LOWER RESPONSE TO INTRAVESICAL ADJUVANT THERAPY IN HIGH-RISK BLADDER CANCER COULD BE RELATED TO THE UROTHELIAL EXPRESSION OF EGFR

LOWER RESPONSE TO INTRAVESICAL ADJUVANT THERAPY IN HIGH-RISK BLADDER CANCER COULD BE RELATED TO THE UROTHELIAL EXPRESSION OF EGFR Cristina Scalici Gesolfo1, Sebastiano Billone1, Alessio Guarneri1, Marco Vella1, Alessandro Perez2, Graziella Cangemi2, Antonio Russo2, Alchiede Simonato1,Vincenzo Serretta1 and GSTU Foundation3 1Section of Urology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Palermo, Italy; 2Section of Medical Oncology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy; 3Palermo, Italy Introduction: Studies on the role of EGFR in non-muscleinvasive bladder cancer (non-MIBC) are lacking. EGFR expression has been determined mainly in tissue specimens of MIBC and its overexpression has been associated with worse prognosis and shorter survival. Urothelial EGFR status after transurethral resection (TUR) of non-MIBC could indicate the risk of recurrence and progression. We investigated the feasibility of EGFR measurement in bladder washings of patients undergoing intravesical adjuvant therapy for non-MIBC and its usefulness in identifying risk subgroups. Patients and Methods: Our prospective study included patients after TUR of non-MIBC and healthy controls. Samples of bladder washings were centrifuged at 4˚C for 10 minutes at 1500 rpm, washed in cold phosphate buffer saline solution and centrifuged again obtaining a cellular pellet stored at −80˚C until RNA extraction was performed by miRNeasy Mini Kit (QiagenR). A Nanodrop ND-2000 spectrophotometer was used to check for good quality of RNA. RNA criteria to proceed with reverse transcription to cDNA: minimum 500 ng/ml, protein (260/280) solvents and organic compounds (260/230), contamination ratio 1.7-2.5. The cDNA obtained from RNA by High Capacity cDNA Reverse Transcription Kit (Life TechnologiesR) was used to perform a gene expression analysis by a real-time PCR, according to the method of the comparative quantification (ΔΔCt) with an endogenous control (cyclophilin). Every reaction was set in triplicate as a further guarantee of quality. The patients were grouped for EAU risk class and maintained in follow-up. EGFR expressions were statistically analyzed according to EAU risk groups and to patients’ outcomes. EGFR gene expression values were expressed in folds of change compared to healthy controls (EGFR=1). Results: Fifty-eight patients and 21 healthy age-matched controls were entered. An adequate cellular pellet was obtained in 50 patients (86.2%) showing a median EGFR expression of 2.0-fold (IQR=0.6-4.3-fold, p=0.0004). The median level of EGFR varied considerably among the EAU risk classes. After TUR and adjuvant intravesical therapy, in 22 (55%) out of 40 high-risk patients, EGFR decreased to 1.3-fold (IQR=0.9-1.5-fold), while 18 (45%) showed elevated EGFR, median=4.7-fold (IQR=4.1-11.6-fold). At 25 months median follow-up (IQR=19.0-34.8 months), 20 (40%) patients experienced recurrence and six (12%) progression. Among patients with and those without EGFR gene increase, disease in nine (22.5%) and five (12.5%) recurred and in five (12.5%) and one (2.5%) progressed, respectively. Conclusion: In our experience EGFR expression measurement was feasible in more than 85% of patients and was related to EAU risk classes for recurrence and progression, showing different behavior during intravesical therapy. It was possible to identify a subgroup of high-risk patients overexpressing EGFR in spite of intravesical adjuvant therapy. EGFR evaluation in bladder washing could represent a repeatable and useful tool to identify a subgroup of patients at risk for progression predicted as not being responsive to intravesical adjuvant therapy and candidates for early radical cystectomy. We wish to thank GSTU Foundation for data and statistical management

Serum Albumin Is Inversely Associated With Portal Vein Thrombosis in Cirrhosis

We analyzed whether serum albumin is independently associated with portal vein thrombosis (PVT) in liver cirrhosis (LC) and if a biologic plausibility exists. This study was divided into three parts. In part 1 (retrospective analysis), 753 consecutive patients with LC with ultrasound-detected PVT were retrospectively analyzed. In part 2, 112 patients with LC and 56 matched controls were entered in the cross-sectional study. In part 3, 5 patients with cirrhosis were entered in the in vivo study and 4 healthy subjects (HSs) were entered in the in vitro study to explore if albumin may affect platelet activation by modulating oxidative stress. In the 753 patients with LC, the prevalence of PVT was 16.7%; logistic analysis showed that only age (odds ratio [OR], 1.024; P = 0.012) and serum albumin (OR, -0.422; P = 0.0001) significantly predicted patients with PVT. Analyzing the 112 patients with LC and controls, soluble clusters of differentiation (CD)40-ligand (P = 0.0238), soluble Nox2-derived peptide (sNox2-dp; P < 0.0001), and urinary excretion of isoprostanes (P = 0.0078) were higher in patients with LC. In LC, albumin was correlated with sCD4OL (Spearman's rank correlation coefficient [r(s)], -0.33; P < 0.001), sNox2-dp (r(s), -0.57; P < 0.0001), and urinary excretion of isoprostanes (r(s), -0.48; P < 0.0001) levels. The in vivo study showed a progressive decrease in platelet aggregation, sNox2-dp, and urinary 8-iso prostaglandin F2 alpha-III formation 2 hours and 3 days after albumin infusion. Finally, platelet aggregation, sNox2-dp, and isoprostane formation significantly decreased in platelets from HSs incubated with scalar concentrations of albumin. Conclusion: Low serum albumin in LC is associated with PVT, suggesting that albumin could be a modulator of the hemostatic system through interference with mechanisms regulating platelet activation

Hypoalbuminemia and Risk of Portal Vein Thrombosis in Cirrhosis.

Background and Aims Hypoalbuminemia, as defined by serum albumin (SA) levels ≤35 g/L, is associated to venous and arterial thrombosis in general population and in patients at risk of cardiovascular disease. It is unknown if SA ≤35 g/L is also associated to portal vein thrombosis (PVT) in cirrhosis. Methods Cirrhotic patients enrolled in the Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry (PRO-LIVER) study (n = 753), were followed-up for 2 years to assess the risk of PVT, that was diagnosed by Doppler ultrasonography. Child-Pugh classes, Model for End-Stage Liver Disease score, presence of hepatocellular carcinoma and laboratory variables including SA, D-dimer, and high-sensitivity C-reactive protein (hs-CRP) were measured at baseline. Results SA ≤35 g/L was detected in 52% of patients. A logistic multivariate regression analysis showed that higher Child-Pugh class, hepatocellular carcinoma and thrombocytopenia were significantly associated to SA ≤35 g/L. In a subgroup of patients where data regarding hs-CRP and D-dimer were available, SA ≤35 g/L was inversely associated with hs-CRP and D-dimer. During the follow-up, a total of 61 patients experienced PVT. A Kaplan Meier survival analysis showed SA ≤35 g/L was associated to increased risk of PVT compared to SA >35 g/L (P = .005). A multivariate Cox proportional hazards regression analysis showed that male sex, lower platelet count, and SA ≤35 g/L remained associated to PVT after adjusting for confounding factors. Conclusion Cirrhotic patients with SA ≤35 g/L are at higher risk of experiencing PVT compared to those with SA >35 g/L and could be considered as potential candidates to anticoagulant prophylaxis for PVT prevention

Incidence and Recurrence of Portal Vein Thrombosis in Cirrhotic Patients

Cirrhosis has been long considered a risk factor for bleeding due to the co-existence of the so-called \u2018coagulopathy\u2019. More recently, however, compelling evidences have been provided on the occurrence of thrombotic events in the portal and systemic circulation.3\u20135 Portal vein thrombosis (PVT) is predominantly observed in patients with moderate to severe liver failure with a variable prevalence ranging from 0.6 to 25%. Only fewstudies have provided a longitudinal assessment of the PVT incidence and its sequelae, including recurrence and survival.9\u201314 Due to the variability of PVT incidence and the paucity of data regarding recurrence and survival,15\u201320 we prospectively analysed the incidence and the recurrence of PVT in the population of Portal vein thrombosis Relevance On Liver cirrhosis: ItalianVenous thromboticEventsRegistry (PROLIVER), a multi-centre study,8 which involved 43 enrolling centres in Italy (ClinicalTrials.gov Identifier: NCT01470547)

Platelet Count Does Not Predict Bleeding in Cirrhotic Patients: Results from the PRO-LIVER Study.

OBJECTIVES: Thrombocytopenia is a hallmark for patients with cirrhosis and it is perceived as a risk factor for bleeding events. However, the relationship between platelet count and bleeding is still unclear. METHODS: We investigated the relationship between platelet count and major or clinical relevant nonmajor bleedings during a follow-up of ∼4 years. RESULTS: A total of 280 cirrhotic patients with different degrees of liver disease (67% males; age 64±37 years; 47% Child-Pugh B and C) were followed up for a median of 1,129 (interquartile range: 800-1,498) days yielding 953.12 patient-year of observation. The annual rate of any significant bleeding was 5.45%/year (3.57%/year and 1.89%/year for major and minor bleeding, respectively). Fifty-two (18.6%) patients experienced a major (n=34) or minor (n=18) bleeding event, predominantly from gastrointestinal origin. Platelet counts progressively decreased with the worsening of liver disease and were similar in patients with or without major or minor bleeding: a platelet count ≤50 × 103/μl was detected in 3 (6%) patients with and in 20 (9%) patients without any bleeding event. Conversely, prothrombin time-international normalized ratio was slightly higher in patients with overall or major bleeding. On Cox proportional hazard analysis, only a previous gastrointestinal bleeding (hazard ratio (HR): 1.96; 95% confidence interval: 1.11-3.47; P=0.020) and encephalopathy (HR: 2.05; 95% confidence interval: 1.16-3.62; P=0.013) independently predicted overall bleeding events. CONCLUSIONS: Platelet count does not predict unprovoked major or minor bleeding in cirrhotic patients

Platelet count does not predict bleeding in cirrhotic patients: Results from the PRO-LIVER Study

OBJECTIVES: Thrombocytopenia is a hallmark for patients with cirrhosis and it is perceived as a risk factor for bleeding events. However, the relationship between platelet count and bleeding is still unclear. METHODS: We investigated the relationship between platelet count and major or clinical relevant nonmajor bleedings during a follow-up of \ue2\u88\ubc4 years. RESULTS: A total of 280 cirrhotic patients with different degrees of liver disease (67% males; age 64\uc2\ub137 years; 47% Child\ue2\u80\u93Pugh B and C) were followed up for a median of 1,129 (interquartile range: 800\ue2\u80\u931,498) days yielding 953.12 patient-year of observation. The annual rate of any significant bleeding was 5.45%/year (3.57%/year and 1.89%/year for major and minor bleeding, respectively). Fifty-two (18.6%) patients experienced a major (n=34) or minor (n=18) bleeding event, predominantly from gastrointestinal origin. Platelet counts progressively decreased with the worsening of liver disease and were similar in patients with or without major or minor bleeding: a platelet count \ue2\u89\ua450\uc3\u97103/\uce\ubcl was detected in 3 (6%) patients with and in 20 (9%) patients without any bleeding event. Conversely, prothrombin time-international normalized ratio was slightly higher in patients with overall or major bleeding. On Cox proportional hazard analysis, only a previous gastrointestinal bleeding (hazard ratio (HR): 1.96; 95% confidence interval: 1.11\ue2\u80\u933.47; P=0.020) and encephalopathy (HR: 2.05; 95% confidence interval: 1.16\ue2\u80\u933.62; P=0.013) independently predicted overall bleeding events. CONCLUSIONS: Platelet count does not predict unprovoked major or minor bleeding in cirrhotic patients

Frequency of Left Ventricular Hypertrophy in Non-Valvular Atrial Fibrillation

Left ventricular hypertrophy (LVH) is significantly related to adverse clinical outcomes in patients at high risk of cardiovascular events. In patients with atrial fibrillation (AF), data on LVH, that is, prevalence and determinants, are inconsistent mainly because of different definitions and heterogeneity of study populations. We determined echocardiographic-based LVH prevalence and clinical factors independently associated with its development in a prospective cohort of patients with non-valvular (NV) AF. From the "Atrial Fibrillation Registry for Ankle-brachial Index Prevalence Assessment: Collaborative Italian Study" (ARAPACIS) population, 1,184 patients with NVAF (mean age 72 \ub1 11 years; 56% men) with complete data to define LVH were selected. ARAPACIS is a multicenter, observational, prospective, longitudinal on-going study designed to estimate prevalence of peripheral artery disease in patients with NVAF. We found a high prevalence of LVH (52%) in patients with NVAF. Compared to those without LVH, patients with AF with LVH were older and had a higher prevalence of hypertension, diabetes, and previous myocardial infarction (MI). A higher prevalence of ankle-brachial index 640.90 was seen in patients with LVH (22 vs 17%, p = 0.0392). Patients with LVH were at significantly higher thromboembolic risk, with CHA2DS2-VASc 652 seen in 93% of LVH and in 73% of patients without LVH (p <0.05). Women with LVH had a higher prevalence of concentric hypertrophy than men (46% vs 29%, p = 0.0003). Logistic regression analysis demonstrated that female gender (odds ratio [OR] 2.80, p <0.0001), age (OR 1.03 per year, p <0.001), hypertension (OR 2.30, p <0.001), diabetes (OR 1.62, p = 0.004), and previous MI (OR 1.96, p = 0.001) were independently associated with LVH. In conclusion, patients with NVAF have a high prevalence of LVH, which is related to female gender, older age, hypertension, and previous MI. These patients are at high thromboembolic risk and deserve a holistic approach to cardiovascular prevention