Long-term neurocognitive, psychosocial, and physical outcomes after prenatal exposure to radiotherapy: a multicentre cohort study of the International Network on Cancer, Infertility, and Pregnancy

BACKGROUND

The main data available on the safety of radiation during pregnancy originate from animal studies and from studies of survivors of atomic or nuclear disasters. The effect of radiotherapy to treat maternal cancer on fetal development is uncertain. This report presents a unique cohort and aims to determine the long-term neurocognitive, psychosocial and physical outcomes of offspring of mothers treated with radiotherapy during pregnancy.

METHODS

In this international, multicentre, mixed retrospective-prospective cohort study, we recruited participants between Aug 5, 2006, and Aug 24, 2023, aged between 1·5 and 46 years, at three referral centres in Belgium, the Netherlands, and the USA. Participants were eligible if they were born from mothers treated with radiotherapy during pregnancy. Fetal radiation doses were obtained from medical records and participants were followed up at predefined ages (1·5, 3, 6, 9, 12, 15, and 18 years) and 5-yearly in adulthood, based on age at enrolment, using a neurocognitive test battery (measuring intelligence, attention, and memory), parent-reported executive function and psychosocial questionnaires, and a medical assessment. Results were compared with test-specific normative data. Linear regression models investigated associations between radiotherapy factors (fetal radiation dose, gestational age at the start and end of radiotherapy, and radiotherapy duration) and outcomes.

FINDINGS

68 maternal cases of radiotherapy during pregnancy were registered by the three participating centres, of which 61 resulted in a livebirth and were therefore eligible to participate in the child follow-up study. After excluding those who did not give consent, 43 participants born from 42 mothers treated with radiotherapy during pregnancy were included in the study (median age at first assessment 3 years [IQR 2-11]; median age at last assessment 12 years [9-18]; median number of assessments two [1-4]). 18 (42%) of the included participants were female and 25 (58%) male, and 37 (86%) were of White ethnicity. Mean neurocognitive outcomes of the entire cohort were within normal ranges. No associations were found with fetal radiation dose or timing of radiotherapy during pregnancy. Six (16%) of 38 participants with neurocognitive outcomes scored lower than one SD on at least one neurocognitive outcome, three (7%) reported chronic medical conditions (spasmophilia, spastic diplegia, and IgG deficiency), and three (7%) were diagnosed with attention-deficit hyperactivity disorder (of whom two scored lower on attention). Of ten (23%) participants with lower neurocognitive score(s), a chronic medical condition, or attention-deficit hyperactivity disorder, eight were born preterm. The remaining 33 (77%) participants showed no neurocognitive, psychosocial, or chronic physical problems.

INTERPRETATION

We show on average normal neurocognitive, psychosocial, and physical outcomes after prenatal exposure to radiotherapy. Differences in outcomes could not be explained by exposure to radiotherapy during pregnancy. These results suggest that extra-abdomino-pelvic radiotherapy exposure during pregnancy in general does not adversely affect outcomes of liveborn children. Further research with a larger sample is necessary to confirm these findings.

FUNDING

Kom Op Tegen Kanker, KWF Kankerbestrijding, Stichting Tegen Kanker, Research Foundation Flanders.

Fluorescent annulated imidazo[4,5-c]isoquinolines via a GBB-3CR/imidoylation sequence - DNA-interactions in pUC-19 gel electrophoresis mobility shift assay

Herein we report the development of a sequential synthesis route towards annulated imidazo[4,5-c]isoquinolines comprising a GBB-3CR, followed by an intramolecular imidoylative cyclisation. X-Ray crystallography revealed a flat 3D structure of the obtained polyheterocycles. Thus, we evaluated their interactions with double-stranded DNA by establishing a pUC-19 plasmid-based gel electrophoresis mobility shift assay, revealing a stabilising effect on ds-DNA against strand-break inducing conditions.

Cost-effectiveness of immediate total-body CT in patients with severe trauma (REACT-2 trial)

BACKGROUND

The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT (standard work-up (STWU)) during the initial trauma evaluation.

METHODS

In this multicentre RCT, adult patients with a high suspicion of severe injury were randomized in-hospital to iTBCT or STWU. Hospital healthcare costs were determined for the first 6 months after the injury. The probability of iTBCT being cost-effective was calculated for various levels of willingness-to-pay per extra patient alive.

RESULTS

A total of 928 Dutch patients with complete clinical follow-up were included. Mean costs of hospital care were €25 809 (95 per cent bias-corrected and accelerated (bca) c.i. €22 617 to €29 137) for the iTBCT group and €26 155 (€23 050 to €29 344) for the STWU group, a difference per patient in favour of iTBCT of €346 (€4987 to €4328) (P = 0.876). Proportions of patients alive at 6 months were not different. The proportion of patients alive without serious morbidity was 61.6 per cent in the iTBCT group versus 66.7 per cent in the STWU group (difference -5.1 per cent; P = 0.104). The probability of iTBCT being cost-effective in keeping patients alive remained below 0.56 for the whole group, but was higher in patients with multiple trauma (0.8-0.9) and in those with traumatic brain injury (more than 0.9).

CONCLUSION

Economically, from a hospital healthcare provider perspective, iTBCT should be the diagnostic strategy of first choice in patients with multiple trauma or traumatic brain injury.

High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial

Objectives

To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning.

Methods

Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings.

Results

In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088–1.854; p < 0.010).

Conclusions

Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning.

Key points

• Total-body CT scanning in trauma results in 1.5 times more incidental findings.

• Evaluation by TBCT in trauma results in more patients with incidental findings.

• In every category of clinical relevance, TBCT detects more incidental findings.

Pharmacological insight into the anti-inflammatory activity of sesquiterpene lactones from Neurolaena lobata (L.) R.Br. ex Cass

PURPOSE

Neurolaena lobata is a Caribbean medicinal plant used for the treatment of several conditions including inflammation. Recent data regarding potent anti-inflammatory activity of the plant and isolated sesquiterpene lactones raised our interest in further pharmacological studies. The present work aimed at providing a mechanistic insight into the anti-inflammatory activity of N. lobata and eight isolated sesquiterpene lactones, as well as a structure-activity relationship and in vivo anti-inflammatory data.

METHODS

The effect of the extract and its compounds on the generation of pro-inflammatory proteins was assessed in vitro in endothelial and monocytic cells by enzyme-linked immunosorbent assay. Their potential to modulate the expression of inflammatory genes was further studied at the mRNA level. In vivo anti-inflammatory activity of the chemically characterized extract was evaluated using carrageenan-induced paw edema model in rats.

RESULTS

The compounds and extract inhibited LPS- and TNF-α-induced upregulation of the pro-inflammatory molecules E-selectin and interleukin-8 in HUVECtert and THP-1 cells. LPS-induced elevation of mRNA encoding for E-selectin and interleukin-8 was also suppressed. Furthermore, the extract inhibited the development of acute inflammation in rats.

CONCLUSIONS

Sesquiterpene lactones from N. lobata interfered with the induction of inflammatory cell adhesion molecules and chemokines in cells stimulated with bacterial products and cytokines. Structure-activity analysis revealed the importance of the double bond at C-4-C-5 and C-2-C-3 and the acetyl group at C-9 for the anti-inflammatory activity. The effect was confirmed in vivo, which raises further interest in the therapeutic potential of the compounds for the treatment of inflammatory diseases.

Altered gene expression in the dorsolateral prefrontal cortex of individuals with schizophrenia

The underlying pathology of schizophrenia (SZ) is likely as heterogeneous as its symptomatology. A variety of cortical and subcortical regions, including the prefrontal cortex, have been implicated in its pathology, and a number of genes have been identified as risk factors for disease development. We used in situ hybridization (ISH) to examine the expression of 58 genes in the dorsolateral prefrontal cortex (DLPFC, comprised of Brodmann areas 9 and 46) from 19 individuals with a premorbid diagnosis of SZ and 33 control individuals. Genes were selected based on: (1) previous identification as risk factors for SZ; (2) cell type markers or (3) laminar markers. Cell density and staining intensity were compared in the DLPFC, as well as separately in Brodmann areas 9 and 46. The expression patterns of a variety of genes, many of which are associated with the GABAergic system, were altered in SZ when compared with controls. Additional genes, including C8orf79 and NR4A2, showed alterations in cell density or staining intensity between the groups, highlighting the need for additional studies. Alterations were, with only a few exceptions, limited to Brodmann area 9, suggesting regional specificity of pathology in the DLPFC. Our results agree with previous studies on the GABAergic involvement in SZ, and suggest that areas 9 and 46 may be differentially affected in the disease. This study also highlights additional genes that may be altered in SZ, and indicates that these potentially interesting genes can be identified by ISH and high-throughput image analysis techniques.

Rapid identification of sibutramine in dietary supplements using a stepwise approach

Adulteration of botanical food supplements with undeclared synthetic drugs is a common problem. One of the most affected product groups are the slimming agents. There are no analytical protocols for the detection of synthetic adulterants from these products. The present study aimed at the development of a multistep analytical method for the quick and reliable determination of sibutramine, one of the most common adulterants among botanical food supplements. The extract of a sibutramine-containing slimming formula was analysed by colour tests, TLC, HPLC-DAD, MS and NMR. The multistep method proposed by the authors allows the quick identification of sibutramine in counterfeit samples in laboratories with different instrumentation.

[Comparison of the iCare tonometer with the Goldmann tonometer in Malawi]

BACKGROUND

The risk for glaucoma is 4-5 times higher in patients from sub-Saharan Africa. Thus, especially in developing countries an easy and effective method for assessing the intraocular pressure (IOP) is needed.

METHODOLOGY

In this hospital-based survey 150 eyes were divided into 3 groups concerning the IOP (group I < 16 mmHg, group II 16-23 mmHg and group III > 23 mmHg) and underwent examination with ultrasound pachymetry followed by iCare tonometry (ICT) and Goldmann applanation tonometry (GAT). Agreement of the measurements by two tonometers was assessed with the Bland-Altman method and the influence of the central corneal thickness (CCT) on the ICT measurements was determined.

RESULTS

The mean difference between the IOD measured with GAT and ICT was 0.84 ± 2.63 mmHg. The differences were similar in all three groups (0.77-0.97 mmHg), however, the standard deviation in group III (4.04 mmHg) was greater than in groups I (1.98 mmHg) and II (1.79 mmHg). The mean CCT was 513.51 ± 36.22 µm.

CONCLUSIONS

The agreement of measurements by GAT and ICT was good for lower IOP values but less accurate in patients with higher IOP values (group III). A dependency of the CCT on the ICT measurements was observed. In comparison to other countries the lowest CCTs were found in Malawian patients.

Constituents of Carpobrotus edulis inhibit P-glycoprotein of MDR1-transfected mouse lymphoma cells

A bioassay-guided separation protocol, including the testing of the extracts, fractions and pure compounds for their ability to inhibit P-glycoprotein (the efflux pump responsible for the multidrug resistance of the used cell line) of mouse lymphoma cells containing the human efflux pump gene MDR1, led to the isolation of seven compounds from the chloroform and ethyl acetate soluble fractions of the methanolic extract of Carpobrotus edulis. The compounds were identified by 1D, 2D NMR and MS investigations as triterpens (beta-amyrin, uvaol and oleanolic acid), monogalactosyldiacylglycerol, catechin, epicatechin and procyanidin B5. Uvaol was the most effective and promising compound in the reversal of multidrug resistance in MDR mouse lymphoma cell line.

Assessment of a biliary hamartoma with contrast-enhanced sonography using two different contrast agents

A 49 year old male with carcinoma of the esophagus was staged using conventional US of the abdomen. US revealed signs of cirrhosis and a hyporeflexive focal liver lesion of about 5 mm in diameter was found. Low-MI contrast-enhanced ultrasound (CEUS) with SonoVue (Bracco, Milano, Italy) showed an enhancement pattern which was typical for benign liver lesions while high-MI CEUS with Levovist (Schering, Berlin, Germany) revealed a contrast defect in the liver late phase (4:30 min p. i.) which is typical for a malignant lesion. Due to these findings the lesion was evaluated as a potentially malignant lesion and a biopsy was performed. Histology showed a benign biliary hamartoma and incomplete cirrhosis. The findings confirmed that liver-specific contrast agents have the ability to detect very small focal liver lesions not derived from hepatic tissue but may lead to a misinterpretation as a malignant lesion. Nevertheless biliary duct adenomas are benign lesions with almost the same perfusion properties as normal liver parenchyma. Therefore, while using SonoVue, such a misinterpretation of these very common but in most cases very small and not detectable lesions seems unlikely.

Quantitative assessment of iron-oxide-enhanced magnetic resonance imaging of the liver: Vessel isointensity is a potential characteristic of liver hemangiomas on late T1-weighted images

PURPOSE

To test whether a new quantitative measure, the tumor-to-vessel ratio, obtained from late post-iron-oxide-enhanced T1-weighted images allows for differentiating hemangiomas from liver metastases or all malignant liver lesions.

MATERIAL AND METHODS

Twenty-six patients (mean 57, range 33-79 years) were prospectively studied at 1.5T magnetic resonance imaging (MRI) with a T1-weighted 2D fast low-angle shot (FLASH) sequence (repetition time/echo time/flip angle; 200 ms/4.8 ms/90 degrees ) and a T2-weighted turbo spin-echo sequence (4072 ms/99 ms/180 degrees ). Imaging was carried out before and at intervals up to 18 min after IV injection of Ferucarbotran (Resovist, Schering, Germany). In 19 patients, one representative malignant lesion was analysed. Eleven hemangiomas were evaluated in 7 patients. Two readers performed a consensus reading with a signal intensity measurement in a lesion, normal liver and hepatic veins, from which ratios were computed.

RESULTS

On T1-weighted iron-oxide-enhanced MRI of 30 lesions, tumor-to-vessel signal intensity ratios were distinct in hemangiomas (median 1.04, range 0.99-1.10) as opposed to either metastases (0.64, 0.33-0.77; P < 0.05) or all malignant lesions taken together (0.64, 0.33-0.98; P < 0.05), while the tumor-to-liver ratio was not.

CONCLUSION

The tumor-to-vessel ratio may help to differentiate between hemangiomas and metastases. A ratio greater than 0.98 allowed differentiating hemangiomas from metastases with a wide safety margin.

Detection of hepatic metastases with low MI real time contrast enhanced sonography and SonoVue

AIM

SonoVue is the first ultrasound contrast agent which allows repeated continuous examination of the liver in real time. The aim of this study was to compare low mechanical index (MI) real time contrast enhanced ultrasound of the liver, using the contrast agent SonoVue, with conventional B-mode sonography for the detection of hepatic metastases.

METHOD

40 patients with known malignancy and at least one liver lesion on conventional B-mode sonography were included. Conventional B-mode sonography was performed followed by contrast enhanced ultrasound (CEUS) of the liver in the arterial (< 30 sec), portal-venous (40-120 sec) and delayed phase (> 120 sec) after injection of SonoVue. CEUS was performed using contrast specific imaging and low MI (< 0.3). Number, location and size of metastases on baseline and CEUS were compared with CT or MRI (blinded reader).

RESULTS

37 patients had 128 metastases on CT or MRI. Baseline US showed 74 metastases confirmed by reference examination (69%), while CEUS yielded 109 metastases (sensitivity 90%) (p < 0.001). On CEUS, 35 additional metastases not seen on baseline but confirmed by reference imaging were detected in 14 patients (36%). In 8 patients, CEUS showed 13 metastases not seen on reference imaging.

CONCLUSION

Detection of hepatic metastases is substantially improved by low MI real time contrast enhanced ultrasound with SonoVue compared to conventional B-mode sonography.

Detection and characterisation of liver metastases

Modern liver imaging of cancer patients requires an imaging modality that is not only highly sensitive in detecting lesions but also provides reliable characterisation of lesions and thus allows differentiation of metastases from frequently found benign lesions. Conventional ultrasound (US) has a relatively poor sensitivity and specificity for imaging liver metastases and US used to be inferior to CT and MRI mainly due to a lack of contrast agents. This has changed with the advent of microbubble contrast agents for US. The use of recent contrast agents such as SonoVue (Bracco, Italy) combined with low mechanical index contrast-specific imaging techniques such as Contrast Pulse Sequencing provides dynamic real time imaging of focal liver lesions in the arterial, portal venous and delayed phase. This improves lesion detection and characterisation. To investigate the benefit of SonoVue for detecting liver metastases we studied 40 cancer patients with liver lesions on reference imaging (CT or MRI), 37 of them had metastases. The mean number of reference confirmed metastases per patient increased from 1.85+/-1.79 on conventional ultrasound to 2.73+/-2.50 post SonoVue (p < 0.05). CEUS showed more individual metastases than baseline in 12 (34%) patients. Using CT or MRI as the reference, the mean sensitivity to individual metastases increased from 69% on baseline US to 90% post contrast (p < 0.0005). The role of SonoVue in characterisation of focal liver lesions was evaluated in 63 patients. One lesion was studied per patient. Based on standardised dynamic enhancement criteria for each lesion type, the number of correctly diagnosed lesions improved from 41 (65%) on baseline US to 58 (92%) post contrast (p < 0.001). On CEUS all 27 metastases were correctly diagnosed, while baseline US misinterpreted 2 of these. The number of correctly diagnosed benign lesions (n = 28) increased from 12 (43%) on baseline to 25 (89%) post SonoVue. In conclusion, detection and characterisation of focal liver lesions by US are markedly improved by the use of SonoVue. Contrast agents add a new dimension to sonography allowing it to rival CT and MRI, especially for lesion characterisation.

In vitro search for synergy between flavonoids and epirubicin on multidrug-resistant cancer cells

The drug accumulation of a human multidrug resistance 1 (mdr1) gene-transfected mouse lymphoma cell line and a multidrug resistance protein (MRP)-expressing human breast cancer cell line MDA-MB-231 was compared in the presence of sixteen flavonoids and five isoflavonoids. The expression of the 170-kDa P-glycoprotein (P-gp) (MDR1) and 190-kDa multidrug resistance protein (MRP) in both cell lines was confirmed by immunocytochemistry. The rhodamine 123 accumulation of the P-glycoprotein (P-gp)-expressing cells increased up to 46.4, while 2,7'-bis(2-carboxyethyl)-5(6)-carboxy-fluorescein acetoxymethyl ester (BCECF-AM) accumulation of the MRP-expressing cells increased up to 1.6, in fluorescence activity ratio (FAR). Major P-gp-mediated efflux pump modifiers are formononetin, amorphigenin, rotenone and chrysin, while MRP-mediated efflux pump modifiers are formononetin, afrormosin, robinin, kaempferol and epigallocatechin. In antiproliferative assay, afrormosin, amorphigenin, chrysin and rotenone exhibited the strongest antiproliferative effects in L5178 (max. ID50: 19.70) and MDA-MB-231 cell lines (max. ID50: 55.47). In a checkerboard microplate method in vitro, furthermore, the most effective multidrug resistance (MDR) resistance modifiers, amorphigenin, formononetin, rotenone and chrysin, were assayed for their antiproliferative effects in combination with epirubicin. Rotenone and afrormosin showed additive effects. Chrysin and amorphigenin on the mouse lymphoma cell line and formononetin on the MDA-MB-231 cell line synergistically enhanced the effect of epirubicin.

Liver metastases in cancer: detection with contrast-enhanced ultrasonography

In patients with known or suspected malignancy, ultrasonography (US) is often the first choice for liver imaging because of its widespread availability and low cost. Compared with contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), the sensitivity of conventional US for detecting hepatic metastases is relatively poor. The advent of microbubble contrast agents changed this situation. Sensitivity and specificity increased substantially with the use of these contrast agents and contrast-specific imaging modes in recent years. Currently, numerous US imaging methods exist, based on Doppler techniques or harmonic imaging. They exploit the complex nonlinear behavior of microbubbles in a sound field to achieve marked augmentation of the US signal. Although microbubble contrast agents are essentially blood pool agents, some have a hepatosplenic specific late phase. Imaging during this late phase is particularly useful for improving the detection of malignant liver lesions and allows US to perform similarly to spiral CT as shown by recent studies. In addition, this late phase imaging is very helpful for lesion characterization. Low mechanical index imaging with the newer perfluor agents permits real-time imaging of the dynamic contrast behavior during the arterial, portal venous, and late phases and is particularly helpful for lesion characterization. The use of US for hemodynamic studies of the liver transit time may detect blood flow changes induced by micrometastases even before they become visible on imaging. In this field of functional imaging, further research is required to achieve conclusive results, which are not yet available.

[Ultrasound contrast agents]

Ultrasound contrast agents consist of tiny gas bubbles encapsulated by a stabilising membrane or shell. When combined with recent contrast-specific ultrasound techniques, they provide substantial enhancement of vessels and solid organs. The clinical use and the diagnostic value of ultrasound contrast agents are in principle comparable to those of contrast agents for CT and MRI. They add an additional dimension of information to sonography, which results in considerable improvement of diagnostic accuracy in many cases. This paper reviews the physicochemical properties of various microbubble contrast agents, discusses non-linear bubble behaviour and contrast-specific imaging techniques. An overview of the most important radiological clinical applications in the liver, kidney and spleen is given.