PurposeSurvival after lung transplantation (LT) is hampered by the development of chronic lung allograft dysfunction (CLAD). There is no treatment available to reverse CLAD once diagnosed, but early intervention could modify the progressive lung function decline. Thus, biomarkers are need for early detection of CLAD. High levels of donor derived cell-free DNA (ddcfDNA) have been described to precede acute cellar rejection and antibody mediated rejection diagnosis. The aim of this study is to assess if there is any association between ddcfDNA and chronic lung allograft dysfunction (CLAD).MethodsThis is a longitudinal study in which ddcfDNA levels were determined in 100 LT recipients at the 3rd, 6th, 9th, 12th, 24th and 36th month after LT. Firstly, real-time PCR was performed to detect an informative INDEL polymorphism for each donor/recipient pair. Secondly, levels of ddcfDNA were determined by quantifying the informative INDEL by digital PCR in the plasma of the recipient. Clinical data was collected during a three years follow-up to determine infections, antibody mediated and acute cellular rejection, and CLAD.ResultsGlobally, we noted an upward trend of ddcfDNA levels at 1, 2 and 3 years of follow-up when referred to 3 months. Levels of ddcfDNA were compared between CLAD and no CLAD patients at different time points, and a cut-off value of 1.86% at 12 months could identify those patients with higher probability of developing CLAD (Figure 1).ConclusionDetermine ddcfDNA levels in plasma could be a useful non-invasive biomarker for CLAD prediction. This study was partially funded by ISCIII ("PI17/01485"), co-funded by ERDF and SEPAR (552/2017). Survival after lung transplantation (LT) is hampered by the development of chronic lung allograft dysfunction (CLAD). There is no treatment available to reverse CLAD once diagnosed, but early intervention could modify the progressive lung function decline. Thus, biomarkers are need for early detection of CLAD. High levels of donor derived cell-free DNA (ddcfDNA) have been described to precede acute cellar rejection and antibody mediated rejection diagnosis. The aim of this study is to assess if there is any association between ddcfDNA and chronic lung allograft dysfunction (CLAD). This is a longitudinal study in which ddcfDNA levels were determined in 100 LT recipients at the 3rd, 6th, 9th, 12th, 24th and 36th month after LT. Firstly, real-time PCR was performed to detect an informative INDEL polymorphism for each donor/recipient pair. Secondly, levels of ddcfDNA were determined by quantifying the informative INDEL by digital PCR in the plasma of the recipient. Clinical data was collected during a three years follow-up to determine infections, antibody mediated and acute cellular rejection, and CLAD. Globally, we noted an upward trend of ddcfDNA levels at 1, 2 and 3 years of follow-up when referred to 3 months. Levels of ddcfDNA were compared between CLAD and no CLAD patients at different time points, and a cut-off value of 1.86% at 12 months could identify those patients with higher probability of developing CLAD (Figure 1). Determine ddcfDNA levels in plasma could be a useful non-invasive biomarker for CLAD prediction. This study was partially funded by ISCIII ("PI17/01485"), co-funded by ERDF and SEPAR (552/2017).

Purpose Plasma donor-derived cell free DNA (dd-cfDNA) has emerged as a potential biomarker for measuring allograft injury after lung transplant. Differences in donor lung mass between single (S) and double (D) lung transplant recipients (LTRs) may impact the amount of circulating dd-cfDNA detected during injury events. The question remains if dd-cfDNA levels should be consistently adjusted when monitored between stable S and D LTRs. We aimed to compare levels of dd-cfDNA in stable LTRs based on S vs D lung status and time post-transplant. Methods Dd-cfDNA was measured in 3 LTR cohorts: 88 from University Health Science Center San Antonio [(UTHSC-SA) 58 D, 29 S] (AlloSure, CareDx), 20 from Memorial Hermann Hospital [(MHH) 19 D, 1 S] (AlloSure), and 100 from Vall d'Hebron Hospital (83 D, 17 S) (real time-PCR to detect informative INDEL polymorphism for each donor/recipient and digital PCR to quantify dd-cfDNA in recipient plasma). LTRs were excluded if they had any donor specific antibodies post-transplant. Dd-cfDNA samples were defined as stable if negative for acute cellular rejection and pulmonary infection within 1-month pre/post-dd-cfDNA draw. Median dd-cfDNA levels were grouped in 3-month buckets. Results A total of 122 dd-cfDNA samples from UTHSC-SA, 60 from MHH, and 286 from Spain were analyzed. Median dd-cfDNA based on S vs D lung status is shown for UTHSC-SA and MHH in Figure 1A, and Spain in Figure 1B. While there were numerical differences in median dd-cfDNA after 12 months post-transplant, these values were influenced by the low number of S LTRs evaluated. Conclusion Based on these data, median dd-cfDNA as measured by 2 different assays did not show appreciable differences between stable S and D lung recipients over time. It remains unclear if all dd-cfDNA levels drawn in S LTRs should be automatically corrected for "threshold" clinical decision making. Future analysis including more S LTRs should be conducted. Evaluation of dd-cfDNA in stable LTRs should rely on assessment of patient-specific trends to guide clinical management.

Purpose Survival after lung transplantation is limited in large part due to the high incidence of chronic lung allograft dysfunction (CLAD). Infection is a recognized risk factor for the development of CLAD, and both acute infection and chronic lung allograft colonization with microorganisms increase the risk for CLAD. The aim of our study was to analyze nasopharyngeal (NP) microbiome composition and modifications following lung transplantation, with a focus on its relationship with CLAD. Methods This was a longitudinal study in which we analyzed bacterial microbiome in NP swab samples in 68 lung transplanted (LT) patients the day of the transplant, when patients were discharged, at 2-5 months and 12 months after lung transplantation. We also analysed NP swab samples from 10 healthy subjects. CLAD was assessed after 2 years of follow-up. DNA was extracted from the NP swabs. To create the amplicon library, the hyper-variable region (V4) of the 16S ribosomal RNA gene was amplified by standard PCR. Amplicons were purified and sequenced in barcoded pools using Illumina MiSeq technology. Raw sequence reads were demultiplexed by using idemp. The resulting single-end reads were processed using the Dada2 pipeline obtaining an amplicon sequence variant table to which taxonomy was assigned. Alpha diversity, including Shannon and Observed indices, and beta diversity metrics were calculated. We compared these metrics and particular taxa relative abundances between samples of LT patients at different time points and samples of healthy subjects. Results From the 68 studied patients, 13 developed CLAD during the two years of follow-up. We observed a significant decrease in the Observed index at the day of the discharge and 2-5 months after transplant when compared with healthy subjects. One year after transplant, CLAD patients had higher Shannon diversity than LT patients who did not develop the dysfunction. On the other hand, a lower beta diversity was observed between healthy subjects and patients with no CLAD. Besides, we detected an increased genus in NP swab samples associated with no CLAD also observed in NP samples from healthy subjects. Conclusion Nasopharyngeal overall microbiome composition, as well as relative abundances of particular taxa of non-CLAD patients, was closest to the one from healthy subjects suggesting a better outcome of the transplant if better microbiome normalization.

Introduction and Objectives: The outbreak of COVID-19 has overwhelmed healthcare systems all over the world. The aim of this article is to describe the process of transforming the Vall d’Hebron University Hospital, the second largest hospital in Spain, into a COVID-19 centre coordinating response to the pandemic in its reference area. Materials and methods: The study draws on the experience of the authors in transforming the hospital into a comprehensive resource in response to the COVID-19 pandemic. The strategy is based on four central strategies: early planning, coordination of all healthcare agents in its reference area, definition of clear leadership roles, and the organisation of care based on multidisciplinary teams with minimal recruitment of new staff. Results: The transformation strategy enabled the hospital to cope with the surge in patients without exceeding its capacity. During the response phases, which amounted to a period of 57 days, 3,106 patients consulted the ER and 2,054 were admitted, 346 of whom were treated at the ICU. To accommodate the number of adult COVID-19 patients, adult ICU availability was progressive increased by 371%, and ordinary beds increased by 240. A total of 671 staff members went on sick leave after testing positive for COVID-19. Conclusion: The transformation experience of the hospital provides insight into how effectively adapt the structures and functioning of large hospitals. The relevance of territorial coordination during the pandemic is stressed as an effective strategy that contributed coping the pandemic.

Aim: The aim of our study was to analyse nasopharyngeal (NP) microbiome composition and modifications following lung transplantation (LT), with a focus on its relationship with chronic lung allograft dysfunction (CLAD) Methods: In this longitudinal study we analysed bacterial microbiome in NP swabs from 68 LT patients at different time-points and NP swabs from 11 healthy subjects. DNA was extracted and the hyper-variable region (V4) of the 16S ribosomal RNA gene was amplified. Amplicons were sequenced in barcoded pools using Illumina MiSeq technology. Raw sequence reads were demultiplexed using idemp. The resulting single-end reads were processed using the Dada2 pipeline obtaining an amplicon sequence variant table to which taxonomy was assigned. Shannon and Observed indices, and Aitchison distance, were calculated Results: From the 68 LT patients, 12 developed CLAD during the 2-years follow-up. Longitudinally, the NP samples from those patients showed a decrease of alpha-diversity measured by Observed index at the day of the discharge and at 2-5 months after LT compared to healthy subjects, but those differences were not observed one year after LT. However, at one year, those patients with CLAD showed a different NP microbiome composition than those without CLAD or healthy subjects as shown by the Aitchison distance (p=0.024). Eleven genera were differently abundant between CLAD and no-CLAD patients Conclusion: One year after LT, NP microbiome seems to normalize in terms of diversity. Overall NP microbiome composition from those without CLAD was closest to the one from healthy subjects suggesting a better outcome of the transplant if better microbiome normalization.

Survival in LAM patients submitted to LT exceeds 10 years. LT in LAM patients allows an improvement in spirometric values. A significant decrease in the number of LT indications in LAM has been observed since the introduction of sirolimus treatment.

Background: The development of chronic lung allograph dysfunction (CLAD) is the leading limitation of long-term survival with good allograft function (LTS) after lung transplantation (LT). The aim of this study was to identify leukocyte subpopulations and to develop a gene model which allows the discrimination of LTS patients. Methods: The cell markers and mRNA expression levels were compared between LTS (n=30) and CLAD patients (n=30) using flow cytometry and microarray techniques. Gene classifiers were built using supervised machine learning methodology and the expression of selected classifier-genes was confirmed by RT-qPCR. Results: In LTS patients, the percentages of CD14highCD16- monocytes, CD56+CD16- NK cells, CD4-CD8- αβ T cell subset and CD62L+granulocytes were elevated whereas the percentage of Vδ1+γδ T cell subpopulation was significantly decreased. The computational process led to the identification of the 25 most relevant genes for LT recipients classification. LASSO method with the 25 classifier genes yielded the optimal results with an Area Under the Curve of 0.87 (sensitivity 0.79 and specificity 0.80). RT-qPCR analysis confirmed the differential expression of 17/18 of the genes selected from the microarrays. The combination of these markers in a model could ultimately improve classification performance. Conclusion: This study identifies a set of lymphocyte subsets and genes associated with LTS after LT which should be validated in an independent LT cohort. The combination of these markers may have utility as a medical tool for safe immunosuppression minimization in LT population. Study financed by ISC III (PI13/01076), FEDER, FUCAP, Astellas, Novartis and Chiesi.

Background Evaluate the safety, toxicity and efficacy of an institutional-simplified SBRT protocol with two short SBRT regimens (three or five fractions) for the treatment of lung cancer and oligometastases, according to the volume and localization of tumours. Methods Patients with stage I (T1 or T2) non-small cell lung cancer or lung oligometastases were treated from August 2011 to October 2015. Patients were required to be considered medically inoperable and were discussed in a multidisciplinary team. Results 100 patients were analysed, 59 had a peripheral location (P), and 41 a central location (C).All patients finished their SBRT course without interruptions related to acute toxicity. The most frequent acute toxicity was grade 1 asthenia, only one patient developed grade 3 toxicity (pneumonitis) and there were no grade 4 or 5 acute toxicities. Three asymptomatic radiation-induced rib fractures were identified, the 1 and 2-year rib fracture-free survival were 97% and 94%, respectively. Two-year progression-free survival and 2-year overall survival of all patients were 52% and 70%, respectively, with a median PFS and OS of 26 and 43 months. Survival free of local progression (SFLP) at 2 years was 89%. A higher PFS in primary lung cancer compared with metastatic tumours was observed, with a median of 35 months with 19 months ( p = 0.01). However, no statistical difference was observed in terms of OS between both diseases. Conclusions SBRT in lung cancer with three sessions for peripheral tumours and five sessions for central tumours may be safely delivered, with low morbidity.

S854 ESTRO 38the patients with CCI >/= to 3.5 (Image 1).Moreover, those patients with high or very high risk, presented a lower survival (p=0.032), as well as patients with higher Gleason (p=0.04).

We hypothesized that lung transplantation (LT) is a procoagulant state. The objective of this study was to profile coagulation before and after LT.

On 2014 the system for allocation of lung recipients for transplant in HUVH changed from allocation based on waiting time to one based on the Lung Allocate Score (LAS score). We have analyzed the postoperative impact of the implementation of the new allocation system.

A lung transplantation (LT) is the last therapeutic option for those who suffer from respiratory chronic diseases. Respiratory rehabilitation plays a crucial role in improving the functional capacity and the quality of life during the different stages of the transplant. After the LT, the pulmonary functions of the receptors are commonly improved, but some limitations in their capacity to exercise and to perform physical activity still remain. The main objective of this study is to evaluate any improvement in effort capacity of patients with lung transplantation that follow a rehabilitation program based on Nordic walking. Almost-experimental prospective study with comparison (before and after surgery). Sample: 8 patients with one year evolution after LT with normal pulmonary function, 5 men (65.5%) and 3 women (37.5%). Medium age of 59.75 years old (DE 4.34 years). Six of the patients had received a double-lung transplant (75%) and the other two, a left lung transplant (25%). The procedure consists in a rehabilitation program with Nordic walking (PRMN) as exercise type. The main variable is the distance walked during the 6 minutes walking test (6′WT); the secondary ones will evaluate the strength of the respiratory muscles (PIM-PEM), the functional capacity (V02pco and VO2AT), the strength of the peripheral muscles (in claw dynamometry and quadriceps) and the quality of life (SF-36 questionnaire). After 12 weeks of PRMN, significant differences have been found in: 6′WT [47 m in mean P < 0.05(P = 0.035)]; in claw dynamometry (D: P = 0.048/I: P = 0.043); VO2PICO % (P = 0.035); VO2AT (P = 0.028) and in the vitality variable of the SF-36 (P = 0.033). No significant differences have been observed in the rest of variables. After a Nordic walking program the patients with LT improve the distances walked in the 6 minutes walking test and the aerobic capacity. Moreover, there is an improvement in the patient's vitality after the procedure.

INTRODUCTION:Head and neck cancer recurrence is a therapeutic challenge due to the anatomical and functional constraints of the head and neck area. Stereotactic body radiotherapy (SBRT) is a high-precision technique of radiotherapy that consists of delivering a high ablative biological dose in 1-5 high-dose fractions, requiring a very high precision of the radiotherapy process with potential application in this clinical setting METHODS: Different studies that investigate the role of SBRT in the treatment of recurrent head and neck cancer have been reviewed. Indications to properly select patients for this treatment are presented.RESULTS:Retrospective studies and phase I-II trials with selected patients have shown low to moderate toxicity, with an efficacy at least similar to that of treatment with combinations of radiotherapy and chemotherapy. In selected patients, SBRT is a treatment option for recurrent head and neck cancer with low toxicity.DISCUSSION:New prospective studies should clarify data regarding the efficacy and toxicity of SBRT in head and neck cancer recurrence.

Long-term survival after lung transplantation (LT) is limited by the development of chronic lung allograph dysfunction (CLAD). Despite this fact, a small number of lung transplant recipients are long-term survivors with a good allograft function (LTS). A study of this particular population could be a first step to search for transplant tolerance biomarkers that can lead to the reduction of immunosuppressive drugs in treatment plans and improve personalized medicine. The objective of this study was to identify leukocyte subpopulations as potential tolerance biomarkers in LTS after lung transplantation.

To analyze 4D CBCT image guided accuracy and dose volume histograms in SBRT for liver tumors. The treatment with SBRT in hepatic cancer using 4D image guidance is analyzed in this work. Patients are inmovilized employing an arm support, knee fix and a dampening system. Respiration correlated 4D CT and diagnostic CT performed using IV contrast media are used to delineate gross tumor volume (GTV). GTVs in eight 4DCT sets and two contrast sets are combined to create an internal target volume (ITV). Comparing center of mass of GTV in every respiratory phase a dampening device is selected and a set of CT images is chosen as reference for planning and simulation. In this reference CT organs at risk are contoured and it is selected to match in the daily image guided radiotherapy (IGRT). IGRT using anatomy fiducials respiration correlated 4DCBCT with automatic registration of the planning reference CT is used to setup patient in every treatment session. Results were compared for three registration techniques: 3D CBCT using mean ITV and soft tissue registration, 4dCBCT clipbox and bone anatomy registration (4D bCBCT), and 4D soft tissue registration using a 0.5 cm mask from ITV (4D mCBCT). Significant differences in ITV localization were observed between 4D mCBCT and the other modalities, up to 16.0 mm ± 6.0 mm (3D vector). The differences between 4D bCBCT and 4D mCBCT are closer than 4DbCBCT and 3D CBCT. These differences are larger when respiratory amplitude increase. Mean respiratory amplitude was 21.1 mm ± 7.0 mm when measured in simulation CT, in agreement with 20.0 ± 7.8 mm when measured in 4D CBCT. Visual comparison of reference respiratory curve and treatment daily respiratory curve makes possible to asses reproducibility of patients and tumor position reproducibility. Interobserver variability was reduced using 4D mCBCT and soft tissue automatic registration. With this protocol we can assert that interpatient variability in dose volume histograms is due mainly to treatment planning technique and tumor volume definition, and not directly correlated with motion amplitude. Respiration correlated 4D CBCT with soft tissue registration improves accuracy of IGRT because of the more precise target localization in the presence of respiratory motion, allowing the comparison of reference respiratory curve with treatment respiratory curve. Moreover, this method enables the realization of 4D CBCT without external surrogates with good correlation with reference 4D CT using external sensors.