P17.09.A Regorafenib and Re-irradiation: analysis of clinical outcomes and toxicities in patients with recurrent glioblastomas

Background

Glioblastoma is the most common and aggressive primary brain tumor in adults.The aggressiveness and poor prognosis related to this disease join to the limited available treatment options. The current standard of care involves surgical resection followed by concomitant radiotherapy and chemotherapy. At recurrence, no standard treatment exists and there are no guidelines to facilitate decisions in the recurrent setting. Available options include re-operation, re-irradiation, systemic therapy, alone or in combination. In recent years, immunotherapy strategies have revolutionized the treatment of many cancers, increasing the hope for GBM therapy. Regorafenib (Stivarga) is an inhibitor of several kinases involved in the mechanisms that regulate neoangiogenesis processes, through the inhibition vascular endothelial growth factor (VEGF) receptors and the modifications of the tumor microenvironment; specifically, Regorafenib binds and stabilizes PSAT1 (phosphoserine aminotransferase 1). The dual regulatory mechanism underlying PSAT1-induced autophagy arrest accounts for the superior anti-GBM effect of Regorafenib compared with Temozolomide.

Material and Methods

15 patients with documented disease progression after surgery followed by RT and TMZ were assigned to receive regorafenib (REG) 160 mg once daily for the first 3 weeks of each 4-week cycle. All patients received prior radiation therapy (RT) to a median dose of 60 Gy (range 40.05 -60). Median time to retreatment after prior RT was 16 months (range 14-33). Tumor volumes ranged from 81.7 cm3 to 422.4 cm3 (CTV) and from 112.7 cm3 to 422.4 cm3 (PTV).3 patients (20%) received concomitant reirradiation with a radiation dose of 37.5 Gy in 15 fractions of 2.5 Gy.

Results

the median follow-up was 9.5 months (range 5-22). The overall survival and the progression-free survival rates were 53,8 %, and 46,6 % respectively at 2 years. In 53% the symptoms were stable. Only one patient developed late toxicity: acute pancreatitis (Grade I) regressed on interruption of Regorafenib. No other neurological deficits occurred during follow-up. At last follow up 60% of patients were alive.

Conclusion

we report our experience with Regorafenib, administered in patients with rapid progression after the end of postoperative radio chemotherapy treatment. Regorafenib might be a new potential treatment option for recurrent glioblastoma: it was well tolerated also in cases of combined treatment with reirradiation and appeared effective. Other studies will be necessary to evaluate and confirm the role of Regorafenib in glioblastoma patients and the potential effectiveness of the combined therapeutic strategy: Regorafenib-reirradiation.

The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies

BACKGROUND

Scabies is a common parasitic skin condition that causes considerable morbidity globally. Clinical and epidemiological research for scabies has been limited by a lack of standardization of diagnostic methods.

OBJECTIVES

To develop consensus criteria for the diagnosis of common scabies that could be implemented in a variety of settings.

METHODS

Consensus diagnostic criteria were developed through a Delphi study with international experts. Detailed recommendations were collected from the expert panel to define the criteria features and guide their implementation. These comments were then combined with a comprehensive review of the available literature and the opinion of an expanded group of international experts to develop detailed, evidence-based definitions and diagnostic methods.

RESULTS

The 2020 International Alliance for the Control of Scabies (IACS) Consensus Criteria for the Diagnosis of Scabies include three levels of diagnostic certainty and eight subcategories. Confirmed scabies (level A) requires direct visualization of the mite or its products. Clinical scabies (level B) and suspected scabies (level C) rely on clinical assessment of signs and symptoms. Evidence-based, consensus methods for microscopy, visualization and clinical symptoms and signs were developed, along with a media library.

CONCLUSIONS

The 2020 IACS Criteria represent a pragmatic yet robust set of diagnostic features and methods. The criteria may be implemented in a range of research, public health and clinical settings by selecting the appropriate diagnostic levels and subcategories. These criteria may provide greater consistency and standardization for scabies diagnosis. Validation studies, development of training materials and development of survey methods are now required. What is already known about this topic? The diagnosis of scabies is limited by the lack of accurate, objective tests. Microscopy of skin scrapings can confirm the diagnosis, but it is insensitive, invasive and often impractical. Diagnosis usually relies on clinical assessment, although visualization using dermoscopy is becoming increasingly common. These diagnostic methods have not been standardized, hampering the interpretation of findings from clinical research and epidemiological surveys, and the development of scabies control strategies. What does this study add? International consensus diagnostic criteria for common scabies were developed through a Delphi study with global experts. The 2020 International Alliance for the Control of Scabies (IACS) Criteria categorize diagnosis at three levels of diagnostic certainty (confirmed, clinical and suspected scabies) and eight subcategories, and can be adapted to a range of research and public health settings. Detailed definitions and figures are included to aid training and implementation. The 2020 IACS Criteria may facilitate the standardization of scabies diagnosis.

Epilepsy and vaccinations: Italian guidelines

Reports of childhood epilepsies in temporal association with vaccination have had a great impact on the acceptance of vaccination programs by health care providers, but little is known about this possible temporal association and about the types of seizures following vaccinations. For these reasons the Italian League Against Epilepsy (LICE), in collaboration with other Italian scientific societies, has decided to generate Guidelines on Vaccinations and Epilepsy. The aim of Guidelines on Vaccinations and Epilepsy is to present recent unequivocal evidence from published reports on the possible relationship between vaccines and epilepsy in order to provide information about contraindications and risks of vaccinations in patients with epilepsy. The following main issues have been addressed: (1) whether contraindications to vaccinations exist in patients with febrile convulsions, epilepsy, and/or epileptic encephalopathies; and (2) whether any vaccinations can cause febrile seizures, epilepsy, and/or epileptic encephalopathies. Diphtheria-tetanus-pertussis (DTP) vaccination and measles, mumps, and rubella vaccination (MMR) increase significantly the risk of febrile seizures. Recent observations and data about the relationships between vaccination and epileptic encephalopathy show that some cases of apparent vaccine-induced encephalopathy could in fact be caused by an inherent genetic defect with no causal relationship with vaccination.

Overexpression of pro-inflammatory genes and down-regulation of SOCS-1 in human PTC and in hypoxic BCPAP cells

Hypoxia-inducible factor-1α (HIF-1α) is frequently overexpressed and activated in many cancer types. However, its regulation and function in thyroid carcinomas are only partially known. Aim of our study was to demonstrate that adaptation to the hypoxic micro-environment by human papillary thyroid carcinoma (PTC) cells, in the absence of leukocyte infiltrate, induces a "molecular inflammation" process characterized by the expression of a large set of genes normally involved in inflammation. To address this, tumor, peritumor or normal host tissue from eleven human PTC surgical samples, were separated by laser capture microdissection (LCMD) and studied by real-time quantitative PCR and Western blot. In such condition, we observed an increased expression and activation of HIF-1α, NF-kB and pro-inflammatory genes only in tumor tissues. Importantly, an anti-inflammatory gene such as SOCS-1 was markedly down-regulated in tumor tissue compared to surrounding normal host tissue. Similar results were found in fine-needle aspiration biopsy (FNAB)-derived specimens from PTC and in hypoxic human papillary thyroid tumor cell line, BCPAP. Moreover, we also detected an elevated expression of metalloproteinase-9 (MMP9) both in solid tumor and in hypoxic-treated BCPAP cells. Our findings reveal that, in human PTC tumor, hypoxic conditions are accompanied by up-regulation of pro-inflammatory genes, down-regulation of anti-inflammatory genes and increased expression of MMP9. We propose that a better understanding of the pro- and anti-inflammatory pathways involved in the "molecular inflammation" process even in the absence of leukocyte, may help to clarify progression toward malignancy and may prove useful for new anti-tumor strategy.

[Results of arthroscopically assisted refixation of fractures of the intercondylar eminence]

AIM

In order to restore ACL function and therefore knee joint stability, the surgical refixation of anterior cruciate ligament avulsion fractures is a consistent recommendation in literature. The objective of this study was to evaluate the clinical results after arthroscopic fixation of dislocated avulsion fracture of the intercondylar eminence depending on patient age and refixation technique.

METHOD

24 patients (50% below 16 years) with anterior cruciate ligament avulsion fractures were treated either with arthroscopic screw fixation (n = 17) or transtibial suture refixation (n = 7). Clinical follow-up examination was conducted on average 4.1 years after operation.

RESULTS

17% of the patients presented with additional intra-articular lesions. Osseous integration of the avulsion fragment was documented on plain radiographs on average 6.1 weeks after surgery in adults and after 3.9 weeks in children. Free range of motion was accomplished after 11.3 weeks. The choice of surgical technique did not show any influence on healing period or rehabilitation. The complication rate was 16.6% in skeletally immature patients and 8.3 % in adults. IKDC scores: A10, B2 in children; A9, B3 in adults. Tegner scores: children 5.8, adults 4.1. Lysholm scores: children 93, adults 88.

CONCLUSIONS

Neither the patients' age nor the refixation technique selected yielded a significant correlation to the accomplished clinical score. Both arthroscopic screw fixation and transtibial suture fixation are appropriate surgical procedures regarding results and complication rate.

Scaphoid and capitate fracture with concurrent scapholunate dissociation

Combined fracture of the scaphoid and capitate bones with concurrent scapholunate dissociation, but without severe dislocation, is a rare lesion which results in significant carpal instability and requires operative treatment. We report a case of this unusual injury and its functional result after 20 months.

Pregnancy and tram-flap breast reconstruction after mastectomy: a case report

A 38-year-old patient had a right radical (Patey) mastectomy for an infiltrating ductal carcinoma followed by chemotherapy and, one year later, a TRAM flap breast reconstruction. She was given clear and exhaustive information about the possible consequences of pregnancy, but despite this she became pregnant four months after the reconstruction. The pregnancy was taken to term despite the appearance at four months of a slow-growing abdominal hernia. In the light of our experience and that of others, we recommend an interval of at least 12 months between breast reconstruction with a TRAM flap and pregnancy.

[Breast reconstruction]

The ideal goal of every post-mastectomy breast reconstruction is to achieve a breast that is as "identical" as possible to the contralateral one in shape, size, consistency, mobility and degree of naturalness. At the same time, however, it is essential to rely on the simplest and safest reconstruction technique as far as the patient is concerned. Mastectomy and restoration of the lost morphology should be performed in a single operation whenever the opportunity arises and there are two reasons for this. First of all, by working this way reconstruction can be performed on an area that is completely free of any scar tissue. Secondly, there are psychological considerations involved, since this makes it possible to avoid the trauma of letting the patient seeing herself, even for just an instant, without her breast. The numerous different techniques used for the morphological reconstruction of breast volume can be classified into two basic groups: reconstruction with insertion of a prosthesis and reconstruction without a prosthesis. Both of these techniques make it possible to personalize surgical choices based on the patient's unique characteristics, in order to achieve a complete symmetry in relation to the contralateral breast.

Dextran cross-linked gelatin microspheres as a drug delivery system

This paper describes the use of oxidized dextran as a cross-linker for the preparation of gelatin microspheres. Microspheres were obtained by a thermal gelation method and their dissolution kinetic was examined. In order to find evidence of sugar mediated cross-linking, swelling tests and gelatin microspheres dissolution experiments were performed. The obtained results indicated that oxidized dextran can form a cross-linked gelatin network which can reduce the dissolution of gelatin. More interestingly, gelatin microspheres treated by both native and oxidized dextran slow down, even if to a different extent, the release of the antitumor drug TAPP-Br used as a model compound. Taken together, our results suggest that oxidized dextran could be an interesting means to cross-link gelatin microspheres allowing the use of this delivery formulation for controlled release of drugs.

[The postoperative expansion of a myocutaneous flap of the large dorsal muscle in postmastectomy breast reconstruction]

BACKGROUND

Reconstructive breast surgery using the myocutaneous flap of the latissimus dorsi muscle with simultaneous insertion of a prosthesis represents a very useful procedure from a clinical standpoint.

METHODS

Twenty-one breast reconstructions were performed using this type of surgery at the Plastic Surgery Clinic of the University of Udine between December 1993 and December 1995.

RESULTS

Good aesthetic results can be obtained due to the relatively moderate functional and scarring complications, as well as to the vitality of the transposed tissue. The percentage of capsular contractures observed frequently in the past was lowered through the use of technologically-advanced prosthetic materials with a texturized surface.

CONCLUSIONS

In addition, since the reconstructed breast can be expanded postoperatively through definitive Becker expanders, aesthetically satisfactory results can be achieved even with contralateral ptosic and/or large breasts.

Myofasciocutaneous expansion in the tegumentary rehabilitation of the amputation stump

In post-traumatic amputations, in particular in leg amputations, the presence of an unstable scar or of ulcerous areas that are difficult to heal in the site of the amputation stump constitutes a repair problem that is not easily solved. In this specific field of reconstruction skin expansion has earned significant agreement, and is even considered to be a safe and reliable method for the surgical rehabilitation of the amputation stump, allowing us to obtain high-quality tegumentary covering, with no excessive thickness, that adapts well to the prosthesis and to the underlying skeleton, and that is characterized by good sensitivity of protection. Tegumentary amplification may, in some cases, also become myocutaneous, allowing us to obtain more tissue thickness for protection in patients submitted to chronic loading that lasts longer and in those with thin teguments, in which traditional expansion could determine excessive narrowing of the tegumentary covering, following atrophy caused by compression of the subcutaneous adipose tissue.

[Anesthesiologic problems in patients with Launois-Bensaude-Madelung disease. Clinical case]

Authors report a Launoise-Bensaude-Madelung disease case, in a 64 year old man, admitted to a Plastic Surgical Department for obesity, dysphonia, dysphagia, dyspnea. Early symptoms appeared 20 years before Hospital admission. Lipomatous tissue occupied nape, mandible, neck and shoulders. Surgical exeresis of lipomatous tissue under general anesthesia needed for the patient. Neck movements and mouth opening were short (Mallampati Score = 4); a neck computed tomography showed a tracheal compression and right displacement. Tracheal intubation was considered difficult or impossible. Nose-tracheal intubation was performed using a pediatric fiberoptic instrument as guide for a small gauge tracheal tube. Tracheal stenosis required many attempts for correct nose-tracheal intubation. Fiberoptic instrument as guide for tracheal tube can be useful for patients with Launoise-Bensaude-Madelung disease, when tracheal intubation is considered difficult or impossible. Knowledge of fiberoptic tracheal intubation techniques is mandatory for anesthesiologists, allowing tracheal intubation in patients with anatomical variations of mouth or upper respiratory airways.

Cytogenetic and immunofluorescence analysis of benzo[a]pyrene-DNA adduct formation and chromosome damage in larval brain neuroblasts of Drosophila melanogaster

Recently we have evaluated the relationship between benzo[a]-pyrene(BaP)-DNA adducts, determined by 32P-postlabelling, and clone frequencies in the somatic mutation and recombination test (SMART) in Drosophila melanogaster. Following that study we proceeded to characterise further the mechanism of induction of genetic damage in vivo by BaP in Drosophila by cytogenetic analysis of larval brain neuroblasts. Third stage larvae were treated with 4 and 10 mM BaP for 24, 48 or 72 h. In all cases, the larvae were killed 72 h after the beginning of treatment, entailing 48, 24 or 0 h post-treatment recovery in BaP-free medium, respectively. At the end of the treatment the following data were collected: (i) the types and levels of chromosome aberrations in neuroblast metaphase and anaphase nuclei; (ii) the distribution and level of BaP-DNA adducts, revealed by indirect immunofluorescence in neuroblast nuclei using an anti-(BaP-DNA) antibody. The results indicate that BaP induces chromosome breaks, deletions and exchanges in this system. In particular, chromosome exchanges decrease as the post-treatment recovery time increases, and the dynamics of breaks and deletions appear to be inversely related to those of the exchanges. This suggests that exchanges may require few preconditions to occur and are thus expressed soon after treatment. Chromosome breaks and deletions could require multiple single events before the actual damage is expressed (even some cell divisions away from the end of treatment). The immunofluorescence analysis suggests that BaP-DNA adducts are more abundant in the heterochromatin of the neuroblast nuclei.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of radiotherapy in patients with bladder carcinoma]

The authors analyse the results of treatment with radiotherapy with therapeutic doses and traditional fractionation scheme 60 patients affected by bladder cancer, from 1980 through 1991, at the Institute of Radiology of the University "La Sapienza" in Rome. We evaluated the association of radiotherapy (RT) with trans-urethral resection and biopsy (TURB) and the association of RT with cystectomy (total or partial), both in T1-T2 and T3-T4 bladder stages. The mean follow-up was 85 months (from 24 months to 11 years). The survival at 5 years after completing the treatment was 33.3%; the survival of stages T1-T2 was of 40% at 5 years while that of stages T3-T4 was of 28.5%. Our study shows that the association of radiotherapy and TURB for T1 or T2 bladder cancer is an alternative to mutilating surgery like total or partial cystectomy; in this group, indeed, we showed a survival of 54.5% at 5 years as compared to the 28.5% of the group treated with cystectomy + RT. For T3 and T4 bladder cancer we had better results with surgery (total or partial cystectomy) and RT: in these patients the survival at 5 years was of 31%, while the group treated with TURB + RT showed a survival of 19%.

Chloral hydrate is recombinogenic in the wing spot test in Drosophila melanogaster

In order to characterise the response of the wing spot test in Drosophila melanogaster to the effects of compounds with known aneugenic properties, experiments were performed with chloral hydrate (CH). Following chronic exposure of 72-h-old larvae to rising concentrations of CH, significant increases in the frequency of small (1-2 cells) single spots were observed. Comparison of results obtained in parallel from the wings of marker-trans-heterozygous individuals and individuals heterozygous for one of two different balancer chromosomes suggests that practically all the single clones originated from recombinational events. Twin clone frequencies were, however, only weakly affected. These results are discussed with reference to the literature regarding the effects of CH in different experimental systems and to the characteristics of Drosophila as a tester organism.

Relationship between benzo(a)pyrene-DNA adducts and somatic mutation and recombination in Drosophila melanogaster

The evaluation of the relationship between the dose to DNA of a mutagen/carcinogen and in vivo somatic cell mutagenesis may provide information on the mechanisms leading to induced mutational events. This can be achieved, for example, by coupling test systems that permit the detection of somatic mutation and recombination on the basis of phenotypic changes in cuticular structures of Drosophila melanogaster, with methods for the quantitation of carcinogen-DNA adducts such as the 32P-postlabeling technique. In this article, we evaluate the quantitative relationship between BaP-DNA adduct formation, determined by 32P-postlabeling, and the induction of mutant cells in the wing marker version of the somatic mutation and recombination test (SMART) in Drosophila melanogaster. The total single clones in the trans-heterozygous mwh/flr3 flies show a linear relationship with the BaP-DNA adduct levels, suggesting a single hit mechanism for the genetic damage giving rise to this type of clones. In contrast, the twin clones (which are of recombinational origin) display a linear-quadratic relationship with the adduct levels, suggesting that multiple hits may be involved in generating these clones. The total single clones in the mwh/TM3, Ser flies (in which mitotic recombination is suppressed) show a logarithmic relationship with the adduct levels. The discussion of these data in terms of the pathways that may be involved in the repair of the BaP-DNA adducts leads to the suggestion that in Drosophila melanogaster the repair of Bap metabolite-DNA adducts in somatic cells may proceed, in large part, via post-replicative recombinational repair.

The genotoxicity of nitrilotriacetic acid (NTA) in a somatic mutation and recombination test in Drosophila melanogaster

The genotoxicity of a chelating agent, the trisodium salt of nitrilotriacetic acid (NTA), was assessed in a somatic mutation and recombination test (SMART) in Drosophila melanogaster employing the wing hair markers mwh and flr3. The experiments were performed in parallel in two different laboratories (Padua, Italy and Schwerzenbach, Switzerland). The effectively absorbed doses of NTA, which was administered by feeding to larvae, were determined by a sensitive method employing [3H]leucine which allowed individual consumption levels to be measured. The particular pattern of clone induction produced by this compound suggests that NTA is active in inducing mitotic recombination and possibly aneuploidy in somatic cells of Drosophila. This is discussed in relation to the data present in the literature regarding the genotoxicity of NTA in a variety of experimental systems.