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Vincini M, Marvaso G, Isaksson L, Zaffaroni M, Pepa M, Corrao G, Summers P, Repetto M, Mazzola G, Rotondi M, Raimondi S, Gandini S, Volpe S, Haron Z, Alessi S, Pricolo P, Mistretta F, Luzzago S, Cattani F, Musi G, De Cobelli O, Cremonesi M, La Torre D, Petralia G, Jereczek-Fossa B. Added value of MRI radiomics to predict pathological status of prostate cancer patients. Eur Urol 2023. [DOI: 10.1016/s0302-2838(23)01276-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Luzzago S, Mistretta F, Piccinelli M, Alessi S, Nizzardo M, Tozzi M, Cioffi A, Cordima G, Ferro M, Petralia G, Musi G, De Cobelli O. Predicting the risk of biochemical recurrence at five years in patients treated with radical prostatectomy for prostate cancer: The PIPEN categories. Eur Urol 2023. [DOI: 10.1016/s0302-2838(23)00306-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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3
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Zaffaroni M, Marvaso G, Corrao G, Gandini S, Pepa M, Vincini M, Zerini D, Castronovo F, Augugliaro M, Cattani F, Mistretta F, Luzzago S, Musi G, Alessi S, Fodor C, Petralia G, Pravettoni G, De Cobelli O, Orecchia R, Jereczek-Fossa B. PO-1360 Nutritional and inflammatory status as predictive biomarkers in oligorecurrent PCa (RADIOSA TRIAL). Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)03324-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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4
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Pepa M, Corrao G, Morigi G, La Fauci F, Zaffaroni M, Vincini M, Augugliaro M, Mazzola G, Comi S, Mistretta F, Luzzago S, Gandini S, Musi G, Petralia G, De Cobelli O, Orecchia R, Cattani F, Marvaso G, Jereczek-Fossa B. PO-1482 Estimation of inter-fraction motion of pelvic organs in SBRT treatments of prostate oligometastases. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)03446-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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5
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Corrao G, Marvaso G, Pepa M, Zaffaroni M, Vincini M, Bellerba F, Gandini S, Volpe S, Rojas D, Zerini D, Fodor C, Pricolo P, Alessi S, Petralia G, Mistretta F, Cambria R, Cattani F, De Cobelli O, Orecchia R, Jereczek-Fossa B. MO-0551 Short-term RT for early PCa with concomitant boost to the DIL (phase II trial AIRC-IG-13218)-updates. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02385-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Anceschi U, Galfano A, Dell'Oglio P, Bravi C, Misuraca L, Tuderti G, Ferriero M, Albisinni S, Luciani L, Secco S, Petralia G, Di Trapani E, Brassetti A, Mastroianni R, Bove A, Ferriero M, Cai T, Puglisi M, Mattevi D, Quackels T, Malossini G, Bocciardi A, Simone G. Assessing the quality of learning curve through a standardized proficiency score and the impact of learning curve on trifecta outcomes of robot-assisted radical prostatectomy (RALP): Results of a multicentric series. Eur Urol 2022. [DOI: 10.1016/s0302-2838(22)01223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mistretta F, Luzzago S, Piccinelli M, Alessi S, Cozzi G, Cioffi A, Fontana M, Bottero D, Marvaso G, Ferro M, Matei D, Jereczek Fossa B, Petralia G, Musi G, De Cobelli O. Conditional survival of patients with low-risk prostate cancer: Temporal changes in active surveillance permanence according to risk stratification. Eur Urol 2022. [DOI: 10.1016/s0302-2838(22)00370-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dell'Oglio P, Tappero S, Longoni M, Buratto C, Scilipoti P, Secco S, Olivero A, Barbieri M, Palagonia E, Napoli G, Strada E, Petralia G, Di Trapani D, Vanzulli A, Bocciardi A, Galfano A. Retzius-sparing robot-assisted radical prostatectomy in high-risk prostate cancer patients. Eur Urol 2022. [DOI: 10.1016/s0302-2838(22)01314-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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la Fauci F, Marvaso G, Augugliaro M, Comi S, Pepa M, Zaffaroni M, Corrao G, Mistretta F, Gandini S, Petralia G, Cattani F, de Cobelli O, Orecchia R, Jereczek-Fossa B. Evaluation of effect on dose due to displacement of bowel and target volume in SBRT treatment for oligorecurrent crastation sensitive prostate cancer patients. Phys Med 2021. [DOI: 10.1016/s1120-1797(22)00425-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Piccinelli M, Luzzago S, Fontana M, Botticelli F, Mistretta F, Catellani M, Di Trapani E, Bianchi R, Cozzi G, Cioffi A, Pricolo P, Alessi S, Cordima G, Ferro M, Matei D, Petralia G, Musi G, de Cobelli O. Active surveillance for prostate cancer: comparison between incidental tumors vs. tumors diagnosed at prostate biopsies. EUR UROL SUPPL 2021. [DOI: 10.1016/s2666-1683(21)00959-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Luzzago S, Piccinelli M, Fontana M, Botticelli F, Cozzi G, Mistretta F, Catellani M, Bianchi R, Cioffi A, Di Trapani E, Pricolo P, Alessi S, Brescia A, Ferro M, Matei D, Petralia G, Musi G, de Cobelli O. Outcomes of serial multiparametric magnetic resonance imaging in patients managed with Active Surveillance for prostate cancer. EUR UROL SUPPL 2021. [DOI: 10.1016/s2666-1683(21)00960-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Zaffaroni M, Carloni G, Volpe S, Garibaldi C, Marvaso G, Gandini S, Rampinelli C, Petralia G, Cassano E, Bellomi M, Cremonesi M, Positano V, Orecchia R, Jereczek-Fossa B. PO-1794 Features robustness in the radiomic workflow: the impact of software choice on feature variability. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger H, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Blanc-Onfroy ML, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McReady D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph D, Tobias JS. New clinical and biological insights from the international TARGIT-A randomised trial of targeted intraoperative radiotherapy during lumpectomy for breast cancer. Br J Cancer 2021; 125:380-389. [PMID: 34035435 PMCID: PMC8329051 DOI: 10.1038/s41416-021-01440-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The TARGIT-A trial reported risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy for breast cancer to be as effective as whole-breast external beam radiotherapy (EBRT). Here, we present further detailed analyses. METHODS In total, 2298 women (≥45 years, invasive ductal carcinoma ≤3.5 cm, cN0-N1) were randomised. We investigated the impact of tumour size, grade, ER, PgR, HER2 and lymph node status on local recurrence-free survival, and of local recurrence on distant relapse and mortality. We analysed the predictive factors for recommending supplemental EBRT after TARGIT-IORT as part of the risk-adapted approach, using regression modelling. Non-breast cancer mortality was compared between TARGIT-IORT plus EBRT vs. EBRT. RESULTS Local recurrence-free survival was no different between TARGIT-IORT and EBRT, in every tumour subgroup. Unlike in the EBRT arm, local recurrence in the TARGIT-IORT arm was not a predictor of a higher risk of distant relapse or death. Our new predictive tool for recommending supplemental EBRT after TARGIT-IORT is at https://targit.org.uk/addrt . Non-breast cancer mortality was significantly lower in the TARGIT-IORT arm, even when patients received supplemental EBRT, HR 0.38 (95% CI 0.17-0.88) P = 0.0091. CONCLUSION TARGIT-IORT is as effective as EBRT in all subgroups. Local recurrence after TARGIT-IORT, unlike after EBRT, has a good prognosis. TARGIT-IORT might have a beneficial abscopal effect. TRIAL REGISTRATION ISRCTN34086741 (21/7/2004), NCT00983684 (24/9/2009).
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Radiation Oncology, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Berlin, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, & Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, University of Southern California, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Fernando Bozza
- Department of Surgery, Instituto Oncologico Veneto (IVO) IRCCS, Padoa, Italy
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology University College London Hospitals, London, UK
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
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Corrao G, Marvaso G, Zaffaroni M, Fodor C, Volpe S, Bergamaschi L, Zerini D, Vingiani A, Petralia G, Alessi S, Pricolo P, Renne G, Orecchia R, Jereczek-Fossa B. PO-1935 CLINICAL OUTCOMES AND RADIO-BIOLOGICAL FEATURES CORRELATION IN EARLY PCa: AN EXPLORATORY ANALYSIS. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Caviglia A, Beverini M, Malinaric R, Petralia G, Dell’Oglio P, Secco S, Bocciardi A, Galfano A. Robotic nephrectomy with inferior vena cava thrombectomy: A good indication also in case of haemodinamic instability. Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)01632-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Piccinelli M, Luzzago S, Fontana M, Botticelli F, Mistretta F, Catellani M, Di Trapani E, Bianchi R, Cozzi G, Cioffi A, Pricolo P, Alessi S, Cordima G, Ferro M, Matei D, Petralia G, Musi G, De Cobelli O. Active surveillance for prostate cancer: Comparison between incidental tumors vs. tumors diagnosed at prostate biopsies. Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)01405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Luzzago S, Piccinelli M, Fontana M, Botticelli F, Cozzi G, Mistretta F, Catellani M, Bianchi R, Cioffi A, Di Trapani E, Pricolo P, Alessi S, Brescia A, Ferro M, Matei D, Petralia G, Musi G, De Cobelli O. Outcomes of serial multiparametric magnetic resonance imaging in patients managed with active surveillance for prostate cancer. Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)01416-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Di Trapani E, Luzzago S, Peveri G, Catellani M, Ferro M, Cordima G, Mistretta FA, Bianchi R, Cozzi G, Alessi S, Matei DV, Bagnardi V, Petralia G, Musi G, De Cobelli O. A novel nomogram predicting lymph node invasion among patients with prostate cancer: The importance of extracapsular extension at multiparametric magnetic resonance imaging. Urol Oncol 2021; 39:431.e15-431.e22. [PMID: 33423938 DOI: 10.1016/j.urolonc.2020.11.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To develop a novel risk tool that allows the prediction of lymph node invasion (LNI) among patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND). METHODS We retrospectively identified 742 patients treated with RARP + ePLND at a single center between 2012 and 2018. All patients underwent multiparametric magnetic resonance imaging (mpMRI) and were diagnosed with targeted biopsies. First, the nomogram published by Briganti et al. was validated in our cohort. Second, three novel multivariable logistic regression models predicting LNI were developed: (1) a complete model fitted with PSA, ISUP grade groups, percentage of positive cores (PCP), extracapsular extension (ECE), and Prostate Imaging Reporting and Data System (PI-RADS) score; (2) a simplified model where ECE score was not included (model 1); and (3) a simplified model where PI-RADS score was not included (model 2). The predictive accuracy of the models was assessed with the receiver operating characteristic-derived area under the curve (AUC). Calibration plots and decision curve analyses were used. RESULTS Overall, 149 patients (20%) had LNI. In multivariable logistic regression models, PSA (OR: 1.03; P= 0.001), ISUP grade groups (OR: 1.33; P= 0.001), PCP (OR: 1.01; P= 0.01), and ECE score (ECE 4 vs. 3 OR: 2.99; ECE 5 vs. 3 OR: 6.97; P< 0.001) were associated with higher rates of LNI. The AUC of the Briganti et al. model was 74%. Conversely, the AUC of model 1 vs. model 2 vs. complete model was, respectively, 78% vs. 81% vs. 81%. Simplified model 1 (ECE score only) was then chosen as the best performing model. A nomogram to calculate the individual probability of LNI, based on model 1 was created. Setting our cut-off at 5% we missed only 2.6% of LNI patients. CONCLUSIONS We developed a novel nomogram that combines PSA, ISUP grade groups, PCP, and mpMRI-derived ECE score to predict the probability of LNI at final pathology in RARP candidates. The application of a nomogram derived cut-off of 5% allows to avoid a consistent number of ePLND procedures, missing only 2.6% of LNI patients. External validation of our model is needed.
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Affiliation(s)
- E Di Trapani
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy.
| | - S Luzzago
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - G Peveri
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - M Catellani
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - M Ferro
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - G Cordima
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - F A Mistretta
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - R Bianchi
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - G Cozzi
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - S Alessi
- Division of Precision Imaging and Radiation Sciences, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - D V Matei
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - V Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - G Petralia
- Division of Precision Imaging and Radiation Sciences, IEO - European Institute of Oncology, IRCCS, Milan, Italy
| | - G Musi
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hematology-Oncology, Università degli Studi di Milano, Milan, Italy
| | - O De Cobelli
- Division of Urology, IEO - European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hematology-Oncology, Università degli Studi di Milano, Milan, Italy
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Marvaso G, Gugliandolo S, Corrao G, Volpe S, Riva G, Rojas D, Zerini D, Pepa M, Pricolo P, Alessi S, Petralia G, Cattani F, De Cobelli O, Orecchia R, Jereczek-Fossa B. PO-1197: Short-term high precision RT for early PCa with SIB to the DIL: QoL assessment (AIRC IG 13218). Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Pepa M, Gugliandolo S, Isaksson L, Marvaso G, Raimondi S, Botta F, Gandini S, Ciardo D, Volpe S, Riva G, Rojas D, Zerini D, Pricolo P, Alessi S, Petralia G, Summers P, Mistretta A, Luzzago S, Cattani F, De Cobelli O, Cassano E, Cremonesi M, Bellomi M, Orecchia R, Jereczek-Fossa B. PO-1576: Assessment of mpMRI-based radiomics tools in PCa for cancer aggressiveness prediction, AIRC IG-. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01594-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Luzzago S, Mistretta F, Piccinelli M, Lorusso V, Morelli M, Bianchi R, Catellani M, Cozzi G, Di Trapani E, Pricolo P, Alessi S, Ferro M, Matei D, Petralia G, Musi G, de Cobelli O. MRI-Targeted or systematic random biopsies for prostate cancer diagnosis in biopsy naïve patients: Follow-up of a precision trial-like retrospective cohort. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)35373-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger HL, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph DJ, Tobias JS. Long term survival and local control outcomes from single dose targeted intraoperative radiotherapy during lumpectomy (TARGIT-IORT) for early breast cancer: TARGIT-A randomised clinical trial. BMJ 2020; 370:m2836. [PMID: 32816842 PMCID: PMC7500441 DOI: 10.1136/bmj.m2836] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine whether risk adapted intraoperative radiotherapy, delivered as a single dose during lumpectomy, can effectively replace postoperative whole breast external beam radiotherapy for early breast cancer. DESIGN Prospective, open label, randomised controlled clinical trial. SETTING 32 centres in 10 countries in the United Kingdom, Europe, Australia, the United States, and Canada. PARTICIPANTS 2298 women aged 45 years and older with invasive ductal carcinoma up to 3.5 cm in size, cN0-N1, eligible for breast conservation and randomised before lumpectomy (1:1 ratio, blocks stratified by centre) to either risk adapted targeted intraoperative radiotherapy (TARGIT-IORT) or external beam radiotherapy (EBRT). INTERVENTIONS Random allocation was to the EBRT arm, which consisted of a standard daily fractionated course (three to six weeks) of whole breast radiotherapy, or the TARGIT-IORT arm. TARGIT-IORT was given immediately after lumpectomy under the same anaesthetic and was the only radiotherapy for most patients (around 80%). TARGIT-IORT was supplemented by EBRT when postoperative histopathology found unsuspected higher risk factors (around 20% of patients). MAIN OUTCOME MEASURES Non-inferiority with a margin of 2.5% for the absolute difference between the five year local recurrence rates of the two arms, and long term survival outcomes. RESULTS Between 24 March 2000 and 25 June 2012, 1140 patients were randomised to TARGIT-IORT and 1158 to EBRT. TARGIT-IORT was non-inferior to EBRT: the local recurrence risk at five year complete follow-up was 2.11% for TARGIT-IORT compared with 0.95% for EBRT (difference 1.16%, 90% confidence interval 0.32 to 1.99). In the first five years, 13 additional local recurrences were reported (24/1140 v 11/1158) but 14 fewer deaths (42/1140 v 56/1158) for TARGIT-IORT compared with EBRT. With long term follow-up (median 8.6 years, maximum 18.90 years, interquartile range 7.0-10.6) no statistically significant difference was found for local recurrence-free survival (hazard ratio 1.13, 95% confidence interval 0.91 to 1.41, P=0.28), mastectomy-free survival (0.96, 0.78 to 1.19, P=0.74), distant disease-free survival (0.88, 0.69 to 1.12, P=0.30), overall survival (0.82, 0.63 to 1.05, P=0.13), and breast cancer mortality (1.12, 0.78 to 1.60, P=0.54). Mortality from other causes was significantly lower (0.59, 0.40 to 0.86, P=0.005). CONCLUSION For patients with early breast cancer who met our trial selection criteria, risk adapted immediate single dose TARGIT-IORT during lumpectomy was an effective alternative to EBRT, with comparable long term efficacy for cancer control and lower non-breast cancer mortality. TARGIT-IORT should be discussed with eligible patients when breast conserving surgery is planned. TRIAL REGISTRATION ISRCTN34086741, NCT00983684.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik L Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynaecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, The Ludwig Maximilian University of Munich, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden Hospital, Charité, Medical University of Berlin, Berlin, Germany
| | - David McCready
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
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Vaidya JS, Bulsara M, Saunders C, Flyger H, Tobias JS, Corica T, Massarut S, Wenz F, Pigorsch S, Alvarado M, Douek M, Eiermann W, Brew-Graves C, Williams N, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer R, Kelemen P, Petralia G, Falzon M, Baum M, Joseph D. Effect of Delayed Targeted Intraoperative Radiotherapy vs Whole-Breast Radiotherapy on Local Recurrence and Survival: Long-term Results From the TARGIT-A Randomized Clinical Trial in Early Breast Cancer. JAMA Oncol 2020; 6:e200249. [PMID: 32239210 PMCID: PMC7348682 DOI: 10.1001/jamaoncol.2020.0249] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Conventional adjuvant radiotherapy for breast cancer given daily for several weeks is onerous and expensive. Some patients may be obliged to choose a mastectomy instead, and some may forgo radiotherapy altogether. We proposed a clinical trial to test whether radiotherapy could be safely limited to the tumor bed. Objective To determine whether delayed second-procedure targeted intraoperative radiotherapy (TARGIT-IORT) is noninferior to whole-breast external beam radiotherapy (EBRT) in terms of local control. Design, Setting, and Participants In this prospective, randomized (1:1 ratio) noninferiority trial, 1153 patients aged 45 years or older with invasive ductal breast carcinoma smaller than 3.5 cm treated with breast conservation were enrolled from 28 centers in 9 countries. Data were locked in on July 3, 2019. Interventions The TARGIT-A trial was started in March 2000; patients were randomized after needle biopsy to receive TARGIT-IORT immediately after lumpectomy under the same anesthetic vs EBRT and results have been shown to be noninferior. A parallel study, described in this article, was initiated in 2004; patients who had their cancer excised were randomly allocated using separate randomization tables to receive EBRT or delayed TARGIT-IORT given as a second procedure by reopening the lumpectomy wound. Main Outcomes and Measures A noninferiority margin for local recurrence rate of 2.5% at 5 years, and long-term survival outcomes. Results Overall, 581 women (mean [SD] age, 63 [7] years) were randomized to delayed TARGIT-IORT and 572 patients (mean [SD] age, 63 [8] years) were randomized to EBRT. Sixty patients (5%) had tumors larger than 2 cm, or had positive nodes and only 32 (2.7%) were younger than 50 years. Delayed TARGIT-IORT was not noninferior to EBRT. The local recurrence rates at 5-year complete follow-up were: delayed TARGIT-IORT vs EBRT (23/581 [3.96%] vs 6/572 [1.05%], respectively; difference, 2.91%; upper 90% CI, 4.4%). With long-term follow-up (median [IQR], 9.0 [7.5-10.5] years), there was no statistically significant difference in local recurrence-free survival (HR, 0.75; 95% CI, 0.57-1.003; P = .052), mastectomy-free survival (HR, 0.88; 95% CI, 0.65-1.18; P = .38), distant disease-free survival (HR, 1.00; 95% CI, 0.72-1.39; P = .98), or overall survival (HR, 0.96; 95% CI, 0.68-1.35; P = .80). Conclusions and Relevance These long-term data show that despite an increase in the number of local recurrences with delayed TARGIT-IORT, there was no statistically significant decrease in mastectomy-free survival, distant disease-free survival, or overall survival. Trial Registration ISRCTN34086741, ClinicalTrials.gov Identifier: NCT00983684.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.,Department of Biostatistics, University of Notre Dame, Fremantle, West Australia, Australia
| | - Christobel Saunders
- University of Western Australia School of Surgery, West Australia, Australia
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, West Australia, Australia
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Frederik Wenz
- University Medical Center Mannheim, Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Steffi Pigorsch
- Red Cross Hospital, Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany
| | | | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Wolfgang Eiermann
- Red Cross Hospital, Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Norman Williams
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, United Kingdom
| | - Elena Sperk
- University Medical Center Mannheim, Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, United Kingdom
| | - Marc Sütterlin
- University Medical Center Mannheim, Department of Gynecology and Obstetrics, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- Helen Rey Breast Cancer Foundation, John Wayne Cancer Institute, University of Southern California, Los Angeles
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Montserrat Pazos
- University Hospital, Department of Radiation Oncology, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - David McCready
- Princess Margaret Cancer Centre Toronto, Toronto, Ontario, Canada
| | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, New York
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, United Kingdom
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, West Australia, Australia
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Luzzago S, Sabatini I, Garelli G, Mistretta F, Conti A, Catellani M, Di Trapani E, Bianchi R, Cozzi G, Alessi S, Pricolo P, Ferro M, Metei D, Musi G, Petralia G, De Cobelli O. MRI-targeted or standard biopsy for prostate cancer diagnosis in biopsy naïve patients. The PRECISION trial follow-up. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Secco S, Barbosa F, Brambillasca P, Dell’oglio P, Barbieri M, Caviglia A, Buratto C, Migliorisi C, Napoli G, Di Trapani D, Vercelli R, Solcia M, Strada E, Petralia G, Bocciardi A, Rampoldi A, Galfano A. Current urological indications for Prostatic Artery Embolization (PAE) in a referral hospital. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)34071-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Ciardo D, Marvaso G, Gandini S, Mambretti M, Fodor C, Zerini D, Volpe S, Riva G, Rojas D, Petralia G, Cambria R, Orecchia R, Jereczek-Fossa B. EP-1550 Give-me-five trial: toxicity assessment in ultra-hypofractionated prostate cancer radiotherapy. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)31970-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rojas D, Jereczek-Fossa B, Zerini D, Fodor C, Viola A, Fanetti G, Volpe S, Marvaso G, Luraschi R, Bazani A, Rondi E, Cattani F, Vavassori A, Bazzani A, Ronchi S, Maucieri A, Alessi S, Petralia G, De Cobelli O, Musi G, Orecchia O. Ep-2372: High-Precision Salvage Re-Irradiation For Local Recurrence Of Prostate Cancer: Series Of 64 Patients. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)32680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Riva G, Timon G, Ciardo D, Bazani A, Maestri D, De Lorenzo D, Pansini F, Cambria R, Cattani F, Marvaso G, Zerini D, Rojas D, Volpe S, Golino F, Scroffi V, Fodor C, Petralia G, De Cobelli O, Orecchia R, Jereczek-Fossa B. EP-1338: High precision radiotherapy for early prostate cancer with concomitant boost to the dominant lesion. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31773-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Jereczek-Fossa B, Ciardo D, Petralia G, Bellomi M, De Cobelli O, Orecchia R. EP-1380: Primary focal prostate radiotherapy: do all patients really need whole-prostate irradiation? Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)32630-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ciardo D, Bazani A, Pansini F, Russo S, Molinelli S, Comi S, Cambria R, Cattani F, Petralia G, Vischioni B, Zerini D, Baroni G, Valvo F, Orecchia R, Jereczek-Fossa B. PO-0995: Evaluation of VMAT-RapidArc, IMRT-VERO and proton-RT for a hypofractionated scheme of prostate cancer treatment. Radiother Oncol 2015. [DOI: 10.1016/s0167-8140(15)40987-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Montagna E, Peccatori F, Petralia G, Tomasi Cont N, Iorfida M, Colleoni M. Whole-body magnetic resonance imaging, metastatic breast cancer and pregnancy: a case report. Breast 2014; 23:295-6. [PMID: 24529906 DOI: 10.1016/j.breast.2014.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/17/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- E Montagna
- Division of Medical Senology, European Institute of Oncology, Milan, Italy.
| | - F Peccatori
- Division of Gynecologic Oncology, European Institute of Oncology, Milan, Italy
| | - G Petralia
- Division of Diagnostic Radiology, European Institute of Oncology, Milan, Italy
| | - N Tomasi Cont
- Division of Gynecologic Oncology, European Institute of Oncology, Milan, Italy
| | - M Iorfida
- Division of Medical Senology, European Institute of Oncology, Milan, Italy
| | - M Colleoni
- Division of Medical Senology, European Institute of Oncology, Milan, Italy
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Ciardo D, Jereczek-Fossa B, Zerini D, Petralia G, Cambria R, Rondi E, Cattani F, Fodor C, Baroni G, Orecchia R. EP-1695: Multimodal image registration to identify the dominant intraprostatic lesion in radiotherapy - AIRC grant IG 13218. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)31813-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Morlino S, Gherardi F, Panzarino C, Villa E, Petralia G, Galetti G, Millul A, Beghi E, Valdagni R, Monfardini S. EP-1365: Multidimensional geriatric evaluation in urological neoplasia: a cooperative prospective study. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)31483-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chen Y, Scully M, Petralia G, Kakkar A. Binding and inhibition of drug transport proteins by heparin: a potential drug transporter modulator capable of reducing multidrug resistance in human cancer cells. Cancer Biol Ther 2013; 15:135-45. [PMID: 24253450 DOI: 10.4161/cbt.27148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
A major problem in cancer treatment is the development of resistance to chemotherapeutic agents, multidrug resistance (MDR), associated with increased activity of transmembrane drug transporter proteins which impair cytotoxic treatment by rapidly removing the drugs from the targeted cells. Previously, it has been shown that heparin treatment of cancer patients undergoing chemotherapy increases survival. In order to determine whether heparin is capable reducing MDR and increasing the potency of chemotherapeutic drugs, the cytoxicity of a number of agents toward four cancer cell lines (a human enriched breast cancer stem cell line, two human breast cancer cell lines, MCF-7 and MDA-MB-231, and a human lung cancer cell line A549) was tested in the presence or absence of heparin. Results demonstrated that heparin increased the cytotoxicity of a range of chemotherapeutic agents. This effect was associated with the ability of heparin to bind to several of the drug transport proteins of the ABC and non ABC transporter systems. Among the ABC system, heparin treatment caused significant inhibition of the ATPase activity of ABCG2 and ABCC1, and of the efflux function observed as enhanced intracellular accumulation of specific substrates. Doxorubicin cytoxicity, which was enhanced by heparin treatment of MCF-7 cells, was found to be under the control of one of the major non-ABC transporter proteins, lung resistance protein (LRP). LRP was also shown to be a heparin-binding protein. These findings indicate that heparin has a potential role in the clinic as a drug transporter modulator to reduce multidrug resistance in cancer patients.
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Affiliation(s)
| | | | - Gloria Petralia
- Thrombosis Research Institute; London, UK; University College London Hospitals NHS Trust; London, UK
| | - Ajay Kakkar
- Thrombosis Research Institute; London, UK; University College London; London, UK
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Monfardini S, Morlino S, Catanzaro M, Tafa A, Bortolato B, Petralia G, Bonetto E, Villa E, Picozzi S, Locatelli M, Galetti G, Millul A, Albanese Y, Panzarino C, Gerardi F, Beghi E. Multidimensional geriatric evaluation at initial treatment in urological neoplasia: A cooperative prospective study. J Geriatr Oncol 2013. [DOI: 10.1016/j.jgo.2013.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The use of magnetic resonance imaging (MRI) for the assessment of breast lesions was first described in the 1970s; however, its wide application in clinical routine is relatively recent. The basic principles for diagnosis of a breast lesion rely on the evaluation of signal intensity in T2-weighted sequences, on morphologic assessment and on the evaluation of contrast enhancement behaviour. The quantification of dynamic contrast behaviour by dynamic contrast-enhanced (DCE) MRI and evaluation of the diffusivity of water molecules by means of diffusion-weighted MRI (DW-MRI) have shown promise in the work-up of breast lesions. Therefore, breast MRI has gained a role for all indications that could benefit from its high sensitivity, such as detection of multifocal lesions, detection of contralateral carcinoma and in patients with familial disposition. Breast MRI has been shown to have a role in monitoring of neoadjuvant chemotherapy, for the evaluation of therapeutic results during the course of therapy. Breast MRI can improve the determination of the remaining tumour size at the end of therapy in patients with a minor response. DCE-MRI and DW-MRI have shown potential for improving the early assessment of tumour response to therapy and the assessment of residual tumour after the end of therapy. Breast MRI is important in the postoperative work-up of breast cancers. High sensitivity and specificity have been reported for the diagnosis of recurrence; however, pitfalls such as liponecrosis and changes after radiation therapy have to be carefully considered.
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Affiliation(s)
- G Petralia
- Division of Radiology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy.
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Petralia G, Bonello L, Summers P, Preda L, Malasevschi A, Raimondi S, Di Filippi R, Locatelli M, Curigliano G, Renne G, Bellomi M. Intraobserver and interobserver variability in the calculation of apparent diffusion coefficient (ADC) from diffusion-weighted magnetic resonance imaging (DW-MRI) of breast tumours. Radiol Med 2011; 116:466-76. [PMID: 21225368 DOI: 10.1007/s11547-011-0616-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 07/30/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE This study evaluated intraobserver and interobserver variability in the measurement of apparent diffusion coefficient (ADC) values in breast carcinomas. MATERIALS AND METHODS Twenty-eight patients with solid breast lesions >10 mm underwent conventional contrast-enhanced magnetic resonance imaging (MRI) and diffusion-weighted MRI (DW-MRI). Two observers (expert and trainee) segmented the lesion from the surrounding breast tissue on DW images with high b-value (1,000 s/mm(2)). This analysis was repeated by the expert reader after 6 months. Volumes were analysed to obtain mean, median and standard deviation (SD) of the ADC values. Interobserver and intraobserver variation was analysed using the Bland-Altman graph. RESULTS All lesions were breast carcinomas, with a mean ADC value of 1.07 × 10(-3) mm(2)/s. The mean of the differences was 0.012 × 10(-3) mm(2)/s, corresponding to an intraobserver variability of 1.1% (limits of agreement: -5%/+8%). The mean interobserver difference was 0.022 × 10(-3) mm(2)/s, corresponding to an interobserver variability of 2% (limits of agreement: -9%/+14%). CONCLUSIONS We found a low intraobserver and interobserver variability in calculating ADC in breast carcinomas, which supports its potential use in routine clinical practice.
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Affiliation(s)
- G Petralia
- Divisione di Radiologia, Istituto Europeo di Oncologia, Via Ripamonti 435, 20141, Milano, Italy.
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Abstract
Diffusion-weighted magnetic resonance imaging (DW-MRI) appears to hold promise as a non-invasive imaging modality in the detection of early microstructural and functional changes of different organs. DW-MRI is an imaging technique with a high sensitivity for the detection of a large variety of diseases in the urogenital tract. In kidneys, DW-MRI has shown promise for the characterization of solid lesions. Also in focal T1 hyperintense lesions DW-MRI was able to differentiate hemorrhagic cysts from tumours according to the lower apparent diffusion coefficient (ADC) values reported for renal cell carcinomas. Promising results were also published for the detection of prostate cancer. DW-MRI applied in addition to conventional T2-weighted imaging has been found to improve tumour detection. On a 3 T magnetic resonance unit ADC values were reported to be lower for tumours compared with the normal-appearing peripheral zone. The combined approach of T2-weighted imaging and DW-MRI also showed promising results for the detection of recurrent tumour in patients after radiation therapy. DW-MRI may improve the performance of conventional T2-weighted and contrast-enhanced MRI in the preoperative work-up of bladder cancer, as it may help in distinguishing superficial from muscle invasive bladder cancer, which is critical for patient management. Another challenging application of DW-MRI in the urogenital tract is the detection of pelvic lymph node metastases. As the ADC is generally reduced in malignant tumours and increased under inflammatory conditions, reduced ADC values were expected in patients with lymph node metastases.
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Affiliation(s)
- G Petralia
- Institute of Diagnostic, Pediatric and Interventional Radiology, University Hospital of Bern, Inselspital, Freiburgstrasse 10, Bern, Switzerland
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Petralia G, Roscigno M, Zigeuner R, Strada E, Sozzi F, Da Pozzo L, Guazzoni G, Cestari A, Salonia A, Scattoni V, Montorsi F, Rigatti P, Bertini R. 450 COMPLETE METASTASECTOMY IS AN INDEPENDENT PREDICTOR OF CANCER-SPECIFIC SURVIVAL IN PATIENTS WITH CLINICALLY METASTATIC RENAL CELL CARCINOMA. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s1569-9056(10)60446-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bellomi M, Viotti S, Preda L, D’Andrea G, Bonello L, Petralia G. Perfusion CT in solid body-tumours part II. Clinical applications and future development. Radiol Med 2010; 115:858-74. [DOI: 10.1007/s11547-010-0545-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 06/23/2009] [Indexed: 01/18/2023]
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Petralia G, Preda L, D'Andrea G, Viotti S, Bonello L, De Filippi R, Bellomi M. CT perfusion in solid-body tumours. Part I: Technical issues. Radiol Med 2010; 115:843-57. [PMID: 20177989 DOI: 10.1007/s11547-010-0519-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 06/26/2009] [Indexed: 11/30/2022]
Abstract
Functional imaging is becoming increasingly important in both research and clinical diagnostic radiology. Perfusion computed tomography (CTP) is a readily available and widely used tool that allows an objective measurement of tissue perfusion through the mathematical analysis of data obtained from repeated scans performed after administration of contrast agent. Recently, CTP has been increasingly used in the oncological field, being studied as a potential marker of neoplastic angiogenesis, which is one of the main targets of new tumour therapies. The aim of this paper was to provide the theoretical background and practical guidance for accurately performing CTP and interpreting results of examinations in solid-body tumours. CTP could be a valid tool for functional imaging of tumours if the acquisition technique is robust, if image and data analysis is accurate and if interpretation of results is adequately inserted within a clinical context.
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Affiliation(s)
- G Petralia
- Divisione di Radiologia, Istituto Europeo di Oncologia IRCCS, Via Ripamonti 435, 20141 Milano, Italy
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Abstract
Robust technique and accurate data analysis are required for reliable computed tomography perfusion (CTp) imaging. Multislice CT is required for high temporal resolution scanning; 16-slice (or 64-slice) scanners are preferred for adequate volume coverage. After tumour localization, the volume of CTp imaging has to be positioned to include the maximum visible area of the tumour and an adequate arterial vessel. Dynamic scans at high temporal resolution (at least 1-s gantry rotation time) are performed to visualize the first pass of contrast agent within the tumour; repeated scans with low temporal resolution can be planned for late enhancement assessment. A short bolus of conventional iodinated contrast agent, preferably with high iodine concentration, is power injected at a high flow rate (>4 ml/s) in the antecubital vein. The breath-hold technique is required for CTp imaging of the chest and upper abdomen to avoid respiratory motion; free breathing is adequate for CTp imaging of the head, neck and pelvis. Using dedicated software, a region of interest (ROI) has to be placed in an adequate artery (as arterial input) to obtain density–time curves; according to different kinetic models, colour maps of different CTp parameters are generated and generally overlaid on CT images. Additional ROIs can be positioned in the tumour, and in all other parts of the CTp volume, to obtain the values of the CTp parameters within the ROI.
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Affiliation(s)
- G Petralia
- Diagnostic Radiology, European Institute of Oncology, Via Ripamonte 435, 20141 Milan, Italy
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Petralia G, Preda L, Chiesa F, Nolè F, d'Andrea G, Giugliano G, Verri E, Cossu Rocca M, Bellomi M. Role of perfusion computed tomography (CTp) for pretherapy assessment and induction chemotherapy monitoring (IC) in patients with squamous cell carcinoma (SCC) of the head and neck. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e17015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17015 Background: Reliable assessment of the response to IC is required to stratify further treatments, as responders are considered the best candidates for organ preservation strategies. We evaluated the role of CTp for pre-therapy assessment and IC monitoring in patients with SCC of the head and neck. Methods: From November 2004, 28 consecutive patients with locally advanced SCC of the head and neck were enrolled, undergoing CTp and volumetric CT before and after IC with cisplatin, administered at a dose of 100 mg/m2 iv, on day 1, and 5-fluorouracil, administered at a dose of 1,000 mg/m2 ci from day 1 to day 5, q3wks for 2 or 3 cycles. Perfusion parameters were calculated for tumor: blood flow (BF), blood volume (BV), mean transit time (MTT) and capillary permeability-surface (PS). The Wilcoxon rank sum test was used to test for differences in the pre-therapy perfusion parameters between the different tumor grades, as well as between responders and nonresponders to IC. The post-therapy perfusion parameters were compared with the pre-therapy ones by the Wilcoxon signed rank test and percent changes in perfusion parameters were correlated with percent changes in tumor volume calculated by volumetric CT after IC by the Spearman correlation coefficient. Results: Pre-therapy BF was significantly higher in G3 tumors, compared to G1 and G2 (p = 0.01) and G2 tumors (p = 0.03), and pre-therapy BV significantly higher in responders than in nonresponders (p = 0.01). Of the 20 patients who underwent post-therapy CTp, the 17 responders had significant reduction of BF (p = 0.003) and BV (p = 0.014) and increase of MTT (p = 0.04) in the post-therapy CTp, whereas the 3 non responders no significant changes in perfusion parameters. In the 17 responders, percent reduction in BF and BV showed correlation (Spearman R = 0.71, p = 0.0013 and R = 0.82, p = 0.00005, respectively) with percent reduction in tumor volume after IC. Conclusions: In our cohort of patients with SCC of the head and neck, CTp showed potential for pre-therapy assessment, as well as for IC monitoring; further studies are required to confirm our preliminary results. No significant financial relationships to disclose.
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Affiliation(s)
- G. Petralia
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - L. Preda
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - F. Chiesa
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - F. Nolè
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - G. d'Andrea
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - G. Giugliano
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - E. Verri
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - M. Cossu Rocca
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - M. Bellomi
- European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
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Nole F, Munzone E, Bertolini F, Sandri MT, Petralia G, Adamoli L, Radice D, Cullura D, di Pietro A, Goldhirsch A. Circulating endothelial cells (CECs), progenitors (CEPs), and circulating tumor cells (CTCs) for prediction of response in patients with advanced breast cancer (ABC) receiving metronomic oral vinorelbine (oV): Preliminary results. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e14572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e14572 Background: Metronomic administration of chemotherapy given once or more per week with no extended gaps was shown to be effectively anti-angiogenic, causing growth arrest or apoptosis of endothelial cells in tumor neo-vessels. Preclinical and clinical studies indicate that ultra-low concentrations of various microtubule inhibitors inhibit proliferation or migration of endothelial cells. We investigated in a phase II study the activity of metronomic administration of oV in ABC, kinetics and response prediction of CECs, CEPs, CTCs and of other biomarkers of angiogenesis (soluble VEGF, VEGFr2, TSP1, bFGF). CT perfusion scans were also performed. Methods: From February 2008, 47 pts with ABC received oV (50 mg/die TTW). Currently 20 pts are evaluable for both activity and biomarker assessment. Baseline levels of biomarkers of angiogenesis were correlated with clinical response. Results: Shown in Table . Conclusions: We found that the baseline value of apoptotic cells (expressed as % of total cells) was significantly correlated with outcome. The baseline total, viable, and apoptotic CEC count and CTCs might provide an indirect measure for angiogenic turnover and an indicator of better response to anti-angiogenic therapy, supporting the use of metronomic treatments in patients expressing high levels of baseline CECs. Updated results will be presented together with correlation with perfusion CT scan and levels of CTCs. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- F. Nole
- European Institute of Oncology, Milan, Italy
| | - E. Munzone
- European Institute of Oncology, Milan, Italy
| | | | | | - G. Petralia
- European Institute of Oncology, Milan, Italy
| | - L. Adamoli
- European Institute of Oncology, Milan, Italy
| | - D. Radice
- European Institute of Oncology, Milan, Italy
| | - D. Cullura
- European Institute of Oncology, Milan, Italy
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Petralia G, Preda L, Raimondi S, D'Andrea G, Summers P, Giugliano G, Chiesa F, Bellomi M. Intra- and interobserver agreement and impact of arterial input selection in perfusion CT measurements performed in squamous cell carcinoma of the upper aerodigestive tract. AJNR Am J Neuroradiol 2009; 30:1107-15. [PMID: 19342547 DOI: 10.3174/ajnr.a1540] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE CT Perfusion (CTP) has shown potential for assessing head and neck tumors. Our purposes were to assess the inter- and intraobserver agreement of CTP measurements and to investigate whether the selection of arterial input, ipsilateral versus contralateral to the tumor or left-versus-right external carotid artery (ECA), may affect CTP measurements in patients with squamous cell carcinoma (SCCA) of the upper aerodigestive tract. MATERIALS AND METHODS Twenty-six patients with SCCA were enrolled in this prospective study and underwent CTP. Data were analyzed by 2 expert readers and by an inexperienced reader for interobserver agreement and by the 2 expert readers for intraobserver agreement assessment, by using the ECA ipsilateral to tumor site as arterial input. All 3 readers repeated their analysis by using the ECA contralateral to tumor site as arterial input. Inter- and intraobserver agreement was assessed by using the Bland-Altman approach; CTP measurements by using ipsilateral-versus-contralateral or left-versus-right ECA were compared by using the Wilcoxon signed rank test. RESULTS The geometric mean of the ratios (95% limits of agreement) for inter- and intraobserver agreement ranged from 0.96 (0.75-1.23) to 1.00 (0.92-1.10) for blood flow (BF), from 0.88 (0.63-1.21) to 1.00 (0.88-1.14) for blood volume (BV), from 0.96 (0.64-1.44) to 0.98 (0.76-1.27) for mean transit time (MTT), and from 0.85 (0.41-1.76) to 1.14 (0.70-1.86) for permeability surface area product (PS). Significantly higher tumor PS and MTT for 2 readers and lower tumor BF for 1 of 3 readers were observed when the arterial input was placed in the left ECA. CONCLUSIONS BF, BV, and MTT demonstrated higher inter- and intraobserver agreement than PS. The selection of arterial input, right-versus-left ECA, may determine changes in CTP measurements in patients with SCCA of the upper aerodigestive tract.
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Affiliation(s)
- G Petralia
- Department of Radiology, European Institute of Oncology, Milan, Italy.
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Dorrucci V, Spinamano L, Petralia G, Griselli F, Cibi N, Adornetto R. Endovascular Repair of a Large Deep Femoral Artery Branch Pseudoaneurysm Following a Femur Fracture: A Case Report. Eur J Vasc Endovasc Surg 2008. [DOI: 10.1016/j.ejvs.2007.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dorrucci V, Griselli F, Petralia G, Spinamano L, Adornetto R. Heparin-bonded expanded polytetrafluoroethylene grafts for infragenicular bypass in patients with critical limb ischemia: 2-year results. J Cardiovasc Surg (Torino) 2008; 49:145-149. [PMID: 18431333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
AIM The use of prosthetic grafts in below-knee (BK) bypasses may be necessary in patients with no available autologous vein and critical limb ischemia not amenable to angioplasty. Such conduits, however, have generally yielded disappointing results. METHODS A new heparin-bonded expanded polytetrafluoroethylene graft (Gore-Tex Propaten Vascular Graft) designed to provide resistance to thrombosis may be associated with decreased early graft failure and increased patency. This graft was implanted in 27 limbs (26 patients; 18 men; mean age 71 years; Rutherford class 4 to 6 disease) in a BK femoropopliteal and femorodistal location, without perioperative complications and with immediate graft patency. RESULTS During a mean follow-up time of 24 months, 4 cases of thrombosis occurred, all at least 6 months postoperatively: 2 cases resolved after fibrinolytic treatment, 1 required surgical revision and in 1 case, amputation was required because of a delay in seeking treatment for thrombosis. Two patients died of cardiac disease during follow-up. The 2-year primary and secondary patency rates for the BK bypasses were 85% and 93%, respectively; the limb-salvage rate was 96%. CONCLUSION These results are encouraging for a prosthetic graft, especially in the light of the severity of the vascular disease in the limbs treated.
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Affiliation(s)
- V Dorrucci
- Department of Vascular Surgery, Umberto I Hospital, Venice, Italy.
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Dorrucci V, Spinamano L, Petralia G, Griselli F, Cibi N, Adornetto R. Endovascular Repair of a Large Deep Femoral Artery Branch Pseudoaneurysm Following a Femur Fracture: A Case Report. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.ejvsextra.2007.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Petralia G, Kakkar A. Venous Thromboembolism Prophylaxis for the General Surgical Patient: Where Do We Stand? Semin Respir Crit Care Med 2008; 29:83-9. [DOI: 10.1055/s-2008-1047566] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Andreoni B, Chiappa A, Pace U, Bertani E, Verweij F, Orsi F, Petralia G, Tullii M, Venturino M, Pelosi G. Surgical 'damage control' treatment of a large retroperitoneal liposarcoma encasing a horseshoe kidney. Ecancermedicalscience 2008; 2:77. [PMID: 22275967 PMCID: PMC3234050 DOI: 10.3332/ecancer.2008.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Indexed: 11/16/2022] Open
Abstract
Damage control is a surgical strategy for severely compromised trauma patients based on speed control of life-threatening injuries that aims to rapidly resuscitate patients in an intensive care unit (ICU). We report on the use of such therapeutic strategy in a patient affected by a retroperitoneal sarcoma concomitant to a horseshoe kidney, a relatively rare anatomical malformation.
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Affiliation(s)
- B Andreoni
- Department of General Surgery, European Institute of Oncology, Milan, Italy.
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