Subjective assessment and IOTA ADNEX model in evaluation of adnexal masses in patients with history of breast cancer

OBJECTIVE

To evaluate the performance of subjective assessment and the Assessment of Different NEoplasias in the adneXa (ADNEX) model in discriminating between benign and malignant adnexal tumors and between metastatic and primary adnexal tumors in patients with a personal history of breast cancer.

METHODS

This was a retrospective single-center study including patients with a history of breast cancer who underwent surgery for an adnexal mass between 2013 and 2020. All patients had been examined with transvaginal or transrectal ultrasound using a standardized examination technique and all ultrasound reports had been stored and were retrieved for the purposes of this study. The specific diagnosis suggested by the original ultrasound examiner in the retrieved report was analyzed. For each mass, the ADNEX model risks were calculated prospectively and the highest relative risk was used to categorize each into one of five categories (benign, borderline, primary Stage I, primary Stages II-IV or metastatic ovarian cancer) for analysis of the ADNEX model in predicting the specific tumor type. The performance of subjective assessment and the ADNEX model in discriminating between benign and malignant adnexal tumors and between primary and metastatic adnexal tumors was evaluated, using final histology as the reference standard.

RESULTS

Included in the study were 202 women with a history of breast cancer who underwent surgery for an adnexal mass. At histology, 93/202 (46.0%) masses were benign, 76/202 (37.6%) were primary malignancies (four borderline and 72 invasive tumors) and 33/202 (16.3%) were metastases. The original ultrasound examiner classified correctly 79/93 (84.9%) benign adnexal masses, 72/76 (94.7%) primary adnexal malignancies and 30/33 (90.9%) metastatic tumors. Subjective ultrasound evaluation had a sensitivity of 93.6%, specificity of 84.9% and accuracy of 89.6%, while the ADNEX model had higher sensitivity (98.2%) but lower specificity (78.5%), with similar accuracy (89.1%), in discriminating between benign and malignant ovarian masses. Subjective evaluation had a sensitivity of 51.5%, specificity of 88.8% and accuracy of 82.7% in distinguishing metastatic and primary tumors (including benign, borderline and invasive tumors), and the ADNEX model had a sensitivity of 63.6%, specificity of 84.6% and similar accuracy (81.2%).

CONCLUSIONS

The performance of subjective assessment and the ADNEX model in discriminating between benign and malignant adnexal masses in this series of patients with history of breast cancer was relatively similar. Both subjective assessment and the ADNEX model demonstrated good accuracy and specificity in discriminating between metastatic and primary tumors, but the sensitivity was low. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

The single-point insulin sensitivity estimator (SPISE) index is a strong predictor of abnormal glucose metabolism in overweight/obese children: a long-term follow-up study

PURPOSE

To investigate the relationship between the single-point insulin sensitivity estimator (SPISE) index, an insulin sensitivity indicator validated in adolescents and adults, and metabolic profile in overweight/obese children, and to evaluate whether basal SPISE is predictive of impaired glucose regulation (IGR) development later in life.

METHODS

The SPISE index (= 600 × HDL^0.185/Triglycerides^0.2 × BMI^1.338) was calculated in 909 overweight/obese children undergoing metabolic evaluations at University of Cagliari, Italy, and in 99 normal-weight, age-, sex-comparable children, selected as a reference group, together with other insulin-derived indicators of insulin sensitivity/resistance. 200 overweight/obese children were followed-up for 6.5 [3.5-10] years, data were used for longitudinal retrospective investigations.

RESULTS

At baseline, 96/909 (11%) overweight/obese children had IGR; in this subgroup, SPISE was significantly lower than in normo-glycaemic youths (6.3 ± 1.7 vs. 7 ± 1.6, p < 0.001). The SPISE index correlated positively with the insulin sensitivity index (ISI) and the disposition index (DI), negatively with age, blood pressure, HOMA-IR, basal and 120 min blood glucose and insulin (all p values < 0.001). A correlation between SPISE, HOMA-IR and ISI was also reported in normal-weight children. At the 6.5-year follow-up, lower basal SPISE-but not ISI or HOMA-IR-was an independent predictor of IGR development (OR = 3.89(1.65-9.13), p = 0.002; AUROC: 0.82(0.72-0.92), p < 0.001).

CONCLUSION

In children, low SPISE index is significantly associated with metabolic abnormalities and predicts the development of IGR in life.

Circulating pro-neurotensin levels predict bodyweight gain and metabolic alterations in children

BACKGROUND AND AIMS

Neurotensin (NT) is an intestinal peptide released after fat ingestion, which regulates appetite and facilitates lipid absorption. Elevated plasma levels of its stable precursor pro-neurotensin (pro-NT) are associated with type 2 diabetes, obesity and cardiovascular mortality in adult populations; no data on pro-NT and metabolic disease are available in children. Aim of the study was to evaluate plasma pro-NT in relation to the presence of obesity in children, and to test if high pro-NT associates with the development of metabolic impairment later in life.

METHODS AND RESULTS

For this longitudinal retrospective study, we studied 151 overweight/obese children undergoing metabolic evaluations at University of Cagliari, Italy. Pro-NT was also assessed in 46 normal-weight, age-, sex-comparable normal-weight children, selected as a reference group. At the baseline, pro-NT was comparable between overweight/obese and normal-weight children and correlated positively with age (p < 0.001), triglycerides (p < 0.001) and inversely with HDL levels (p = 0.008). Plasma pro-NT associated with high triglycerides with OR = 5.9 (95%CI: 1.24-28.1; p = 0.026) after adjustment for multiple confounders. At the 6.5-year follow-up, high basal pro-NT associated with impaired β-cell function to compensate for insulin-resistance (disposition index: r = -0.19, p = 0.035) and predicted bodyweight increase, as indicated by percentage change of standard deviation score BMI (median(95%CI) = +20.8(+4.9-+27.5)% in the highest tertile), independently from age, sex, triglycerides and insulin-resistance (standardized β = 0.24; p = 0.036).

CONCLUSIONS

Elevated pro-NT levels in children are significantly associated with weight gain later in life and may represent a marker of susceptibility to metabolic impairment in presence of obesity.

Renewing primary care: the bottom-up experience of an Italian health professional movement

Sustainability of the National Health Systems (NHS) has been facing different challenges. A community-oriented Comprehensive Primary Health Care (CommOr C-PHC) could help its survival. Such a framework, focused on health promotion, primary prevention, not communicable disease management, requires new capabilities among health professionals. Considering teamwork and interprofessional collaboration (IPC) as PHC core elements, there is growing recognition of the need of interprofessional education (IPE). Nevertheless, italian medical education is distant from other disciplines and mainly based on hospital care settings. Since this situation represents an obstacle to implement a CommOr C-PHC model of health service, new ways of training students and retraining actual health workers should be developed.

The aim of the project is to design IPE programs and to improve IPC within the C-PHC framework, shared learning environments placed in the community were developed.

At the end of 2017 a group of young italian health professionals (public health resident, young general practitioner, social assistant, nurse, medical anthropologist, etc) founded the Campaign “2018 Primary Health care: Now or never”, a cultural movement of public health advocacy. Its goals are: The creation of a common cultural background through the study of PHC evidence and best italian and international practices. Organization of workshops all over Italy: peer education training session, site-visits, lectures with Italian and foreigner health professionals, based on need assessment methods.

Individuation of learning environments placed in the community and in a primary care setting where students can apprehend social determinants of health, exercise critical thinking and develop transprofessional knowledge.

Key messages

Young health professionals from Italy, starting from the need for a different educational framework, based on IPE, created a movement to defend the NHS and promote PHC principles. The success and large participation of a national campaign sustaining PHC and aimed at promoting interprofessional education shows the need for a change in the medical education field.

A public health Italian ethical movement to sustain the beveridge model: health promotion and equity

Worldwide sustainability of the National Health Systems (NHS) has been facing different challenges, such as population ageing, epidemiologic transition and deep social transformations. All these changes are struggling Italian welfare state and its public NHS. Following the principle of the Right to Health of the Declaration of Human Right and the Italian Constitution, a group of young health professionals from all over Italy founded a campaign called “2018 Primary Health care: Now or Never”(PHC Campaign) reminding WHO report of 2008 “primary Health Care: Now more than never”. This movement promotes a reform of the NHS focusing on comprehensive-PHC (C-PHC) and health promotion to guarantee sustainability of the Beveridge model italian system, fight health inequalities and answer the complexity of population needs in a period of spending cuts.

Since the beginning, the movement started an educational program through the study of the literature and the research of the Italian and international best practices of C-PHC and community health promotion. As a result, to achieve the goal of this project, PHC campaign organized peer education training sessions, educational site-visit of some Italian best practices, lectures and workshops with Italian and foreigner health professionals experts on the field. Several national and regional events had been organized all over Italy. Members of “PHC” Campaign have been invited to write books, news on web-based newspapers on this topic and participate in congresses. To date, PHC campaign might be considered one of the strongest not-institutional voices in Italy in supporting the public beveridge-model NHS

Moved from a strong ethical health policy view underlined the importance of the Right-to-Health and of a C-PHC based NHS, since the beginning, “2018 Primary Health care: Now or Never” Movement identified three asset of action: advocacy, education/knowledge and diffusion.

Key messages

The experience showed the importance of health professionals engagement in public health topics such as sustainability of public NHS in order to promote a reform towards health promotion and equity. PHC Campaign is an example of how a bottom-up ethical movement on public health from different Health professionals could actively contribute to promoting cultural and health policy change.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus

BACKGROUND

Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated.

METHODS

The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy.

DISCUSSION

To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

Real time control of water distribution networks: A state-of-the-art review

This paper presents a review of the current state of the art of real time control (RTC) of water distribution networks (WDNs). After proving the basic concept and terms of RTC and presenting sensors, regulation devices and controllers typically used in WDNs, the paper goes on by describing the most frequent control objectives, which mainly include service pressure regulation, control of tank filling and energy production in each WDN district. Various control methodologies recently proposed in the scientific literature are presented and discussed, along with experimental and numerical results achieved. Also, aspects related to the cost-effectiveness of RTC are critically analyzed. The paper ends by giving an outlook into potential future developments in the area of RTC for WDNs.

A priori prediction of the probability of survival in vehicle crashes using anthropomorphic test devices and human body models

Objective: In the development of restraint systems, anthropomorphic test devices (ATDs) and human body models (HBMs) are used to estimate occupant injury risks. Due to conflicting objectives, this approach limits an injury severity risk tradeoff between the different body regions. Therefore, we present and validate a protocol for the aggregation of injury risks of body regions to a probability of survival (PoS). Methods: Injuries were clustered in regions similar to ATD or HBM investigations and the most severe injury as rated by the Maximum Abbreviated Injury Scale (MAIS) per body region was determined. Each injury was transformed into a dichotomous variable with regard to the injury severity level (e.g., MAIS 3+) whose injury risk was computed using the German In-Depth Accident Study (GIDAS) and NASS-CDS databases. Without loss of generality, we focus on 2 body regions-Head/face/neck (HFN) and chest (C)-at the MAIS 3+ level. The PoS was calculated using injury outcomes from the databases. The method of predicting PoS was validated by stratifying the database by crash type and technical crash severity. Results: The PoS of occupants injured in both HFN and C at the AIS 3+ level was found to be lower, at a statistically significant level, than that of occupants with AIS 3+ injuries to just one of the body regions. Focusing on occupants with only one body region injured at the AIS 3+ level, HFN injuries tended to decrease PoS more than chest injuries. For the validation cases, observed PoS could be reproduced in the majority of cases. When comparing predicted to observed values, a correlation of R2 = 0.92 was observed when not taking the restraint system into account. Focusing on frontal crashes, the correlation was R2 = 0.89. Considering only belted occupants, R2 increased to 0.93, whereas for cases with deployed airbag systems the R2 decreased to 0.68. The PoS for side crashes is reproduced with R2= 0.97 independent of the restraint system; it was 0.95 with belted occupants and 0.55 when also factoring in airbag deployment. Conclusions: The method showed an excellent predictive capability when disregarding the restraint system, or restraint-specific subgroups, for the considered validation cases.

Mitomycin-c, Adriamycin, 5-Fluorouracil and Leucovorin (L-FAM2) in the Treatment of Advanced Gastric Cancer: A Phase II Study

Thirty previously untreated patients with advanced measurable gastric cancer were given a combination chemotherapy consisting of 5-fluorouracil, 400 mg/m2, and leucovorin, 200 mg/m2 iv on days 1 to 3, mitomicyn-C, 10 mg/m2 on day 1 (every other cycle) and adriamycin, 40 mg/m2 on day 2, repeated every 21 days. The overall response rate was 46 % (14/30; 95 % confidence limits: 28 %-64 %) including 4 patients with a complete remission. Eight patients progressed. Median duration of remission (CR+PR) was 10 months, with a median survival of 13, 8 and 4 months for CR + PR, NC and PD, respectively. Main toxicities were leukopenia (WHO grade III-IV in 36 % of the patients) and alopecia. One patient died from myocardial infarction after an adriamycin cumulative dose of 480 mg/m2. No other treatment-related death occurred. L-FAM2 is an effective combination for advanced gastric carcinoma. Further studies based on the association of leucovorin and 5-fluorouracil in combination with other active drugs are warranted.

Breast Cancer Estrogen and Progesterone Receptors: Associations with Patients' Clinical and Epidemiologic Characteristics

A total of 1095 patients with operable breast cancer and en-rolled in a randomized clinical trial were analysed for estrogen (ER) and progesterone (PgR) receptor content of their primary tumor, and the relationships between steroid receptor status and several epidemiologic characteristics were studied. The proportion of ER+ and median ER levels increased with age: compared to women younger than 40, those aged 66 or more were approximately three times more likely to have an ER+ tumor (OR = 3.0, 95% C.I. = 1.6–5.7). This difference tended to be more marked after comparison between patients with ER > 100 fmol/mg protein and ER- within the same age groups: OR = 7.04, 95 % C.I. = 2.89–17.12. No association emerged between age and PgR. ER status and concentrations were independent of menopausal status after adjustment for age, whereas the proportion of PgR+ and PgR levels were significantly lower in postmenopausal patients of the same age. The distribution of ER and PgR profiles was similar in relation to family history of breast cancer, reproductive events and other selected epidemiologic characteristics of the patients.

Postmastectomy Radiotherapy and Concomitant Adjuvant Chemotherapy Versus Adjuvant Chemotherapy Alone in Premenopausal Breast Cancer Patients with Positive Axillary Nodes

AIMS

To evaluate the efficacy of postmastectomy radiotherapy (RT) combined with adjuvant chemotherapy compared to adjuvant chemotherapy alone as regards overall survival (OS), overall disease-free survival (ODFS), local disease-free survival (LDFS) and distant disease-free survival (DDFS).

METHODS

We reviewed retrospectively two non-randomized groups of premenopausal high-risk breast cancer patients treated from 1985 to 1990 in the following Institutions: Department of Radiation Oncology of Brescia University, "Istituto del Radio O. Alberti" (IRA), and Department of Oncology of Brescia Hospital "Beretta Foundation" (BF). A total of 163 patients was found to satisfy the criteria of the current analysis: 81 patients received adjuvant chemotherapy alone [6 cycles CMF(1-8)] at BF and 82 patients received postoperative radiotherapy and chemotherapy [8 cycles CMF(1-21)] at IRA. A modified CMF schedule was chosen at IRA to avoid the feared increase in toxicity due to the association with RT. Primary surgical treatment was modified radical mastectomy with axillary node dissection in both cases.

RESULTS

A statistically significant improvement in OS was found in systemic adjuvant therapy patients compared to those also given RT (77.6% vs 59%; P = 0.0025). No statistically significant improvement in ODFS was found in the CMF(1-8) arm compared to the RT and CMF(1-21) stm: 51.6% vs 43.6%; P = 0.46. A statistically significant improvement in LDFS at 5 years was found in irradiated patients (89.3% vs 76.2%; P <0.05). The DDFS was also improved, although without evidence of statistical significance, in the CMF(1-8) group: at 5 years 65% vs 44% (P = 0.059).

CONCLUSIONS

The study confirmed that RT reduces the risk of local recurrence but without a statistically significant reduction in mortality. The lack of a survival benefit may somehow reflect the dose reduction in CMF(1-21). The evidence that CMF(1-8) offers undoubtable advantages over the CMF(1-21) regimen in OS and, perhaps, in distant control suggests that the dose intensity of CMF in this setting may also be important. In fact, although many CMF(1-8) patients received a dose intensity lower than 100%, 95% of them received a dose intensity higher than the maximum one of the CMF(1-21) patients. Although our results should be interpreted with caution, they seem to provide further rationale for testing the association of postoperative radiotherapy and the CMF(1-8) regimen in stage II breast cancer with positive nodes and treated with demolitive surgery, as already done in the conservative management of breast cancer, also in view of the new support therapies now available (i.e. hematologic growth factors).

Emerging and re-emerging infectious disease in otorhinolaryngology

SUMMARY

Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

Morphological changes in rat rectus abdominis muscle induced by diabetes and pregnancy

The urethral muscle of diabetic pregnant rats is affected by long-term mild diabetes and short-term severe diabetes, which plays a crucial role in the pathogenesis of pelvic floor disorders. We hypothesized that muscles outside the pelvis are subject to similar changes. The current study aimed at analyzing the effects of long-term mild and short-term severe diabetes on the structure and ultrastructure of fiber muscles and collagen in rats' rectus abdominis (RA) muscle. Therefore, the RA muscle of virgin, pregnant, long-term mild diabetic, short-term severe diabetic, long-term mild diabetic pregnant and short-term severe diabetic pregnant 3-month-old Wistar rats were collected. The structure was analyzed by picrosirius red staining, immunohistochemistry for fast and slow muscle fibers and transmission electron microscopy. We investigated two levels of STZ- induced diabetes: long-term mild diabetes (blood glucose level: 120–200 mg/dL) and short-term severe diabetes (blood glucose level >300 mg/dL). Long-term mild diabetic pregnant and short-term severe diabetic pregnant rats had decreased fast fibers and increased slow fibers, disrupted areas of sarcomere, intermyofibrillar mitochondria and myelin figures in the RA muscle. Both groups enabled us to analyze the specific influence of pregnancy, separately from diabetes. The current study demonstrated that diabetes and pregnancy induced intramuscular transformation and reorganization of RA muscle with a switch of fiber type adjusting their architecture according to intensity and duration of hyperglycemic insult within pregnancy.

In silico investigation of vertebroplasty as a stand-alone treatment for vertebral burst fractures

BACKGROUND

The use of percutaneous vertebroplasty as a stand-alone treatment for stable vertebral burst fractures has been investigated in vitro and in clinical studies. These studies present inconsistent results on the mechanical response of vertebroplasty-treated burst fractures. In addition, observations of the loss of sagittal alignment after vertebroplasty raise questions on the applicability of vertebroplasty for burst fractures. Therefore, the aim of this study was to investigate the mechanical stability of burst fractures after stand-alone treatment by vertebroplasty.

METHODS

Finite element simulations were performed with models generated from two laboratory-induced burst fractures in human thoracolumbar specimens. The burst fracture models were virtually injected with various cement volumes using a unipedicular or bipedicular approach. The models were subjected to four individual loads (compression, lateral bending, extension and torsion) and a multi-axial load case in the physiological range.

FINDINGS

All treated burst fractures showed improvements in stiffness and a reduction in inter-fragmentary displacements, thus potentially providing a suitable mechanical environment for fracture healing. However, large volumes of the trabecular bone (<43%), cement (<53%) and bone-cement composite (<58%) were predicted to experience strain levels exceeding the yield point. While damage was not specifically modeled, this implies a potential collapse of the treated vertebra due to local failure.

INTERPRETATION

To improve the primary stability and to prevent the collapse of treated burst fractures, the use of posterior instrumentation is suggested as an adjunct to vertebroplasty.

Mild diabetes models and their maternal-fetal repercussions

The presence of diabetes in pregnancy leads to hormonal and metabolic changes making inappropriate intrauterine environment, favoring the onset of maternal and fetal complications. Human studies that explore mechanisms responsible for changes caused by diabetes are limited not only for ethical reasons but also by the many uncontrollable variables. Thus, there is a need to develop appropriate experimental models. The diabetes induced in laboratory animals can be performed by different methods depending on dose, route of administration, and the strain and age of animal used. Many of these studies are carried out in neonatal period or during pregnancy, but the results presented are controversial. So this paper, addresses the review about the different models of mild diabetes induction using streptozotocin in pregnant rats and their repercussions on the maternal and fetal organisms to propose an adequate model for each approached issue.

A continuum description of the damage process in the arterial wall of abdominal aortic aneurysms

In the present work, we develop a three-dimensional isotropic finite-strain damage model for abdominal aortic aneurysm (AAA) wall that considers both the characteristic softening of the material caused by damage and the spatial variation of the material properties. A strain energy function is formulated that accounts for a hyperelastic, slightly compressible, isotropic material behavior during the elastic phase, whereas the damage process only contributes to the material response when the elastic limit of the AAA wall is exceeded. Material and damage parameters are obtained by fitting the strain energy function to the experimental data obtained by uniaxial tensile tests of freshly harvested AAA wall samples. The damage model extends the validity of the material law to a strain range of up to 50%. Purely elastic material laws for AAA wall are only valid for a strain range of up to 17%. In a series of finite element simulations of patient-specific AAAs, serving as numerical examples, we investigate the applicability of the damage model. The use of the damage model does not yield a more distinct identification of rupture-prone AAAs than other computational-based risk indices. However, the benefit of the finite-strain damage model is the potential capability to trigger growth and remodeling processes in mechanobiological models.

A multicentre Phase II study of non-pegylated liposomal doxorubicin in combination with trastuzumab and docetaxel as first-line therapy in metastatic breast cancer

To evaluate the cardiotoxicity, general toxicity, and activity of non-pegylated liposomal doxorubicin, in combination with docetaxel and trastuzumab, as first-line therapy in metastatic breast cancer. Thirty-one patients with metastatic human epidermal growth factor receptor 2-overexpressing breast cancer, who had not previously received chemotherapy for metastatic disease, received non-pegylated liposomal doxorubicin (50 mg/m(2)), docetaxel (75 mg/m(2)) and trastuzumab (2 mg/kg/week) for up to eight cycles, followed by trastuzumab alone for up to 52 weeks. Cardiotoxicity was defined as a decrease in left ventricular ejection fraction (LVEF) to below 45%, or a decrease in LVEF of at least 20% from baseline. Mean LVEF was maintained at baseline level also in the subset of patients who had received anthracycline previously. Cardiotoxicity developed in three patients during the treatment cycles, and in two further patients after the end of the study. The most common adverse events were haematological toxicity, alopecia, asthenia and fever. The best overall response rate was 65.5%. Median time to progression was 13.0 months. The combination of non-pegylated liposomal doxorubicin, docetaxel and trastuzumab combines acceptable cardiac and general toxicity and promising activity as first-line therapy in metastatic breast cancer.

Needs in breast cancer patients (pts) during chemotherapy: Customer satisfaction evaluation

e20679

Background: Satisfied patients demonstrate higher levels of compliance for the course of their treatment and the probability of successful treatment completion thus considerably increases. Analysis of pts needs is the base of pts satisfaction. The present analysis aims to identify the needs of our in-outpatients who received chemotherapy. Methods: 134 pts with breast cancer who underwent chemotherapy during 3 months (from 15 September to 30 November) were eligible for study. We administered the “Need Evaluation Questionnaire” (NED) validated by U.O. Psiconcologia Istituto Nazionale Tumori Mi) to 125 pts after consent, 9 pts (7%) refused to answer items. NED was built on 23 items in 7 domains of necessity: 1) information on diagnoses, prognoses, diagnostics tests and treatments (items 1–4); 2) relationship between pts and physicians or nurses (items 5–8), 3) nursing and supportive care (items 9 -13) 4) Hospital service (item 14); 5) economical aspects (items 15–16); 6) psychological, ethical, spiritual care (items 17,18,19,23); 7) relationship with relative. NED makes a quantitative evaluation of necessity with simple questions. Eligibility criteria required age ≥ 18 yrs (median age of pts was 55 yrs), histologically proven breast cancer; at lest 1 completed cycles of neoadjuvant or adjuvant or palliative chemotherapy. 96 (77%) pts completed questionnaire by their self, and 29 pts (23%) were helped because of practical problems (infusional therapy, no glasses at so on ). We choose a descriptive quantitative statistical evaluation for every item. Results: 93 % of pts completed NED questionnaire. More significant data were reported afterward and answers were allocated among the 7 domains: 1) more information about prognosis was required by 52 % of pts; 2) 90 % of pts thought that physicians embroiled them in therapeutic choices, but 36% of pts required information about future and quality of life 3) 96% of pts considered very good nursing care; 4) positive for all pts 5) 26% of pts required more informations about insurance, tickets 6) 13 and 14 % of pts required psychological or spiritual relationship; 7) women generally had support by relatives. Conclusions: this analysis shows that needs of our pts generally received responses, but answers also emphasized assurances on pts’ future.

No significant financial relationships to disclose.

Proliferation heterogeneity in synovial sarcoma (SS) defines different patterns of clinical outcome: A retrospective study of 32 patients

e21511

Background: SS is an aggressive soft tissue sarcoma (STS) characterized by a constitutive overexpression of the bcl-2 proteins and high proliferation rate (Ki67). The aim of the study was to evaluate prognostic value of proliferative activity and apoptosis in SS. Methods: A retrospective analysis of 32 patients treated at three oncology centers between January 2000 and August 2008 was conducted. Histologic diagnosis of SS was confirmed by FISH analysis of t(X;18). Bcl-2 and Ki67 were determined by immunohistochemistry at baseline and after neoadjuvant chemotherapy (CT). A cut-off value of 20% was established for Ki67. The bcl-2 gene status was evaluated by FISH in neoadjuvant subgroup. Treatment-induced pathological response (pCR) was defined as tumor necrosis of 100%. Endpoints were recurrence rate (RR), disease-free survival (DFS) and overall survival (OS). Clinical and pathological variables were considered in uni- and multivariate analysis. Results: 13/32 patients received an anthracycline/ifosfamide-based chemotherapy (CT) before surgery. 8 pts received concomitant radiotherapy. A median number of 3 cycles of neoadjuvant CT was administered. All patients underwent surgical resection and pathologic assessment of the coexpression of bcl-2 and Ki67 was evaluated in the resected specimens. At baseline, all samples showed immunoexpression of bcl-2 and 9/13 had Ki67 more than 20%. After neoadjuvant CT, Ki67 was downregulated <20% in 11/13 samples and bcl-2 was negative in 4/13 pts. At FISH analysis, bcl-2 gene was neither rearranged nor amplified. After a median follow-up of 21 months (range 13–64 months), 9/13 pts without pCR experienced progression disease and 5 of them were dead of SS. At uni- and multivariate analysis, both pCR and downregulation of bcl-2 and Ki67 activity had a significant impact on DFS and OS (p=0.03). Conclusions: 1. Downregulation of bcl-2 and Ki67 index after treatment could be a predictor of recurrence and overall survival. 2. SS is characterized by cellular heterogeneity in which a high proliferative compartment coexists with low proliferative/anti-apoptotic compartment with different response to treatment.

No significant financial relationships to disclose.

A multicenter phase II study of non-pegylated liposomal doxorubicin (MYOCET®) in combination with trastuzumab and docetaxel as first line therapy in metastatic breast cancer

Abstract #3156

The objective of the phase II study is to evaluate the cardiotoxicity, general safety, and efficacy of non-pegylated liposomal doxorubicin, in combination with docetaxel and trastuzumab, as first line treatment of metastatic breast cancer.&#x2028; Patients and methods: Patients (n = 31) with metastatic HER2-overexpressing breast cancer, who had not previously received chemotherapy for metastatic disease, received non-pegylated liposomal doxorubicin (50 mg/m2), docetaxel (75 mg/m2) every 3 weeks and trastuzumab (2 mg/kg/week) for up to eight cycles, followed by trastuzumab alone for up to 52 weeks. Cardiotoxicity was defined as signs and/or symptoms of congestive heart failure (CHF) and/or an absolute decrease in left ventricular ejection fraction (LVEF) of ≥ 20 units or a decline to ≤ 45%. Patients were allowed to receive adjuvant doxorubicin or epirubicin to cumulative doses up to 240 mg/m2 or 450 mg/m2, respectively.&#x2028; Results: The mean LVEF at baseline was 62.8 ± 7.1% and decreased to 60.2 ± 6.5% at cycle 2, but did not change significantly during the rest of the study; mean values at cycle 8 and at the end of the study were 58.7 ± 7.0% and 57.3 ± 9.5% respectively. One case of symptomatic CHF occurred during the study.&#x2028; The most common adverse events were hematologic toxicities, alopecia, asthenia and fever. The Overall Response Rate was 65.5% (CR 31%, PR 34.5%).The median progression free survival was 15.5 months (95% CI 11-24 months). The average overall survival was 27.9 months.Conclusions: These results suggest that the combination of non-pegylated liposomal doxorubicin, docetaxel and trastuzumab has shown a good cardiac safety profile at a long term follow up, comparatively to recent published results data in HET study. A promising efficacy including CR and PFS has been noted in 1st line MBC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3156.

Targeted therapy with trastuzumab in dysplasia and adenocarcinoma arising in Barrett's esophagus: a translational approach

AIM

Human epidermal growth factor receptor (HER2) protooncogene, overexpressed/ amplified in preneoplastic lesions and in adenocarcinoma (ADC) of the esophagus, can be considered a target for treatment of esophageal dysplasia/ADC. The aim of this study was to evaluate the therapeutic role of the anti-HER2 monoclonal antibody, trastuzumab, in the management of ADC originating from HER2-positive Barrett's esophagus (BE).

METHODS

Two patients with high-grade dysplasia and ADC of the esophagus after esophageal mucosectomy and no metastatic disease were studied. Patients were not eligible for radical surgery or chemo-radiotherapy because of age and comorbidities. HER2 status was assessed by immunohistochemistry and fluorescence in situ hybridization. Additional immunohistochemical analyses were performed. The whole panel was analysed at baseline, after treatment and at follow-up.

RESULTS

At baseline, the two patients showed HER-2 overexpression/amplification in all areas of dysplasia and ADC but not in BE. Six months after treatment no significant differences in terms of endoscopical and histological patterns of the disease were found. HER-2, EGFR, TOPOII-alpha and anti-ssDNA analysis demonstrated a down-regulation of these markers and increased apoptosis.

CONCLUSION

This study demonstrates that this treatment is feasible. No clear evidence of dysplasia regression was observed. However, HER2 and TopoII-alpha downregulation and induction of apoptosis occurring 6 months after treatment encourages further investigation.

Inclusive K(S);(0)K(S);(0) resonance production in ep collisions at HERA

Inclusive K_{S};{0}K_{S};{0} production in ep collisions at the DESY ep collider HERA was studied with the ZEUS detector using an integrated luminosity of 0.5 fb;{-1}. Enhancements in the mass spectrum were observed and are attributed to the production of f_{2}(1270)/a_{2};{0}(1320), f_{2};{'}(1525) and f_{0}(1710). Masses and widths were obtained using a fit which takes into account theoretical predictions based on SU(3) symmetry arguments, and are consistent with the Particle Data Group values. The f_{0}(1710) state, which has a mass consistent with a glueball candidate, was observed with a statistical significance of 5 standard deviations. However, if this state is the same as that seen in gammagamma-->K_{S};{0}K_{S};{0}, it is unlikely to be a pure glueball state.

Deep electro-hyperthermia (EHY) with or without thermo-active agents in patients with advanced hepatic cell carcinoma: Phase II study

15168

Background: Advanced HCC has no standard chemotherapy , all pts would be valuabled in clinical trials. We evaluated effectiveness and toxicity of capacitatively coupled low-frequency 13.56 MHz deep hyperthermia (Oncotherm-EHY 2000) treatment on chemo- refractory malignant primary liver cancer which underwent all other possible treatment. Methods: From February 2005 to July 2006, we enrolled 22 pts with advanced HCC. ECOG PS was 1 or O. Viral hepatic infection status was 7 HBV+, 8 HCV+, 1 HCV/HBV+. Median age was 67,5 y (range 63 -78), male/female 20/2 . 15 pts were uneligible for liver surgery, 3 pts received TACE, 1 PEI, 1 a lot of therapy. 7 pts were pre-treated with surgery, 2 also received TACE, 1 PEI and 1 a lot of therapy. 75% of pts were in stage C of BCLC classification. 2 pts had also distant metastases, 70% of pts had portal vein thromboses. 8 pts underwent only to EHY without CT. Schedule : EHY was achieved by arrangements of capacitative electrodes with a radiofrequency field of 13.56 Mhz (RF-DHT) at 80- 130 W equivalent to 41 °- 47° C for 60 minutes, 2 times/w for 5 weeks in combination with thermo-active agents . EHY was applied over 2 time a week over 1 hour as mono - combined therapy . Concomitant chemotherapy was oxaliplatin 50 mgr at fixed dose on D 1and D 15 . One cycle is 10 treatments of EHY ; 4 pts underwent 2 cycles and 2 pts to 3 cycles and 1 pt to 4 cycles . Median number of cycles was 1,5 (range 1–4), total EHY applications were 365. Results: EHY plus thermo-active drug is beneficial on clinical conditions off treated pts with an excellent compliance on out- patients. We observed 1 CR ( pt has only one bone metastases after 6 months without liver relapse), no PR, 25% of SD. Median survival time was 20’5 weeks (5 - 81+) We noted that 11 pts (50%) presented evidence of increasing well-being. Toxicity : 4 pts had skin reaction after application of EHY. In 3 pts we observed cutaneous hyperemia on the area of treatment and mild burn on the skin ; all symptoms disappeared after local steroid therapy , treatment was interrupted until resolution . Conclusions: Low toxicity and clinical benefit will be confirmed in further clinical studies. Capacitively coupled low-frequency 13.56 deep-hyperthermia is feasible for chemo-refractory HCC.

No significant financial relationships to disclose.

CXCR4/SDF-1 expression in early breast cancer (BC) is not influenced by circulating estrogens serum levels

21159

Background: The chemokine SDF-1 and its receptor CXCR4 have been found to enhance the metastatic potential of BC cells and correlate with a poorer prognosis of BC patients. Estradiol is a known mitogenic factor for BC cells. SDF-1 has been reported to be an estradiol (E2)-inducible autocrine growth factor that supports the growth of breast cancer cell lines in vitro. The aim of this study was to verify whether estrogens serum levels may influence SDF-1 and CXCR4 expression in vivo, in a series of patients with early stage BC. Methods: 68 patients sequentially observed at the Spedali Civili di Brescia from 2001 to 2002, with a diagnosis of T1a,b,c, N0 breast cancer were retrospectively analysed. CXCR4 and SDF-1 expression was determined by immunohistochemistry with anti-human CXCR4 (Clone 44716) and anti-human SDF-1 (Clone 79018) monoclonal antibodies (R&D Systems, Minneapolis, USA) followed by incubation with the EnVision peroxidase kit (Dakocytomation, Glostrup, Denmark). A serum sample was obtained from all patients at baseline before surgery. Serum estrone (E1) and estradiol (E2) were measured by radioimmunoassay by using commercial kits (Alifax, Padua, IT and Ortho-Clinical Diagnostics, Amersham, UK, respectively). Results: Estrogens serum levels analysis revealed elevated levels of E1 in 9/54 (16%) post-menopausal patients, while E2 levels were in the normal ranges. SDF-1 was expressed in 68/68 (100%) patients with a diffuse and intense cytoplasmatic pattern of staining and CXCR4 was coexpressed in 15/68 (22%) patients with a predominant faint nuclear distibution (p 0,06). No significant correlations were found between CXCR4, SDF-1 and E1 or E2, respectively, as well as with other clinico-pathological characteristics. After a median follow-up of 48 months, 3/68 (4%) patients which all resulted CXC4/SDF1-positive, relapsed and are dead for metastatic disease. Conclusions: This study demonstrates that in T1N0 BC patients: 1) SDF-1 is high levels in the majority of cases; 2) CXCR4 is expressed in approximately 20% of cases with restriction to the nucleus and 3) serum levels of circulating E2 and E1 in pre- or post-menopausal patients, respectively, do not influence CXCR4/SDF-1 expression on breast cancer cells.

No significant financial relationships to disclose.

Loss of CXCR4 nuclear immunoreactivity in synovial sarcoma (SS) correlates with poor survival

10069

Background: The chemokine receptor CXCR4 has been found to be expressed in mesenchymal neoplasms including osteosarcoma, rhabdomyosarcoma, Ewing's sarcoma and SS. Gene products of the HER oncogenic family, such as EGFR and HER2, have been described to be overexpressed in SS and we previously demonstrated coexpression of CXCR4 and EGFR but not HER2 in SS patients. In this study we analysed CXCR4 expression in terms of subcellular localization and extended results to 15 SS patients. Methods: Fifteen SS patients were included in the study. In all cases morphological diagnoses were confirmed molecularly by FISH or RT-PCR specific for t(X;18). HER2 and EGFR expression were determined by immunohistochemistry (IHC) while HER2 gene status was assessed by FISH analysis. CXCR4 expression was determined with an anti-human CXCR4 monoclonal antibody (Clone 44716, R&D Systems, Minneapolis, USA) followed by incubation with the EnVision peroxidase kit (Dakocytomation, Glostrup, Denmark). CXCR4 nuclear vs cytoplasmic expression was correlated with outcome. Results: In all samples IHC analysis for HER2 was negative and no amplification was found by FISH. EGFR expression was observed in 13/15 patients. CXCR4 immunoreactivity was identified in 9/15 cases. CXCR4 and EGFR were coexpressed in 8/15 tumors. Follow-up ranged from 9 to 127 months. After a median follow-up of 39 months, 7 patients were dead of SS, 8 patients were alive (7 of them are disease-free and one has evident disease in the retroperitoneum). All alive and disease-free patients showed nuclear CXCR4 expression whereas 6/7 dead patients expressed cytoplasmic or membrane CXCR4 (p = 0.0008). Conclusions: Loss of nuclear CXCR4 expression is associated with fatal course and may represent a novel prognostic factor. CXCR4 is frequently coexpressed with EGFR but not with HER2. In contrast with previous reports HER2 seems not involved in the carcinogenesis of SS.

No significant financial relationships to disclose.

CXCR4, EGFR and HER2 expression in patients with high-risk synovial sarcoma (SS): A clinicopathologic study

9580

Background: CXCR4 is overexpressed in many human tumors and plays important role in targeted metastasis. CXCR4 activation has been described in osteosarcoma, rhabdomyosarcoma and Ewing’s sarcoma both in vivo and in vitro, but its role has not been elucidated in SS yet. EGFR and Her2/neu, have been described to be overexpressed in patients with SS and proposed as potential therapeutic targets. Because CXCR4 and Her2 have been found to be functionally linked in breast cancer cell lines, we characterized SS in terms of CXCR4, Her2 and EGFR coexpression. Materials and Methods: Six patients sequentially observed at the Spedali Civili di Brescia from 1999 to 2005, with a diagnosis of synovial sarcoma were included in the study. The diagnosis of SS, a FISH analysis for t(X;18) was performed by using a commercial probe specific for the SYT gene breakpoint region (18q11) or by RT-PCR. Her2 and EGFR expression were determined by IHC and Her2 gene amplification by FISH analysis. CXCR4 expression was determined by IHC with anti-human CXCR4 monoclonal antibody (Clone 44716, R&D Systems) followed by incubation with the EnVision peroxidase kit (Dakocytomation, Glostrup, Denmark). Results: All patients were classified high-risk (stage III-IV) according to the AJCC/UICC VI Edition Staging System for soft tissue sarcomas. In all samples IHC analysis for Her2 was negative and no amplification was found by FISH. EGFR staining demonstrated positivity in 5 patients out of 6. CXCR4 reactivity was identified in 4 cases (nuclear staining in 3 and membrane staining in 1). CXCR4 and EGFR were coexpressed in 3 tumors. After a median follow-up of 24 months, 2 patients are dead of SS, 4 patients are alive, 3 of them are disease-free and one relapsed to the lung. The 3 patients alive and disease-free resulted positive for nuclear CXCR4 and EGFR while membrane CXCR4 was expressed in one dead patient. Conclusion: This study provides evidence that CXCR4 is expressed in cases of SS and is frequently coexpressed with EGFR but not with Her2. Due to the small size of this series it is not possible to establish any definitive prognostic or predictive value of CXCR4. However, nuclear expression of CXCR4 seems to be associated with a more indolent behaviour of the tumor and requires confirmation in larger series.

No significant financial relationships to disclose.

Alternative schedules of adjuvant temozolomide in glioblastoma multiforme: A 6-year experience

1511

Background: Temozolomide (TMZ) is an oral alkylating agent with proven efficacy in the therapy of glioblastoma multiforme (GBM). The activity of TMZ is drug-exposure dependent, however dosages are primarily limited by myelotoxicity. In the attempt to increase survival while limiting toxicity, we treated GBM patients (pts) with one of 3 alternative adjuvant TMZ schedules, including a low-dose daily regimen. Methods: We assessedthe overall survival and the development of grade 3–4 myelotoxicity in pts with GBM who were treated in our centre (November 1998-October 2005), following surgery, with one of the following TMZ schedules: standard schedule (SS: 200–300 mg/m2 × 5 days, every 28 days); extended schedule (ES: 150 mg/m2 × 7 days every 15 days); daily schedule (DS: 75 mg/m2 daily). Pts were treated until death or tumour progression. The analysis of survival was based on the Kaplan-Meier (KM) and the Cox models. Adverse events were graded according to NCICTC 3.0. Results: We evaluated 117 pts (73 m, 44 f, avg. age 57 yrs, 53% received radiotherapy, RT) with histologically diagnosed gliomas (GBM=92.3%) treated with TMZ SS (tot pts=48, RT pts=22, no. cycles: 1÷33, avg 6) or ES (tot pts=35; RT pts=19, no. cycles: 1÷43, avg 16) or DS (tot pts=34; RT pts=21, days of treatment: 25÷671, avg 212). The overall survival significantly differed among the 3 schedules (KM), with DS providing the best outcome (p=0.0357, log-rank). Median survival time was markedly increased in DS pts (DS=29.47 months; ES=15.73 months; SS=11.90 months) as well as the survival rate at 2 yrs after diagnosis (DS=51%; ES=30%; SS=21%). DS, but not ES, significantly reduced the mortality hazard ratio (HR) compared to SS (Cox: HR=0.494; IC95% 0.253–0.966, p=0.039). Grade 3–4 myelotoxicity (leukopenia, LP; neutropenia, NP; thrombocytopenia,TP) occurred less frequently with DS (NP=2.9%; TP=2.9%; any=5.9%) than with ES (LP=11.4%; NP=14.3%; TP=17.1%; any=28.6%) and SS (LP=14.6%; NP=8.3%; TP=20.8%; any=22.9%). Conclusions: In our experience with adjuvant TMZ in GBM, a continuous daily dose of 75 mg/m2 was on the whole more advantageous than a standard monthly or a biweekly regimen, as it resulted in the highest overall survival with the lowest hematologic toxicity.

No significant financial relationships to disclose.

Behavioral and electrophysiological changes induced by acetyl-L-carnitine in aged freely-moving rats

In chronically-implanted, drug-free, behaving aged Fischer rats, intracerebroventricularly (i.c.v.) and intraperitoneally (i.p.) acetyl-L-carnitine (ALCAR) injections powerfully enhanced motor behavior and head movements aimed at attention and exploratory activity. This effect was dose-dependent and associated with the abolition or substantial reduction of the incidence and duration of the spontaneous EEG generalized hypersynchronous patterns termed High Voltage Spindle (HVS), with an increase in EEG monitored theta activity. The results suggest that ALCAR may stimulate the motivational system and disrupt the hypersynchronous processes by inhibiting the GABAergic thalamic reticular neurons and/or activating the brain stem cholinergic reticular system (pedunculo pontine tegmental, PPT and laterodorsal tegmental, LDT nuclei).

Supervised machine learning techniques for the classification of metabolic disorders in newborns

MOTIVATION

During the Bavarian newborn screening programme all newborns have been tested for about 20 inherited metabolic disorders. Owing to the amount and complexity of the generated experimental data, machine learning techniques provide a promising approach to investigate novel patterns in high-dimensional metabolic data which form the source for constructing classification rules with high discriminatory power.

RESULTS

Six machine learning techniques have been investigated for their classification accuracy focusing on two metabolic disorders, phenylketo nuria (PKU) and medium-chain acyl-CoA dehydrogenase deficiency (MCADD). Logistic regression analysis led to superior classification rules (sensitivity >96.8%, specificity >99.98%) compared to all investigated algorithms. Including novel constellations of metabolites into the models, the positive predictive value could be strongly increased (PKU 71.9% versus 16.2%, MCADD 88.4% versus 54.6% compared to the established diagnostic markers). Our results clearly prove that the mined data confirm the known and indicate some novel metabolic patterns which may contribute to a better understanding of newborn metabolism.

Spontaneous K-complexes in behaving rats

The K-complex (KC) is an electrographic rhythmic pattern present in human and cat sleep EEG. In long-term multisite videoEEG recordings in behaving Sprague-Dawley (SD) rats, well-defined spontaneous KCs were observed during sleep. Sprague-Dawley rats were implanted with multiple electrodes bilaterally along the antero-posterior axes at the locations F1, F2, F7, F8, T3, T4, P3, P4, all against a ground reference placed in the midline above the cerebellum. Multiple, closely spaced cortical electrodes allowed two-dimensional surface brain mapping of the power spectra distribution. Two silver wires were also inserted into nuchal muscles to record EMG activity. Each rat was monopolarly recorded from 0900 h to 1500 h in a natural dark-light rodents, we examined the patterns of appearance in various conditions, the progression through a full sleep-waking cycle, the shape, density, spectral components, and spatial distribution in power spectra. The rat KC appears to share similar features with the human and cat KC.

[Accidents among ambulance employees: epidemiologic features]

The accidents have been esteemed that are verified in four years in a group of 824 employees. The study has underlined a meaningful percentage (30.1%) of road accidents. This suggests the opportunity of contemplate preventive actions: corrected maintenance of the ambulance, control of the conditions of environmental comfort, organization of the job, individualization of conditions that reduces the attention and the concentration, as the use of alcohol and of other substances.