Predictors of Disease Progression and Adverse Clinical Outcomes in Patients With Moderate Aortic Stenosis Using an Artificial Intelligence-Based Software Platform

Patients with moderate aortic stenosis (AS) have a greater risk of adverse clinical outcomes than that of the general population. How this risk compares with those with severe AS, along with factors associated with outcomes and disease progression, is less clear. We analyzed serial echoes (from 2017 to 2019) from a single healthcare system using Tempus Next (Chicago, Illinois) software. AS severity was defined according to American Heart Association/American College of Cardiology guidelines. Outcomes of interest included death or heart failure hospitalization. We used Cox proportional hazards models and logistic regression to identify predictors of clinical outcome and disease progression, respectively. From 82,805 echoes for 61,546 patients, 1,770; 914; 565; and 1,463 patients had no, mild, moderate, or severe AS, respectively. Both patients with moderate and those with severe AS experienced a similar prevalence of adverse clinical outcomes (p = 0.45) that was significantly greater than that of patients without AS (p <0.01). In patients with moderate AS, atrial fibrillation (hazard ratio 3.29, 95% confidence interval 1.79 to 6.02, p <0.001) and end-stage renal disease (hazard ratio 3.34, 95% confidence interval 1.87 to 5.95, p <0.001) were associated with adverse clinical outcomes. One-third of patients with moderate AS with a subsequent echo (139/434) progressed to severe AS within 1 year. In conclusion, patients with moderate AS can progress rapidly to severe AS and experience a similar risk of adverse clinical outcomes; predictors include atrial fibrillation and low left ventricular ejection fraction. Machine learning algorithms may help identify these patients. Whether these patients may warrant earlier intervention merits further study.

Clinical Predictors of Mortality in Patients with Moderate to Severe Mitral Regurgitation

BACKGROUND

Mitral regurgitation is the most common form of valvular heart disease worldwide, however, there is an incomplete understanding of predictors of mortality in this population. This study sought to identify risk factors of mortality in a real-world population with mitral regurgitation.

METHODS

All patients with moderate or severe mitral regurgitation were identified at a single center from January 1, 2016 to August 31, 2017. Multivariate regression was performed to evaluate variables independently associated with all-cause mortality.

RESULTS

A total of 490 patients with moderate (76.3%) or severe (23.7%) mitral regurgitation due to primary (20.8%) or secondary (79.2%) etiology were identified. The mean age was 66.7 years; 50% were male. At a median follow-up of 3.1 years, the incidence of all-cause mortality was 30.1%, heart failure hospitalization 23.1%, and mitral valve intervention 11.6%. Of 117 variables, multivariate analysis demonstrated 5 that were independently predictive of mortality: baseline creatinine (hazard ratio [HR] 1.2; 95% CI, 1.0-1.3; P = .02), right atrial pressure by echocardiogram (HR 1.3; 95% CI, 1.07-1.55; P = .008), hemoglobin (HR 0.65; 95% CI, 0.52-0.83; P = .001), hospitalization for heart failure (HR 1.6; 95% CI, 1.1-2.4; P = .015), and mitral valve intervention (HR 0.40; 95% CI, 0.16-0.83; P = .049).

CONCLUSION

In this retrospective, pragmatic analysis of patients with moderate or severe mitral regurgitation, admission for heart failure exacerbation, elevated right atrial pressure, renal dysfunction, anemia, and lack of mitral valve intervention were independently associated with increased risk of all-cause mortality. Whether these risk factors may better identify select patients who may benefit from more intensive monitoring or earlier intervention should be considered in future studies.

Clinical Factors Associated With Long-Term Benefit in Patients With Metastatic Renal Cell Carcinoma Treated With Axitinib: Real-World AXILONG Study

BACKGROUND

Axitinib monotherapy obtained approval in pre-treated mRCC patients and recently in combination with pembrolizumab or avelumab in the first-line setting. However, patient profiles that may obtain increased benefit from this drug and its combinations still need to be identified.

PATIENTS AND METHODS

Retrospective multicentre analysis describing clinical characteristics associated with axitinib long-responder (LR) population by comparing two extreme-response sub-groups (progression-free survival [PFS] ≥9 months vs. disease progression/refractory patients [RP]). A multivariate logistic-regression model was used to analyse clinical factors. Efficacy and safety were also analysed.

RESULTS

In total, 157 patients who received axitinib in second or subsequent line were evaluated (91 LR and 66 RP). Older age at start of axitinib and haemoglobin levels > LLN were independent predictive factors for LR in multivariate analyses. In LR patients, median (m) PFS was 18.1 months, median overall survival was 36.0 months and objective response rate (ORR) was 45.5%. In 59 LR patients receiving axitinib in second-line, mPFS was 18.7 months, mOS was 44.8 months and ORR was 43.9%. mOS was significantly longer in second line compared to subsequent lines (44.8 vs. 26.5 months; P = .009). In LR vs. RP, mPFS with sunitinib in first-line was correlated with mPFS with axitinib in second-line (27.2 vs. 10.9 months P < .001). The safety profile was manageable and consistent with known data.

CONCLUSIONS

This study confirms the long-term benefits of axitinib in a selected population, helping clinicians to select the best sequential approach and patients who could obtain a greater benefit from axitinib.

Atezolizumab in locally advanced or metastatic urothelial cancer: a pooled analysis from the Spanish patients of the IMvigor 210 cohort 2 and 211 studies

Background

The studies IMvigor 210 cohort 2 and IMvigor211 evaluated the efficacy of atezolizumab in patients with locally advanced or metastatic urothelial cancer (mUC) upon progression to platinum-based chemotherapy worldwide. Yet, the real impact of this drug in specific geographical regions is unknown.

Materials and methods

We combined individual-level data from the 131 patients recruited in Spain from IMvigor210 cohort 2 and IMvigor211 in a pooled analysis. Efficacy and safety outcomes were assessed in the overall study population and according to PD-L1 expression on tumour-infiltrating immune cells.

Results

Full data were available for 127 patients; 74 (58%) received atezolizumab and 53 (42%) chemotherapy. Atezolizumab patients had a numerically superior median overall survival although not reaching statistical significance (9.2 months vs 7.7 months). No statistically significant differences between arms were observed in overall response rates (20.3% vs 37.0%) or progression-free survival (2.1 months vs 5.3 months). Nonetheless, median duration of response was superior for the immunotherapy arm (non-reached vs 6.4 months; p = 0.005). Additionally, among the responders, the 12-month survival rates seemed to favour atezolizumab (66.7% vs 19.9%). When efficacy was analyzed based on PD-L1 expression status, no significant differences were found. Treatment-related adverse events of any grade occurred more frequently in the chemotherapy arm [46/57 (81%) vs 44/74 (59%)].

Conclusion

Patients who achieved an objective response on atezolizumab presented a longer median duration of response and numerically superior 12 month survival rates when compared with chemotherapy responders along with a more favorable safety profile. PD-L1 expression did not discriminate patients who might benefit from atezolizumab.

Trabectedin for reversing platinum resistance and resensitization to platinum in patients with recurrent ovarian cancer

Aims: We evaluated trabectedin in patients with platinum-resistant/refractory and partially platinum-sensitive recurrent ovarian cancer and the outcomes after reintroduction of platinum. Methods: Twenty-seven patients (platinum-resistant/refractory n = 24/PPS; n = 3) treated with trabectedin were retrospectively analyzed. Results: Trabectedin resulted in an objective response rate (ORR) of 18.2% with a 59.1% of disease control rate (ORR plus stable disease). The median progression-free and overall survival were 3.0 and 21.3 months, respectively. Subsequently, 17 patients were retreated with platinum and yield an ORR of 41.2% and DCR of 47.0%. The median progression-free and overall survival after platinum rechallenge were 5.0 and 14.7 months, respectively. Conclusion: Our results suggest that trabectedin may contribute to resensitize tumor cells to platinum rechallenge.

Dynamic circulating tumor DNA quantificaton for the individualization of non-small-cell lung cancer patients treatment

Background

Liquid biopsy has evolved from being a promising line to becoming a validated approach for biomarker testing. However, its utility for individualization of therapy has been scarcely reported. In this study, we show how monitoring levels of EGFR mutation in plasma can be useful for the individualization of treatment.

Results

Longitudinal EGFR mutation levels in plasma always correlated with tumor response ascertained by RECIST criteria. Moreover, decreasing EGFR mutation levels were detected in all patients benefiting from locoregional radiotherapy, whereas the opposite occurred when a patient progressed soon after radiotherapy treatment. Similarly, increasing EGFR mutation levels anticipated disease progression after TKI dose reduction, discontinuation of treatment, or reduced bioavailability due to drug interactions. In addition, EGFR mutation levels were useful to monitor treatment outcome of new therapies and constituted a decisive factor when the clinical situation of the patient did not correlate with responses ascertained by radiologist. Finally, our results indicate that cancer associated body fluids (pleural, pericardial or cerebrospinal fluid) are certainly a suitable source for biomarker testing that can extend EGFR mutation detection to biofluids other than blood.

Materials and Methods

A total of 180 serial plasma samples from 18 non-small-cell lung cancer patients who carried an activating EGFR mutation were investigated by digital PCR.

Conclusions

Monitoring levels of EGFR mutation in plasma allows resolving doubts that frequently arise in daily clinical practice and constitutes a major step towards achieving personalized medicine.

Multicenter analysis of neoadjuvant docetaxel, carboplatin, and trastuzumab in HER2-positive breast cancer

PURPOSE

In an era where neoadjuvant dual blockade is emerging as the standard of care for early and locally advanced HER2-positive breast cancer, we aimed to identify predictors of response to single-blockade chemotherapy.

METHODS

This retrospective analysis reviewed all the incident stage I-III HER2-positive breast cancer patients who received neoadjuvant docetaxel, carboplatin, and trastuzumab (TCH) in three institutions. pCR was defined as the absence of invasive tumor in breast and axillary nodes (ypT0/isypN0).

RESULTS

From 2008 to 2015, 84 patients receiving neoadjuvant TCH were identified within our institutions. The mean age at diagnosis was 51.8 years. 59.5% of the patients were hormone receptor (HR) positive, lymph node involvement occurred in 67.9%, and clinical distribution was 2.4, 65.5, and 32.1% for stage I, II, and III, respectively. pCR rate was 47.6%; there was a significantly lower response in HR-positive patients compared to HR-negative ones (34 vs 67.6%, p = 0.005). pCR rate was associated with tumor size, whereas differences did not reach significance either for stage or for nodal status. Multivariate analysis found that only HR status was associated with response (p = 0.003). At a median follow-up of 31.7 months, disease-free survival, distant disease-free survival, and overall survival were 78.6, 85.7, and 94%, respectively. Breast-conserving surgery was performed in 44% of the patients. Overall, TCH was well tolerated, with low rates of grade 3-4 adverse events, and neither late toxicities nor cardiac dysfunctions were reported.

CONCLUSIONS

Neoadjuvant TCH, an anthracycline-free single-blockade regimen, achieved a pCR of 47.6%. Further molecular analyses are required in order to identify stronger predictive markers of pCR and thus for an accurate selection of patients who do not benefit from dual blockade.

Abstract P4-02-10: Detection of H1047R and E545K PIK3CA mutations from peripheral blood in ER positive breast cancer patients

Background: Digital polymerase chain reaction (PCR) is a new technology that enables detection and quantification of cancer DNA molecules from peripheral blood. Detecting tumor-specific mutations in circulating plasma DNA may potentially be useful to select systemic therapies for solid tumors. The aim of our study is to evaluate the feasibility of detecting PIK3CA mutations from plasma of breast cancer patients.

Methods: We have designed an allele-specific PCR assay and used a digital PCR system for the detection of PIK3CA mutations H1047R and E545K. Formalin-fixed paraffin-embedded (FFPE) tumor samples were analyzed by COBAS and by digital PCR. The matched plasma samples were then analyzed by digital PCR. Kappa Cohen’s coefficient (κ) was used to test agreement between methods

Results: 37 ER positive breast cancer and matched plasma were evaluated. 31 (84%) patients were stage IV disease. E545K mutation was detected in 4 out of 37 (11%) tumor specimens and H1047R mutation was identified in 8 out of 37 (22%) tumor samples. The proportion of observed agreement between H1047R and E545K detection in tumor samples by COBAS and digital PCR was 100%. Regarding E545K mutation assay we found that the proportion of observed agreement between mutation status in FFPE samples and circulating tumor DNA (ctDNA) was 94.6% (kappa= 0.770; Sensitivity=100%; Specificity=93.9%). In H1047R assay the proportion of observed agreement between FFPE samples and ctDNA was 83.78% (Kappa=0.561; Sensitivity=60%; Specificity=92.59%).

Conclusions: The agreement between methodologies when assessing the PIK3CA status in tumor samples was perfect. However, a moderate-to-fair agreement was found between FFPE samples and ctDNA which might be due to the heterogeneity of the disease. The methodology presented in this study is a feasible approach for PIK3CA mutation detection in blood derived samples.

Citation Format: Jose Angel Garcia-Saenz, Daniel Acosta, Fernando Moreno, Paticia Ayllon, Miguel Sotelo, Trinidad Caldes, Eduardo Diaz-Rubio, Atocha Romero. Detection of H1047R and E545K PIK3CA mutations from peripheral blood in ER positive breast cancer patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-02-10.

Un nuevo caso de Blastomicoma Blastomicoide Sudamericano

Desde 1937, año en que P. WEISS y T. ZAVALETA publicaron el primer caso peruano de la micosis profunda denominado Blastomicosis Sudamericana, esta afección ha sido objeto de estudio entre nosotros habiéndose referido hasta ahora 20 casos publicados y 10 en curso de estudio y motivo de Tesis (O.R.), todos procedentes de nuestra amazonía.

Application of suppressive subtractive hybridization to the identification of genetic differences between two Lactococcus garvieae strains showing distinct differences in virulence for rainbow trout and mouse

Lactococcus garvieae is the causative microbial agent of lactococcosis, an important and damaging fish disease in aquaculture. This bacterium has also been isolated from vegetables, milk, cheese, meat and sausages, from cow and buffalo as a mastitis agent, and even from humans, as an opportunistic infectious agent. In this work pathogenicity experiments were performed in rainbow trout and mouse models with strains isolated from human (L. garvieae HF) and rainbow trout (L. garvieae UNIUDO74; henceforth referred to as 074). The mean LD(50) value in rainbow trout obtained for strain 074 was 2.1 × 10(2) ± 84 per fish. High doses of the bacteria caused specific signs of disease as well as histological alterations in mice. In contrast, strain HF did not prove to be pathogenic either for rainbow trout or for mice. Based on these virulence differences, two suppressive subtractive hybridizations were carried out to identify unique genetic sequences present in L. garvieae HF (SSHI) and L. garvieae 074 (SSHII). Differential dot-blot screening of the subtracted libraries allowed the identification of 26 and 13 putative ORFs specific for L. garvieae HF and L. garvieae 074, respectively. Additionally, a PCR-based screening of 12 of the 26 HF-specific putative ORFs and the 13 074-specific ones was conducted to identify their presence/absence in 25 L. garvieae strains isolated from different origins and geographical areas. This study demonstrates the existence of genetic heterogeneity within L. garvieae isolates and provides a more complete picture of the genetic background of this bacterium.

[Phyllodes tumor and pregnancy. A report of a case]

Phyllodes tumor is a rare breast fibroepithelial neoplasm of the breast, predominant in females (0.3 to 0.5%). Few cases have been described in males. Phyllodes tumor during pregnancy grows fast and its size is relatively big. These tumors can be classified as benign, malignant or neighboring. A 32-year-old patient at 23.4 week of gestation was admitted in the National Institute of Perinatology with a rapidly growing mass in the right breast; diagnosis confirmed by ultrasound study reporting echoic images on right breast, 10 x 10 cm the greatest and 3x3 cm the smallest. A simple mastectomy was performed at the 26.6 week of gestation on the right breast. A possible phyllodes tumour in the right breast was observed during surgery, weight 9.6 pounds, with partial infiltration to major pectoral muscle. Pathology reported a benign phyllodes tumor in the right breast, with surgical borders free of tumor. Phyllodes tumor is rare and can occur during pregnancy. It is unknown if the tumor is hormone-dependent. The growth of a tumor on a subsequent pregnancy is not necessarily associated with recurrency or with a new disorder on the patient, who has had a complete excision.

Anal intercourse and disclosure of HIV infection among seropositive gay and bisexual men

Human immunodeficiency virus (HIV)-infected gay and bisexual men (n = 609) randomly selected from two HIV outpatient clinics in Los Angeles completed confidential, self-administered questionnaires at the clinics, reporting sexual activities and disclosure during the previous 2 months. Approximately 9% had engaged in unprotected insertive anal intercourse with one or more partners. This activity was 3.27 times more likely to have occurred with seropositive partners than with partners who were seronegative or whose serostatus was unknown. Fourteen men (2.3% of total sample) had engaged in unprotected insertive anal sex with 25 seronegative or unknown serostatus partners who were not informed of their risk of infection. Thirty-three men (5.4% of total sample) had engaged in this activity with 37 seropositive partners who were informed. Clinicians and other health professionals can play an important role in helping to control the HIV epidemic by discussing with seropositive patients the importance of using safer sex and informing sexual partners. Such discussion should include information about the potentially negative health effects of unprotected sex between seropositive persons.

Further experience in stereotactic pontine tractotomy

The problem with percutaneous and even stereotactic cordotomy is the difficulty in obtaining sufficiently high analgesic levels without autonomic complications, although the problem seemed to apply to relatively few patients since percutaneous and stereotactic spinal procedures achieved sufficiently high analgesic levels to encompass most patients' pain. There is a group of patients, however, with high pain in the shoulder and neck where conventional percutaneous and stereotactic spinal procedure are dangerous. From the standpoint of achieving high levels of analgesia with a low incidence of dysaesthesia, pontomedullary lesions appear to have advantages.