SU-E-J-19: How Should CTV to PTV Margin Be Created - Analysis of Set-Up Uncertainties of Different Body Parts Using Daily Image Guidance

PURPOSE

The objective for this study is to systematically evaluate how the CTV to PTV margin should be created to compensate for setup error as afunction of treatment site.

METHODS

A total of 1757 setup MVCT images were analyzed using the registration between the MVCT and planning KVCT images. Among them, 526 images were from patients with head and neck cancers; 342 were from thoracic site; 447 from upper abdomen and 442 from patients treated at pelvic region. The correction was shifts in 3 directions from setup with skin marks to final treatment position due to volumetric image registration. Registration was based on soft tissue anatomy when tumor was visible in both KVCT and MVCT. Otherwise, bony landmarks were used when tumors could not be identified.

RESULTS

The anterior to posterior (A/P) direction requires the smallest correction for all body sites. The percentage of treatment with < 3mm set-up correction in A/P direction was 82.4%-96.0% for all disease sites. In medial to lateral direction (M/L), that number was 51.5%-74.7%. The largest set-up correction occurred in the superior to inferior (S/I) direction. As a function of the body site, 68.6% of head and neck patient had <3mm shift in the S/I direction. However, that number dropped to 41.8%〠42.5% and 31.9% for thoracic, upper abdomen and pelvic sites respectively. In addition, 48.0% of pelvic tumor required >5mm shift in the S/I direction. For thoracic and abdominal tumors, there were still 34.9% and 30.7% of the treatments where >5mm shift in the S/I direction was needed.

CONCLUSIONS

Uniform expansion margins in all directions are often used in radiation oncology practice. Our study showed setup error was directionally dependent. Therefore, non-uniform margin should be applied. Smaller margin can be used in A/P while larger expansion needs to be given in the S/I direction.

Development and application of a loop-mediated isothermal amplification assay for rapid detection of Borrelia burgdorferi s. l. in ticks

A loop-mediated isothermal amplification (LAMP) assay was developed to detect Borrelia burgdorferi s. l. in ticks, which is a pathogen that causes Lyme disease. Cross-reactions with Chlamydia psittaci, Mycoplasma mycoides subsp. capri and some tick-borne pathogens were excluded. Analytical sensitivity of LAMP showed its detection limit was from 0.02 to 0.2 pg of DNA in detection of the reference samples at 65°C for 40 min. The performance of LAMP was assessed by testing 110 samples from susceptible tick species and comparing the results with conventional and nested PCR tests previously described. The results demonstrated that LAMP was significantly more sensitive than the conventional PCR (32.7% versus 15.5%, P < 0.05) and slightly more sensitive, although not significantly so, than nested PCR (32.7% versus 26.4%, P > 0.05). The assay was used to analyse a total of 1052 ticks collected from eight provinces in China. The results showed that the infection rates of B. burgdorferi s. l. varied from 12.5% to 88.9% across the different geographical sites. Selected positive samples were subjected to sequencing and sequence analysis for conformation of the accuracy of the assay. Here we report a highly sensitive, specific and easy diagnostic assay based on LAMP technology. These data indicate that LAMP is a useful approach for detecting B. burgdorferi s. l. in field-collected ticks and has the potential as an alternative tool for the ecological and epidemiological surveillance of Lyme disease.

Administration of vitamin E prevents thymocyte apoptosis in murine sarcoma S180 tumor bearing mice

Many reports claimed that thymic involution occurred in tumor bearing host, which led to a reduction of proliferation in T cells and an impaired immune system. In this study, murine sarcoma S180 tumor cells were used to establish tumor model. There was distinct apoptosis in thymus of the S180 tumor bearing host after 3-week tumor inoculation. High level reactive oxygen species generation was detected in thymocytes of S180 tumor bearers. Vitamin E, a potent antioxidant, was oral administrated to S180 tumor bearing mice in order to eliminate redundant ROS in the host and evaluate the effect against thymic apoptosis. Intact thymic structure and less apoptosis of thymocytes demonstrated that partial restoration of thymuses in S180 tumor bearing mice after 3—week VE treatment. Besides, VE treatment normalized ROS level, MDA level and SOD level of S180 tumor bearers. Thus, it could be concluded that thymic involution prevented by VE treatment in S180 tumor bearing mice was mainly due to inhibition of apoptosis in thymus and elimination of ROS over—production in the host.

Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study

OBJECTIVES

The aim of this study was to examine a large cohort of adults who received the zoster vaccine for evidence of an increased risk of prespecified adverse events requiring medical attention.

DESIGN

Two self-comparison approaches, including a case-centred approach and a self-controlled case series (SCCS) analysis were used.

SETTING

Eight managed-care organizations participating in the Vaccine Safety Datalink project in the United States.

SUBJECTS

A total of 193 083 adults aged 50 and older receiving a zoster vaccine from 1 January 2007 to 31 December 2008 were included.

MAIN OUTCOME MEASURES

Prespecified adverse events were identified by aggregated International Classification of Diseases, Ninth Revision (ICD-9) codes in automated health plan datasets.

RESULTS

The risk of allergic reaction was significantly increased within 1-7 days of vaccination [relative risk = 2.13, 95% confidence interval (CI): 1.87-2.40 by case-centred method and relative rate = 2.32, 95% CI: 1.85-2.91 by SCCS]. No increased risk was found for the following adverse event groupings: cerebrovascular events; cardiovascular events; meningitis; encephalitis; and encephalopathy; and Ramsay-Hunt syndrome and Bell's palsy.

CONCLUSIONS

The results of this study support the findings from the prelicensure clinical trials, providing reassurance that the zoster vaccine is generally safe and well-tolerated with a small increased risk of allergic reactions in 1-7 days after vaccination.

Precision placement of separated dairy sludge improves early phosphorus nutrition and growth in corn ( L.)

Efficient use of manure nutrients by crops is necessary to minimize losses to the environment. This field study examined the possibility of replacing side-banded mineral P with precision-placed high-P sludge (6.2-11.0% dry matter) obtained after settling dairy manure slurry. The sludge was injected at about 30 kg P ha (36.0-51.2 m ha) into the soil at corn row spacing, and the corn was planted 5, 10, and 15 cm beside the injection furrow. Controls included no added P and side-banded commercial P fertilizer. The treatments were tested on corn with low and high root colonization by arbuscular mycorrhizae (AM). The study showed that sludge did not impede AM root colonization, corn germination, or seedling growth. Corn plants with both high and low levels of AM colonization responded to the sludge from the three-leaf stage and showed the greatest benefit at the six-leaf stage. Corn responded more to sludge placed at 5 than at 15 cm from the corn rows, whereas the response at the 10-cm spacing was intermediate. There was little difference in seedling growth or final harvest parameters between the side-banded fertilizer P and the 5-cm sludge treatment. The results show a new way to use manure nutrients, namely precision-placement sludge for corn. This may obviate the need for chemical fertilizers for improving farm nutrient balances. Other anticipated benefits are less energy use for hauling and injection of the sludge fraction and reduced risk of nutrient loss by runoff and volatilization (ammonia) and nuisance odors due to injection.

First Report of Multiple Species of the Botryosphaeriaceae Causing Bot Canker Disease of Indian Laurel-Leaf Fig in California

Indian laurel-leaf fig (Ficus microcarpa L.) is a commonly used indoor and outdoor ornamental tree. F. microcarpa is most frequently encountered as lining city streets, especially in warmer southern California climates. A disease known as 'Sooty Canker,' caused by the fungus Nattrassia mangiferae (Syd. & P. Syd) B. Sutton & Dyko, is particularly devastating on F. microcarpa. Disease symptoms are characterized by branch dieback, crown thinning, and if the disease progresses to the trunk, eventual tree death (2). Recent taxonomic revisions have renamed Nattrassia mangiferae as Neofusicoccum mangiferae (Syd. & P. Syd.) Crous, Slippers & A. J. L. Phillips (1). An initial survey conducted during the spring of 2011 across four cities in Los Angeles County included, Culver City, Lakewood, Santa Monica, and Whittier. Five symptomatic branches per city were collected from trees showing branch cankers and dieback. Pieces of symptomatic tissue (2 mm²) were plated onto one-half-strength potato dextrose agar. Most isolates initially identified by morphological characteristics, such as growth pattern, speed of growth, and colony color, resembled those in the Botryosphaeriaceae (4). Two representative isolates from each site location were sequenced. Sequences obtained from amplification of the internal transcribed spacer region (ITS1-5.8rDNA-ITS2) and the β-tubulin gene were compared in a BLAST search in GenBank. Results identified isolates as Botryosphaeria dothidea (identity of 99% to EF638767 and 100% to JN183856.1 for ITS and β-tubulin, respectively); Neofusicoccum luteum (100% to EU650669 and 100% to HQ392752); N. mediterraneum (100% to HM443605 and 99% to GU251836); and N. parvum (100% to GU188010 and 100% to HQ392766) and have been deposited in GenBank with the following accession numbers: JN543668 to JN543671 (ITS) and JQ080549 to JQ080552 (β-tubulin). Pathogenicity tests were conducted in the greenhouse on 6-month-old F. microcarpa with one isolate from each previously listed fungal species. Five plants per isolate were stem-wound inoculated with mycelial plugs and wrapped with Parafilm. Uncolonized agar plugs were used as a control. Inoculations were later repeated a second time in the same manner for a total of 10 plants per isolate. Plants were observed for 6 weeks and destructively sampled to measure vascular lesion lengths. Mean vascular lesion lengths were 26, 22, 54, and 46 mm for B. dothidea, N. luteum, N. mediterraneum, and N. parvum, respectively. The mean lesion lengths for all isolates were significantly different (P = 0.05) from the control. Each species was consistently recovered from inoculated plants, except the control, thus fulfilling Koch's postulates. To our knowledge, this is the first report on the pathogenicity of multiple Botryosphaeriaceae species causing branch canker and dieback on F. microcarpa in California. These results are significant since trees along sidewalks in southern California are often crowded and undergo extensive root and branch pruning and some Botryosphaeriaceae spp. are known to enter its host through wounds caused by pruning or mechanical injury (2,3). Further sampling is imperative to better assess the distribution of these canker-causing fungal pathogens on F. microcarpa. References: (1) P. W. Crous et al. Stud. Mycol. 55:235, 2006. (2) D. R. Hodel et al. West. Arborist 35:28, 2009. (3) V. McDonald et al. Plant Dis. 93:967, 2009. (4) B. Slippers et al. Fungal Biol. Rev. 21:90, 2007.

CXCL13 activation of c-Myc induces RANK ligand expression in stromal/preosteoblast cells in the oral squamous cell carcinoma tumor-bone microenvironment

CXC chemokine ligand-13 (CXCL13) has been implicated in oral squamous cell carcinoma (OSCC) tumor progression and osteolysis. The tumor necrosis factor family member RANKL (receptor activator of NF-κB ligand), a critical bone resorbing osteoclastogenic factor, has an important role in cancer invasion of bone/osteolysis. Here, we show high-level expression of CXCL13 in primary human OSCC tumor specimens; however, human bone marrow-derived stromal (SAKA-T) and murine preosteoblast (MC3T3-E1) cells produce at very low level. Recombinant CXCL13 (0-15 ng/ml) dose dependently induced CXCR5 expression in SAKA-T and MC3T3-E1 cells. Conditioned media obtained from OSCC cell lines increased the RANKL expression and an antibody against the CXCL13 specific receptor, CXCR5 markedly decreased RANKL expression in these cells. Furthermore, CXCL13 increased hRANKL-Luc promoter activity. Superarray screening identified c-Myc and NFATc3 transcription factors upregulated in CXCL13-stimulated SAKA-T cells. Immunohistochemical analysis of OSCC tumors that developed in athymic mice demonstrated RANKL and NFATc3 expression in tumor and osteoblast cells, however, showed p-c-Myc expression specific to osteoblastic cells at the tumor-bone interface. We further identified NFATc3 expression, but not c-Myc activation in primary human OSCC tumor specimens compared with adjacent normal tissue. Also, CXCL13 significantly increased p-ERK1/2 in SAKA-T and MC3T3-E1 cells. siRNA suppression of c-Myc expression markedly decreased CXCL13-induced RANKL and NFATc3 expression in preosteoblast cells. Chromatin-immuno precipitation assay confirmed p-c-Myc binding to the hRANKL promoter region. In summary, c-Myc activation through CXCL13-CXCR5 signaling axis stimulates RANKL expression in stromal/preosteoblast cells. Thus, our results implicate CXCL13 as a potential therapeutic target to prevent OSCC invasion of bone/osteolysis.

Simultaneous detection of piroplasma infections in field Haemaphysalis qinghaiensis ticks by reverse line blotting

Piroplasmosis is caused by tick-borne haemoprotozoan parasites in the genera of Theileria and Babesia, in which numbers of agents are highly pathogenic for cattle, sheep and goats. We developed a reverse line blot (RLB) assay for detection and differentiation of four different parasites, in which 18S ribosomal RNA gene sequence was amplified with a set of universal primers specific for all members in the genera of Theileria and Babesia; and the probes were designed on the basis of hypervariable region 4 (V4 region) of 18S rRNA gene. Three Theileria and one Babesia can be detected simultaneously on this system and it was sensitive to detect a parasitemia level between 10(-5) and 10(-8)%. A total of 149 Haemaphysalis qinghaiensis ticks collected from Lintan County of Gannan Tibetan Autonomous Region was tested by RLB. Among these, 136 tick samples were also tested by a nested PCR assay developed previously. After comparison of these results, it showed that more T. luwenshuni was detected in RLB assay, while more T. uilenbergi was detected in H. qinghaiensis ticks by nested PCR. The RLB has shown capability for simultaneous detection of four species of piroplasm in H. qinghaiensis ticks, indicating its usefulness for epidemiological studies of piroplasmosis.

ETS1 transcriptional activity is increased in advanced prostate cancer and promotes the castrate-resistant phenotype

Advanced disease accounts for the majority of prostate cancer-related deaths and androgen deprivation therapy (ADT) is the standard of care for these patients. Many patients undergoing ADT become resistant to its effects and progress to castrate-resistant prostate cancer (CRPC). Current therapies for CRPC patients are inadequate, with progression-free survival rates as low as 2 months. The molecular events that promote CRPC are poorly understood. ETS (v-ets erythroblastosis virus E26 oncogene) transcription factors are regulators of carcinogenesis. Protein levels of the archetypical ETS factor, ETS1, are increased in clinical and latent prostate cancer relative to benign prostatic hyperplasia and normal prostate to promote multiple cancer-associated processes, such as energy metabolism, matrix degradation, survival, angiogenesis, migration and invasion. Our studies have found that ETS1 expression is highest in high-grade prostate cancer (Gleason 7 and above). Increased ETS1 expression and transcriptional activity promotes an aggressive and castrate-resistant phenotype in immortalized prostate cancer cells. Elevated AKT (v-akt murine thymoma viral oncogene homolog) activity was demonstrated to increase ETS1 protein levels specifically in castrate-resistant cells and exogenous ETS1 expression was sufficient to rescue invasive potential decreased by inhibition of AKT activity. Significantly, targeted androgen receptor activity altered ETS1 expression, which in turn altered the castrate-resistant phenotype. These data suggest a role for oncogenic ETS1 transcriptional activity in promoting aggressive prostate cancer and the castrate-resistant phenotype.

Hepatic arterial perfusion is essential for the spontaneous recovery from focal hepatic venous outflow obstruction in rats

We previously observed that focal hepatic venous outflow obstruction recovered spontaneously by the formation of sinusoidal canals in a rat model of portal hyperperfusion. We aimed to investigate whether the lack of hepatic arterial perfusion aggravates parenchymal damage, decelerates recovery and influences the formation of sinusoidal canals after focal hepatic venous outflow obstruction. Rats were subjected to arterialized versus nonarterialized syngeneic liver transplantation after ligating the right median hepatic vein in the donor. Hepatic damage, microcirculation, regeneration and vascular remodeling were evaluated. In arterialized-recipients, confluent necrosis interspersed with viable periportal islands of hepatocytes, and vascularized sinusoidal canals with visible blood flow, surrounded by normal sinusoidal structure, were visible on postoperative day (POD) 2. Complete parenchymal recovery was consequently established by resorption of necrosis and hepatocyte proliferation, detected in viable portal islands and border zone. Lack of hepatic arterial perfusion caused complete necrosis in the obstruction zone without viable hepatocytes in the periportal area on POD2. Hepatocyte proliferation was only visible in the border zone. On POD28, perfused vascular structures, without neighboring normal sinusoidal structures, were observed in the scar-like area. Hepatic arterial perfusion determined the extent of hepatic necrosis, the formation of vascularized sinusoidal canals and the parenchymal recovery, after focal hepatic venous outflow obstruction.

Logistic regression analysis of biomarker data subject to pooling and dichotomization

There is growing interest in pooling specimens across subjects in epidemiologic studies, especially those involving biomarkers. This paper is concerned with regression analysis of epidemiologic data where a binary exposure is subject to pooling and the pooled measurement is dichotomized to indicate either that no subjects in the pool are exposed or that some are exposed, without revealing further information about the exposed subjects in the latter case. The pooling process may be stratified on the disease status (a binary outcome) and possibly other variables but is otherwise assumed random. We propose methods for estimating parameters in a prospective logistic regression model and illustrate these with data from a population-based case-control study of colorectal cancer. Simulation results show that the proposed methods perform reasonably well in realistic settings and that pooling can lead to sizable gains in cost efficiency. We make recommendations with regard to the choice of design for pooled epidemiologic studies.

Desensitization regimens for drug allergy: state of the art in the 21st century

Adverse reactions to drugs are increasingly being recognized as important contributions to disease in their own right as well as impediments to the best treatment of various conditions, including infectious, autoimmune, and neoplastic maladies. Rapid drug desensitization (RDD) is an effective mechanism for safely administering important medications while minimizing or entirely circumventing such adverse reactions in sensitized patients. We reviewed the literature on RDD in the last 10 years, including our experience from the Brigham and Women's Hospital Desensitization Program with hundreds of patients desensitized to a broad variety of drugs. RDD in our programme has been uniformly successful in patients with hypersensitivity reactions to antibiotics, chemotherapeutics, and monoclonal antibodies. Any reactions that occur during desensitization are generally much less severe than the initial hypersensitivity reaction to the drug, and patients have received the full dose of the desired medication 99.9% of the time out of (796) desensitizations. To date, there have been no fatalities. RDD is a safe and highly effective method for treating sensitized patients with the optimal pharmacologic agents. Its use should be expanded, but because patient safety is paramount, protocols must be created, reviewed, and overseen by allergist-immunologists with special training and experience in modern techniques of desensitization.