Whole-exome sequencing of individuals from an isolated population implicates rare risk variants in bipolar disorder

Bipolar disorder affects about 1% of the world's population, and its estimated heritability is about 75%. Only few whole genome or whole-exome sequencing studies in bipolar disorder have been reported, and no rare coding variants have yet been robustly identified. The use of isolated populations might help finding variants with a recent origin, more likely to have drifted to higher frequency by chance. Following this approach, we investigated 28 bipolar cases and 214 controls from the Faroe Islands by whole exome sequencing, and the results were followed-up in a British sample of 2025 cases and 1358 controls. Seventeen variants in 16 genes in the single-variant analysis, and 3 genes in the gene-based statistics surpassed exome-wide significance in the discovery phase. The discovery findings were supported by enrichment analysis of common variants from genome-wide association studies (GWAS) data and interrogation of protein-protein interaction networks. The replication in the British sample confirmed the association with NOS1 (missense variant rs79487279) and NCL (gene-based test). A number of variants from the discovery set were not present in the replication sample, including a novel PITPNM2 missense variant, which is located in a highly significant schizophrenia GWAS locus. Likewise, PIK3C2A identified in the gene-based analysis is located in a combined bipolar and schizophrenia GWAS locus. Our results show support both for existing findings in the literature, as well as for new risk genes, and identify rare variants that might provide additional information on the underlying biology of bipolar disorder.

Radiation dose intensification in pre-operative chemo-radiotherapy for locally advanced rectal cancer

BACKGROUND

To assess the role of radiation dose intensification with simultaneous integrated boost guided by 18-FDG-PET/CT in pre-operative chemo-radiotherapy (ChT-RT) for locally advanced rectal cancer.

METHODS

A prospective study was approved by the Internal Review Board. Inclusion criteria were: age >18 years old, World Health Organization performance status of 0-1, locally advanced histologically proven adenocarcinoma of the rectum within 10 cm of the anal verge, signed specific informed consent. High-dose volumes were defined including the hyper-metabolic areas of 18-FDG-PET/CT of primary tumor and the corresponding mesorectum and/or pelvic nodes with at least a standardized uptake values (SUV) of 5. A dose of 60 Gy/30 fractions was delivered. A total dose of 54 Gy/30 fractions was delivered to prophylactic areas. Capecitabine was administered concomitantly with RT for a dose of 825 mg/mq twice daily for 5 days/every week.

RESULTS

Between September 2011 and July 2015 fortypatients were recruited. At the time of the analysis, median follow up was 20 months (range 5-51). The median interval from the end of ChT-RT to surgery was 9 weeks (range 8-12). Thirty-seven patients (92.5 %) were submitted to sphincter preservation. Tumor Regression Grade (Mandard scale) was recorded as follows: grade 1 in 7 (17.5 %), grade 2 in 17 (42.5 %), grade 3 in 15 (37.5 %) and grade 4 in 1 (2.5 %). Post-surgical circumferential resection margin was negative in all patients. A tumor downstaging was reported in 62.5 % (95 % CI: 0.78-0.47). A nodes downstaging was registered in 85 % (95 % CI: 0.55-0.25). 18-FDG-PET/CT was not able to predict pCR. No correlation was found between pre-treatment SUV-max values and pCR. A metabolic tumor volume >127 cc was related to ypT ≥2 (p 0.01). Patients with TRG >2 had higher tumor lesion glycolysis values (p 0.05).

CONCLUSION

Preliminary results did not confirm some advantages in terms of primary tumor downstaging/downsizing compared to conventional schedules reported in historical series. The role of 18-FDG-PET/CT in neoadjuvant rectal cancer management needs to be confirmed in further investigations. Long terms results are necessary.

Genetic Screening in a Large Cohort of Italian Patients Affected by Primary Lymphedema Using a Next Generation Sequencing (NGS) Approach

Primary lymphedema is a rare inherited condition characterized by swelling of body tissues caused by accumulation of fluid, especially in the lower limbs. In many patients, primary lymphedema has been associated with variations in a number of genes involved in the development and maintenance of the lymphatic system. In this study, we performed a genetic screening in patients affected by primary lymphedema using a next generation sequencing (NGS) approach. With this technology, based on a custom-made oligonucleotide probe library, we were able to analyze simultaneously in each patient all the coding exons of 10 genes (FLT4, FOXC2, CCBE1, GJC2, MET, HGF, GATA2, SOX18, VEGFC, KIF11) associated with primary lymphedema. In the study population, composed of 45 familial and 71 sporadic cases, we identified the presence of rare variants with a potential pathogenic effect in 33% of subjects. Overall, we found a total of 36 different rare nucleotidic alterations, 30 of which had not been previously described. Among these, we identified 23 mutations that we considered most likely to be disease causing. Patients with an FLT4 or FOXC2 alteration accounted for the largest percentage of the sample, followed by MET, HGF, KIK11, GJC2 and GATA2. No alterations were identified in SOX18, VEGFC, and CCBE1 genes. In conclusion, we showed that NGS technology can be successfully applied to perform molecular screening of lymphedema-associated genes in large cohort of patients with a reasonable effort in terms of cost, work, and time.

Intensity modulated radiation therapy with simultaneous integrated boost in early breast cancer irradiation. Report of feasibility and preliminary toxicity

PURPOSE

To investigate the feasibility and tolerance in the use of adjuvant intensity modulated radiation therapy (IMRT) and simultaneous integrated boost in patients with a diagnosis of breast cancer after breast-conserving surgery.

PATIENTS AND METHODS

Between September 2011 to February 2013, 112 women with a diagnosis of early breast cancer (T1-2, N0-1, M0) were treated with IMRT and simultaneous integrated boost after breast-conserving surgery in our institution. A dose of 50Gy in 25 fractions was prescribed to the whole breast and an additional dose of radiation was prescribed on the tumour bed. A dose prescription of 60Gy in 25 fractions to the tumour bed was used in patients with negative margins after surgery, whereas if the margins were close (<1mm) or positive (without a new surgical resection) a dose of 64Gy was prescribed. All patients were followed with periodic clinical evaluation. Acute and late toxicity were scored using the EORTC/RTOG radiation morbidity score system. Both patient and physician recorded cosmetic outcome evaluation with a subjective judgment scale at the time of scheduled follow-up.

RESULTS

The median follow-up was 28 months (range 24-40 months). The acute skin grade toxicity during the treatment was grade 0 in 8 patients (7%), grade 1 in 80 (72%), grade 2 in 24 cases (21%). No grade 3 or higher acute skin toxicity was observed. At 12 months, skin toxicity was grade 0 in 78 patients (70%), grade 1 in 34 patients (30%). No toxicity grade 2 or higher was registered. At 24 months, skin toxicity was grade 0 in 79 patients (71%), grade 1 in 33 patients (29%). No case of grade 2 toxicity or higher was registered. The pretreatment variables correlated with skin grade 2 acute toxicity were adjuvant chemotherapy (P=0.01) and breast volume ≥700cm(3) (P=0.001). Patients with an acute skin toxicity grade 2 had a higher probability to develop late skin toxicity (P<0.0001). In the 98% of cases, patients were judged to have a good or excellent cosmetic outcome. The 2-year-overall survival and 2-year-local control were 100%.

CONCLUSION

These data support the feasibility and safety of IMRT with simultaneous integrated boost in patients with a diagnosis of early breast cancer following breast-conserving surgery with acceptable acute and late treatment-related toxicity. A longer follow-up is needed to define the efficacy on outcomes.

Dose-volume-related dysphagia after constrictor muscles definition in head and neck cancer intensity-modulated radiation treatment

OBJECTIVE

Dysphagia remains a side effect influencing the quality of life of patients with head and neck cancer (HNC) after radiotherapy. We evaluated the relationship between planned dose involvement and acute and late dysphagia in patients with HNC treated with intensity-modulated radiation therapy (IMRT), after a recontouring of constrictor muscles (PCs) and the cricopharyngeal muscle (CM).

METHODS

Between December 2011 and December 2013, 56 patients with histologically proven HNC were treated with IMRT or volumetric-modulated arc therapy. The PCs and CM were recontoured. Correlations between acute and late toxicity and dosimetric parameters were evaluated. End points were analysed using univariate logistic regression.

RESULTS

An increasing risk to develop acute dysphagia was observed when constraints to the middle PCs were not respected [mean dose (Dmean) ≥50 Gy, maximum dose (Dmax) >60 Gy, V50 >70% with a p = 0.05]. The superior PC was not correlated with acute toxicity but only with late dysphagia. The inferior PC was not correlated with dysphagia; for the CM only, Dmax >60 Gy was correlated with acute dysphagia ≥ grade 2.

CONCLUSION

According to our analysis, the superior PC has a major role, being correlated with dysphagia at 3 and 6 months after treatments; the middle PC maintains this correlation only at 3 months from the beginning of radiotherapy, but it does not have influence on late dysphagia. The inferior PC and CM have a minimum impact on swallowing symptoms.

ADVANCES IN KNOWLEDGE

We used recent guidelines to define dose constraints of the PCs and CM. Two results emerge in the present analysis: the superior PC influences late dysphagia, while the middle PC influences acute dysphagia.

Disinfection of urban wastewater by solar driven and UV lamp - TiO₂ photocatalysis: effect on a multi drug resistant Escherichia coli strain

The effect of TiO₂ photocatalysis on the inactivation of an antibiotic resistant Escherichia coli strain selected from an urban wastewater treatment plant (UWWTP) effluent was investigated. Different light sources including a 250 W wide spectrum lamp, a 125 W UV-A lamp and solar radiation, as well as, photocatalysts loadings (TiO₂ Degussa P25) in the range from 0.05 to 2.00 g TiO₂ L(-1) were evaluated. The higher efficiency (total bacterial inactivation after 10 min of irradiation) was observed in the absence of TiO₂ when the wastewater was irradiated using the 250 W lamp. In the presence of TiO₂ a decreasing inactivation trend was observed (99.76% and 72.22% inactivation after 10 min irradiation at 0.10 and 2.00 g TiO₂ L(-1) respectively). Under solar simulated conditions the highest inactivation efficiency (93.17%) after 10 min of irradiation was achieved at the lower photocatalyst loading (0.05 g TiO₂ L(-1)). The concept of "reactor optical thickness" was introduced to explain the rates of disinfection observed. The optimum photocatalyst loading estimated by radiation absorption-scattering modeling was found to be 0.1 g TiO₂ L(-1) for all lamps. The difference between experimental tests and modeling may be due to TiO₂ particles aggregation. Comparative kinetic tests between solar and solar simulated photocatalytic (SSP) processes using 0.05 g TiO₂ L(-1) in suspension showed a quite similar inactivation behavior up to 30 min of irradiation, but only the SSP process resulted in a total inactivation of bacteria after 60 min of exposure. Antibiotic resistant test (Kirby-Bauer) on survived colonies showed that the SSP and SP processes affected in different ways the resistance of E. coli strain to the target antibiotics.

Clinically relevant quality assurance for intensity modulated radiotherapy plans: gamma maps and DVH-based evaluation

PURPOSE

To explore a novel patient-dose DVH-based method for pretreatment dose quality assurance tests.

METHODS

20 IMRT plans for head-and-neck cancer patients were used. A comparison was performed between the planned dose distributions, the computed, and the reconstructed ones using the gamma-index (GI) method. The GI analysis was performed using both the 3%/3 mm and the 2%/2 mm criteria.

RESULTS

No significant DVH-deviation was observed. Considering the 3%/3 mm criteria the mean GI% < 1 for the body and structures was significantly higher compared to 2%/2 mm criteria.

CONCLUSIONS

Our results underline the importance of QA-methods based on DVH-metrics to predict the impact of delivered dose.

To evaluate the accuracy of dynamic versus static IMRT delivery using portal dosimetry

INTRODUCTION

To evaluate the delivery accuracy of dynamic (DMLC) and static (SMLC) intensity modulated radiation therapy (IMRT) techniques using portal dosimetry (PD) in Varian Eclipse Treatment Planning System.

MATERIALS AND METHODS

Seven DMLC IMRT Head and Neck plans were retrospectively generated for the study using SMLC mode at 20, 10 and 5 levels of intensity (SMLC20, SMLC10, SMLC5). Dosimetric verifications performed by PD on a total of 107 fields were evaluated using the gamma index (maximum (γmax), average (γavg), percentage of points with (γ%) ≤ 1). The images were acquired at a source-detector distance of 100 cm at gantry zero degree and also at clinically planned gantry angles.

RESULTS

For both modes, measurements are within acceptable criteria. (γ%) ≤ 1 improves by increasing SMLC levels (+3.4 % from SMLC5 to SMLC20, p < 0.001) and using DMLC (+3.9 % and +0.6 % compared to SMLC5 and SMLC20, respectively, p < 0.001). Also (γmax) parameter improves significantly by increasing SMLC levels (+22 % from SMLC5 to SMLC20) and using DMLC (+34 % and +16 % compared to SMLC5 and SMLC20, respectively). The effect of the gantry rotation influences the delivery accuracy by up to -7 % (p < 0.05). The effect of leaves travelling direction was almost negligible (1 %).

CONCLUSIONS

A good agreement between calculated and measured fluences was obtained for DMLC and SMLC techniques at higher intensity levels; however, DMLC delivery ensures the best reproduction of computed fluence maps. The gantry rotation influences the delivery accuracy in particular for SMLC modes at lower intensity levels.

Impact of machines on plan quality: volumetric modulated arc therapy and intensity modulated radiation therapy

PURPOSE

To evaluate the impact of different machines on plan quality using both intensity modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) techniques.

MATERIALS AND METHODS

Eight patients with squamous cell carcinoma of the oropharynx were selected at random. Plans were computed for IMRT and VMAT Smart Arc, using Pinnacle TPS for an Elekta (IMRT-E, VMAT-E) and Varian linac (IMRT-V, VMAT-V). A three-dose level prescription was used to deliver 70, 63 and 58.1 Gy to regions of macroscopic, microscopic high- and low-risk disease, respectively. All doses were given in 35 fractions. Comparisons were performed on dose-volume histogram data, monitor units (MU), and delivery time.

RESULTS

VMAT-E plans resulted slightly MU efficient (-24 % p < 0.05) compared to VMAT-V while IMRT-V shortened delivery time (-19 % p < 0.05) compared to IMRT-E. All the delivery techniques resulted in equivalent target coverage in terms of D(98) % and D(2) %. For VMAT technique, a significant improvement of 7 % in homogeneity index (HI) for PTV58.1 was observed for Varian machine. A slight improvement in OARs sparing was observed with Elekta machine both for IMRT and VMAT techniques.

CONCLUSION

Similar plan quality was observed for Elekta and Varian linacs, significant differences were observed in delivery efficiency, as MU number and delivery times, in favor of Elekta and Varian, respectively.

Planning target volume assessment in lung tumors during 3D conformal radiotherapy by means of an aSi electronic portal imaging device in cine mode

PURPOSE

The major uncertainties in treating lung cancer are the repositioning errors and respiratory lung tumor motion. Typically, margins are added to the clinical target volume (CTV) to obtain a planning target volume (PTV) allowing the accommodation of such uncertainties. We want to test a new technique to assess the adequacy of the chosen PTV using an aSi electronic portal imaging device (EPID).

METHODS

Four patients affected by lung cancer and treated by radical 3D conformal radiotherapy (3DRT) were studied. During treatment the EPID was used in cine mode acquisition: acquired images were used to the aim.

RESULTS AND CONCLUSIONS

Treatment monitoring with an EPID in cine mode is shown to be a clinically feasible and useful tool.

Trace metals, peroxidase activity, PAHs contents and ecophysiological changes in Quercus ilex leaves in the urban area of Caserta (Italy)

Trace metals and polycyclic aromatic hydrocarbons, severely affecting human, animal and plants health, highly contribute to the air pollution in urban areas mainly due to car traffic. In this study the air biomonitoring of the city of Caserta (South Italy) has been performed by using Quercus ilex L., a widespread ornamental plant in parks, gardens and avenues. The plant leaves from different sites within the urban area were collected and used to determine the concentrations of V, Cd, Cr, Pb, Ni, Cu, and PAHs as well as the free amino acid content and peroxidase enzyme activity as indices of the leaf physiological conditions. All the tested trace metals showed concentrations higher than the control site. Lead was positively correlated to Cd and Cr and showed, also, a positive trend with Ni and Cu that, in their turn, were highly correlated between them. Positive and significant correlations were evidenced between total PAHs and carcinogenic PAHs and negative correlations between those and all trace metals assayed except V. Cu and Cd contents evidence negative correlations with peroxidase activity, and the free amino acid contents. The PAHs, in particular Carc-PAHs, were negatively correlated to the tested heavy metals. POD was positively correlated only with V and negatively correlated with Cu and Cd.

[Adjuvant radiochemotherapy in the elderly affected by glioblastoma: single-institution experience and literature review]

PURPOSE

Radiochemotherapy (RCT) is the standard adjuvant treatment for patients affected by glioblastoma (GBM). As there is no evidence in elderly patients with GBM, combined, single modality or best supportive care is used. The aim of this retrospective study was to evaluate acute toxicity and outcome of elderly patients with GBM treated with RCT with temozolomide (TMZ).

MATERIALS AND METHODS

Patients >65 years with newly diagnosed GBM who underwent surgery or biopsy and RCT were evaluated. Recursive Partitioning Analysis (RPA) class and National Cancer Institute--Common Toxicity Criteria (NCI-CTC) version 3 were used to classify patients and evaluate acute toxicity, respectively.

RESULTS

From April 2005 to January 2011, 35 patients (18 women and 17 men) with GBM were treated at our institution. Only 31.43% of cases underwent complete resection. Median progression-free survival (PFS) was 8 months and median overall survival (OS) 13 months. At univariate and multivariate analysis, only RPA class correlated with OS (p=0.01, p=0.03, respectively). During RCT, toxicity was mild (thrombocytopaenia G3-4, 11.43%; neurological toxicity, G3-4, 8.57%).

CONCLUSIONS

Our data suggest that RCT with TMZ seems to produce a better outcome with a mild toxicity profile in elderly patients affected by GBM.

Effect of solar radiation on multidrug resistant E. coli strains and antibiotic mixture photodegradation in wastewater polluted stream

The effect of solar radiation on the inactivation of multidrug resistant Escherichia coli (MDR) strains selected from an urban wastewater treatment plant (UWWTP) effluent and the change of their resistance to a mixture of three antibiotics (evaluated in terms of minimum inhibit concentration (MIC)) in wastewater polluted stream were investigated. The solar photodegradation of the mixture of the three target antibiotics (amoxicillin (AMX), ciprofloxacin (CPX), and sulfamethoxazole (SMZ)) was also evaluated. Additionally, since UWWTP effluents are possible sources of antibiotics and antibiotic resistant bacteria, the disinfection by conventional chlorination process of the UWWTP effluent inoculated with MDR strains was investigated too. Solar radiation poorly affected the inactivation of the two selected antibiotic resistant E. coli strains (40 and 60% after 180 min irradiation). Moreover, solar radiation did not affect strain resistance to AMX (MIC>256 μg/mL) and SMZ (MIC>1024 μg/mL), but affected resistance of the lower resistance strain to CPX (MIC decreased by 33% but only after 180 min of irradiation). Chlorination of wastewater sample strongly decreased the number of the two selected antibiotic resistant E. coli strains (99.667 and 99.999%), after 60 min of contact time at 2.0 mg/L initial chlorine concentration, but the resistance of survived colonies to antibiotics was unchanged. Finally, the solar photodegradation rate of the antibiotic mixture (1mg/L initial concentration respectively) resulted in the following order (half-life time): CPX (t(1/2)=24 min)<AMX (t(1/2)=99 min)<SMZ (t(1/2)=577 min). Accordingly, the risk of the development of resistance to SMZ in surface water is significantly higher compared to CPX and AMX.

Parotid gland volumetric changes during intensity-modulated radiotherapy in head and neck cancer

OBJECTIVE

To evaluate volumetric changes of parotid glands (PGs) during intensity-modulated radiotherapy (IMRT) in head and neck cancer patients.

METHODS

During IMRT all patients underwent kilovolt cone-beam CT (CBCT) scans to verify the set-up positioning in a protocol study. On each CBCT scan, the PGs were retrospectively contoured and evaluated with a dose-volume histogram.

RESULTS

From February to June 2011, 10 patients were enrolled. 140 CBCT scans were registered (280 PGs): for each patient, a median of 14 CBCT scans were performed (range 14-16). At the start of radiation, the average volume for ipsilateral PGs (iPGs) was 18.77 ml (range 12.9-31.2 ml), whereas for contralateral PGs (cPGs) it was 16.63 ml (range 8.3-28.7 ml). At the last CBCT scan, the average volume loss was 43.5% and 44.0% for the iPG and cPG, respectively. When we analysed the percentage of volume loss, we observed that the volume decreased by linear regression (r(2)=0.92 for iPG; r(2)=0.91 for cPG), with an average volume loss rate of 1.5% per day for both PGs. During the third week of treatment the volume of both PGs reduced by 24-30%.

CONCLUSION

Our data show that, during IMRT, the shrinkage of PGs should be taken into account. A replan could be indicated in the third week of radiotherapy.

The role of radiotherapy in adult medulloblastoma: long-term single-institution experience and a review of the literature

Medulloblastoma (MB) occurs infrequently in adult patients and standard treatment is still controversial. We report our long-term, single-institution experience of adult MB and a review of the literature. We analysed adult patients with histologically proved MB treated by postoperative radiotherapy. Primary endpoints were local control (LC), disease-free survival (DFS), and overall survival (OS). Acute toxicity was reported according to CTC-NCI score vers. 3.0 and specific neuropsychological assessment analysis was performed to define late brain toxicity. From 1990-2008, 13 patients were treated by craniospinal (CSI, 12/13) or cranial irradiation (1/13, because of bad clinical conditions). Median follow up was 101 months (64-218). Complete radiological response was observed in 12/13 patients and a partial response in 1/13. Ten-year LC, OS, and DFS were 91, 76, and 84%, respectively. Two patients died because of local and spinal progression after 13 and 62 months. Acute G3 haematological toxicity (RTOG score) was observed for one patient only. The neuropsychological analysis did not reveal late toxicity related to brain radiotherapy. This experience confirms the efficacy and safety of radiotherapy in adult MB patients, resulting in very interesting 10-year LC and OS.