Cardiological Safety of 5-Fraction Whole Breast Irradiation

PURPOSE/OBJECTIVE(S)

Our study aims to assess heart toxic effect using a reliable cardiac assessment with standard and 3-dimensional (3D) echocardiography and left ventricular (LV) global longitudinal strain (GLS) in patients receiving a 5-fraction (total dose 26 Gy) postoperative radiation therapy (RT) for breast cancer (BC).

MATERIALS/METHODS

SAFE-FORWARD is an observational prospective cohort study (NCT04842409). Inclusion criteria were: (1) patients with invasive BC receiving ultra-hypofractionated whole breast irradiation (WBI) (26 Gy in 5 fractions) after breast conserving surgery (BCS) (2) without cardiovascular comorbidity and (3) previous thoracic irradiation. All enrolled patients are prospectively monitored for 12 months, receiving a complex cardiological assessment before RT start (baseline), and at 2-, 6-, and 12-month after RT end of treatment. Both acute and early-late toxicity are evaluated according to CTCAE (v.5) scales. The primary endpoint is defined as detection of any subclinical impairment in myocardial function and deformation (decrease ≥10%) measured with standard and 3D echocardiography and LV GLS.

RESULTS

Overall, 40 women (median age 66 years; range, 48-84) were enrolled in the study. We analyzed patients who had completed the cardiological assessment at 12 months. Baseline patient's characteristics are summarized in Table 1. All patients received ultra-hypofractionated WBI (26 Gy in 5 fractions), 25 patients also received adjuvant endocrine therapy. GLS worsened 4% or less, both for the left- and right-side treated breast, and remained in normal range for all the time points. The only exception was for RVGLS at 6 months for right-sided treatment where it reached a borderline value (-17.4±4.9 SE). 3D-LVEF remains stable during observation, both for the left- and right-side treated breast CONCLUSION: The 5-fraction schedule after BCS is well tolerated and the intensive 1-year cardiological monitoring showed no significant differences overtime in cardiac functioning.

ABBREVIATIONS

DIBH, deep inspiration breath hold; AI, aromatase inhibitors; BCCT, Breast Cancer Conservation Treatment.

Phenotyping the right heart according to left ventricular geometry patterns in severe HFrEF

Background

Right ventricular (RV) failure significantly impact on heart failure with reduced ejection fraction (HFrEF) prognosis. How and whether specific functional and geometrical phenotypes of the RV function adapt and combined with left ventricular (LV) geometry is unknown.

Purpose

To test the RV function across LV geometrical patterns looking at respective prognostic roles.

Methods

We retrospectively examined a population of patients homogenously diagnosed with chronic HFrEF (defined as LV ejection fraction (EF) less than 35%) and treated with optimal therapy (OT) and all implanted with ICD for primary prevention of sudden cardiac death. Patients were categorized by echocardiography according to remodeling pattern based on left ventricular mass index and relative wall thickness into four groups: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). RV parameters were: tricuspid annulus plane systolic excursion (TAPSE), TAPSE/pulmonary artery pressures (PAPs), RV basal diameter and fractional area change (FAC). Outcome variable was all-cause mortality, assessed with multivariable Cox proportional hazard (PH) models.

Results

Among 193 patients (age 66±11 years, 81% men, 74% with ischemic etiology of HF and EF 28±5%) 21% had NG, 3% had CR, 8% had CH, and 68% had EH. Distribution of RV echo parameters across LV remodeling groups is shown in table 1. Over a median follow-up time of 4 (1.9 – 6.1) years, 65 deaths occurred. In multivariable Cox PH models adjusted for age, LVEF, ischemic etiology and LV geometry, TAPSE, TAPSE/PAPs, RV basal diameter and FAC strongly and independently predicted the outcome variable [HR 0.92 (95% C.I. 0.86–0.98), HR 0.08 (95% C.I. 0.01–0.57), HR 1.87 (95% C.I. 1.29–2.71), HR 0.97 (95% C.I. 0.95–1.00), respectively all p-value <0.05].

Conclusion

In a homogeneously defined population of severe HFrEF outpatients receiving OT, the majority showed EH remodeling pattern, which did not predict the primary outcome. LV geometry did not further stratify patients in this high risk group. Conversely, RV dysfunction proved to be a strong predictor of mortality, independently of age, LV function and etiology of HF, regardless LV morphology.

Funding Acknowledgement

Type of funding sources: None.

In phantom evaluation of targeting accuracy in MRI-based brain radiosurgery

PURPOSE

To determine the targeting accuracy of brain radiosurgery when planning procedures employing different MRI and MRI + CT combinations are adopted.

MATERIALS AND METHOD

A new phantom, the BrainTool, has been designed and realized to test image co-registration and targeting accuracy in a realistic anatomical situation. The phantom was created with a 3D printer and materials that mimic realistic brain MRI and CT contrast using a model extracted from a synthetic MRI study of a human brain. Eight markers distributed within the BrainTool provide for assessment of the accuracy of image registrations while two cavities that host an ionization chamber are used to perform targeting accuracy measurements with an iterative cross-scan method. Two procedures employing 1.5 T MRI-only or a combination of MRI (taken with 1.5 T or 3 T scanners) and CT to carry out Gamma Knife treatments were investigated. As distortions can impact targeting accuracy, MR images were preliminary evaluated to assess image deformation extent using GammaTool phantom.

RESULTS

MR images taken with both scanners showed average and maximum distortion of 0.3 mm and 1 mm respectively. The marker distances in co-registered images resulted below 0.5 mm for both MRI scans. The targeting mismatches obtained were 0.8 mm, 1.0 mm and 1.2 mm for MRI-only and MRI + CT (1,5T and 3 T), respectively.

CONCLUSIONS

Procedures using a combination of MR and CT images provide targeting accuracies comparable to those of MRI-only procedures. The BrainTool proved to be a suitable tool for carrying out co-registration and targeting accuracy of Gamma Knife brain radiosurgery treatments.

The Frailty Index in centenarians and their offspring

Frailty has been indicated as a way for capturing biological aging of the individual and Frailty Index (FI) may serve for this purpose. This study designed the FI in a cohort of centenarians, their offspring and control subjects sex- and age-matched with offspring. The FI mean value was 0.47 (SD 0.13) in centenarians, 0.15 (SD 0.12) in their offspring, and 0.22 (SD 0.14) in controls (p < 0.001). The difference between offspring and controls was statistically significant (p = 0.003). The correlation between FI and age was significant in offspring (r = 0.46, p < 0.001), close to significance in controls (r = 0.25, p = 0.08) and not significant in centenarians. Our study confirms that FI is a marker of biological age useful to discriminate different degrees of frailty even at extremely advanced age.

The Triggering Receptor Expressed on Myeloid Cells-2 (TREM-2) as Expression of the Relationship between Microglia and Alzheimer's Disease: A Novel Marker for a Promising Pathway to Explore

Alzheimer's disease (AD) is a common neurodegenerative disorder, strongly related with age. It has been reported that genetic variants of the Triggering Receptor Expressed on Myeloid Cells-2 (TREM2), a cell-surface receptor expressed in microglial cells, greatly increase the risk of AD, thus suggesting an involvement of the microglia in the AD pathogenesis. The aim of this report is to provide an overview of the TREM2 and of its possible implication in the pathogenesis of AD.

Apolipoprotein E gene in physiological and pathological aging

INTRODUCTION

The genetic background plays a role on longevity. The distribution of the apolipoprotein E gene (APOE) variants (ε2, ε3, ε4) may differ across age groups, especially in the oldest old and despite geographical and ethnic specificities. Since the ε4 variant is associated with Alzheimer's disease (AD), it might represent an opportunity for exploring the relationship of APOE with physiological and pathological aging.

AIM

To explore the role played by APOE genotype/alleles on physiological and pathological brain aging.

MATERIALS AND METHODS

The study was conducted in a cohort of centenarians (n = 106), and two cohorts of octogenarians (without cognitive decline, n = 351 controls; and with AD, n = 294).

RESULTS

No significant differences in genotype/allele distributions were observed comparing controls to centenarians. The prevalence of ε2/ε3, ε3/ε3, ε3/ε4 and ε4/ε4 genotypes were significantly different in centenarians compared to AD. The prevalence of ε2 and ε3 alleles were significantly higher in centenarians, whereas the ε4 was less frequent. The ε4 allele was positively associated with AD, whereas a negative association was found for ε2 and ε3 alleles.

CONCLUSIONS

Our study indicates that ε4 allele is strongly associated with AD. APOE significantly affects AD risk, but apparently not longevity.

Increased expression of TREM2 in peripheral cells from mild cognitive impairment patients who progress into Alzheimer's disease

BACKGROUND AND PURPOSE

Neuroinflammation plays a role in the aetiopathogenesis of Alzheimer's disease (AD). Triggering receptor expressed on myeloid cells 2 (TREM2), a cell surface receptor of the immunoglobulin superfamily, seems to have protective anti-inflammatory activity in AD.

METHODS

Triggering receptor expressed on myeloid cells 2 expression was analysed in peripheral blood mononuclear cells from healthy subjects (CT) and from patients with either AD or mild cognitive impairment (MCI). MCI patients were re-evaluated at a 2-year follow-up to investigate their progression to AD (MCI-AD) or lack thereof (MCI-MCI).

RESULTS

Triggering receptor expressed on myeloid cells 2 gene expression was higher in AD than CT patients, but was highest in MCI. At recruitment TREM2 levels were higher in MCI-AD than in MCI-MCI, and in MCI-AD were higher initially than at follow-up. TREM2 displayed a moderate degree of sensitivity and specificity for identifying MCI-AD in all MCI patients. Our data showed higher TREM2 levels in allele ε4 of apolipoprotein E (ApoE ε4) carriers than non-carriers in MCI and particularly in MCI-AD.

CONCLUSIONS

These data seem to confirm the protective role of TREM2 in the pre-clinical stage of AD. Upregulation of TREM2 in MCI-AD could be a mechanism to counteract the activation of neuroinflammatory processes. It is possible that TREM2 and ApoE ε4 interact synergistically in the pre-clinical stage of AD. Therefore, TREM2 may be useful as an early peripheral biomarker for the development of AD.

Immunogenetic and population genetic analyses of Iberian cattle

Blood samples were collected from more than 100 animals in each of 2 Spanish cattle breeds (Retinto and De Lidia), 2 Portuguese breeds (Alentejana and Mertolenga), and American Longhorn cattle. All samples for the 4 Iberian breeds were tested for 20 polymorphic systems; American Longhorn were tested for 19 of the 20. For each breed an average inbreeding coefficient was estimated by a comparison of the observed and expected heterozygosity at 7 or 8 codominant systems tested. All breeds had positive values but only 3 breeds had estimates of inbreeding that were statistically significantly different from 0: De Lidia with f = 0.17, Retinto with f = 0.08 and Mertolenga with f = 0.05. The De Lidia breed especially may be suffering from inbreeding depression since this high value is greater than expected if all of the animals were progeny of half-sib matings. Genetic distances were calculated from the gene frequency data on these 5 breeds plus 9 other European breeds. Analyses of these distances show a closely related group of the 4 Iberian breeds and American Longhorn, confirming the close relationships among the Iberian breeds and the Iberian, probably Portuguese, origin of American Longhorn cattle.

Safety of use, efficacy and degree of parental satisfaction with the nasal aspirator Narhinel in the treatment of nasal congestion in babies

AIM

The aim of this study was to assess the safety, effectiveness and parental compliance with a medical device on the market in Europe for removing excess nasal secretions by aspiration in babies viral infections of the upper respiratory tract.

METHODS

A prospective observational noncomparative cohort study, as part of postmarketing and customer satisfaction surveillance was specifically performed among family paediatricians in Lombardy, Italy. Two hundred and forty patients were admitted from 22 different family pediatricians belonging to the Italian Federation of Paediatricians (Federa-zione Italiana Medici Pediatri, FIMP) in Lombardy. All patients took part in the safety assessment. Two hundred and twelve patients (104 females, 108 males, average age 9.6 months, age range 1.8-27.6 months) also underwent clinical efficacy assessment (28 patients were excluded). Upon admission and at the first outpatient examination (E1), parents were taught by their family pediatrician to clean their babies' noses by nasal aspiration 3 times a day for 7 consecutive days immediately before feeding. At the end of treatment, a second outpatient examination (E2) was carried out at which parents' treatment diaries were collected and the parents answered a satisfaction questionnaire. SAFETY of use was checked using: 1) Italian Health Ministry incident/near incident report forms and 2) treatment diaries where the parents noted any events that had occurred while using the device every day. EFFICACY was assessed by analysing various clinical parameters (anterior and posterior rhinorrhea, oral respiration, noisy nasal respiration, and nasally transmitted chest sounds) measured by the pediatrician at the two examinations (E1 and E2), and the entries in the parents' treatment diary regarding quality of sleep, feeding and respiration, and use of any drugs. Parental satisfaction and compliance were assessed through a questionnaire given to the parents at E2. The device is marketed in 2007 under the name of Narhinel in Italy, Spain and Portugal; Otrisalin in Greece; Prorhinel in France; Rhinomer in the Baltic countries (Lithuania, Latvia, Estonia); Otrivin Baby in Russia and Otri-Baby in Sweden.

SAFETY

no incidents were reported to the Italian Ministry of Health. There were 40 cases of mild side effects such as nose bleed (6), protracted crying (30), restlessness/irritation (2), vomiting and others (2).

EFFICACY

clear improvements were seen in all the clinical parameters assessed at the post-treatment examination (E2) when compared to E1: anterior rhinorrhea (decreased by 74%), posterior rhinorrhea (decreased by 80%), oral respiration (decreased by 78%), noisy respiration (decreased by 73%), and nasally transmitted chest sounds (decreased by 82%). The entries in the treatment diaries also showed progressive improvement in the children's' conditions during the treatment period: peaceful sleep increased by 67%, quality of feeding increased by 36%, respiration improved by 76%, and the administration of drugs decreased by 41%. The P values for each item (clinicians observations and parents' observations) are statistically significative P<0.001, between the day 1 and the day 8. Satisfaction and compliance were excellent: 92% of parents were satisfied (56% very and 42.7 fairly). Seventy-eight percent reported that the device was simple to use, and 86% of parents judged Narhinel to be more effective than other similar devices.

CONCLUSION

Narhinel proved to be a safe, effective and simple to use device. The parents of babies with nasal obstruction caused by upper respiratory infection were extremely satisfied.

Pretreatment verification of IMRT absolute dose distributions using a commercial a-Si EPID

A commercial amorphous silicon electronic portal imaging device (EPID) has been studied to investigate its potential in the field of pretreatment verifications of step and shoot, intensity modulated radiation therapy (IMRT), 6 MV photon beams. The EPID was calibrated to measure absolute exit dose in a water-equivalent phantom at patient level, following an experimental approach, which does not require sophisticated calculation algorithms. The procedure presented was specifically intended to replace the time-consuming in-phantom film dosimetry. The dosimetric response was characterized on the central axis in terms of stability, linearity, and pulse repetition frequency dependence. The a-Si EPID demonstrated a good linearity with dose (within 2% from 1 monitor unit), which represent a prerequisite for the application in IMRT. A series of measurements, in which phantom thickness, air gap between the phantom and the EPID, field size and position of measurement of dose in the phantom (entrance or exit) varied, was performed to find the optimal calibration conditions, for which the field size dependence is minimized. In these conditions (20 cm phantom thickness, 56 cm air gap, exit dose measured at the isocenter), the introduction of a filter for the low-energy scattered radiation allowed us to define a universal calibration factor, independent of field size. The off-axis extension of the dose calibration was performed by applying a radial correction for the beam profile, distorted due to the standard flood field calibration of the device. For the acquisition of IMRT fields, it was necessary to employ home-made software and a specific procedure. This method was applied for the measurement of the dose distributions for 15 clinical IMRT fields. The agreement between the dose distributions, quantified by the gamma index, was found, on average, in 97.6% and 98.3% of the analyzed points for EPID versus TPS and for EPID versus FILM, respectively, thus suggesting a great potential of this EPID for IMRT dosimetric applications.