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Purpose: Patient-reported outcome (PRO) and National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) data for patients with squamous cell carcinoma of the anus (SCCA) treated with modern radiation therapy (RT) are lacking. The primary aim of this study was to report bowel and bladder PRO and NCI-CTCAE for patients with SCCA 1 year after RT. Methods and Materials: From 2015 to 2020, we included patients in a prospective Danish national study. Data were collected before treatment (PT) and 1 year after treatment (1Y) using NCI-CTCAE version 4.0, as well as European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR29. We evaluated the combined PRO scores according to the European Organisation for Research and Treatment of Cancer scoring guidelines, and classified changes according to score difference from PT to 1Y as no change (0-5), minor (5-10), moderate (11-20), and major (>20). Raw scores were reported as frequencies of each of the scores: Not at all, a little, quite a bit, and very much. Results: Of the 270 patients, 81% had complete data sets, including PT and 1Y answers. Functional mean scores were equal to a matched normal population cohort at PT and 1Y. From PT to 1Y, C30 scores were stable despite minor improvements in global health status/quality of life (7.3), emotional functioning (9.3), insomnia (8.0), and appetite loss (7.8). For questionnaire CR29, bowel and bladder symptoms and sore skin improved with minor change (6.2), and buttocks, anal, or rectal pain improved with moderate change (18.3). Flatulence worsened moderately (12.6), and fecal incontinence had minor worsening (7.8). Agreement between PROs and NCI-CTCAE was generally only fair to moderate, especially for quantitative symptoms, such as pain (κ = 0.25). Conclusions: For patients with SCCA who underwent definitive RT, only a few patients had high scores (indicating quite a bit or very much frequency of bother) regarding bowel and bladder symptoms.

Background First‐line platinum‐based therapy for advanced squamous cell carcinomas of the anal canal (SCCA) implies a risk of substantial side effects, and data on second‐line treatment options are limited. Paclitaxel and Capecitabine are a well‐known regimen with a moderate toxicity profile, but its efficacy has not been evaluated. Methods We conducted a retrospective study using Danish Hospital Registers of patients treated with Paclitaxel and Capecitabine for inoperable, recurrent, or advanced metastatic SCCA in Denmark, between January 2000 and July 2018. Results A total of 52 patients met the eligibility criteria. Median age was 60.7 years (range 42–83). Efficacy was observed, with an overall response rate in patients receiving first‐line (N = 28) and second‐line (N = 23) Paclitaxel and Capecitabine of 39.3% (2 with complete responses) and 17.4%, respectively. Median progression‐free survival (PFS) was 4.5 months (95% CI 3.3–5.9) and 3.8 months (95% CI 2.4–5.5) with OS of 6.7 months (95% CI 5.9–8.5) and 5.9 months (95% CI 3.9–14), respectively. Performance status ≥2 and neutrophil to lymphocyte ratio ≥4 were significantly associated with a short PFS. Conclusion This study recognizes Paclitaxel and Capecitabine as a potential regimen for advanced SCCA, when recommended first‐line therapy is not feasible or as a potential second‐line treatment after failure of platinum‐based chemotherapy., Paclitaxel and Capecitabine is recognized for advanced anal cancer when recommended first‐line therapy is not feasible or as second‐line treatment after failure of platinum‐based chemotherapy.

Background and purpose: Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects. Materials and methods: Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations. Scientific evidence: Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available. Conclusion: Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.

Background The Danish Breast Cancer Group (DBCG) Proton Trial randomizes breast cancer patients selected on high mean heart dose (MHD) or high lung dose (V20Gy/V17Gy) in the photon plan between photon and proton therapy. This study presents the proton plans and adaptation strategy for the first 43 breast cancer patients treated with protons in Denmark. Material and methods Forty-four proton plans (one patient with bilateral cancer) were included; 2 local and 42 loco-regional including internal mammary nodes (IMN). Nineteen patients had a mastectomy and 25 a lumpectomy. The prescribed dose was either 50 Gy in 25 fractions (n = 30) or 40 Gy in 15 fractions (n = 14) wherefrom five received simultaneous integrated boost to the tumor bed. Using 2-3 en face proton fields, single-field optimization, robust optimization and a 5 cm range shifter ensured robustness towards breathing motion, setup- and range uncertainties. An anatomical evaluation was performed by evaluating the dose after adding/removing 3 mm and 5 mm tissue to/from the body-outline and used to define treatment tolerances for anatomical changes. Results The nominal and robust criteria were met for all patients except two. The median MHD was 1.5 Gy (0.5-3.4 Gy, 50 Gy) and 1.1 Gy (0.0-1.5 Gy, 40 Gy). The anatomical evaluations showed how 5 mm shrinkage approximately doubled the MHD while 5 mm swelling reduced target coverage of the IMN below constraints. Ensuring 3-5 mm robustness toward swelling was prioritized but not always achieved by robust optimization alone emphasizing the need for a distal margin. Twenty-eight patients received plan adaptation, eight patients received two, and one received five. Conclusion This proton planning strategy ensured robust treatment plans within a pre-defined level of acceptable anatomical changes that fulfilled the planning criteria for most of the patients and ensured low MHD.

Simple Summary The primary treatment modality for anal cancer is chemoradiotherapy, but patients with locally advanced disease (i.e., large tumors and/or involvement of regional lymph nodes) have a high risk of treatment failure. The use of chemotherapy prior to radiotherapy (induction chemotherapy) can potentially shrink the tumor and/or eradicate small cancer cells with metastatic potential, with a chance of a better outcome. With this paper, the authors present 20 years of nationwide experience with intensified induction chemotherapy in the treatment of locally advanced anal cancer, which indicates a role for further investigation in the most advanced cases. Abstract Locally advanced squamous cell carcinoma of the anus (LASCCA) has a poor prognosis with a high risk of treatment failure calling for intensified therapy. We present the long-term follow-up of a nationwide cohort of LASCCA treated with intensified induction chemotherapy (ICT). The study included patients with LASCCA (T3-4N0 or T1-4N+) treated with at least one cycle of ICT (cisplatin, ifosfamide, leucoverin, and 5-flourouracil) between 1998–2018. Data were retrospectively collected from medical records, and statistics were performed in STATA 16.1. In total, 166 patients with LASCCA were identified. Following ICT, 157 patients (95%) received primary curative treatment with either radiotherapy (70%), chemoradiotherapy (27%), or abdominal perineal resection (3%). The overall local tumor response rate after ICT was 76% with 20 (13%) achieving complete local tumor response. After the primary treatment, 123 patients (79%) obtained complete response, and 27 underwent salvage surgery due to persistent disease. The median follow-up time was 6 years, local and distant failure rates 22% and 13%, respectively. The 3- and 5-year disease-free survival rates were 70% and 67%, and the 3- and 5-year overall survival rates were 76% and 70%, respectively. Intensified ICT regimen could be a supplementary treatment option in the most advanced cases of LASCCA. Prospective randomized trials are needed to investigate this approach further.

Background and purpose: Circulating tumor DNA (ctDNA) is investigated in various cancers. In squamous cell carcinoma of the anus (SCCA) infection with human papilloma virus (HPV) is found in around 90% of cases and here, plasma HPV (pHPV) can be used as ctDNA. Preliminary data have proved the ability to detect pHPV16 and -18 in SCCA. We have developed a highly sensitive method for measurement of six relevant pHPV subtypes, to investigate the elimination pattern of pHPV during chemo-radiotherapy (CRT) for SCCA and its clinical value. Material and methods: Patients treated at Aarhus University Hospital from 2016–2020 were included. P16 status in the primary biopsy was measured and 82% of patients had P16 positive tumor. Blood samples were collected prior to treatment (PT), mid treatment (MT), end of therapy (EOT), and during follow-up (FU). An in-house multiplex digital droplet PCR method measured pHPV subtypes 16, 18, 31, 33, 51, 58. Results: Samples from 88 patients were drawn PT (n = 73), MT (n = 72), EOT (n = 64) and during FU (n = 41). Plasma HPV was detectable in 52 patients and PT pHPV levels correlated to tumor stages. Three elimination patterns were observed during CRT with correlation to outcome: fast responders with no local or distant failures (0/12), slow responders with high risk of local failures (4/20), no distant failures, persistent molecular responders with high risk of distant failures (4/13), but no local failures, p &lt, 0.01. Conclusion: During CRT, pHPV can divide patients with SCCA into three groups with significantly different risk of failure. The use of pHPV can potentially assist in clinical treatment decision.

Background and purpose Chemoradiotherapy is the primary treatment for localized anal cancer (AC). This treatment offers high rates of cure and organ preservation. Radiotherapy can however, result in late persisting anorectal dysfunction, with anal incontinence, urge and clustering. Correlation of radiation doses to pelvic substructures and functional outcome is not well described in AC. We correlated patient reported anorectal function to radiation doses to sphincters and pelvic floor muscles. Materials and methods Patients treated with (chemo)radiotherapy for AC were asked to fill out LARS (lower anterior resection syndrome) questionnaires at follow-up. We compared patients with no LARS (score 0–19) and patients with major LARS (30–42) as well as individual LARS questions to specific radiation doses to sphincters, levators and puborectal muscles. Results Thirty-six patients were included, 18 with no LARS and 18 with major LARS. Gender, age, TNM stage, PTV, chemotherapy, time to LARS score (mean 660 and 749 days) were comparable between the two groups. LARS symptoms, occurring at least once per week, were reported between 25–55.7%, and poorer LARS outcome was associated to worse quality of life. Dose to sphincter complex (Dmean, V50Gy and D90%) differed significantly between patients with no and major LARS (p = 0.048, 0.035 and 0.02 respectively). Further, D90% to the sphincter complex was significantly higher in patients who had accidental leakage of stool, (p = 0.044). Conclusion: Patients treated with (chemo)radiotherapy for AC show high frequency of patient reported anorectal dysfunction. Specific doses to the sphincters could become a useful predictor of anal incontinence and major LARS and incorporated into future radiotherapy planning studies.

PURPOSE: Cardiac implantable electronic devices (CIED) are sensitive to scattered secondary neutrons from proton beam irradiation. This experimental in vitro study investigated risk of CIED errors during pencil beam proton therapy.METHODS AND MATERIAL: We used 62 explanted CIEDs from four manufacturers; 49 CIEDs were subjected to a simulated clinical protocol with daily 2 Gy relative biological effectiveness (RBE) fractions prescribed to the phantom. Devices were located at three different lateral distances from the spread-out Bragg peak to investigate risk of permanent or temporary device errors. Additionally, 13 devices with leads connected, were monitored live during consecutive irradiations to investigate risk of noise, over- or under-sense, pace-inhibition and inappropriate shock-therapy.RESULTS: We detected 61 reset errors in 1,728 fractions and all except one CIED were reprogrammed to normal function. All, except one reset, occurred in devices from the same manufacturer. These were successfully reprogrammed to normal function. The one remaining CIED was locked in permanent safety mode. Secondary neutron dose, as estimated by Monte Carlo simulations, was found to significantly increase the odds of CIED resets by 55% per mSv. Clinically significant battery depletion was observed in five devices. We observed no noise, over- or under-sense, pace-inhibition or inappropriate shock therapy during 362 fractions of live-monitoring.CONCLUSION: Reprogrammable CIED reset was the most commonly observed malfunction during proton therapy and reset risk depended on secondary neutron exposure. The benefits of proton therapy are expected to outweigh the risk of CIED malfunctioning for most patients.

Background: Measuring circulating-free-deoxyribonucleic-acid (cfDNA) has created a new framework for personalized treatment in oncology. The aim of this study was to analyze the relation between cfDNA and risk factors and outcome in squamous cell carcinoma of the anus (SCCA). Methods: Patients treated with radiotherapy for localized SCCA were included in Aarhus, Denmark from 2016 to 2019. Serum samples from baseline, during and after therapy, were measured for the level of cfDNA in copies per mL by a direct fluorescent assay. Results: Eighty patients were included. Samples were available at baseline (n = 73) mid-therapy (n = 74), end-therapy (n = 67) and one-year follow-up (1Y) (n = 29). P16-positivity was found in 89% (n = 55). The median level of cfDNA was higher for P16 negative tumors (1.48) compared with the P16 positive tumors (0.90, P = 0.04). Data showed a correlation between baseline cfDNA levels and Gross Tumor Volume (R2 = 0.13, P < 0.01), and increasing levels with increasing T-stage (T1 = 0.80, T2 = 0.94, T3 = 1.11, T4 = 1.3). Higher cfDNA levels were observed in patients with poor performance status (P < 0.01). The cfDNA level decreased from baseline to mid-therapy (0.92–0.78, P < 0.01) and from baseline to 1Y (0.92–0.71, P < 0.01). Baseline levels for patients with treatment failure (n = 8) were above the 25th percentile (p = 0.05) which translates into difference in disease free survival. Conclusion: Results indicate an association between baseline cfDNA levels and risk factors in SCCA and a low baseline level correlates to lower risk of treatment failure. Findings contribute with new knowledge of the biological role of cfDNA in SCCA and holds potential knowledge for personalized treatment of SCCA.

OBJECTIVES To evaluate differences in coronary microvascular function approximately 12 years after delivery between women who had had early- (EO-PE) or late- (LO-PE) onset pre-eclampsia and those who had had a normotensive pregnancy, and to assess the relationship between microvascular function and myocardial deformation at follow-up in these women. METHODS This was a case-control study of 88 women who had delivered at the Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark, between 1998 and 2008. Coronary flow velocity reserve (CFVR) was assessed by Doppler echocardiography approximately 12 years after delivery. Women were grouped according to whether the pregnancy had been complicated by EO-PE (n = 29) or LO-PE (n = 20), or had been normotensive (controls) (n = 39). Study groups were matched for maternal age and time since delivery. CFVR at follow-up was compared between the study groups. Regression analysis was used to assess the association between gestational age at onset of PE and CFVR. The association between left ventricular global longitudinal strain (LV-GLS) and CFVR at follow-up was also evaluated. RESULTS Resting coronary flow velocity assessed 12 years after delivery was comparable between the study groups (P = 0.55), whereas peak hyperemic flow velocity was significantly lower in the EO-PE group than in the LO-PE group (P

BACKGROUND AND PURPOSE: Chemoradiotherapy (CRT) is the standard therapy for localized anal cancer (AC), but this treatment is associated with substantial toxicity. However, there is a lack of prospectively collected toxicity and patient reported outcome (PRO) data from larger cohorts. The purpose was to prospectively collect and determine agreement between physician assessed toxicity (CTCAE) and PRO during and after CRT and to compare IMRT, VMAT and proton-based planning in a subgroup of patients.MATERIAL AND METHODS: Patients, treated with CRT for AC, were included between 2015 and 2017. NCI-CTCAE v.4.0, EORTC QLQ-C30 and CR29 data were collected baseline, mid-therapy, end-of therapy and 2-4 weeks posttherapy. Treatment planning with 5- or 6-fixed field IMRT, 2 and 3 arc VMAT, and 3- and 4-field proton plans were compared.RESULTS: One-hundred patients were included. Both CTCAE and PROs related to acute toxicity reached a maximum at end of therapy. Incidences of PROs were markedly higher with only slight to fair agreement to CTCAE, (κ 13-37). Comparative planning revealed dosimetric equality of IMRT and VMAT plans, but superiority of proton plans.CONCLUSIONS: The high incidence of PRO scores and weak agreement to CTCAE suggest that PROs are important tools complementary to CTCAE in evaluating patient symptoms during and after CRT. Proton therapy has the potential to lower radiation doses to most organs at risk.

Objectives: Preeclampsia is associated with maternal morbidity and mortality during pregnancy, and also an increased cardiovascular disease (CVD) risk later in life. During preeclampsia, alterations in secreted placental factors leading to systemic maternal endothelial dysfunction are evident. However, little is known about the associated endothelial intracellular signaling. STAT3 is a latent cytoplasmic transcription factor involved in endothelial cell differentiation, survival, and angiogenesis. We aimed to test if preeclampsia and preeclampsia-related placental factors could alter serum-induced STAT3(Y705) activation in endothelial cells. Furthermore, if altered serum-induced endothelial STAT3 (Y705) activation is related to post-preeclamptic CVD risk. Study design: HUVECs were used as a model of maternal endothelium. Experiments entailed addition of 20% human pregnancy serum as well as addition of recombinant PlGF, sFLT1 and VEGF-A165a to the cells. Main outcome measures: Levels of pSTAT3(Y705) related to STAT3 levels were evaluated by immunoblotting analysis. Results: Our results show that preeclamptic serum induces significantly lower STAT3(Y705) phosphorylation compared with uncomplicated pregnancy serum (P = 0.0089) in endothelial cells. Furthermore, STAT3(Y705) phosphorylation was not changed upon addition of PlGF, sFLT1, or VEGF-A165a together with pregnancy sera compared with sera alone. Finally, sera from women with previous preeclampsia and current hypertension and carotid atherosclerotic plaques show significantly lower STAT3(Y705) phosphorylation capabilities compared with healthy women with previous uncomplicated pregnancies 8–18 years after deliveries (P = 0.029). Conclusions: Reduction in serum-induced endothelial STAT3(Y705) activation may play an important role in the preeclampsia-associated endothelial dysfunction. Additionally, reduced endothelial STAT3(Y705) phosphorylation may contribute to increased post-preeclamptic CVD risk 8–18 years after delivery.

Highlights • Mesorectal-only RT for early rectal cancer requires dedicated planning guidelines. • A multi-centre study was conducted to identify planning objectives. • Robust optimisation objectives for organs at risk are presented., Background and purpose Organ preservation strategies are increasingly being explored for early rectal cancer. This requires revision of target volumes according to disease stage, as well as new guidelines for treatment planning. We conducted an international, multicentre dose planning study to develop robust planning objectives for modern radiotherapy of a novel mesorectal-only target volume, as implemented in the STAR-TReC trial (NCT02945566). Materials and methods The published literature was used to establish relevant dose levels for organ at risk (OAR) plan optimisation. Ten representative patients with early rectal cancer were identified. Treatment scans had mesorectal target volumes as well as bowel cavity, bladder and femoral heads outlined, and were circulated amongst the three participating institutions. Each institution produced plans for short course (SCRT, 5 × 5 Gy) and long course (LCRT, 25 × 2 Gy) treatment, using volumetric modulated arc therapy on different dose planning systems. Optimisation objectives for OARs were established by determining dose metric objectives achievable for ≥90% of plans. Results Sixty plans, all fulfilling target coverage criteria, were produced. The planning results and literature review suggested optimisation objectives for SCRT: V10Gy

Chemotherapy resistance remains a challenge in the clinical management of metastatic colorectal cancer (mCRC). Here, early changes in cell-free circulating tumour DNA (ctDNA) levels were explored as a marker of therapeutic efficacy. Twenty-four mCRC patients were enrolled and treated with FOLFIRI based first-line therapy. Blood samples collected pre-treatment, at day 7, 14, 21, 60 and at progression were analysed for cell-free DNA (cfDNA) and ctDNA levels using digital droplet PCR. A subset of samples were additionally analysed by targeted sequencing. Patients with high pre-treatment ctDNA or cfDNA levels (≥75th centile) had significantly shorter progression free survival (PFS) than patients with lower levels. Despite an overall decline in ctDNA levels from pre-treatment to first CT-scan, serial analysis identified seven patients with temporary increases in ctDNA consistent with growth of resistant cells. These patients had shorter PFS and shorter overall survival. Targeted sequencing analyses of cfDNA revealed dramatic changes in the clonal composition in response to treatment. Our study suggests that increasing ctDNA levels during the first cycles of first-line FOLFIRI treatment is a predictor of incipient progressive disease and poorer survival. Thus, we demonstrate the importance of monitoring ctDNA levels as early as one week after treatment onset to enable early detection of treatment failure.

To determine overall survival and baseline prognostic variables in a cohort of patients with metastatic colorectal cancer receiving a FLIRI-based stop-and-go treatment strategy.Clinical information was collected from patient files in consecutive patients treated with palliative combination chemotherapy using a stop-and-go strategy from September 2007 until June 2011. The primary outcome was overall survival. Cox regression analysis was used to examine the effect of prognostic variables on survival. Baseline variables were performance status, primary tumor site, status of primary tumor (resected or unresected), synchronous metastases,1 metastatic site, liver-only metastases, alkaline phosphatase (300 U/l), lactate dehydrogenase (300 U/l), platelets (400 × 10(9)/l), and leucocytes (10 × 10(9)/l).We included 314 patients (median age 64.5 (57-70) years). Median overall survival was 20.9 (95 % confidence interval (CI), 19.1-223.4) months with a median follow-up of 21.3 months (interquartile range (IQR) 13-34.8). Independent prognostic markers of decreased survival were PS 1 and 2 vs. 0 hazard ratio (HR) 1.47 (95 % CI 1.14-1.91, p = 0.003) and HR 2.06 (95 % CI 1.19-3.56, p = 0.01), colon as the primary tumor site HR 1.43 (95 % CI 1.09-1.88, p = 0.009), unresected primary tumor HR 2.22 (95 % CI 1.61-3.07, p 0.001), and elevated leucocytes (10 × 10(9)/l) HR 1.53 (95 % CI 1.12-2.09, p = 0.007).Overall survival in metastatic colorectal cancer using a FLIRI-based stop-and-go strategy in an unselected consecutive cohort proved comparable to RCTs from the same period. Baseline prognostic markers of poorer prognosis were PS 1 or 2, colon as primary tumor site, unresected primary tumor, and leucocytes10 × 10(9)/l. These variables are all easy accessible in daily clinical practice.

The purpose of this study is to identify treatment-related factors prognostic of survival in a cohort of patients with metastatic colorectal cancer (mCRC) receiving a palliative, stop-and-go chemotherapy regimen. Consecutive patients receiving first-line treatment with biweekly FLIRI plus bevacizumab were included. The outcome was overall survival. Cox regression analysis was used to identify predictors of outcome. We analysed reduction in chemotherapy dosage (no vs. ≤25 or >25 % reduction), bevacizumab administrated to

Introduction Women with a history of preeclampsia have increased risk of cardiovascular disease later in life. However, it is unclear if early gestational age at preeclampsia onset is associated with higher cardiovascular disease risk. This study aimed to test the association between gestational age at preeclampsia onset (including the early-onset/late-onset preeclampsia distinction) and subclinical atherosclerosis and arterial stiffness in age-matched women 12 years after index pregnancy Material and methods Eligible participants were identified in two Danish registries. Main outcome measures were carotid plaque presence, carotid intima-media thickness, aortic pulse wave velocity, and augmentation index adjusted for heart rate Results Twenty-four women with previous early-onset preeclampsia, 24 with previous late-onset preeclampsia and 24 with previous normotensive pregnancies were included after matching on age (+/- 2 years) and time since delivery (+/- 1 year). In all outcome measures, the early-onset group had the highest percentage or mean value. In the adjusted analysis, the early-onset group significantly differed from the late-onset group in all outcome measures except aortic pulse wave velocity. The early-onset group also had significantly higher carotid intima-media thickness (average and left) compared to the normotensive group. Noteworthy, gestational age at preeclampsia onset as a continuous variable was significantly associated to both carotid plaque presence and carotid intima-media thickness (average and right) Conclusions Gestational age at preeclampsia onset is negatively associated with markers of subclinical atherosclerosis 12 years after delivery. Potentially, gestational age at preeclampsia onset might be helpful in directing cardiovascular disease prevention after preeclampsia. This article is protected by copyright. All rights reserved.

OBJECTIVES: Epidemiological studies associate preeclampsia with increased risk of premature cardiovascular disease (CVD) later in life. This study aims to make a comprehensive CVD risk assessment comparing women with previous preeclamptic pregnancies to women with previous normotensive pregnancies 10years after index pregnancy.STUDY DESIGN: A nested, matched, observational cohort study.MAIN OUTCOME MEASURES: Markers of arterial stiffness, aortic pulse wave velocity (aPWV) and augmentation index (AIx-75), and markers of atherosclerosis, carotid intima-media thickness (cIMT) and carotid plaque presence. Traditional CVD risk factors and 10-year and 30-year Framingham CVD risk scores were also assessed.RESULTS: Women were included from April 2014 to October 2014 at a tertiary referral hospital in Denmark. Twenty-one exposed women with a history of preeclampsia and 21 unexposed with a history of normotensive pregnancies were included. Ten years after delivery, significantly more exposed women suffered from hypertension and received antihypertensive treatment and significantly more fulfilled the hypertension-definition at screening. Previously preeclamptic women also tended to have more unfavorable CVD risk estimates. The Framingham risk scores seemed to extend the unfavorable CVD risk. The exposed women tended to have a higher aPWV compared to unexposed women, (P=0.057). No differences were shown in the other examined arteriosclerotic or atherosclerotic variables.CONCLUSIONS: Ten years after delivery, we found increased risk of hypertension and trend toward unfavorable CVD risk profile in 40-year-old previously preeclamptic women. However, arterial stiffness and atherosclerosis did not uncover any additional CVD risk information at this time point.

Objective Pre-eclampsia is a serious pregnancy complication causing both fetal and maternal distress. Proteinuria is a diagnostic criterion frequently determined by albuminuria. We determined the protein excretion pattern of additional proteins, immunoglobulin G, transferrin, α1-microglobulin and β2-microglobulin, in urine samples collected prospectively during pre-eclamptic and healthy pregnancies. Design A prospective cohort study of 1,631 consecutive pregnant women. Setting A Danish regional hospital. Sample Thirty-two women with pre-eclampsia and 185 healthy control women were identified from the cohort. Urine samples were obtained from the 18th week until delivery and divided into six gestational intervals. Methods Protein analyses of urine immunoglobulin G, transferrin, α1-microglobulin and β2-microglobulin were done with a sandwich ELISA method. Main outcome measures Urine levels of specific proteins during pre-eclamptic and healthy pregnancies. Results Immunoglobulin G and transferrin were significantly increased in pre-eclampsia after the 30th week of pregnancy. α(1)-Microglobulin and β(2)-microglobulin were differently excreted and found to be higher after the 36(th) week of pregnancy in pre-eclampsia, but only α1-microglobulin increased significantly. Conclusions Immunoglobulin G, transferrin, α1- and β2-microglobulin excretion patterns indicate initial glomerular damage followed by altered tubular handling of proteins.

Objective. To evaluate differences in plasma cytokine levels longitudinally in pre-eclamptic and normotensive pregnancies. An increased inflammatory response has long been associated with pre-eclampsia, both early and late in the pre-eclamptic pregnancy. Design. Blood samples were collected longitudinally during pregnancy from a cohort of 1 631 pregnant women. Thirty-two women with pre-eclampsia and 67 normotensive pregnant women were identified from the cohort. Setting. A Danish regional hospital. Samples. Samples were collected from the 18th week of pregnancy until delivery and divided into the following four gestational intervals: 36th week. Methods. Simultaneous measurement of all nine cytokines was done using a capture bead system. Main Outcome Measures. Plasma levels of interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, tumor necrosis factor-α, interferon-γ and granulocyte macrophage colony-stimulating factor during pre-eclamptic and normotensive pregnancies. Results. Pre-eclampsia was associated with increased tumor necrosis factor-α between the 26th and 29th week (p=0.0421) and increased IL-6 after the 36th week (p=0.0044). The other cytokines measured were comparable in the two groups. Conclusions. This large prospective collection of blood samples was undertaken to determine inflammatory status during pre-eclamptic and normotensive pregnancies. Our results support a tendency towards increased inflammation in pre-eclampsia, but the measured cytokines are not eligible for prediction, monitoring or diagnosing pre-eclampsia.

Udgivelsesdato: 2007-null BACKGROUND: Alternatively activated macrophages expressing the CD163 and CD206 surface receptors are the dominant immune-cell type found in the placenta. The placental number and distribution of macrophages is altered in pre-eclampsia, and the generalised inflammatory reaction associated with pre-eclampsia might lead to shedding of soluble CD163 into the circulation. METHODS: Serum samples from 18 women with pre-eclampsia and 90 normal pregnancies were obtained from a longitudinal study of 955 pregnant women at Randers County Hospital, Denmark. sCD163 and Neopterin were measured by ELISA on samples collected in weeks 18, 28, 32, and 38 of pregnancy. RESULTS: sCD163 levels in pregnancy (2-3 mg/l) were similar to previously measured levels in non-pregnant women, and did not increase from week 18 to 38. There was a tendency towards higher sCD163 in week 38 in pre-eclamptic women compared to healthy women. Neopterin increased throughout pregnancy in both healthy (from median 5.4 to 6.7 nmol/l, p

The signal transducer and activator of transcription 3 (STAT3) is a well-described pro-oncogene found constitutively activated in several cancer types. Folates are B vitamins that, when taken up by cells through the Reduced Folate Carrier (RFC), are essential for normal cell growth and replication. Many cancer cells overexpress a glycophosphatidylinositol (GPI)-anchored Folate Receptor α (FRα). The function of FRα in cancer cells is still poorly described, and it has been suggested that transport of folate is not its primary function in these cells. We show here that folic acid and folinic acid can activate STAT3 through FRα in a Janus Kinase (JAK)-dependent manner, and we demonstrate that gp130 functions as a transducing receptor for this signalling. Moreover, folic acid can promote dose dependent cell proliferation in FRα-positive HeLa cells, but not in FRα-negative HEK293 cells. After folic acid treatment of HeLa cells, up-regulation of the STAT3 responsive genes Cyclin A2 and Vascular Endothelial Growth Factor (VEGF) were verified by qRT-PCR. The identification of this FRα-STAT3 signal transduction pathway activated by folic and folinic acid contributes to the understanding of the involvement of folic acid in preventing neural tube defects as well as in tumour growth. Previously, the role of folates in these diseases has been attributed to their roles as one-carbon unit donors following endocytosis into the cell. Our finding that folic acid can activate STAT3 via FRα adds complexity to the established roles of B9 vitamins in cancer and neural tube defects.

Objectives: To evaluate the clinical performance of a rapid point-of-care test, Triage PLGF (Alere, San Diego) in the diagnosis of preeclampsia. Study design: For the reference range 2212 plasma samples were collected from 595 subjects with normotensive pregnancies, between week 17 of gestation and delivery. In the case-control part, two cohorts of women with preeclampsia (80 women) were matched for maternal age, gestational age (GA) at sampling and parity with normotensive women who delivered at 37 weeks or more. Results: The areas under the receiver operating characteristic curves (GA < 35 weeks) were 1.0 and 0.994 (cohort 1 and 2, respectively). The clinical sensitivity of the Triage PLGF test for the pooled GA range of 21 ≤ GA < 35, using a GA dependent cut-off, was 1.0 for both cohorts with specificities of 1.0 and 0.940. Conclusions: The Triage PLGF test distinguishes well between preterm pregnancies with and without preeclampsia. © 2011 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.

Objectives Circulating placental growth factor (PlGF) is a potential biomarker for preeclampsia. Prior studies show its limited precision in predicting or diagnosing preeclampsia, underscoring a common problem in biomarker data analyses in general – that large studies are needed to overcome clinical heterogeneity and to provide sufficient statistical power. Attaining such sample sizes often requires aggregation of cohorts. Different studies may use disparate platforms for laboratory analyses, complicating data merging. Here, we assessed whether PlGF concentrations could be merged across studies using inter-platform standardization. Methods Of 16516 pregnancies from 23 cohorts, 12,804 had at least one PlGF concentration (gestational age >20 weeks), analyzed using one of four platforms: R&D Systems, Alere-Triage, Roche-Elecsys or Abbott-Architect. Two merging algorithms, using Z -Score or Multiple of Median (MOM) transformations, were applied. A single Best Reference Curve (BRC), based on merged non-case PlGF concentrations, was constructed. Case-identification performance of the BRC for PlGF was compared to platform-specific curves. Results PlGF concentrations from different analytical platforms were merged ( Z -scores marginally better than MOMs) and, overall, BRC case-identification rates out-performed platform-specific curves. Conclusions Laboratory measurements from different platforms can be standardised and merged to give reference curves from aggregated PlGF datasets. This method allows for analysis of PlGF as a diagnostic marker for preeclampsia and is generalisable to other medical questions, thereby extending the scope of individual studies to answer a variety of important medical questions. Disclosures O. Burke: None. S. Benton: None. P. Szafranski: None. P. von Dadelszen: None. C. Buhimschi: None. I. Cetin: None. L. Chapell: None. F. Figueras: None. A. Galindo: None. I. Herraiz: None. C. Holzman: None. C. Hubel: None. U. Knudsen: None. C. Kronborg: None. H. Laivuori: None. T. McElrath: None. M. Moertl: None. J. Meyers: None. R.B. Ness: None. L. Oliviera: None. G. Olson: None. L. Poston: None. C. Ris-Stalphers: None. J.M. Roberts: None. E. Schistermann: None. E. Steegers: None. H. Stepan: None. O. Lapaire: None. D. Schlembach: None. S. Timmermans: None. V. Tsatsaris: None. J.A. van der Post: None. S. Verlohren: Consultant, Research Support Recipient, Commercial Interest: Roche Diagnostics, ThermoFisher, Novartis. P.M. Villa: None. D. Williams: None. H. Zeisler: None. C. Zhang: None. C.W. Redman: None. A. Staff: None.

Objectives Several studies have demonstrated an association between preeclampsia and premature development of cardiovascular disease (CVD) later in life. Although the association is incompletely understood, it probably includes pre-existing common risk factors. However, preeclampsia may also induce permanent vascular and metabolic alterations that could affect the systemic arterial elastic properties. In this regard, arterial stiffening could represent a link between the systemic effects of preeclampsia and CVD risk. We aimed to evaluate the effect of preeclampsia on markers of arterial stiffness and subclinical atherosclerosis in women with a history of preeclampsia. Methods A 10-year follow-up study comparing 19 exposed women (previous pre-eclamptic pregnancies) and 19 unexposed women (previous normotensive pregnancies) matched on age and time since delivery. Markers of arterial stiffness (aortic pulse wave velocity and augmentation index) and of atherosclerosis (carotid intima-media thickness and atheromatous plaques presence) – as well as traditional CVD risk factors - were compared between the two groups. Results Paired analysis showed a higher aortic pulse wave velocity in women with a history of preeclampsia than in unexposed women (7.96 ± 1.45 vs. 7.16 ± 0.66 m/s, respectively, P = 0.055). However, the difference fell marginally short of statistical significance. Waist-Hip ratio ( P = 0.04) and percentage with hypertension (defined as elevated systolic and/or diastolic blood pressure and/or antihypertensive drug treatment ( P = 0.03)) were significantly higher in previous preeclamptic women. No difference was observed in augmentation index, intima-media thickness or plaque presence. Conclusions Women with preeclamptic pregnancies 10 years earlier tended to have higher pulse wave velocity compared to women with previous normotensive pregnancies. To the best of our knowledge, this is the first comparative assessment of arterial stiffness 10 years after pregnancies complicated by preeclampsia. Disclosures M. Christensen: None. C.J. Kronborg: None. U.B. Knudsen: None.

Pre-eclampsia is a serious pregnancy complication causing both fetal and maternal distress. Proteinuria is a diagnostic criterion frequently determined by albuminuria. We determined the protein excretion pattern of additional proteins, immunoglobulin G, transferrin, α1-microglobulin and β2-microglobulin, in urine samples collected prospectively during pre-eclamptic and healthy pregnancies.A prospective cohort study of 1,631 consecutive pregnant women.A Danish regional hospital.Thirty-two women with pre-eclampsia and 185 healthy control women were identified from the cohort. Urine samples were obtained from the 18th week until delivery and divided into six gestational intervals.Protein analyses of urine immunoglobulin G, transferrin, α1-microglobulin and β2-microglobulin were done with a sandwich ELISA method.Urine levels of specific proteins during pre-eclamptic and healthy pregnancies.Immunoglobulin G and transferrin were significantly increased in pre-eclampsia after the 30th week of pregnancy. α(1)-Microglobulin and β(2)-microglobulin were differently excreted and found to be higher after the 36(th) week of pregnancy in pre-eclampsia, but only α1-microglobulin increased significantly.Immunoglobulin G, transferrin, α1- and β2-microglobulin excretion patterns indicate initial glomerular damage followed by altered tubular handling of proteins.

Endothelial-cell dysfunction is central in the preeclamptic pathogenesis. Several components present in the blood of the preeclamptic mother are capable of mediating this dysfunction. We analyzed the regulation of the ISG12A gene by serum from the third trimester, to elucidate the role of type 1 interferon ISGs late in both healthy and preeclamptic pregnancies. The ISG12A transcription was up-regulated by serum from healthy pregnant women, but not by preeclamptic serum in HeLa and human umbilical vein endothelial cells (HUVEC). However, the ISG12A up-regulation by healthy pregnancy serum was not due to a general type 1 interferon response, since 6-16 and OAS1 were not up-regulated similarly. Also, the up-regulation of ISG12A was independent of the interferon-alpha receptor 2, but dependent on STAT1. Stimulation with folic acid alone or in combination with preeclamptic serum up-regulated ISG12A and 6-16. We conclude that type 1 interferon is not increased in third trimester serum, neither from healthy nor preeclamptic pregnancies. However, since ISG12A mRNA is up-regulated in healthy pregnancies, the ISG12A protein might take part in maintaining endothelial stability, as this function is lacking in preeclamptic pregnancies. Folic acid may ameliorate endothelial cell stability in preeclampsia by up-regulating ISG12A.

Udgivelsesdato: 2007-null BACKGROUND: Although the pre-eclamptic pathogenesis begins at least around the 18th week of pregnancy, clinically evident disease often does not appear until the third trimester. This long pre-symptomatic latency period has led to intensive research for early markers of evolving disease. We evaluated urine excretion and plasma levels of orosomucoid and albumin longitudinally in healthy and pre-eclamptic pregnancies. Orosomucoid is an acute phase protein involved in inflammation and protection of the endothelium. METHODS: From a prospective, longitudinal cohort study consisting of 1,631 women, 32 women developed pre-eclampsia, and 5 controls for every case of pre-eclampsia were found. Blood samples were collected 4 times and urine samples 6 times from the 18/19th week and throughout pregnancy. Orosomucoid and albumin in plasma were analysed by standard methods, and in urine by sandwich ELISA. RESULTS: Orosomucoid/creatinin excretion ratio was significantly higher early in pre-eclamptic pregnancies (from the 20th week of pregnancy, p=0.0053) compared with healthy pregnancies, the difference increased throughout pregnancy. Albumin/creatinin ratio increased subsequent to the increase in orosomucoid. In the plasma samples, orosomucoid was significantly higher late in pre-eclamptic pregnancies (>or=36th week, p=0.0275). CONCLUSIONS: Pre-eclampsia is associated with a pre-symptomatic increase in the urine excretion of orosomucoid, and orosomucoid excretion precedes that of albumin. Orosomucoid excretion can probably be used as a prognostic tool in combination with other screening methods, and seems to be a more sensitive marker for evolving pre-eclampsia than albumin. Plasma orosomucoid is significantly increased late in pre-eclampsia. Thus, the increased excretion of orosomucoid must primarily originate from altered renal processing of orosomucoid.BACKGROUND: Although the pre-eclamptic pathogenesis begins at least around the 18th week of pregnancy, clinically evident disease often does not appear until the third trimester. This long pre-symptomatic latency period has led to intensive research for early markers of evolving disease. We evaluated urine excretion and plasma levels of orosomucoid and albumin longitudinally in healthy and pre-eclamptic pregnancies. Orosomucoid is an acute phase protein involved in inflammation and protection of the endothelium. METHODS: From a prospective, longitudinal cohort study consisting of 1,631 women, 32 women developed pre-eclampsia, and 5 controls for every case of pre-eclampsia were found. Blood samples were collected 4 times and urine samples 6 times from the 18/19th week and throughout pregnancy. Orosomucoid and albumin in plasma were analysed by standard methods, and in urine by sandwich ELISA. RESULTS: Orosomucoid/creatinin excretion ratio was significantly higher early in pre-eclamptic pregnancies (from the 20th week of pregnancy, p=0.0053) compared with healthy pregnancies, the difference increased throughout pregnancy. Albumin/creatinin ratio increased subsequent to the increase in orosomucoid. In the plasma samples, orosomucoid was significantly higher late in prBACKGROUND: Although the pre-eclamptic pathogenesis begins at least around the 18th week of pregnancy, clinically evident disease often does not appear until the third trimester. This long pre-symptomatic latency period has led to intensive research for early markers of evolving disease. We evaluated urine excretion and plasma levels of orosomucoid and albumin longitudinally in healthy and pre-eclamptic pregnancies. Orosomucoid is an acute phase protein involved in inflammation and protection of the endothelium. METHODS: From a prospective, longitudinal cohort study consisting of 1,631 women, 32 women developed pre-eclampsia, and 5 controls for every case of pre-eclampsia were found. Blood samples were collected 4 times and urine samples 6 times from the 18/19th week and throughout pregnancy. Orosomucoid and albumin in plasma were analysed by standard methods, and in urine by sandwich ELISA. RESULTS: Orosomucoid/creatinin excretion ratio was significantly higher early in pre-eclamptic pregnancies (from the 20th week of pregnancy, p=0.0053) compared with healthy pregnancies, the difference increased throughout pregnancy. Albumin/creatinin ratio increased subsequent to the increase in orosomucoid. In the plasma samples, orosomucoid was significantly higher late in pre-eclamptic pregnancies (>or=36th week, p=0.0275). CONCLUSIONS: Pre-eclampsia is associated with a pre-symptomatic increase in the urine excretion of orosomucoid, and orosomucoid excretion precedes that of albumin. Orosomucoid excretion can probably be used as a prognostic tool in combination with other screening methods, and seems to be a more sensitive marker for evolving pre-eclampsia than albumin. Plasma orosomucoid is significantly increased late in pre-eclampsia. Thus, the increased excretion of orosomucoid must primarily originate from altered renal processing of orosomucoid.-eclamptic pregnancies (>or=36th week, p=0.0275). CONCLUSIONS: Pre-eclampsia is associated with a pre-symptomatic increase in the urine excretion of orosomucoid, and orosomucoid excretion precedes that of albumin. Orosomucoid excretion can probably be used as a prognostic tool in combination with other screening methods, and seems to be a more sensitive marker for evolving pre-eclampsia than albumin. Plasma orosomucoid is significantly increased late in pre-eclampsia. Thus, the increased excretion of orosomucoid must primarily originate from altered renal processing of orosomucoid

e14105 Background: Patients with non-resectable metastatic colorectal cancer can survive several years with palliative chemotherapy and newer biological agents. However, survival varies greatly within this group. The aim of the present study was to identify baseline predictors of overall mortality in an unselected cohort of patients with metastatic colorectal cancer. Methods: Clinical information was collected from patient files in consecutive patients treated with palliative chemotherapy from August 2007 until June 2011. The primary outcome was overall survival. Cox regression analysis was used to examine the effect of predictive variables on time to outcome. The variables analysed were: Gender, age, performance status, primary tumor site (colon or rectum), status of primary tumor (resected or un-resected), metachronous metastases, more than two metastatic sites, liver-only metastases, and low albumin. Results: We included 314 patients (Median age 64.5 IQ (57-70) years, 194 (61.8%) male). Median follow-up for survival was 471 days IQ (257-708). One-year survival was 79%, CI (74-84%). Median overall survival was 676 days, CI (577-750). Following baseline variables were independent predictors of all-cause mortality: Primary tumor site colon HR: 1.49, CI (1.03-2.16), p=0.036, un-resected primary tumor HR 2.92, CI (1.85-4.62), p

e14063 Background: Patients with metastatic colorectal cancer (mCRC) undergo month to year-long therapy with different chemotherapy regimens and biological agents. We aimed to identify predictors of mortality during an intermittent treatment regimen in an unselected cohort of patients with mCRC. Methods: Consecutive patients, treated from August 2007 until June 2011, were included. Standard 1st line treatment was biweekly FLIRI plus Bevacizumab. Clinical information was obtained from patient files. The outcome was overall survival. Cox regression analysis was used to identify predictors of outcome. We analyzed reduction in chemotherapy dosage (no reduction, ≤75% or >75%), administration of Bevacizumab to ≤50% of chemotherapy treatments, best response during the first 6 months of treatment (NC, RD or PD), and local treatment of metastases (any type). We adjusted for following baseline variables: Gender, age, PS, primary tumor site, resection of primary tumor, metachronous metastases, more than two metastatic sites, liver-only metastases, and low albumin Results: We included 314 patients (median age 64.5 IQ (57-70) years, 194 (61.8%) male). Median follow-up for survival was 471 IQ (257-708) days. One-year survival was 79%, CI (74-84%). Median overall survival was 676 days, CI (577-750). Chemotherapy reduction did not influence outcome, ≤75%: HR 1.08 CI (0.64-1.83), p=0.77, >75%: HR 0.66 CI (0.29-1.5), p=0.32. Local treatment of metastases was borderline significant: HR 0.45 CI (0.20-1.00), p=0.051. Bevacizumab was administered in 262 patients and a reduction in bevacizumab treatments was associated with increased mortality: HR 1.90 CI (1.12-3.23), p=0.018. Regression vs. NC improved outcome HR 0.48 (0.30-0.78), p=0.003, whereas PD vs. NC increased mortality HR 3.84 (1.75-8.42), p=0.001. Conclusions: In an unselected cohort of mCRC patients, using an intermittent treatment regimen, administration of Bevacizumab to less than 50% of chemotherapy treatments and PD were associated with increased mortality. Regression improved outcome compared to stable disease. Local treatment of metastases was borderline significant. Reduction in chemotherapy dosage did not influence outcome.

T13.6 – Table 2. Comparison table Normal Chronic hypertension Superimposed hypertension Pre-eclampsia Gestational hypertension Normal – P = 0.377 P = 0.031 P< 0.0001 P = 0.002 Chronic hypertension P = 0.377 – P = 0.107 P = 0.003 P = 0.021 Superimposed hypertension P = 0.031 P = 0.107 – P = 0.218 P = 0.673 Pre-eclampsia P< 0.0001 P = 0.003 P = 0.218 – P = 0.201 Gestational hypertension P = 0.002 P = 0.021 P = 0.673 P = 0.201 – sensitivity and specificity increased to 100% and 92%, respectively. Combined, a positive PlGF test was able to diagnosis early onset pre-eclampsia or nIUGR with 94% sensitivity and 93% specificity. Conclusion: This evidence suggests that PlGF can be used to confirm diagnosis of early onset pre-eclampsia and identify nIUGR of placental origin from mimics. Funding: Biosite, CIHR, MSFHR, CFRI T13.6 Urinary placental growth factor differentiates the hypertensive disorders of pregnancy Neil Campbell1, Robert Ogle1, Annemarie Hennessy2, Charlene Thornton1. 1Royal Prince Alfred Hospital, Sydney, Australia; 2University of Western Sydney and Heart Research Institute, Australia Objective: The objective of this study is to establish whether urinary placental growth factor (uPlGF) is capable of discriminating between the different types of hypertensive disease in pregnancy in the third trimester. Design: This is a prospective descriptive case control study. Setting: Royal Prince Alfred Hospital, Urban tertiary referral hospital in Sydney, Australia. The Canterbury Hospital, district general hospital, Sydney, Australia Patients: Women in the third trimester of pregnancy who were currently inpatients on the antenatal ward or patients attending the antenatal outpatients department. Interventions: Patients in the third trimester of pregnancy were selected from the above settings, reviewed for eligibility and demographic data extracted. Patients were then asked to provide a urine specimen some of which was analysed for protein and creatinine and the rest stored and then later analysed for urine PlGF level. These levels after correction for creatinine concentration were then used in the final analysis. Measurements & main results: We have identified 36 women in the hypertensive group (preeclampsia (n=15), Gestational hypertension (n=13), Chronic hypertension (n=8), Preeclampsia superimposed on chronic hypertension (n=5)) and 47 women in the normal control group. There is a statistically significant difference in PlGF levels between the preeclamptic group and the normotensive controls (P