Aflibercept, ranibizumab and bevacizumab upcoming biosimilars: a general overview

Anti-vascular endothelial growth factors currently are the first-line treatment option for neovascular age-related macular degeneration (nAMD) and other retinal vascular disorders, and their clinical use is associated with high financial burden. Biosimilars are a type of biological product highly similar to referral biologic drugs; they are increasing competition among biologics and have the potential to reduce the overall expenditures on biologics. In this comprehensive literature review, the current investigational biosimilars acting on retinal diseases are discussed. The authors review the results of clinical studies and highlight ongoing trials. Several biosimilar candidates are under evaluation and the pipeline will rapidly change in the future, as soon as each patent expires. Clinicians have to know these new therapeutic agents, which might come in the mainstream clinical practice as a more cost-efficient option.

Pharmacological, surgical and diagnostic innovations in Meniere's disease: a review

Meniere's disease is an inner ear disorder characterized by the presence of endolymphatic hydrops in the inner ear and symptomatology of recurrent and debilitating vertigo attacks, tinnitus, aural fullness, and fluctuating sensorineural hearing loss. Although many therapeutic options for MD have been proposed during years, no consensus has been reached by the scientific community. In the last decade, many therapeutic options have been proposed, as intratympanic steroid, intratympanic gentamicin, and intravenous glycerol. Recently, the role of the antisecretory factor in the diet of MD patients have been investigated. Surgery is recommended for intractable MD; some authors proposed new approaches including transcanal endoscopic infracochlear vestibular neurectomy, new marsupiliazation technique in sac surgery, and tenotomy of the stapedius and tensor tympani muscles.

Pharmacological, Surgical and Diagnostic Innovations in Meniere's Disease: A Review

PURPOSE

To investigate literature about pharmacological, surgical, and diagnostic innovations for Meniere's Disease (MD).

SUMMARY

Meniere's disease is an inner ear disorder characterized by the presence of endolymphatic hydrops in the inner ear and symptomatology of recurrent and debilitating vertigo attacks, tinnitus, aural fullness, and fluctuating sensorineural hearing loss. Although many therapeutic options for MD have been proposed during years, no consensus has been reached by the scientific community. In the last decade, many therapeutic options have been proposed, as intratympanic steroid, intratympanic gentamicin, and intravenous glycerol. Recently, the role of the antisecretory factor in the diet of MD patients have been investigated. Surgery is recommended for intractable MD; some authors proposed new approaches including transcanal endoscopic infracochlear vestibular neurectomy, new marsupiliazation technique in sac surgery, and tenotomy of the stapedius and tensor tympani muscles.

Sub-Clinical Effects of Chronic Noise Exposure on Vestibular System

AIM

to investigate the effect of chronic noise exposure on vestibular function of subjects without clinical evidence of vestibular disorders and with documented cochlear damage from noise.

SUBJECTS AND METHODS

25 patients with chronic noise-induced hearing loss (NIHL) and without vestibular complaints (group A) and 25 matched controls with sensorineural hearing loss without noise exposure (group B), underwent audiological and vestibular test including caloric and cervical vestibular-evoked myogenic potentials tests (cVEMPs).

RESULTS

In subjects chronically exposed to noise, similarly to that of the auditory threshold, an increase in the evocation threshold of VEMPs has been documented, statistically significant (p<0,05) and independent of the performance of the auditory threshold. p1-n1 amplitude values showed a significant difference between group A and group B. No significant difference for p1-n1 latencies between the two groups was found.

CONCLUSION

We have documented the possibility of vestibular lesion, along with cochlear damage, related to chronic acoustic trauma.

When tumor doesn't read textbook. Third case of TTF1 and p40 co-expression in the same tumour cells in a non-small cell carcinoma. A potential new entity to consider?

Introduction

The 2011 WHO Classification for lung adenocarcinoma enlightened the need for a wise use of immunohistochemistry to preserve tissue for both diagnosis and molecular studies. The current recommendation is to use a panel comprising TTF1 and p40 to classify tumors with no clear squamous or glandular differentiation as many studies have showed the higher specificity of p40 over p63 as marker of squamous differentiation. However, the co-expression of both markers opens a new scenario with subsequent classification and potentially treatment issues.

Materials and methods

We report a case of a non-small lung cell carcinoma (NSCLC) with coexistent expression of TTF1 and p40 in the same tumour cells. To our knowledge, this peculiar immunohistochemical profile is very rare, and thus a review of the clinical and molecular features including molecular variances of the tumour was performed. Review of the pertinent literature was also carried out.

Results

Two additional articles describing unusual cases of NSCLC with coexistent expression of TTF1 and p40 were found and compared to our case. Interestingly, they all carried out aberrant mutation in TP53 oncogene and were of advance stage.

Conclusion

The positivity for both “squamous” and “adenocarcinomatous” markers and mutations of TP53 could be the expression of a not fully recognized variant of NSCLC with possible implications for classification, diagnosis and therapy.

Pleural chondroid metaplasia in a background of IgG4 plasma cell rich chronic inflammatory infiltrate: report of a rare case with review of literature

Mesothelial reactive and degenerative changes secondary to inflammatory conditions, toxin exposure, neoplastic and non-neoplastic disease are often encountered in routine histopathology practice. Herein, we report a very rare case of pleural chronic inflammation with features suggestive for IgG4-related disease associated with the formation of a nest of mature, benign looking cartilage in the pleura of a middle age male patient. The review of the pertinent literature reveals that to date, only few cases of chondroid metaplasia or benign tumor (choristoma) are reported in mesothelium and only occasionally in this change is found in the pleura.

Validation of the Chronic Tinnitus Acceptance Questionnaire (CTAQ-I): the Italian version

Tinnitus is a widespread symptom that is chronically experienced by approximately 10% of the adult population. While the vast majority of individuals do not feel impaired by their ear noise, about 0.5-3% of the adult population develops severe distress and feels impaired in everyday life. The severity of the distress experienced can only partially be explained by the characteristics of the ear noise itself (e.g. objective tinnitus loudness or duration). Psychological variables such as tinnitus acceptance are being increasingly investigated by tinnitus research. The aim of this study was to analyse the psychometric quality of the Italian version of the “Chronic Tinnitus Acceptance Questionnaire” (CTAQ-I). The CTAQ-I is an adaption of the Italian “Chronic Pain Acceptance Questionnaire (CPAQ)” and altered for the study of tinnitus acceptance. This cross-sectional multicentre questionnaire study included 141 outpatients with chronic tinnitus. Sociodemographic and clinical data were assessed with the Tinnitus Sample Case History (TSCH), tinnitus acceptance with the Italian “Chronic Tinnitus Acceptance Questionnaire” (CTAQ-I), tinnitus distress with the Tinnitus Handicap Inventory (THI) and the Tinnitus Questionnaire Short Form (TQ 12-I). Furthermore, we assessed the patient’s general psychological distress (Brief Symptom Inventory - BSI) and Health Related Quality of Life (SF-36). Psychometric and factorial evaluation of the CTAQ-I were carried out. To investigate the influence of sociodemographic and numerous clinical variables on tinnitus acceptance we calculated correlation coefficients, analysis of variance and independent sample-t-tests. The factor analysis revealed a two-factor solution (“activity engagement” and “tinnitus willingness”), accounting for 41.1% of the variance. Good internal consistency for the total score (α = 0.84) and both factors (α = 0.80-0.88) was found. Moderate negative correlations with tinnitus distress indicated good validity. Tinnitus acceptance was further correlated with lower psychological distress and subjective tinnitus loudness, as well as increased emotional well-being. Tinnitus acceptance is considered to be an important source of therapeutic change in behavioural-based treatments as well as in professional counselling for tinnitus. Our study shows that the CTAQ-I is a reliable and valid instrument to measure the acceptance of patients suffering from chronic tinnitus.

Anionic Glycoproteins and their Hexosamine Content in Neoplastic Patients: Relationships with the Clinical Stage and the Course of the Disease

In 40 healthy subjects, in 47 non-cancer patients, and in 142 cancer patients, perchloric acid-soluble glycoproteins (PASG) and hexosamines were determined to investigate their tumor specificity and correlation with the tumor mass. Cancer patients were divided into three subgroups: CI, no evidence of cancer (after radical surgery); CII, locoregional disease; CIII, widespread metastatic disease. There was no statistically significant difference in PASG among normals, non-cancer and CI patients; hexosamines in non-cancer and in CI patients were higher (P < 0.002) than in normals; both PASG and hexosamines were significantly higher in CII and CIII patients than in normals (P < 0.001). In the CI group, 62% of patients who relapsed within 10 months after surgery had high hexosamine values, whereas 69% of patients who did not relapse showed normal levels (P < 0.05). PASG and hexosamines significantly increased with cancer progression and decreased when objective response to treatment was achieved. They are not tumor specific, but seem to be related to the tumor burden; hexosamines seem to have some prognostic value.

Breast Cancer Estrogen and Progesterone Receptors: Associations with Patients' Clinical and Epidemiologic Characteristics

A total of 1095 patients with operable breast cancer and en-rolled in a randomized clinical trial were analysed for estrogen (ER) and progesterone (PgR) receptor content of their primary tumor, and the relationships between steroid receptor status and several epidemiologic characteristics were studied. The proportion of ER+ and median ER levels increased with age: compared to women younger than 40, those aged 66 or more were approximately three times more likely to have an ER+ tumor (OR = 3.0, 95% C.I. = 1.6–5.7). This difference tended to be more marked after comparison between patients with ER > 100 fmol/mg protein and ER- within the same age groups: OR = 7.04, 95 % C.I. = 2.89–17.12. No association emerged between age and PgR. ER status and concentrations were independent of menopausal status after adjustment for age, whereas the proportion of PgR+ and PgR levels were significantly lower in postmenopausal patients of the same age. The distribution of ER and PgR profiles was similar in relation to family history of breast cancer, reproductive events and other selected epidemiologic characteristics of the patients.

Patients’ Assessment of Quality of Care: A Survey of a Group of Breast Cancer Patients in Italy

Patients’ assessment of quality of care was investigated in 825 women with breast cancer treated in a group of specialized and non-specialized institutions in Italy. A 10-page mail questionnaire explored patients’ adjustment to the disease, satisfaction with care, and quality of the information on diagnosis and treatment. Most of the 428 (52 %) responders reported good or acceptable adjustment to the disease (as reflected by acceptable performance in some daily living activities), and favorable judgment about care providers, but many women complained of hospital organizational deficiencies. A contradictory picture emerged regarding the quality of information. Completeness and thoroughness appeared seriously deficient when examined objectively using a series of explicit predefined criteria, but patients’ assessments showed in most cases moderate or high satisfaction. The paper presents these results and discusses pros and cons in the use of patients’ opinions for evaluation of quality of care.

Cellular fibroma in the Douglas cavity, mimicking a malignant neoplasia: fibroma, fibrosarcoma or mitotically active cellular fibroma?

INTRODUCTION

Ovarian fibroma is a benign stromal tumour composed of spindle/ovoid fibroblastic cells producing collagen. Approximally 10% of fibromas are densely cellular with small amount of collagen. In these cases, if mild nuclear atypia is present, they are best addressed as cellular fibroma. However cellular fibroma may show a greater mitotic activity and therefore they should be referred as mitotically active cellular fibromas. Mostly benign, it is necessary to differentiate them from malignant tumours such as fibrosarcomas.

METHODS

We report a case of an unusual presentation of mitotically active cellular fibroma, detected in the Douglas cavity of a young woman, with normal appearing ovaries and uterus, mimicking a malignant neoplasia clinically and on imaging. In fact abdominal mass may be associated with acute pain, resulting in clinical emergency, really difficult to distinguish from a frank malignancy, before surgical procedure.

RESULTS

We described the clinical, radiological and pathological characteristics of our case and we make a comparison of what previously described in literature.

DISCUSSION

The differential diagnosis among those entities is based on the microscopic features such as atypia and the number of mitoses. However, according to their dimensions, it may be necessary to generously sample these tumours and sometimes, to perform a panel of immunohistochemical markers, in order to make a correct diagnosis, establish the best treatment and the right follow-up. In fact, the prognosis is not certain, due to the possible recurrence, especially if not completely excised.

Transcranial brain photoplethysmography to study the venules of cerebral cortex in patients with multiple sclerosis

Objective

To evaluate the utility of a transcranial brain photoplethysmography parameter as a potential marker for patients with multiple sclerosis.

Methods

We investigated 38 patients affected by multiple sclerosis, according to the revised McDonald criteria (12 males and 26 females, mean age 41.1 ± 8.5 years, Expanded Disability Status Scale mean value 2.6 ± 2.1) and compared them with 20 age- and sex-matched healthy controls. By means of transcranial brain photoplethysmography, a safe and non-invasive technology, we measured the increase in cerebral blood volume during compression for 10 s of the internal jugular veins of both sides in sitting position.

Results

The cerebral blood volume increase was significantly smaller in the multiple sclerosis patients (left frontal cortex: −58%, p < 0.0001; right frontal cortex: −59%, p < 0.0001) compared with the controls.

Conclusions

Our study reveals that a minor increase in cerebral blood volume on the frontal cortex of both sides in sitting position is associated with a diagnosis of multiple sclerosis and might be a new marker.

Combined uterine smooth muscle tumour: a challenging case

Uterine smooth muscle tumours that cannot be diagnosed unequivocally as benign or malignant should be termed 'smooth muscle tumours of uncertain malignant potential' (STUMP). Since there are no unequivocal morphological and ancillary criteria to differentiate this group of tumours, we present a case of a 49-year-old woman with a combined, benign and borderline lesion, which could have different clinical management strategies, and discuss the diagnostic issues.

Solitary plasmacytoma of the tonsillar site associated with actinomyces infection: the possible role of IL-6

ExtraMedullary Plasmacytoma (EMP) is a rare plasma cell tumor. It can occur in the upper aerodigestive tract and presents as a large nodule causing local compressive symptoms. A 79-year old woman presented to Otorhinolaryngology Department with progressive hearing loss and no other symptoms. Following PET/TC examination due to the suspicion of a lymphoproliferative disease, the patient underwent tonsillectomy and the diagnosis of solitary EMP was formulated. In addition to that, the histological examination of the tonsillar tissue revealed large colonies of filamentous bacteria, showing abundant sulphur granules and Splendore-Hoeppli phenomenon; these evidences indicating the presence of a chronic Actinomyces infection. Immunohistochemical analysis demonstrated a marked IL-6 immunoreactivity of the neoplastic plasma cells. Interestingly, a marked IL-6 immunoreactivity was also found in the tissue surrounding the Actinomyces colonies. In the present study we report for the first time a solitary EMP associated with Actinomycosis. It is tempting to speculate that the unsuspected and untreated Actinomyces infection, through chronic IL-6 production, could contribute to the neoplastic transformation of plasma cells.

Correlation between the arterial pulse wave of the cerebral microcirculation and CBF during breath holding and hyperventilation in human

OBJECTIVE

To evaluate if relative changes in the amplitude of the arterial pulse wave of the cerebral microcirculation (APWCM) measured by near-infrared spectroscopy (NIRS) may provide information about relative changes of cerebral blood flow (CBF) in cerebral cortex.

METHODS

In 10 healthy human volunteers, through simultaneous recording of the APWCM amplitude by means of NIRS and the mean blood flow velocity (MBFV) of middle cerebral artery by means of transcranial Doppler (TCD) at rest and during breath holding and hyperventilation, we evaluate a possible correlation between relative changes of the mean APWCM amplitude and relative changes of MBFV.

RESULTS

We found a significant linear correlation: breath holding: R(2) 0.84, p < 0.001, hyperventilation: R(2) 0.81, p<0.001.

CONCLUSION

The relative changes of the mean APWCM amplitude seem able to provide information about relative changes of CBF of cerebral cortex in healthy adult humans during breath holding and hyperventilation.

SIGNIFICANCE

APWCM detected by NIRS, a safe, repeatable, inexpensive technology and at the bedside may improve the study of cerebral cortex microcirculation in neurological diseases.

Portal dose measurements by a 2D array

A 2D array (PTW, type 10024), equipped with 729 vented plane parallel ion-chambers, has been calibrated as a detector for the in vivo comparison between measured and predicted portal doses for head-neck tumors. The comparison of absolute portal doses measured to ones predicted by a commercial treatment planning system within the field of view of the CT scanner, can help the delivered dose verification during different treatment fractions, in particular when the patient's present weight loss. This paper reports the preliminary results of the comparison of the portal doses measured by a PTW 2D array during several radiotherapy fractions and the predicted portal doses for seven patients undergoing head-neck tumor radiotherapy. The gamma index analysis supplied an agreement of more than 95% of the dose-point P(gamma)>95% within acceptance criteria, in terms of dose difference, DeltaD(max), and distance-agreement, Deltad(max), equal to 5% and 4mm, respectively. After the third week, one patient showed a decrease of P(gamma) values due to the markedly reduced patient's thickness. Even if the spatial resolution of the 2D array was 1cm, there were two advantages in the use of this 2D array as a portal dose device for IMRT quality control. The first one was the use of a stable and efficient absolute dosimeter for in vivo verification, although its construction and behavior for other gantry angles need to be tested, and the second one was the time efficiency in verifying the correct dose delivery in several fractions of the therapy. This study presents acceptance criteria for the comparison of TPS-predicted portal dose images with in vivo 2D ion-chamber measurements for IMRT. In particular, portal dose measurements offer clues for additional studies as to which indicators can signal the need for replanning during treatment.

The wall correction factor for a spherical ionization chamber used in brachytherapy source calibration

The effect of wall chamber attenuation and scattering is one of the most important corrections that must be determined when the linear interpolation method between two calibration factors of an ionization chamber is used. For spherical ionization chambers the corresponding correction factors A(w) have to be determined by a non-linear trend of the response as a function of the wall thickness. The Monte Carlo and experimental data here reported show that the A(w) factors obtained for an Exradin A4 chamber, used in the brachytherapy source calibration, in terms of reference air kerma rate, are up to 1.2% greater than the values obtained by the linear extrapolation method for the studied beam qualities. Using the Aw factors derived from Monte Carlo calculations, the accuracy of the calibration factor N(K,Ir) for the Exradin A4, obtained by the interpolation between two calibration factors, improves about 0.6%. The discrepancy between the new calculated factor and that obtained using the complete calibration curve of the ion-chamber and the 192Ir spectrum is only 0.1%.

Experimental dosimetry of a 32P catheter-based endovascular brachytherapy source

The experimental dosimetry in a water phantom of a 32P linear source, 20 mm in length, used for the brachytherapy of coronary vessels is reported. The source content activity, A, was determined by means of a calibrated well ion-chamber and the value was compared with the contained activity reported in the manufacturer's certification. In this field of brachytherapy dosimetry, radiochromic film supplies a high enough spatial resolution. A highly sensitive radiochromic film, that presents only one active layer, was used in this work for the source dosimetry in a water phantom. The radiochromic film was characterized by electron beams produced by a clinical linac. A Monte Carlo calculation of beta spectra in water at different distances along the source transverse bisector axis allowed to take into account the low dependence of film response from the electron beam energy. The adopted experimental set-up, with the source in its catheter positioned on the film plane inside the water phantom, supplies accurate dosimetric information. The measured dose rate to water per unit of source activity at reference distance, D(r0, theta0)/A, in units of cGy s(-1) GBq(-1), was in agreement with the value reported in the manufacturer's certification within the experimental uncertainty. The radial dose function, g(r), is in good agreement with the literature data. The anisotropy function F(r, theta) is also reported. The analysis of the dose profile obtained at 2 mm from the source longitudinal axis shows that the uniformity is within 10% along 75% of the 20 mm treatment length. The adopted experimental set-up seems to be adequate for the quality control procedure of the dose homogeneity distribution in the water medium.

A passive radon dosemeter suitable for workplaces

The results obtained in different international intercomparisons on passive radon monitors have been analysed with the aim of identifying a suitable radon monitoring device for workplaces. From this analysis, the passive radon device, first developed for personal dosimetry in mines by the National Radiation Protection Board, UK (NRPB), has shown the most suitable set of characteristics. This radon monitor consists of a diffusion chamber, made of conductive plastic with less than 2 cm height, containing a CR-39 film (Columbia Resin 1939), as track detector. Radon detectors in workplaces may be exposed only during the working hours, thus requiring the storage of the detectors in low-radon zones when not exposed. This paper describes how this problem can be solved. Since track detectors are also efficient neutron dosemeters, care should be taken when radon monitors are used in workplaces, where they may he exposed to neutrons, such as on high altitude mountains, in the surroundings of high energy X ray facilities (where neutrons are produced by (gamma, n) reactions) or around high energy particle accelerators. To this end, the response of these passive radon monitors to high energy neutron fields has been investigated.

[Amnioinfusion: techniques, indications, and controlled retrospective study of 55 cases]

Amnioinfusion is a relatively recent procedure introduced among fetal medicine techniques. Its applications focus on two different methods: transcervical and transabdominal. The first procedure usually is carried out during "intrapartum amnioinfusion" to prevent or treat fetal heart rate (FHR) decelerations related to oligohydramnios or to dilute thick meconium staining of the amniotic fluid. The latter method used during "antepartum amnioinfusion" is usually indicated for severe oligohydramnios in order to avoid the complications related such as pulmonary hypoplasia, deforming effects of oligohydramnios, variable FHR decelerations and intraventricular hemorrhages. Antepartum amnioinfusion, also used to improve ultrasound visualisation in presence of oligohydramnios, is less employed as compared to intrapartum amnioinfusion, therefore its risks are not well established. In order to study possible adverse effects on the mother or foetus, fifty five patients affected by oligohydramnios at 17th-34th week of gestational age were submitted to antepartum amnioinfusion (1-5 procedures) and were matched retrospectively with forty seven women with the same characteristics treated with the conservative and expectant management. The trend of pregnancy was the same for both groups in relation to maternal fever > 38 degrees (10.9% in the amnioinfused group vs 17.0% in control group ns), leukocyte count > 18,000/mm3 (25.5% vs 21.3%, ns), C-reactive protein > 10 ng/ml (10.9% vs 6.4%, ns). The latency period between admission and delivery was significantly longer in the amnioinfused group than in the control one [21 (range 1-98) vs 9 days (range 0-72); p < 0.001] and the frequency of Apgar score < 7 at the 5th min was less represented in the amnioinfused group than in the control group (32.3% vs 66.6%; p < 0.001). In conclusion, it was interesting to note that antepartum amnioinfusion seems to increase the latency period between premature rupture of membranes and delivery, but it remains to clarify if this procedure is as much safe for the fetus as for the mother.