Locally advanced squamous cervical carcinoma (M0): management and emerging therapeutic options in the precision radiotherapy era

Squamous cervical carcinoma (SCC) requires particular attention in diagnostic and clinical management. New diagnostic tools, such as (positron emission tomography-magnetic resonance imaging) PET-MRI, consent to ameliorate clinical staging accuracy. The availability of new technologies in radiation therapy permits to deliver higher dose lowering toxicities. In this clinical scenario, new surgical concepts could aid in general management. Lastly, new targeted therapies and immunotherapy will have more room in this setting. The aim of this narrative review is to focus both on clinical management and new therapies in the precision radiotherapy era.

Oligometastatic sarcoma treated with Curative intent Ablative Radiotherapy (OSCAR): A multicenter study on behalf of AIRO (Italian association of Radiotherapy and clinical Oncology)

BACKGROUND AND PURPOSE

Stereotactic Ablative Radiotherapy (SABR) is emerging as a valid alternative to surgery in the oligometastatic setting in soft tissue sarcomas (STS), although robust data are lacking. The aim of this study is to evaluate toxicity and efficacy of SABR in oligometastatic STS.

MATERIALS AND METHODS

This is a retrospective multicenter study including adult patients affected by stage IV STS, treated with SABR for a maximum of 5 cranial or extracranial metastases in up to 3 different organs. SABR was delivered with ablative purposes. Study endpoints were overall survival (OS), local control (LC), distant progression free survival (DPFS), time to polymetastatic progression (TTPP), time to new systemic therapy (TTNS) and toxicity.

RESULTS

From 10 Italian RT centers, 138 patients (202 metastases) treated between 2010 and 2022 were enrolled in the study. Treatment was generally well tolerated, no acute or late toxicity ≥ G3 was recorded. Median follow up was 42.5 months. Median OS was 39.7 months. Actuarial OS at 1 and 2 years was 91.5 % and 72.7 %. Actuarial LC at 1 and 2 years was 94.8 % and 88.0 %. Median DPFS was 9.7 months. Actuarial DPFS at 1 and 2 years was 40.8 % and 19.4 %.

CONCLUSION

SABR is a safe and effective approach for the treatment of oligometastatic sarcoma. One out of 5 patients is free of progression at 2-years.

Management of Patients with Gastric or Gastroesophageal Junction Cancer: From Theory to Integrated Clinical Path- ways Implementation in the Real World

INTRODUCTION

Best care of esophagogastric junction and gastric cancer (EGC) requires a complex, timely interaction between members of a multi-disciplinary team (MDT). An integrated clinical pathway (ICP) is necessary to achieve this goal as well as the implementation of its use in daily practice. The objective of this study was to elaborate on an integrated clinical pathway for the multi-disciplinary management of ECG. Authors also put in act an implementation program to improve adherence to guidelines thought an ICP.

METHOD

This prospective work carried out by a multi-institutional MDT in Italy identified expert panel extracted relevant recommendations and/or statements from published papers and guidelines obtaining a set of crucial interventions employed the Estimate-Talk-Estimate method. A flow-chart diagram was elaborated to elicit the process at a glance. The primary outcome measure was the elaboration of an ICP with a high consensus rate also reported as a snapshot diagram and its implementation in daily clinical practice. An accredited certification body agency validated results, and an implementation process was started in several hospitals known to treat ECG.

RESULTS

A methodologist aggregated a multi-disciplinary panel of experts from different institutions. The panel elaborated a flow-chart diagram with crucial intervention highlight and connecting lines, as well as outcome measures. An accredited certification body agency validated the entire process, representing the basis for empowerment and implementation among patients and oncological professionals in various hospitals.

CONCLUSION

The multi-disciplinary and multi-institutional expert panel successfully elaborated on a validated ICP for all stages ECG. An in-hospital implementation program has been programmed.

Expression of Langerin/CD207 in airways, lung and associated lymph nodes of a stranded striped dolphin (Stenella coeruleoalba)

The airways and lungs of vertebrates are an entrance way for several microbial pathogens. Cetaceans present an upper and lower respiratory anatomy that allows the rapid flow of large air volumes, which may lead to high susceptibility to respiratory infections. Mortality and stranding rate of Cetaceans increased dramatically, so wide the knowledge about the immune system and specific antibodies identifying immune cells populations, is of fundamental importance to monitor and document cetacean health. The aim of this study was to identify the localization of dendritic cells marked by Langerin/CD207 in airways, lungs and associated lymph nodes, of the striped dolphin Stenella coeruleoalba. Samples of trachea, bronchi, lungs and lung-associated lymph nodes were obtained from a stranded adult male of Stenella coeruleoalba. Our results showed abundant lymphoid aggregates (LAs) in the lung of S. ceruleoalba. Langerhans-like dendritic cells were well distributed along the epithelium and interstitium of respiratory tract and in associated lymph nodes. The present study deepens the knowledge about the cetacean's immune system and report about the exploitability of a commercial antibody (Langerin/CD207) for cetacean species.

Intestinal immunity of dogfish Scyliorhinus canicula spiral valve: A histochemical, immunohistochemical and confocal study

The present study describes histochemical and immunohistochemical characteristics of the spiral valve and its associated lymphoid tissue (GALT) in the dogfish Scyliorhinus canicula. The mucosal surface of the spiral valve represents the first line of defense against pathogens coming from the external environment through food. Epithelial, mucus and immune cells play a key role in controlling the inflammatory response. Valve intestine of S. canicula had many folds lined by simple columnar cells and goblet cells, which later reacted positive to PAS, AB and AB-PAS, histochemical stains differentiated the different types of mucins; lectin histochemistry (PNA and WGA), detected neutral and acid mucins secreted that plays an important role in protection against invading pathogens. Integrin α5β1 was expressed in enterocytes that line the valve's folds with greater marking in the apical part of the cells. Laminin was found on the apical side of the epithelium, in fibrillar and cellular elements of the lamina propria and in the muscularis mucosa. In the spiral valve gut-associated lymphoid tissue (GALT) has been studied. For the first time, massive leucocytes aggregates were identified by confocal immunofluorescence techniques, using the following antibodies: TLR2, S100, Langerin/CD207. Our results expand knowledge about Dogfish valve intestine giving important news in understanding comparative immunology.

Immunohistochemical characterization of epidermal dendritic-like cells in giant mudskipper, Periophthalmodon schlosseri

Giant Mudskipper, Periophthalmodon schlosseri (Pallas, 1770), is euryhaline, amphibious, and air-breathing fish. These fishes live in close association to mangrove forests and often spend over 90% of time out of water, in adjacent mudflats. They have developed morphological and physiological adaptations to satisfy their unique lifestyles. The skin is the primary interface between the body and the environment, and has a central role in host defence. The initiation of immune responses to antigens in the vertebrate skin has often been attributed to epidermal Langerhans'cells (LC) that are dendritic cells (DC), antigen-presenting cells (APC) which reside in the epidermis. Dendritic cells have been characterized morphologically and functionally in the teleost fish tissues such as rainbow trout, salmonids, medaka, African catfish and zebrafish. However, there is no evidence of the presence of DCs and their role in mudskippers immunity. The aim of this preliminary study was to characterize, through use of specific antibodies: Toll-like receptor 2, S100, serotonin (5-HT), and Vesicular acetylcholine transporter VAChT, a specific DC-like subpopulation in Pn. schlosseri's epidermis.

Immunohistochemical characterization of Toll-like receptor 2 in gut epithelial cells and macrophages of goldfish Carassius auratus fed with a high-cholesterol diet

Toll-like receptors (TLRs) are a group of pattern recognition molecules that play a crucial role in innate immunity. The structural conservation of the archaic TLR system suggests that the regulation of the immune response might be similar in fish and mammals. Several TLRs (TLR-1, -2, and -4) are expressed by activated macrophages, "foam cells" in human atherosclerotic lesions. To date, 20 different TLRs were identified in more than a dozen different fish species. In this study we found that feeding goldfish, Carrassius auratus, a high-cholesterol diet (HCD) resulted macrophage foam cell formation in the intestinal tissues. The expression of TLR2 has been found in foam cells and in the cytoplasm of enterocytes, however the staining was more intense at the apical surface of polarized intestinal epithelial cells and in the lamina propria. In the intestinal epithelial cells and in the lamina propria cells of the control fish the TLR2 was expressed at low levels. The intestinal epithelium is directly involved in the mucosal immune response through its expression of proinflammatory genes, release of inflammatory cytokines, and recruitment of inflammatory cells.

Use of the Word “Cured” for Cancer Patients—Implications for Patients and Physicians: The Siracusa Charter

Long-term survival for adult patients with solid tumours continues to increase. For some cancers, the possibility of recurrence after a number of years is extremely low, and the risk of death becomes similar to that of the general population of the same sex and age. During the Fifth European Conference on Survivors and Chronic Cancer Patients held in Siracusa, Italy, June 2014, oncologists, general practitioners, epidemiologists, cancer patients and survivors, and patient advocates joined to discuss the possible use of the term “cured” in reference to some adult patients with solid tumours. The specific focus was the appropriateness of using the term in communicating with cancer patients, survivors, and their families. Initial results of the discussion, in concert with a review of the published literature on the subject, were later further discussed by all participants through electronic communication. The resulting final statement aims to suggest appropriate ways to use the word “cured” in the clinical and communicative setting, to highlight the potential impact of the word on patients, and to open a critical discussion concerning this timely and delicate matter.

High-Dose Robotic Stereotactic Body Radiotherapy in the Treatment of Patients With Prostate Cancer: Preliminary Results in 26 Patients

BACKGROUND

Stereotactic body radiotherapy (SBRT) can emulate high dose rate brachytherapy (HDR-BRT) dose fractionation. We report our preliminary results using SBRT in monotherapy or pre-external-beam radiotherapy (EBRT) boost in patients with localized prostate cancer (LpC). The primary end point was the evaluation of both acute and late toxicities; secondary end point was the observation of prostate-specific antigen (PSA) nadir.

PATIENTS AND METHODS

Patients with LpC having prostate volume ≤90 cm(3) were enrolled in the present study. Patients were treated with SBRT alone or in combined modality (SBRT + EBRT). SBRT was performed using a CyberKnife System (Accuray Incorporated, Sunnyvale, California) and fiducial tracking system.

RESULTS

From February 2008 to July 2013, 21 patients for monotherapy (38 Gy/4 fractions) and 5 for combined modality (9.5 Gy/2 fractions plus 46 Gy/23 fractions EBRT) were enrolled. Androgen deprivation therapy (ADT) was administered in 16 of the 26 patients. The median pretreatment PSA was 9.4 (range, 4.5-14.3) ng/mL. All patients completed the planned therapy. Acute Grade 1 toxicity was observed in 18 patients, genitourinary (GU) in 12 / 26 patients, and gastrointestinal (GI) in 6 / 26 patients. Acute Grade 2 GU toxicity was reported in 1 / 26 patients, and Grade 2 GI toxicity was observed in 2 / 26 patients. The median PSA nadir was 0.15 (range, 0.02 = 1.4) ng/mL. Late toxicities were observed in 5 / 26 patients: Grade 1 GU (3 of 26), Grade 2 GU (1 of 26), and Grade 1 GI (1 of 26). Median follow-up was 21.5 (range, 8-65) months.

CONCLUSIONS

Our preliminary results of SBRT "simulating" HDR for LpC confirm a minimal toxicity and an optimal PSA response. The PSA nadirs appear comparable with HDR-BRT.

Induction Chemotherapy to Weekly Paclitaxel Concurrent with Curative Radiotherapy in Stage IV (M0) Unresectable Head and Neck Squamous Cell Carcinoma: a Dose Escalation Study

The purpose was to determine the maximum tolerated dose (MTD) of weekly paclitaxel with concurrent, daily irradiation in patients with unresectable head and neck squamous cell carcinoma previously submitted to induction chemotherapy. Patients with stage IV, and unresectable tumor and/or node/s were enrolled. Nine male patients were submitted to a course of paclitaxel 175 mg/m2 day 1 and cisplatin 75 mg/m2 day 2 given every 3 weeks for three courses. Curative radiotherapy (RT) started 3 weeks after the last cycle of chemotherapy with the goal of delivering a total dose of 66-70 Gy. During RT weekly paclitaxel was administered for 6 courses if feasible; paclitaxel was given according to a dose escalation schema in cohorts of three patients. Dose level A, 30 mg/m2; dose level B, 40 mg/m2; dose level C, 50 mg/m2. During weekly paclitaxel the major toxicity was mucositis that required a treatment break in two of three patients in dose level C; mucositis grade 4 required interruption of paclitaxel administration in all these patients. RT can be given in a continuous fashion with weekly paclitaxel after induction chemotherapy. The MTD of weekly paclitaxel was 40 mg/m2.

Effect of polysaccharides from Opuntia ficus-indica (L.) cladodes on the healing of dermal wounds in the rat

In traditional medicine extracts of polysaccharide-containing plants are widely employed for the treatment of skin and epithelium wounds and of mucous membrane irritation. The extracts of Opuntia ficus-indica cladodes are used in folk medicine for their antiulcer and wound-healing activities. The present study describes the wound-healing potential of two lyophilized polysaccharide extracts obtained from O. ficus-indica (L.) cladodes applied on large full-thickness wounds in the rat. When topically applied for 6 days, polysaccharides with a molecular weight (MW)>10(4)Da from O. ficus-indica cladodes induce a beneficial effect on cutaneous repair in this experimental model; in particular the topical application of O. ficus-indica extracts on skin lesions accelerates the reepithelization and remodelling phases, also by affecting cell-matrix interactions and by modulating laminin deposition. Furthermore, the wound-healing effect is more marked for polysaccharides with a MW ranging 10(4)-10(6)Da than for those with MW>10(6)Da, leading us to suppose that the fine structure of these polysaccharides and thus their particular hygroscopic, rheologic and viscoelastic properties may be essential for the wound-healing promoter activity observed.

Study on the increment of the production of gastric mucus in rats treated with Opuntia ficus indica (L.) Mill. cladodes

Opuntia ficus indica cladodes are used in traditional medicine of many countries for their cicatrisant activity. The major components of cladodes are carbohydrate-containing polymers, which consist of a mixture of mucilage and pectin. In this paper we studied the cytoprotective effects of cladodes on experimental ethanol-induced ulcer in rat. The O. ficus indica cladodes administration gives rise to cytoprotection phenomena by breaking up the epithelial cells and stimulating an increase in mucus production. When O. ficus indica cladodes are administered as a preventive therapy, keep the gastric mucosa under normal condition by preventing mucus dissolution caused by ethanol and favouring mucus production. An increase of mucus production is also observed during the course of the curative treatment. The treatment with O. ficus indica cladodes provokes an increase in the number of secretory cells. Probably, the gastric fibroblasts are involved in the antiulcer activity.

Prophylaxis of diarrhoea in patients submitted to radiotherapeutic treatment on pelvic district: personal experience

Diarrhoea is a severe side-effect of radiotherapy on the pelvic area. It is due to acute enteric damage. We aimed at determining the ability of a highly concentrated freeze-dried living bacteria compound (VSL/3) to reduce these side-effects in 190 patients receiving radio therapy on the pelvic area. A total of 95 patients received radiotherapy alone and 95 were also administered VSL/3 bags, at doses of one bag three times a day beginning on the first day of the radiotherapy treatment. The same diet was indicated for both groups. All patients were irradiated for 6 to 7 weeks, with Linac X-6 MV or 15 MV through a box multiportal technique with the lower limit of the fields below the obturator foramina, upper limit at L5-S1, lateral limit 1.5 cm beyond the innominate hip. The total radiated dose ranged from 60 to70 Gy for a daily dose of 180 cGy. Gastroenteric toxicity was rated in WHO degrees. Two patients receiving radiotherapy alone had to discontinue the treatment due to acute enteritis. Toxicity was found in 52 (50.6%) patients with radiotherapy alone vs 36 (30.5%) patients receiving VSL/3. None of them had to discontinue radiotherapy. Toxicity of degrees 3 or 4 was found in 28 patients receiving radiotherapy alone vs 7 with VSL/3. These preliminary data suggest the effectiveness of VSL/3 in preventing the occurrence of diarrhoea in patients submitted to radiotherapy with a direct and indirect improvement of their quality of life and a good tolerance.

Novel therapeutic approaches to cancer patients with bone metastasis

Bone metastases are a common event in advanced cancer. Breast, lung, prostate and thyroid neoplasms have striking osteotropism. Bone metastatic cancer may be associated with catastrophic consequences for the patients. Therefore, new strategies are warranted in order to reduce the incidence of bone metastases and to palliative established skeletal disease. External beam radiation therapy, endocrine treatments, chemotherapy, bisphosphonates and radioisotopes are all important. Bisphosphonates have become the treatment of choice for tumor-induced hypercalcaemia and more recently they have been used alone or in combination with cytotoxic agents in the palliative treatment of patients with bone metastases. The results are encouraging. Currently, new bisphosphonates that are a hundred times more powerful with respect to clodronate and pamidronate are under investigation. The treatment of metastases to bone and mechanisms of pain relief after radiation therapy are poorly understood. Up to date, there are not standard criteria for the irradiation of bone metastases and bone pain relief may be reached using a variety of fractionation schemes. Radionuclide therapy is the systemic use of radioisotopes for bone pain. It is currently regarded as suitable for comparison with wide-field irradiation, but appears to have major disadvantages in terms of pain relief and toxicity.

Hepatoprotective activity of Trichilia roka on carbon tetrachloride-induced liver damage in rats

Trichilia roka Chiov. (Meliaceae) is a tree widely distributed in tropical Africa. It has been used in Mali folk medicine for the treatment of various illnesses. A decoction of the roots is taken as a remedy for colds and pneumonia, and it is used as a diuretic and in hepatic disorders. We have evaluated the hepatoprotective effects of a decoction of Trichilia roka root on CCl4-induced acute liver damage in rats. Treatment with the decoction showed a significant protective action made evident by its effect on the levels of glutamate oxalacetate transaminase and glutamate pyruvate transaminase in the serum, on the protein content and lipid peroxidation levels in the liver homogenate. Histopathological changes produced by CCl4, such as necrosis, fatty change, ballooning degeneration and inflammatory infiltration of lymphocytes around the central veins, were clearly recovered by the treatment with Trichilia root decoction. On fractionating this extract into diethyl ether-soluble and water-soluble fractions, the activity was retained in the diethyl ether-soluble fraction. Moreover, the administration of decoction prevented a preferential deposition of collagen around the sinusoidal cell layer, which is responsible for the perisinusoidal fibrosis in the early stage of CCl4 damage. This study showed that treatment with Trichilia roka extracts or silymarin (as reference) appeared to enhance the recovery from CCl4-induced hepatotoxicity. The hepatoprotective properties of Trichilia roka may be correlated to polyphenol content of the decoction and its diethyl ether-soluble fraction.

Ipsilateral supraclavicular lymph nodes metastases from breast cancer as only site of disseminated disease. Chemotherapy alone vs. induction chemotherapy to radical radiation therapy

BACKGROUND

To define the role of radiotherapy (RT) in the treatment of ipsilateral supraclavicular lymph-nodes metastases (ISLM) from breast cancer as only site of disseminated disease, we started a prospective non-randomized clinical trial in 1989. Here we report the final results with a median follow-up of 8.75 years.

PATIENTS AND METHODS

Thirty-seven patients (pts), with ISLM from breast cancer, were consecutively enrolled into two arms. Arm A (18 pts): chemotherapy (CT) for six courses. Arm B (19 pts): CT for three courses followed by RT to the site of ISLM at 'radical' dose of 50-60 Gy.

RESULTS

In arm A, a median Time to Progression (TtP) of 7 months with a median Overall Survival (OS) of 28 months was recorded. In comparison, patients in arm B had a longer median TtP with 20 months as well as a better median OS with 41 months, respectively. An actuarial five-year disease-free survival of 5.5% was obtained in arm A vs. 21% in arm B. A statistically significant difference in TtP was demonstrated between the two groups (P = 0.01).

CONCLUSIONS

These data demonstrate that a better event-free survival could be achieved in patients with ISLM submitted to induction CT and radical irradiation. This also translated into a longer survival although this did not achieve statistical significance. We want to stress the importance of local control by RT since it does imply that not all of these patients have micrometastases at the time of relapse in the supraclavicular fossa.

Cannabinoid CB1-mediated inhibition of stress-induced gastric ulcers in rats

The effect of cannabinoid drugs (i.p.) on cold/restraint stress-induced gastric ulcers was studied in rats. The cannabinoid receptor agonist (WIN 55,212-2, 0.1-1 mg/kg), but not the less active isomer WIN 55,212-3 (1 mg/kg), reduced gastric ulceration. The protective effect of WIN 55,212-2 (1 mg/kg) was counteracted by the cannabinoid CB1 receptor antagonist SR141716A, but not by the cannabinoid CB2 receptor antagonist SR144528. These results indicate that the antiulcer effect of the cannabinoid receptor agonist WIN 55,212-2 is mediated by cannabinoid CB1 receptors.

Cisapride and dexamethasone in the prevention of delayed emesis after cisplatin administration

Management of delayed emesis (DE) remains unsatisfactory, and only 50% of the patients achieve complete protection. Cisapride is a strong prokinetic gastrointestinal drug that could have a role in the prevention of DE. We enrolled 31 adult naive outpatients who were scheduled to receive cisplatin chemotherapy at doses of > or = 75 mg/m2. All patients received the same prophylactic treatment for acute emesis (20 mg dexamethasone and 8 mg ondansetron i.v.) and, as preventive therapy for DE, oral cisapride, 10 mg every 8 h on days 2-4, combined with dexamethasone i.m., 8 mg twice daily on days 2 and 3, and 4 mg twice daily on day 4. All patients were evaluable for activity. Complete protection from acute vomiting was 80.7%, from nausea 71% and from nausea/vomiting 64.5%. The overall protection from DE (days 2-4) was 74.1% for vomiting, 64.5% for nausea and 58% for nausea/vomiting. In our study the combination of cisapride and dexamethasone was effective, giving 58% of complete protection from DE, and it is therefore worthy of further studies.

[Prevention and control of Legionella infection in the hospital environment]

An outbreak of nosocomial legionnaires' disease in a hospital of Northern Italy is described, together with the epidemiological survey and the control measures adopted. Two patients developed Legionella pneumophila (serogroup 1) pneumonia, one (immunodepressed) died. The Task Group organised by the Health Service excluded other previous nosocomial infections, and made controls on patients and personnel of at risk units (all negative). An intensive programme of environmental sampling and educational activities on personnel have been carried out. The environmental surveillance revealed that the centralised hot water distribution system of the hospital was colonised with Legionella. Shock heating and hyperchlorination of water were applied, which reduced the number of contaminated sites short term, but recolonisation took place two months later. We underline the difficulties encountered to control Legionella by active surveillance of water quality; once the system is contamined, Legionella eradication may be difficult and expensive, and cases of hospital-acquired legionnaieres' disease are likely to occur.

What is the best position of the arms in mantle field for Hodgkin's disease?

PURPOSE

To evaluate the best position of the arms in mantle field for Hodgkin's disease.

METHODS AND MATERIALS

In 12 patients, with surgical clips placed at the time of an axillary dissection for breast cancer, the radiological projection of the clips according to three arm positions was prospectively evaluated: akimbo (A), extended (E), and up over the head (U). The surgical clips were arbitrarily separated into two groups: lower and upper. In each patient, the distance between the surgical clips and chest wall was measured, and the possibility of shielding the lungs and humeral heads was evaluated.

RESULTS

The mean displacement of the lower clips away from the chest wall when the patients were in A, E, and U positions was 2.5, 3.0, and 4.6 cm, respectively. The upper group clips showed a lower difference in distance from chest wall. In the U position, there was always a clip of the lower group that projected over the humeral head, making it impossible to block this structure.

CONCLUSION

In the A position, there is the possibility of blocking the humeral head, but it is necessary to irradiate more lung parenchyma. Type E treatment setup allows the shielding of both lung and humeral head, while maintaining adequate margins around the axillary nodes. In the U position, there is a greater possibility of shielding the lung parenchyma, but it is impossible to block the humeral heads.

Magnetic resonance imaging of bronchioloalveolar carcinoma

The purpose of this study is to describe the magnetic resonance (MR) features of bronchioloalveolar carcinoma. MR examinations of 18 patients with proven bronchioloalveolar carcinoma were reviewed. Detection at computed tomography (CT) and pathologic confirmation were the entry criteria. Nine patients had a solitary nodule, three patients a lobar consolidation, and six patients had diffuse disease. For each patient, both breath-hold T2-weighted fast spin-echo, and breath-hold T1-weighted gradient-echo images, before and after injection of gadolinium, were available. Nine patients with pulmonary consolidation or diffuse disease had also heavily T2-weighted MR imaging (Haste or TSE 240; Siemens, Erlangen, Germany). MR imaging showed pulmonary abnormalities in 17 of 18 patients. Unenhanced T1-weighted and T2-weighted images depicted tumor in 16 of 18 patients. Contrast-enhanced T1-weighted images showed tumor in 17 of 18 patients. In no case did MR imaging depict abnormalities corresponding to the ground-glass opacities seen on CT scans. In three patients with mucinous bronchioloalveolar carcinoma, heavily T2-weighted images showed lesions isointense with respect to static fluid of the human body. In conclusion, the ability of MR imaging in detecting small nodules and ground-glass opacities is limited. However, heavily T2-weighted sequences are able to show the presence of mucin. This is useful information because mucinous bronchioloalveolar carcinoma carries a poor prognosis.

Surveillance of legionellosis within a hospital in northern Italy: May 1998 to September 1999

The incidence of legionella infection in Europe overall in 1997 was 3.9 cases per million population, with the lowest rates reported by Malta and Norway and the highest by Denmark. Ninety cases were reported in Italy (1.5 cases/million), 20% of which were

The dermoepidermal junction in psoriatic skin as revealed by scanning electron microscopy

Our previous ultrastructural and immunohistochemical studies, in vivo and in vitro, have shown important modifications of the basement membrane of psoriatic skin, which could play a key role in the alterations of keratinocyte adhesion, migration, proliferation and differentiation. In order to complete the morphological examination of all the structures in the dermoepidermal junction of psoriatic skin, we carried out a scanning electron microscopic study using biopsies taken from eight psoriatic patients. The biopsies were fixed in a mixture of 0.2% paraformaldehyde and 0.25% glutaraldehyde in 0.1 M cacodylate buffer at pH 7.4. The specimens were then frozen in liquid nitrogen and fractured following the natural cleavage planes and observed under a Jeol JSM-6301F field emission scanning electron microscope operating at 1.8-2.0 kV. The basal keratinocytes observed showed pore-like depressions on the lateral plasmalemma and villous-like projections in very dilated intercellular spaces. Moreover the basal cell plasma membrane was seen to rest on the papillary dermis without interposition of the lamina densa. The detachment of some keratinocytes enabled the examination of the lamina densa, which appeared slightly granular with numerous focal interruptions through which it was possible to observe the underlying collagen fibres. These findings, together with previously reported findings, support the hypothesis that in psoriasis molecular and structural alterations of the dermoepidermal junction are present, that could fundamentally alter the regulation of the cytomorphological processes and the normal functions of the basement membrane.

External radiation therapy boost to the vaginal vault: feasibility of intracavitary dosimetry using a commercial diode system

PURPOSE

An overall check of the whole dosimetry procedure by intracavitary in vivo dosimetry, using n-type silicon diode dosimeter, was performed during 6-MV x-ray irradiation of the vaginal vault. The dose delivered to the isocenter by all treatment fields was evaluated.

METHODS AND MATERIALS

The diode dosimeter was calibrated against an ion chamber and tissue maximum ratio, field size factor, SSD factor, and temperature dependence studies were performed. Diode system accuracy, linearity, and reproducibility were also tested. Patients' dose data were collected and comparision was made with respect to treatment-planning dose calculations. Ten patients with cervical cancer and endometrial cancer were treated with surgery and irradiation. During the boost to the vaginal vault, a diode was inserted by an intravaginal device and the vaginal vault was the isocenter of the four fields. The field size generally was not larger than 10 x 10 cm2.

RESULTS

Diode-measured "tissue maximum ratio" agreed to within 1% with those measured with an ion chamber in field from 7 x 7 to 10 x 10 cm2. The diode also exhibited a temperature dependence of 0.1% degrees C(-1). For 10 patients treated with a 6-MV beam, the agreement with treatment-planning dose calculations was shown to be better than +/-4%.

CONCLUSION

The good accuracy and reproducibility of the diode system shows that determination of the dose at isocenter, for patients treated in the pelvic region, can be performed with n-type diodes accurately. On the other hand, in the vaginal vault boost, external-beam radiotherapy is delivered accurately and in vivo dosimetry is really not indicated.

Prognostic factors in ambulatory patients with inoperable locoregionally recurrent rectal cancer following curative surgery

BACKGROUND

The optimal treatment for locoregionally recurrent rectal cancer after curative surgery has not yet been defined. The definition of prognostic factors could lead to the selection of an aggressive therapeutic approach in patients with favourable prognosis alone.

PATIENTS AND METHODS

The records of thirty-nine ambulatory pts, 15 female and 24 male, with diagnosis of locoregionally recurrent rectal cancer (LRRC) after curative surgery and treated with radiotherapy were retrospectively analyzed. The following factors were analyzed for their ability to predict the clinical response and outcome for LRRC: age, sex, initial tumor grading, primary surgical approach, initial primary tumor stage according to Dukes' classification, disease free survival (time to primary surgery and detection of a LRRC), pelvic-perineal structure affected by recurrence, total radiation dose, chemotherapy with fluorouracil, symptomatic response to the therapy, locoregional symptomatic re-recurrence, systemic progression disease.

RESULTS

In the univariate analysis, predictive factors for survival, were graded (G1-2 vs G3 p = 0.04), Dukes' stage at first diagnosis (A-B vs C p = 0.01), and site of pelvic-perineal recurrence (Pelvic mass alone yes vs no p = 0.01; Nerve and/or Osseous involvement yes vs no p < 0.001). Following therapy for LRRC, a better survival was observed in pts with a complete symptomatic response (complete remission vs partial remission vs no change p < 0.001), without a further locoregional symptomatic re-recurrence (re-recurrence, yes vs no p = 0.001) and/or appearance of metastatic disease (yes vs no p < 0.001).

Etoposide, l-leucovorin and fluorouracil (ELF) regimen in metastatic gastric cancer: a phase II study

The role of chemotherapy in metastatic gastric cancer (MGC) is predominantly palliative, therefore regimens with mild toxicity and acceptable activity should be preferred. The combination of etoposide, leucovorin and 5-fluorouracil (ELF) is suitable chemotherapy in this situation. We have enrolled 33 patients with MGC, using the following chemotherapy schedule: l-leucovorin 150 mg/m2 10 minute i.v., followed by etoposide 120 mg/m2 50 minute i.v., followed by 5-fluorouracil 500 mg/m2 10 minute i.v. on days 1-3, every 22 days. All patients are valuable for response, toxicity and survival. Two patients achieved complete response (6%), 10 patients (30%) had a partial response (PR), 9 patients (27%) had stabilization of disease (SD) and 12 patients had disease progression (PD). The median survival for all patients was 6 months (range, 1 to 40+). ELF was well tolerated, the main toxicity being myelosuppression. No toxic deaths occurred. In conclusion, the ELF regimen in our trial demonstrated, in this kind of patient, moderate activity in the absence of relevant toxicity, confirming its suitability in patients in generally poor condition.

Primitive sinonasal malignant mucosal melanoma: description of a case treated with radiotherapy (0-7-21 regimen)

Mucosal malignant melanoma (MMM) of the nasal cavity and paranasal sinuses is rare and has a poor prognosis. The rarity of MMM of the ethmoid is also noteworthy and primary treatment has been, till now, surgery and/or radiotherapy (RT). Here we report a case of MMM arising in the ethmoid of a caucasian man and treated with hypofractionated RT. A 32 year-old man presented with symptoms of cephalalgia, obstruction and nasal bleeding; a computed tomography (CT) showed a large mass that involved ethmoid, left orbit and roof of the nasal cavity. After biopsy, a MMM was found. Chest radiography demonstrated the presence of multiple lung metastases and still the patient was submitted to palliative radiotherapy according to 0-7-21 regimen with a total dose of 24Gy/3 fraction/21dd, dose per fraction 8Gy. The patient was asymptomatic one month after the end of RT and three months later a CT demonstrated a partial remission. The patient died 17 months after the initiation of RT for disseminated disease, without clinical signs of tumoral regrowth in the irradiated site. This case confirms the efficacy and the safety of 0-7-21 RT regimen; the absence of symptoms after 17 months and the poor prognosis encourage the use of RT as primary treatment for MMM of the head and neck.

Immunohistochemical study of epidermal nerve fibres in involved and uninvolved psoriatic skin using confocal laser scanning microscopy

Psoriasis is a typical hyperproliferative epidermal disease whose aetiopathogenesis is still to be defined. One of the most likely hypotheses is that it has a neurogenic origin correlated with an altered release of some neuropeptides by sensitive cutaneous nerves via antidromic pathways. As there are conflicting reports about the existence of cutaneous nerve alterations in psoriasis, we carried out an immunolocalization study using the protein gene product 9.5 as a marker for neuronal structures observed by confocal laser scanning microscopy in order to determine the pattern of sensory nerves in psoriatic skin. The investigation was carried out on cutaneous biopsies taken from involved (mature and long-established lesions) and uninvolved skin of ten patients with extensive chronic plaque psoriasis. In uninvolved psoriatic skin a significant decrease in epidermal nerve fibres was found, a further decrease was observed in mature lesions and almost a complete lack of epidermal nerve fibres in long-established psoriatic lesions. The reduction in epidermal nerve fibres and the consequent loss of relationship between these nerve structures and the skin immunocompetent cells (antigen-presenting cells, Langerhans cells, keratinocytes) might be a factor of fundamental importance in the self-maintenance of the disease.

Escalating dose of oral ondansetron in the prevention of radiation induced emesis

BACKGROUND

Radiation-induced emesis is an event linked to the release of serotonin during abdominal irradiation. Ondansetron is able to prevent emesis, but an optimal scheme has not yet been established. The aim of our study was to evaluate the efficacy of an escalating dose of oral ondansetron (Oral OND) in the prevention of emesis induced by fractionated radiotherapy.

PATIENTS AND METHODS

We enrolled 30 patients who underwent fractionated radiotherapy involving the upper abdomen which received this schedule of antiemetic therapy: phase A Oral OND 4 mg p.o. immediately after irradiation (RT) with a dose < or = 20 Gy; phase B Oral OND 8 mg p.o. immediately after RT with dose > 20 Gy and < 30 Gy; phase C Oral OND 8 mg p.o. every 12 hours starting immediately after RT with a dose > or = 30 Gy.

RESULTS

During phase A we obtained a 100% of CR in all 30 patients. In phase B 22 CR (92%) and 2 MR (8%). In phase C on a total of 11 patients we recorded 6 CR (55%), 3 MR (27%) and 2 F (18%). The toxicity was mild.

CONCLUSION

Our data confirm the efficacy and safety of Oral OND and, moreover, show the possibility to reduce the cost without compromising the activity.

Denervation muscular atrophy. Studies on the soleus muscle of the albino rat (LM, TEM, immunofluorescence, image analysis)

In previous researches the Authors hypothesized that the loss of cytoskeletal proteins such as desmin and vinculin lead to degenerative ultrastructural changes which occur in muscular disuse atrophy. In order to support this hypothesis they carried out a morphometric, structural, ultrastructural and immunofluorescence study on the soleus muscle of albino rats after resection of the ischiatic nerve. It was demonstrated that a chronological sequence of the damage took place in particular three levels of damage. The last level of damage proved to be irreversible; the first level assured complete recovery in the case of rapid reinnervation, whereas the possible reversibility of the second level remained open to question. The disappearance of vinculin and desmin was observed in a period between 72 hours and 7 days, i.e. before the appearance of ultrastructural damage. On this ground the Authors explained the correlation between the loss of the proteins and degenerative changes. In conclusion the Authors correlated the gene expression of cytoskeletal and contractile proteins with the neuropeptides released by motor axon.

Curative radiotherapy (RT) using limited RT treatment fields in elderly patients with non-small cell lung cancer in clinical stage IIIA

We report a prospective phase II study utilizing limited radiotherapy (RT) treatment fields in elderly (greater than or equal to 75 years) patients (pts) with non-small cell lung cancer (NSCLC) in clinical stage IIIA. Sixteen good risk pts with histologically confirmed NSCLC in clinical stage IIIA, age greater than or equal to 75 years (yr) (range 75-83; median age 77) were entered in the study. All pts were treated with Limited RT fields (including T and N1-2 usually with a 1.5 cm, radiographic margin) and received a minimum of 54 Gy (range 54-62 Gy, median 60 Gy, dose/fraction 2 Gy/5 dd a week). All pts have been followed-up for a median time of 3.5 years (range 1.75-6.58). Median survival (MS) was 18 months (range 7-52 months). No acute and/or late significant toxicity was recorded. Univariate analysis showed a better survival in pts receiving a radiation dose greater than or equal to 60 Gy, with an MS of 34 vs 14 months (p=0.017) and in pts with Karnofsky Performance Status greater than or equal to 80, with an MS of 34 vs 12 months (p=0.0O2). There are scarce data available on survival in elderly pts with NSCLC in clinical stage IIIA. Pts submitted to 'standard' RT in unresectable NSCLC have a poor median survival time and 5-year survival rates. The results obtained in our pts encourage us to use 'limited' RT in elderly but the results require a phase III study before definitive recommendations can be made.

Defibrotide in the prevention of venous irritation by vinorelbine administration

BACKGROUND

Vinorelbine is active in a variety of malignancies. The most common side effects are leukopenia and granulocytopenia, moreover Vinorelbine is a vescicant and venous irritant, the incidence of the latter being 10-26% in patients who received VNB as a 20-30 minute peripheral infusion. To prevent venous toxicity we have carried out a study in order to evaluate the efficacy of Defibrotide in this issue.

MATERIALS AND METHODS

41 patients were enrolled in the study, the experimental schedule was: Defibrotide 400 mg on 250 cc of normal saline iv, after 15 minutes of infusion, we delivered quick, brief and repeated pulses of Vinorelbine through the plastic tube followed by remaining Defibrotide: For grading venous irritation we used the scale by Rittenberg et al.

RESULTS

A total of 360 infusion were delivered, the incidence of any venous irritation was 5% and maximum grade 2. No severe toxicity was recorded.

CONCLUSION

These data show that Defibrotide might serve as a therapeutic drug to prevent vascular toxicity by Vinorelbine.

Changes in the distribution of actin-associated proteins in psoriatic keratinocytes. Immunohistochemical study using confocal laser scanning microscopy

Recent studies support the presence of adherens junctions at the dermal-epidermal interface in addition to hemidesmosomes. In this area the integrin/actin-containing cytoskeleton connection occurs by means of a complex of proteins called actin-associated proteins (talin, vinculin, alpha-actinin). As previous studies have demonstrated the presence in psoriatic lesions of marked alterations in both the basement membrane molecular composition and the polarized expression of integrins, we decided to determine whether alterations in the behaviour of the actin-associated proteins could be demonstrated. We thus undertook an immunolocalization study with monoclonal antibodies directed against talin, vinculin, and alpha-actinin in cutaneous biopsies taken from involved and uninvolved skin of 12 patients with extensive chronic plaque psoriasis. The findings showed an almost total lack of reaction against talin and vinculin in the basal layer and an increased positivity against the proteins in the suprabasal layers. Similar, though less marked, alterations were present in uninvolved psoriatic skin. These results, in agreement with those of previous studies, confirm serious alterations in the matrix protein/cytoskeleton connection system, and support the hypothesis that this condition may play a key role in the pathogenesis of the disease.