BRCA-mutant pancreatic ductal adenocarcinoma

Despite continued research, pancreatic ductal adenocarcinoma (PDAC) remains one of the main causes of cancer death. Interest is growing in the role of the tumour suppressors breast cancer 1 (BRCA1) and BRCA2-typically associated with breast and ovarian cancer-in the pathogenesis of PDAC. Indeed, both germline and sporadic mutations in BRCA1/2 have been found to play a role in the development of PDAC. However, data regarding BRCA1/2-mutant PDAC are lacking. In this review, we aim to outline the specific landscape of BRCA-mutant PDAC, focusing on heritability, clinical features, differences between BRCA1 and 2 mutations and between germline and sporadic alterations, as well as established therapeutic strategies and those that are still under evaluation.

Liquid biopsy-driven anti-EGFR rechallenge in patients with metastatic colorectal cancer

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Background: The rechallenge with EGFR inhibitors represents an emerging strategy for anti-EGFR pre-treated patients with RAS wild type colorectal cancer (CRC). Unfortunately definitive selection criteria for anti-EGFR rechallenge in this setting are lacking. Very recently RAS wild type status on circulating tumor DNA (ct-DNA) at the time of rechallenge along with already known clinical criteria emerged as a potential watershed for this strategy. In the present study we explored liquid biopsy-driven anti-EGFR rechallenge strategy in the clinical practice for patients with metastatic colorectal cancer. Methods: Ct-DNA from RAS and BRAF wild type metastatic CRC patients previously treated with an anti-EGFR containing therapy was analyzed for RAS/BRAF mutations with the aim to evaluate the rechallenge strategy with anti-EGFR. The ct-DNA was analyzed for RAS-BRAF mutations using pyro-sequencing (PyroMark Q24 MDx Workstation) and nucleotide sequencing (Genetic Analyzer ABI3130) assays. Real-time PCR (Idylla) and droplet digital PCR (QX200 System) were performed to confirm the RAS-BRAF mutation status. Several clinical variables including previous response to anti EGFR containing therapy, tumor sidedness and anti-EGFR free interval were evaluated in relation to outcome. Tumor response evaluation was performed according to RECIST 1.1. Differences between categorical variables were evaluated using the Fisher’s exact test. Survival probability over time was estimated by the Kaplan–Meier method. Significant differences in the probability of survival between the strata were evaluated by log-rank test. Results: Twenty patients were included in the study. All patients were tested for RAS-BRAF mutations in ct-DNA. Fourteen patients (70%) showed a RAS-BRAF WT molecular profile, six patients (30%) showed a KRAS mutation. All the patients with ct-DNA RAS-BRAF WT profile underwent rechallenge with anti-EGFR. In details 11 patients (78.6%) underwent irinotecan+ cetuximab treatment, whereas 3 patients (21.4%) underwent panitumumab monotherapy. As for the outcome results to the rechallenge strategy, the median OS was 7 months (95% CI 5.0 to 13.0), the median PFS was 3 months (95% CI 2.0 to 6.0), the ORR was 27.3% with a DCR of 54.5%. Among the clinical variables evaluated as putative predictive/prognostic factors, previous response to anti-EGFR treatment was related to a not statistically significant improved OS (12 months vs 5 months HR:0.19 p: 0.06) and to a statistically significant improved ORR (75% vs 0% p:0.03). Conclusions: The rechallenge strategy with anti-EGFR confirmed to be feasible in clinical practice. The clinical outcome resulted consistent with the literature data. In addition to the molecular selection through the analysis of ct-DNA for RAS, previous response to anti EGFR treatment is confirmed as a prospective selection criteria for this therapeutic option.

Comparison of the Efficacy of Different Concentrations of Diclofenac Sodium Phonophoresis (1.16% vs 2.32%) in Patients with Knee Osteoarthritis: a Randomized Double-Blind Controlled Trial

PURPOSE OF THE STUDY The objective of the present study is to compare the efficacy of two different concentrations of diclofenac sodium phonophoresis (DSPH) (1.16% vs 2.32%) in patients with knee osteoarthritis (OA). MATERIAL AND METHODS A randomized, double-blind, controlled design was applied. Ninety patients (mean age± SD, 59.98 ± 8.89 years) who had Kellgren-Lawrence (K-L) grades II to III knee OA were randomly allocated into three groups; 1.16% DSPH, 2.32% DSPH, TUS (30 in each group). Each patient was treated five sessions per week for two weeks. A 100-mm visual analogue scale (VAS) for usual pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were evaluated before and after treatment in all groups. RESULTS The VAS pain and WOMAC scores were significantly improved after treatment in all groups (p < 0.05). The 2.32% DSPH showed more significant effects than the 1.16% DSPH, both in improving WOMAC- pain and physical function scores (p = 0.020, p = 0.008) and reducing the VAS pain measure, although it did not reach the level of significance (p = 0.077). The 2.32% DSPH was superior to the TUS, both in reducing the VAS pain measure (p < 0.001) and in improving WOMAC-pain, stiffness, physical function and total scores (p = 0.022, p = 0.016, p < 0.001, p < 0.001 respectively). 1.16% DSPH significantly reduced stiffness and physical function scores compared with TUS (p = 0.042, p = 0.047). CONCLUSIONS DSPH and TUS are effective treatments for knee OA. Our results indicated that 2.32% DSPH produces additional benefits to functional improvement and pain reduction compared with 1.16% DSPH in K-L grades II to III knee OA. Key words: diclofenac sodium, knee osteoarthritis, phonophoresis, therapeutic ultrasound, topical formulation.

A Rare Case of Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: a Case Report

Tuberculosis (TB) is still a worldwide problem. We present a case of flexor tenosynovitis due to tuberculosis in the hand and wrist. A 42-year-old man presented to the outpatient clinic with a 2-year history of a slowly growing mass over the volar aspect of the left wrist. His MRI showed multiple rice bodies in the wrist and hand. An open biopsy was performed. Pathology specimens showed granulomatous lesions with central necrosis. The purified protein derivative (PPD) test was positive. In this case, granulomatous lesions with central necrosis, rice bodies, and positive PPD test confirmed the diagnosis of TB in the wrist and hand. There was no other concurrent evidence of TB elsewhere. Antituberculosis chemotherapy was commenced. Tuberculous tenosynovitis of the wrist and hand is very rare. The tuberculous tenosynovitis should be kept in mind as an infectious agent when patients are presenting with atypical clinical. Key words: tuberculosis, rice bodies, flexor tenosynovitis, wrist, hand.

Introducing immunotherapy for advanced hepatocellular carcinoma patients: Too early or too fast?

Advanced hepatocellular carcinoma (HCC) is the most frequent liver cancer. Immunotherapy has been explored in this disease in order to improve survival outcomes. Nowadays, scientific research is focusing especially on immune checkpoint inhibitors, in particular anti-PD1, anti-PD-L1 and anti-CTLA4 monoclonal antibodies (mAbs), as single-agent or in combination with other immunotherapy agents, target therapies, anti-vascular endothelial growth factor (VEGF) and other agents targeting specific molecular pathways. Other immunotherapy strategies have been assessed or are under investigation in advanced HCC, namely cytokines, adoptive cell therapy, oncolytic virus, cancer vaccines. Each treatment presents specific efficacy and toxicity profiles, strictly related to their mechanism of action and to advanced HCC tumour microenvironment (TME). The aim of this review is to outline the state-of-the-art of immunotherapy in advanced HCC treatment, highlighting data on already investigated treatment strategies, safety and toxicity (including HBV/HCV-related HCC), and ongoing clinical trials focusing on new promising therapeutic weapons.

Molecular-Biology-Driven Treatment for Metastatic Colorectal Cancer

BACKGROUND

Metastatic CRC (mCRC) is a molecular heterogeneous disease. The aim of this review is to give an overview of molecular-driven treatment of mCRC patients.

METHODS

A review of clinical trials, retrospective studies and case reports was performed regarding molecular biomarkers with therapeutic implications.

RESULTS

RAS wild-type status was confirmed as being crucial for anti-epidermal growth factor receptor (EGFR) monoclonal antibodies and for rechallenge strategy. Antiangiogenic therapies improve survival in first- and second-line settings, irrespective of RAS status, while tyrosine kinase inhibitors (TKIs) remain promising in refractory mCRC. Promising results emerged from anti-HER2 drugs trials in HER2-positive mCRC. Target inhibitors were successful for BRAFV600E mutant mCRC patients, while immunotherapy was successful for microsatellite instability-high/defective mismatch repair (MSI-H/dMMR) or DNA polymerase epsilon catalytic subunit (POLE-1) mutant patients. Data are still lacking on NTRK, RET, MGMT, and TGF-β, which require further research.

CONCLUSION

Several molecular biomarkers have been identified for the tailored treatment of mCRC patients and multiple efforts are currently ongoing to increase the therapeutic options. In the era of precision medicine, molecular-biology-driven treatment is the key to impro patient selection and patient outcomes. Further research and large phase III trials are required to ameliorate the therapeutic management of these patients.

New therapeutic targets in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is associated with poor survival. Of all newly diagnosed patients, only about 20% can benefit from a potentially curative surgical resection, the remaining 80% presenting with unresectable locally advanced (LAPC) or metastatic (MPC) disease. Currently, there are limited therapeutic options for LAPC and MPC patients. Furthermore, despite intensive research efforts to better understand the molecular bases of PDAC and the biological relevance of its tumor microenvironment, treatments still largely consist of classical cytotoxic chemotherapy agents. Several studies of genetic and epigenetic sequencing have demonstrated the existence of 4 molecular PDAC subtypes, with heterogeneous genetic characteristics and different biological behaviour: squamous, pancreatic progenitor, immunogenic and aberrantly differentiated endocrine exocrine (ADEX). These distinct subtypes derive from alterations at multiple levels. Apart from the DNA repair pathway, however, none of these has so far been validated as a clinically relevant therapeutic target. Also, PDAC is unique from an immunological perspective and many studies have recently tried to elucidate the role of intratumoral effector T-cells, RAS oncogene, immunosuppressive leukocytes and desmoplastic reaction in maintaining the immunological homeostasis of this disease. However, there still remains much to be learned about the mechanisms whereby the pancreatic immune microenvironment promotes immune escape of cancer cells. Furthermore, while therapies targeting the stroma as well as immunotherapies hold promise for the future, these are not yet standard of care. This review aims to outline the state-of-the-art of LAPC and MPC treatment, highlighting data on the target therapies failure and current ongoing clinical trials on new promising therapeutic strategies.

Social interactions impact on the dopaminergic system and drive individuality

Individuality is a striking feature of animal behavior. Individual animals differ in traits and preferences which shape their interactions and their prospects for survival. However, the mechanisms underlying behavioral individuation are poorly understood and are generally considered to be genetic-based. Here, we devised a large environment, Souris City, in which mice live continuously in large groups. We observed the emergence of individual differences in social behavior, activity levels, and cognitive traits, even though the animals had low genetic diversity (inbred C57BL/6J strain). We further show that the phenotypic divergence in individual behaviors was mirrored by developing differences in midbrain dopamine neuron firing properties. Strikingly, modifying the social environment resulted in a fast re-adaptation of both the animal's traits and its dopamine firing pattern. Individuality can rapidly change upon social challenges, and does not just depend on the genetic status or the accumulation of small differences throughout development.

Nicotinic receptors mediate stress-nicotine detrimental interplay via dopamine cells' activity

Epidemiological studies report strong association between mood disorders and tobacco addiction. This high comorbidity requires adequate treatment but the underlying mechanisms are unknown. We demonstrate that nicotine exposure, independent of drug withdrawal effects, increases stress sensitivity, a major risk factor in mood disorders. Nicotine and stress concur to induce long-lasting cellular adaptations within the dopamine (DA) system. This interplay is underpinned by marked remodeling of nicotinic systems, causing increased ventral tegmental area (VTA) DA neurons' activity and stress-related behaviors, such as social aversion. Blocking β2 or α7 nicotinic acetylcholine receptors (nAChRs) prevents, respectively, the development and the expression of social stress-induced neuroadaptations; conversely, facilitating α7 nAChRs activation specifically in the VTA promotes stress-induced cellular and behavioral maladaptations. Our work unravels a complex nicotine-stress bidirectional interplay and identifies α7 nAChRs as a promising therapeutic target for stress-related psychiatric disorders.

Prognostic neutrophil-to-lymphocyte ratio in head and neck cancer: A single center experience

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Background: The Neutrophil-to-Lymphocytes ratio (NLR) represents a potential prognostic and predictive marker in a different tumor types. The purpose of our study was to investigate the prognostic value of the pretreatment inflammatory marker NLR in patients with head and neck squamous cell carcinoma (HNSCC). Methods: Pretreatment NLR were retrospectively investigated for correlation with overall survival (OS). Kaplan-Meier statistic and long rang test were used. Univariate analysis for categorical and descriptive variables were performed. Results: Thirty-nine patients, from local to advanced stage disease, were included in our analysis. At a median follow up of 9.44 months (2.04 – 30.3), of the total patients 30.7% died and 41.9% had progression of disease. The median PFS was 4.6 months (2.9 – 27.2) and the median OS (mOS) was 18.9 months. Following ROC curve analysis the optimum cut-off value of NLR was 3.93 (p = 0.017). Patient with NLR > 3.92 had a mOS of 11.9 months, whereas the mOS for NLR ≤ 3.92 was 30.3 months (Log-rank p = 0.189). The 1 year Kaplan-Meier estimates of OS for NLR ≤ 3.92 vs. >3.92 was 72% vs. 45% respectively (Log-rank p = 0.243). According to COX univariate analysis, the risk of death increases of 7.7% each unitary rise of NLR mean value (p = 0.3407). Conclusions: In our limited case series NLR was not significantly associated with clinical outcome. Therefore, multicenter studied are needed to determine an optimal NLR cutoff value. [Table: see text]

Co-activation of VTA DA and GABA neurons mediates nicotine reinforcement

Smoking is the most important preventable cause of mortality and morbidity worldwide. This nicotine addiction is mediated through the nicotinic acetylcholine receptor (nAChR), expressed on most neurons, and also many other organs in the body. Even within the ventral tegmental area (VTA), the key brain area responsible for the reinforcing properties of all drugs of abuse, nicotine acts on several different cell types and afferents. Identifying the precise action of nicotine on this microcircuit, in vivo, is important to understand reinforcement, and finally to develop efficient smoking cessation treatments. We used a novel lentiviral system to re-express exclusively high-affinity nAChRs on either dopaminergic (DAergic) or γ-aminobutyric acid-releasing (GABAergic) neurons, or both, in the VTA. Using in vivo electrophysiology, we show that, contrary to widely accepted models, the activation of GABA neurons in the VTA plays a crucial role in the control of nicotine-elicited DAergic activity. Our results demonstrate that both positive and negative motivational values are transmitted through the dopamine (DA) neuron, but that the concerted activity of DA and GABA systems is necessary for the reinforcing actions of nicotine through burst firing of DA neurons. This work identifies the GABAergic interneuron as a potential target for smoking cessation drug development.

The surgical treatment of supra-intercondylar fractures of the femur

The authors report their results in the surgical treatment of supra-intercondylar fractures of the femur and compare the efficacy of the different methods used. Their analysis shows that anatomical restoration of the joint line and firm stabilisation of the supracondylar fragments in correct alignment with the metaphysis are the essential aims of surgery capable of producing satisfactory results.

Surgical treatment of subtrochanteric fractures of the femur: biomechanical aspects

The internal fixation of subtrochanteric fractures of the femur must meet precise mechanical requirements in order to be capable of resisting the considerable bending stresses acting on this part of the body. On the basis of the results obtained in ninety two fractures treated surgically with various fixation devices, the authors analyse the biomechanical characteristics of the various implants in relation to the different types of fractures.

Classification and treatment of intercondyloid fractures of the humerus

The authors describe the satisfactory results obtained in sixteen intercondyloid fractures of the humerus, thirteen of which were treated surgically. The preference for surgical treatment in such fractures is based in the assumption that, as in all articular fractures, a good functional result can only be achieved if there is the most perfect possible reconstruction of the fragments and the joint surface. A classification is therefore suggested which is based not purely on anatomical criteria, but is also related to treatment and prognosis. The slendor nature of the distal end of the humerus and the danger of metal reaction call for the use of fixation devices that are efficient but slender, such as fine screws and crossed wires. The precise method of fixation is conditioned above all by the direction of the fracture lines. More solid fixation with early mobilisation can be achieved by compression screws, and less solid fixation with longer immobilisation is achieved by fixation with crossed Kirschner wires. Consequently, the more oblique types of fracture with fragments with long beaks that allow more stable fixation with compression screws have the more favourable prognosis. In the evaluation of results, the authors emphasize the importance of using parameters which take into account the functionally useful range of joint movement.