRS duration and QTc duration was not statistically different in the two Groups.

The ECG-QRS dispersion was significantly more pronounced in Group 1 (42 ms ± 15, range 20–70 ms) than in Group 0 (26 ms ± 8, range 16–36 ms) (p=0.013). The BSM-QRS dispersion was significantly longer in Group 1 (68 ms ± 17, range 29–90ms) than in Group 0 (30 ms ± 7, range 22–41ms) (p=0.001). Only one ARVC patient had a BSM-QRS dispersion <50 msec, whereas none of the controls had a QRS dispersion over 50 msec (Fig. 1).

Conclusion

BSM-QRS dispersion, specifically using the cut off <50 ms, can potentially be a more sensitive and specific method than other ECG related techniques for diagnosing ARVC patients versus non-ARVC patients. Larger patient cohorts and further studies are required to confirm our findings.

Figure 1. ECG and BSM-QRS dispersion

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Selanders Stiftelse

The repolarization pattern of ARVC patients, healthy gene carriers and controls as analyzed with a 252-leads Body Surface Mapping Vest

Background

Repolarization abnormalities have a central role on the diagnosis of ARVC according to recent HRS consensus document from 2019 stating that T wave inversion in the right precordial leads is a major criteria if it appears in V1-V3 or a minor criteria if it appears in only V1-V2.

Purpose

The aim of our study was to investigate whether repolarization patterns as recorded by a Body Surface Mapping (BSM) system consisting of a vest with 252 ECG leads, could differentiate ARVC patients and even gene carriers from normal individuals. Our hypothesis is that the method can potentially identify repolarization disturbances earlier or better than conventional 12-lead ECG.

Method

12 definite ARVC patients, 20 healthy gene carriers and 8 family members who tested negative for the family mutation (controls) were included. All patients underwent 12-lead ECG, including right precordial leads (V4R) and BSM recordings. Repolarization (T-wave polarity and concordance with QRS complex vector) was analyzed qualitatively in all BSM recordings, the results of which were displayed on a color code map (fig.1).

Results

The mean age was 49.6, 43.6 and 38.8 years in ARVC patients, healthy gene carriers and controls, respectively. The number of males in the three groups were 8/12, 8/20 and 5/8, respectively.

All 8 controls had similar repolarization patterns with negative and concordant T waves on the right back panel, and T waves that successively changed from negative concordant (green) to positive disconcordant (red) and finally positive concordant (blue) on the left front panel (pattern 1). All 12 ARVC patients had different repolarization patterns as compared to the controls. Two of these patients had no apparent repolarization changes on conventional 12 lead ECG. The pattern type 2 repolarization, as defined by same pattern as the controls at the right back panel but different pattern at the front left panel was seen in 3/12 ARVC patients. The remaining 9 ARVC patients had different repolarization patterns both on the front and on the back panel (pattern 3). Among gene carriers, 15 had a normal repolarization pattern (pattern 1) and 5 demonstrated an abnormal repolarization pattern (4 had pattern type 2 and one pattern 3) despite normal surface ECG.

Conclusions

Using BSM recordings, abnormal repolarization patterns can be detected in all ARVC patients, even in those without repolarization changes on conventional surface ECG. The observation that 25% of gene carriers had divergent repolarization patterns, may indicate an early stage of the disease, and be used as an early diagnostic marker of the disease. Further and larger studies are warranted to confirm these observations.

Repolarisation patterns recorded by BSM

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Selanders Stiftelse

Comparison of different scoring systems in predicting short-term mortality after liver transplantation

BACKGROUND

Many scoring systems have been used in predicting the outcomes of liver transplantations. The aim of this study was to compare between 4 scoring systems-Sequential Organ Failure Assessment (SOFA), Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Child Turcotte-Pugh -among patients who underwent living-donor liver transplantation (LDLT) seeking to evaluate the best system to correlate with post-operative outcomes.

METHODS

This study retrospectively reviewed the medical records of 53 patients who had received LDLT in a tertiary care hospital from January 2005 to December 2010. Demographic, clinical, and laboratory data were recorded. Each patient was assessed by use of 4 scoring systems before transplantation and on post-operative days 1 to 7 and at 3 months.

RESULTS

The overall 3-month survival rate was 64%. The pre-transplant SOFA score had the best discriminatory power; moreover, the SOFA score on post-operative day 7 had the best Youden index (.875). The survival rate at 3-month follow-up after liver transplantation differed significantly (P = .00023, highest area under the receiver operator characteristic curve = .952) between patients who had SOFA scores <8 and those had SOFA score >8 on post-liver transplant day 7. This study also demonstrated that respiratory rate (P = .017) and serum bilirubin level (P = .048) and duration of intensive care unit stay (P = .04) are significant risk factors related to early mortality after LDLT.

CONCLUSIONS

The pre-transplant SOFA score was a statistically significant predictor of 3-month mortality; SOFA score on post-liver transplant day 7 had the best discriminative power for predicting 3-month mortality.