Oligometastatic Prostate Cancer Treated with Stereotactic Body Radiation Therapy: The Role of Three-Dimensional Tumour Volume in Patient Survival

AIMS

The definition of oligometastatic prostate cancer (OPCa) is currently based solely on the maximum number of detectable metastases, as there are no validated biomarkers available. The aim of this study was to identify novel predictive factors for OPCa patients who underwent metastases-directed therapy.

MATERIALS AND METHODS

This monocentre, retrospective study included consecutive OPCa patients with a maximum of five metastases in up to two organs, detected with choline- or PSMA-positron emission tomography, who were treated with metastases-directed stereotactic body radiation therapy. Endpoints were overall survival and progression-free survival, assessed with Kaplan-Meier analysis. Univariate and multivariable Cox regression was carried out to evaluate the association between clinical factors and survival outcomes.

RESULTS

Between 2009 and 2021, 163 patients and 320 metastases were treated with 226 stereotactic body radiation therapy courses. The median three-dimensional metastatic tumour volume was 4.1 cm3, with a range from 0.01 to 233.4 cm3. In total, 87 (53.4%), 21 (12.9%) and 55 (33.7%) metastases were classified as cN1, cM1a and cM1b, respectively. The median follow-up was 28.5 months. The rates of overall survival at 1, 3 and 5 years were 89.5% (95% confidence interval 83.4-93.4), 74.9% (95% confidence interval 66.1-81.7) and 57.2% (95% confidence interval 45.8-67.1), respectively. Multivariable analysis showed that overall survival reduced with the increase in three-dimensional total tumour volume (hazard ratio 1.93, 95% confidence interval 1.06-3.52; P = 0.030) and confirmed a significant difference between cN1 versus cM1a-b disease (hazard ratio 1.81, 95% confidence interval 1.01-3.25; P = 0.046). The cut-off value of total volume correlated with the highest risk of death was 20 cm3 (hazard ratio 2.37, 95% confidence interval 1.34-4.18; P = 0.003). The median progression-free survival was 17.8 months, with 1-, 3- and 5-year rates of 63.7% (95% confidence interval 55.4-70.9), 31.5% (95% confidence interval 22.8-40.6) and 24.7% (95% confidence interval 16.0-34.3).

CONCLUSIONS

This study identified three-dimensional total tumour volume and the site of oligometastases as significant predictors of survival in OPCa patients treated with metastases-directed therapy. These parameters can potentially be used to personalised treatment and improve patient outcome.

Dosimetric Impact of Intrafraction Prostate Motion and Interfraction Anatomical Changes in Dose-Escalated Linac-Based SBRT

PURPOSE/OBJECTIVE(S)

The aim of this study was to investigate the impact of intrafraction prostate motion and interfraction anatomical changes on dose metrics and the effect of beam gating and motion correction in dose-escalated Linac-based SBRT.

MATERIALS/METHODS

Thirteen patients (56 fractions) with organ-confined prostate cancer underwent dose-escalated FFF-VMAT SBRT. Accurate patient setup was ensured by CBCT, and real-time 3D prostate motion data were obtained using a novel electromagnetic tracking device. Treatment was interrupted when the signals exceeded a 2 mm threshold in any of the three spatial directions and couch position was corrected unless the offset was transient. Prostate trajectories with and without beam gating and motion correction events were reconstructed and analyzed. Rectum and bladder volumes on each daily CBCT were recorded and compared with volumes at simulation. The prostate motion observed for each fraction was incorporated into the patient original treatment plan with an isocenter shift method. Actually, delivered treatments were then obtained by recalculating the reconstructed motion-encoded plan on deformed CTs reflecting the patient CBCT-anatomy of the day. Non-gated treatments were also simulated using the prostate motion data assuming that no treatment interruptions have occurred.

RESULTS

Treatment interruptions because of target motion trespassing the predefined threshold occurred in 25 fractions (45%). Rectum and bladder volume changes were relevant in most patients. The mean relative dose differences between actually delivered and planned treatments were -3.0% [-18.5 - 2.8] for CTV D99% and -2.6% [-17.8 - 1.0] for PTV D95% over all 56 fractions. However, the median cumulative CTV coverage with 93% of the prescribed dose turned out to be satisfactory. Urethra sparing was slightly degraded and a mean reduction of rectum and bladder dose was seen in all but two dose metrics: the maximum dose to rectum mucosa and the bladder D40%. Nevertheless, only 2 major deviations in rectum mucosa D0.035cc were observed at the end of the treatment. The greatest contribution to target missing and OARs doses came from the interfraction anatomical variations, while intrafraction prostate motion marginally contributed in gated treatments. In non-gated treatments, further deteriorations by 2.4 - 2.8% in minimum target coverage metrics and by 3.1 - 11.6% in bladder dose parameters would have occurred on average.

CONCLUSION

The implemented motion management strategy and the strict patient preparation regimen, along with current PTV margins, robustness of original treatment plans, and fast FFF beam delivery, ensured no significant degradations of dose metrics due to both intrafraction motion and interfraction anatomical changes. Non-gated treatments would have more widely deteriorated the dosimetry of some individual fractions. Thus, continuous monitoring, beam gating and motion correction are recommended to safely deliver dose-escalated prostate SBRT.

Bayesian spatiotemporal modelling for disease mapping: an application to preeclampsia and gestational diabetes in Florida, United States

Morbidities generally show patterns of concentration that vary by space and time. Disease mapping models are useful in estimating the spatiotemporal patterns of disease risks and are therefore pivotal for effective disease surveillance, resource allocation, and the development of prevention strategies. This study considers six spatiotemporal Bayesian hierarchical models based on two spatial conditional autoregressive priors. It could serve as a guideline on the development and application of Bayesian hierarchical models to assess the emerging risk trends, risk clustering, and spatial inequality trends, with estimation of covariables' effects on the interested disease risk. The method is applied to the Florida Birth Record data between 2006 and 2015 to study two cardiovascular risk factors: preeclampsia and gestational diabetes. High-risk clusters were detected in North Central Florida for preeclampsia and in Central Florida for gestational diabetes. While the adjusted disease trend was stable, spatial inequality peaked in 2011-2012 for both diseases. Exposure to PM2.5 at first or/and second trimester increased the risk of preeclampsia and gestational diabetes, but the magnitude is less severe compared to previous studies. In conclusion, this study underscores the significance of selecting appropriate disease mapping models in estimating the intricate spatiotemporal patterns of disease risk and suggests the importance of localized interventions to reduce health disparities. The result also identified an opportunity to study potential risk factors of preeclampsia, as the spike of risk in North Central Florida cannot be explained by current covariables.

Dosimetric Impact of Setup Errors in Single-Isocenter VMAT Radiosurgery for Brain Metastases

PURPOSE/OBJECTIVE(S)

In stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) of brain metastases (BM) using single-isocenter VMAT, intra-fraction positioning errors may affect target coverage. This study aims to investigate geometric and dosimetric accuracy in single and multiple BM treatments.

MATERIALS/METHODS

Seventy patients with single (n = 38) and multiple (n = 32) BM treated with 15-21 Gy in 1 (n = 59) or 27 Gy in 3 (n = 11) fractions using coplanar FFF-VMAT technique were analyzed. PTV was defined by a 2 mm isotropic GTV expansion. Pre-treatment setup errors were evaluated with CBCT and corrected with a robotic six degrees-of-freedom couch. For each fraction, intra-fractional errors were measured by post-treatment CBCT and applied to the planning CT. Plans involving translations and rotations (Fx-plan) were recalculated with Monte Carlo TPS. Original and Fx-plans were compared in terms of target and brain dose parameters, performing the Wilcoxon-Mann-Whitney test (alpha = 0.05). The relationships of the BM volume, maximum dimension, distance-to-isocenter (for multiple BM cases only) and barycenter shift with the difference in target coverage between the two plans were investigated.

RESULTS

The median post-treatment 3D error and maximum rotational error over all 129 BM were 0.5 mm [0.1-2.7] and 0.3° [0.0-1.3], respectively. The resulting median BM barycenter shift was 0.5 mm [0.1-2.7]. The percentage of fractions in which at least one BM barycenter shifted by more than 2 mm from the planned position was 4% and 1% for single and multiple BM cases, respectively. The median single GTV volume was 0.27 cc [0.01-10.48], while the PTV had a median volume of 1.05 cc [0.12-17.05]. The median BM maximum dimension was 10.7 mm [2.9-34.1] and for multiple BM the median distance-to-isocenter was 5.15 cm [0.89-7.52]. For single BM patients, the GTV D95% was never reduced by > 5%, while PTV D95% reductions > 1% occurred in only 11 (29%) PTV. For multiple BM patients, the target statistics were slightly worse, with dose deficits larger than 5% and 1% occurring respectively in 2 BM and 34 (37%) PTV. Anyway, the majority of single and multiple BM had a loss of coverage for both GTV and PTV below 1% in Fx-plans. Larger than 5% brain V12 Gy (SRS) and V20 Gy (fSRS) increases were observed for only one single BM patient. None of the two dosimetric comparisons resulted statistically significant (p>0.05). The differences in target coverage showed a moderate-to-strong correlation only with the BM barycenter shift in both cases (R2 = 0.70-0.73 for single and R2 = 0.44-0.50 for multiple BM).

CONCLUSION

Due to the optimal patient setup, as well as the full six degrees-of-freedom corrections, the safety PTV margin, and the fast beam delivery, the dosimetric effects of residual setup and patient motion errors for both single and multiple BM cases were negligible. These findings warrant a potential reduction in the PTV margin with this treatment technique.

Manganese-Induced Parkinsonism: Evidence from Epidemiological and Experimental Studies

Manganese (Mn) exposure has evolved from acute, high-level exposure causing manganism to low, chronic lifetime exposure. In this latter scenario, the target areas extend beyond the globus pallidus (as seen with manganism) to the entire basal ganglia, including the substantia nigra pars compacta. This change of exposure paradigm has prompted numerous epidemiological investigations of the occurrence of Parkinson's disease (PD), or parkinsonism, due to the long-term impact of Mn. In parallel, experimental research has focused on the underlying pathogenic mechanisms of Mn and its interactions with genetic susceptibility. In this review, we provide evidence from both types of studies, with the aim to link the epidemiological data with the potential mechanistic interpretation.

POLYPHARMACY AND FRAILTY AMONG WORLD TRADE CENTER GENERAL RESPONDERS

Polypharmacy in older adults is associated with increased risk of adverse events such as falls, adverse drug reactions and functional decline. WTC responders suffer from conditions related to WTC exposure and are at higher risk of polypharmacy. We examined patterns of medication use among WTC general responders aged 50 and over who had at least one visit from 2017 to 2019 (n=7,679); 56.1% took 5+ medications and 22.5% took 10+ medications. Factors associated with polypharmacy (taking 5+ medications) include age (OR 1.08, p<0.001), female sex (OR 1.33, p<0.001), obesity (1.90, p<0.001), fair/poor self-rated health (OR 1.32, p<0.001) and limitations on performing moderate activity (OR 1.52, p<0.001). Frailty, as measured by the deficit count in the Clinical Frailty Index, is associated with polypharmacy after adjusting for other covariates (OR 1.23, p<0.001). Addressing polypharmacy by improving medication use may yield health benefits for this rapidly aging population at risk for adverse outcomes.

Occupational Safety and Health Staging Framework for Decent Work

The 2030 United Nations Goal 8 for sustainable development focuses on decent work. There is utility in identifying the occupational safety and health aspects of Goal 8, as they pertain to the four pillars of decent work: job creation, social protection, rights of workers, and social dialogue. A workgroup of the International Commission on Occupational Health and collaborators addressed the issue of decent work and occupational safety and health (OSH) with the objective of elaborating a framework for guidance for practitioners, researchers, employers, workers, and authorities. This article presents that framework, which is based on an examination of the literature and the perspectives of the workgroup. The framework encompasses the intersection of the pillars of decent (employment creation, social protection, rights of workers, and social dialogue) work with new and emerging hazards and risks related to various selected determinants: new technologies and new forms of work; demographics (aging and gender); globalization; informal work; migration; pandemics; and OSH policies and climate change. The OSH field will need an expanded focus to address the future of decent work. This focus should incorporate the needs of workers and workforces in terms of their well-being. The framework identifies a starting point for the OSH community to begin to promote decent work.

Reducing disease and death from Artisanal and Small-Scale Mining (ASM) - the urgent need for responsible mining in the context of growing global demand for minerals and metals for climate change mitigation

Artisanal and small-scale mining (ASM) takes place under extreme conditions with a lack of occupational health and safety. As the demand for metals is increasing due in part to their extensive use in 'green technologies' for climate change mitigation, the negative environmental and occupational consequences of mining practices are disproportionately felt in low- and middle-income countries. The Collegium Ramazzini statement on ASM presents updated information on its neglected health hazards that include multiple toxic hazards, most notably mercury, lead, cyanide, arsenic, cadmium, and cobalt, as well as physical hazards, most notably airborne dust and noise, and the high risk of infectious diseases. These hazards affect both miners and mining communities as working and living spaces are rarely separated. The impact on children and women is often severe, including hazardous exposures during the child-bearing age and pregnancies, and the risk of child labor. We suggest strategies for the mitigation of these hazards and classify those according to primordial, primary, secondary, and tertiary prevention. Further, we identify knowledge gaps and issue recommendations for international, national, and local governments, metal purchasers, and employers are given. With this statement, the Collegium Ramazzini calls for the extension of efforts to minimize all hazards that confront ASM miners and their families.

COVID-19, Mental health and intervention-priorities among Northern Italian University students

 

During the first wave of COVID-19 pandemic, the most affected area in Italy was the southeast part of the Lombardy region. The University of Brescia is one of the largest in Northern Italy. The aim of this study is to investigate the psychological and somatic symptoms driven by lifestyle changes due to the lockdown among the students of the University of Brescia.15261 University students were enrolled through institutional email;14302 were Master's and Bachelor's Degreestudents,724 were Residents and 235 doctorates.3553 students (23.28% of total),aged on average 22 years, completed the survey. Physical health, dietary and sleep habits, physical activities, economic and social issues were investigated through an anonymous, online ad hoc form, available until July 2020 and approved by the local Ethic Committee. Five psychosomatic outcomes were assessed: digestive disorders, headache, panic-anxiety crises, depression-sadness, fear od COVID-19.Factor analysis was applied to reduce the number of variables while logistic and ordinal logistic regression models were used to test the association between the latent variables and each outcome. Female gender, medium-intensive use of telephone, worsening of sleep quality, mnemonic difficulties and performance reduction were associated with all the outcomes. Low physical activity, increased time spent watching television and the worsening of dietary habits represented a significant risk factor for at least three of the outcomes. Despite the relatively low compliance, the survey clearly identified few priorities of intervention to prevent psychological and somatic effects of pandemic in the next future: circadian rhythm, nutritional habits, physical activity, use of media, gender issues. The results of this study show the psychosomatic effects of social isolation and the pandemic on a population at risk of young adults and can promote interventions to minimize the occurrence of psychosomatic consequences on young adults.

Key messages

Analysis of the main risk and protection factors in a population of young adults in the development of psycho-physical symptoms during the period of isolation due to the covid-19 pandemic.

Support the need to implement public health services also to reduce health costs with possible methods of intervention, in harmony with the findings.

Coming Together for Climate and Health: Proceedings of the Second Annual Clinical Climate Change Meeting, January 24, 2020

Climate change is imposing increasingly severe impacts on public health. Addressing these impacts requires heightened awareness of climate-driven health conditions and appropriate clinical practices to manage these conditions. Within this context, the 2nd Annual Clinical Climate Change Conference, held January 24, 2020 at the New York Academy of Medicine, brought together more than 150 allied health practitioners from across the United States for a one-day conference showcasing the state of the science on the climate and health. Eight platform presentations—including a keynote address from Karenna Gore of the Center for Earth Ethics at Union Theological Seminary—covered a range of environmentally induced, climate-related disease areas as well as topics related to environmental justice. Additionally, key workshops engaged participants in the clinical management of climate-related health conditions. Communicating the existing evidence base for climate change-driven impacts on human health is crucial for preparing practitioners to identify and address these impacts. Further partnership between researchers and practitioners to extend and disseminate this evidence base will yield important advancements toward protecting patients and improving health outcomes in an era of climate crisis.

Family life stress, maternal depression and child behavioral health in industrialized Italian cities

Although family life stress adversely impacts child health, few tools measure its relationship to child outcomes in the setting of maternal variables. This study validates the Italian version of Crisis in Family Systems-Revised (CRISYS-R) and characterizes relationships between family life stress, maternal depression and child behavior in two Italian cities.

This cross-sectional study was nested in current research on health impacts of neurotoxic environmental exposures in children. 101 mother-child pairs (child age=9.91±2.17yrs; 53% female) and children's teachers were enrolled in Taranto (south Italy) and Brescia (north Italy). Mothers performed the Italian CRISYS-R and PHQ9; teachers completed Child Behavior Checklist (CBCL/6-18). Spearman's rank correlation coefficients showed associations of family CRISYS-R, maternal PHQ9 and child CBCL/6-18. Wilcoxon Rank-Sum test compared groups of continuous variables.

Mothers with depressive symptoms (PHQ9≥5) reported higher ongoing stress and proportion of negative stressors on CRISYS-R than non-depressed mothers (p < 0.05). Children of depressed mothers performed worse in all CBCL/6-18 domains: Internalizing Problems, Externalizing Problems and Total Problems (p < 0.01). Specifically, children of depressed mothers scored higher on subscales of Anxious-Depressed (p < 0.05), Withdrawn-Depressed (p < 0.01), Rule-Breaking (p < 0.01) and Aggressive Behavior (p < 0.05). Maternal depressive symptoms correlated with ongoing stress (rs = 0.27; p < 0.01), child Internalizing Problems (rs = 0.34; p < 0.001), Externalizing Problems (rs = 0.28; p < 0.01) and Total Problems (rs = 0.35; p < 0.001).

This study describes links among maternal depression, family life stress, and child behavioral health. It is first to validate Italian CRISYS-R and to explore these factors conjointly in Italian contexts with known neurotoxic exposures. Findings support considering maternal depression and family life stress in child behavioral and environmental health research and policy.

Key messages

Family life stress, maternal depressive symptoms, and preadolescent behavioral health were highly interrelated in two industrialized Italian cities. The Italian version of CRISYS-R is a useful instrument for assessing and understanding family life stress, a crucial yet under-explored contributor to child behavioral health outcomes.

Multi-media biomarkers: Integrating information to improve lead exposure assessment

Exposure assessment traditionally relies on biomarkers that measure chemical concentrations in individual biological media (i.e., blood, urine, etc.). However, chemicals distribute unevenly among different biological media; thus, each medium provides incomplete information about body burden. We propose that machine learning and statistical approaches can create integrated exposure estimates from multiple biomarker matrices that better represent the overall body burden, which we term multi-media biomarkers (MMBs). We measured lead (Pb) in blood, urine, hair and nails from 251 Italian adolescents aged 11-14 years from the Public Health Impact of Metals Exposure (PHIME) cohort. We derived aggregated MMBs from the four biomarkers and then tested their association with Wechsler Intelligence Scale for Children (WISC) IQ scores. We used three approaches to derive the Pb MMB: one supervised learning technique, weighted quantile sum regression (WQS), and two unsupervised learning techniques, independent component analysis (ICA) and non-negative matrix factorization (NMF). Overall, the Pb MMB derived using WQS was most consistently associated with IQ scores and was the only method to be statistically significant for Verbal IQ, Performance IQ and Total IQ. A one standard deviation increase in the WQS MMB was associated with lower Verbal IQ (β [95% CI] = -2.2 points [-3.7, -0.6]), Performance IQ (-1.9 points [-3.5, -0.4]) and Total IQ (-2.1 points [-3.8, -0.5]). Blood Pb was negatively associated with only Verbal IQ, with a one standard deviation increase in blood Pb being associated with a -1.7 point (95% CI: [-3.3, -0.1]) decrease in Verbal IQ. Increases of one standard deviation in the ICA MMB were associated with lower Verbal IQ (-1.7 points [-3.3, -0.1]) and lower Total IQ (-1.7 points [-3.3, -0.1]). Similarly, an increase of one standard deviation in the NMF MMB was associated with lower Verbal IQ (-1.8 points [-3.4, -0.2]) and lower Total IQ (-1.8 points [-3.4, -0.2]). Weights highlighting the contributions of each medium to the MMB revealed that blood Pb was the largest contributor to most MMBs, although the weights varied from more than 80% for the ICA and NMF MMBs to between 30% and 54% for the WQS-derived MMBs. Our results suggest that MMBs better reflect the total body burden of a chemical that may be acting on target organs than individual biomarkers. Estimating MMBs improved our ability to estimate the full impact of Pb on IQ. Compared with individual Pb biomarkers, including blood, a Pb MMB derived using WQS was more strongly associated with IQ scores. MMBs may increase statistical power when the choice of exposure medium is unclear or when the sample size is small. Future work will need to validate these methods in other cohorts and for other chemicals.

Lack of TdT and Immunoglobulin and T-Cell Receptor Gene Rearrangements in Hodgkin's Disease

To study the pathogenesis of Hodgkin's disease (HD), which today remains obscure, we have undertaken a combined experimental approach: determination of TdT and molecular analysis of rearrangements of immunoglobulin heavy chain (IgH), T-cell receptor (TCR) beta chain and the T-cell rearranging gamma (TRG) genes. TdT determination indicate would the presence of immature cells that are not detected in the normal lymphnode; molecular analysis of the rearrangements of these genes would reveal the presence of even a small monoclonal population of both T and B lineages in the lymphnodes. We believe that the combination of these two types of analysis can indicate whether an expanding lymphoid clone is responsible for this disease. TdT determination was negative in all 41 cases tested. Gene rearrangements were studied in 10 cases for IgH and TCR beta genes and in 5 cases for the TRG gene. No abnormal band beside the germ-line ones was detected in any of our cases, ruling out the presence of a minor neoplastic population. We can explain these results in at least three ways: first, the neoplastic population could represent less than 1% of the total, thus escaping detection by current techniques; second, the neoplastic population is not lymphoid in nature or is composed of mature cells that do not rearrange Ig and TCR genes and therefore belongs to a true non-B, non-T lineage; third, the pathogenesis of HD is completely different from that of non-Hodgkin's lymphomas (NHL) and does not involve the clonal expansion of a cell frozen at a particular maturative stage as is thought to happen in most NHL.

Poly(A) Polymerase Distribution in Normal and Malignant Lymphoid Cells

The incorporation of ATP on poly(A) primers catalyzed by poly(A) polymerase was investigated in normal and neoplastic lymphoid cells from animal and human sources. High levels of the enzyme were found in mouse thymus, in chicken bursa and thymus, as well as in neoplastic cells from patients affected by lymphoblastic and Burkitt's lymphomas. Low or very low quantities were found in peripheral blood lymphocytes, chronic lymphocytic leukemia cells, normal lymph nodes and solid lymphoid tissues of Hodgkin's disease. In general, the enzymatic content of neoplastic lymphoid cells reflected those of their normal counterpart. No effect of fasting or cortisone treatment on poly(A) polymerase in mouse spleen, thymus or liver was found. No particular relationships with B, T or non-T, non-B lineages were observed, but some relationship with DNA polymerase alpha was found. Therefore, it may be that poly(A) polymerase levels are related to the proliferative activity of the cellular populations.

Lactate Dehydrogenase Levels in Cellular Extracts of Human Malignant Lymphomas

Serum lactate dehydrogenase (LDH) levels have been claimed as an independent prognostic factor in non-Hodgkin's lymphomas (NHL). In the present study, the intracellular and serum LDH levels in Hodgkin's (HD) and NHL were investigated. We found that among NHL, the histologic types of high-grade malignancy (lymphoblastic, immunoblastic and centroblastic), according to the Kiel classification, have a significantly higher intracellular (p < 0.01) and serum (p < 0.05) content of this enzyme than those of low-grade malignancy. This finding could explain in part the relation between high serum LDH levels and poor prognosis. It is also possible that the stage of the disease at the moment of the serum determination could be related to the serum LDH level, because a large tumor burden is likely to release more enzyme than a smaller one. However, we could not test this hypothesis because in our series there was ony one NHL patient with stage I or II. Serum LDH level could be a predictor of prognosis in NHL because of its relationship with more malignant histological types, and possibly with more advanced diseases.

Cancer mortality disparities among New York City's Upper Manhattan neighborhoods

The East Harlem (EH), Central Harlem (CH), and Upper East Side (UES) neighborhoods of New York City are geographically contiguous to tertiary medical care, but are characterized by cancer mortality rate disparities. This ecological study aims to disentangle the effects of race and neighborhood on cancer deaths. Mortality-to-incidence ratios were determined using neighborhood-specific data from the New York State Cancer Registry and Vital Records Office (2007-2011). Ecological data on modifiable cancer risk factors from the New York City Community Health Survey (2002-2006) were stratified by sex, age group, race/ethnicity, and neighborhood and modeled against stratified mortality rates to disentangle race/ethnicity and neighborhood using logistic regression. Significant gaps in mortality rates were observed between the UES and both CH and EH across all cancers, favoring UES. Mortality-to-incidence ratios of both CH and EH were similarly elevated in the range of 0.41-0.44 compared with UES (0.26-0.30). After covariate and multivariable adjustment, black race (odds ratio=1.68; 95% confidence interval: 1.46-1.93) and EH residence (odds ratio=1.20; 95% confidence interval: 1.07-1.35) remained significant risk factors in all cancers' combined mortality. Mortality disparities remain among EH, CH, and UES neighborhoods. Both neighborhood and race are significantly associated with cancer mortality, independent of each other. Multivariable adjusted models that include Community Health Survey risk factors show that this mortality gap may be avoidable through community-based public health interventions.

Determinants of serum manganese levels in an Italian population

Manganese (Mn) is both essential and toxic for humans, mainly depending on the total levels and its species. Main sources of exposure include food and air pollution, particularly motorized traffic. We sought to determine the potential influence of these sources on serum total levels of Mn and Mn species. We selected a random sample of municipality residents from an Italian urban municipality, from whom we collected detailed personal information, dietary habits and a blood sample for serum Mn determination. We also assessed outdoor air Mn exposure, by modeling levels of particulate matter ≤10 µm (PM10) from motorized traffic at the residence of geocoded subjects. Serum Mn species generally showed higher levels in males and positive correlation with age, while no such differences were found according to smoking habits or use of dietary supplements. Among nutrients, only iron intake showed a relation with Mn [an inverse correlation with Mn‑ferritin (Mn‑Fer) and a direct one with inorganic‑Mn (Inorg‑Mn)]. Meat consumption directly correlated and fish and seafood inversely correlated with total Mn, Mn‑transferrin (Mn‑Tf) and Mn-citrate (Mn-Cit). Fruits and vegetables, including legumes and nuts, generally showed a positive correlation with all Mn species, especially Mn‑Cit, and an inverse one with Inorg‑Mn. Odds ratios (ORs) of having serum Mn levels above median value increased with increasing PM10 tertiles, with an OR for highest‑to‑lowest tertile of 7.40 (1.36‑40.25) in multivariate analysis. Analyses for Mn species did not highlight a clear comparable pattern. In conclusion, our results seem to demonstrate that PM10 exposure positively influences total Mn serum levels, while single Mn species show conflicting results.

Obesity and weight gain among former World Trade Center workers and volunteers

A high prevalence of obesity has been observed among former World Trade Center (WTC) workers and volunteers. We hypothesized that unemployment and disability status would predict obesity. We surveyed 220 participants at the [INST] Mount Sinai WTC Clinical Center to assess their obesity and current employment and disability status, WTC occupational exposure level, medical comorbidities, and dietary and exercise habits. Bivariate and logistic regression multivariate analyses were used to explore associated risk factors. Obesity was associated with active employment status. Other significant covariates included non-Latino African American race, having a high number of comorbid chronic diseases, low exercise frequency, and not drinking any glass of juice daily. The association of obesity with active employment suggests that interventions that favor healthy habits among actively employed individuals are warranted.

Myoblastoma of the breast: Our experience and review of literature

INTRODUCTION

Breast myoblastoma or granular cell tumor involving the breast parenchyma has been described in detail for the first time since Abrikossoff in 1931. The location of this injury to the breast is very rare, accounting for between 5% and 15% of all cases of cancer of the granular cells. We present our experience regarding the identification of two cases because of the relative rarity of this tumor. It is often confused with breast cancer on clinical and radiological, and its diagnosis can then be difficult for physicians, radiologists and pathologists.

PRESENTATION OF CASES

We report the cases of two young women who came to our attention because of the presence of mass shoveled breast, mobile and accompanied by pain cycle independent. In both cases, mammography and ultrasound revealed the presence of heterogeneous mass and irregular, but in one of two such mass located at the Union of external quadrants of the left breast and was in contact with his serratus anterior and suspicion for malignancy. In both cases the 'histology combined with immunohistochemical study proved to be a granular cell tumor.

CONCLUSION

Although a granular cell tumor of the breast is a rare tumor breast, should be considered in the differential diagnosis of benign and malignant lesions. Surgeons and pathologists should keep in mind when considering a granular cell tumor cells with abundant granular cytoplasm containing materials to avoid misdiagnosing breast cancer, which could lead to unnecessary surgery.

Cancer in World Trade Center responders: Findings from multiple cohorts and options for future study

BACKGROUND

Three longitudinal studies of cancer incidence in varied populations of World Trade Center responders have been conducted.

METHODS

We compared the design and results of the three studies.

RESULTS

Separate analyses of these cohorts revealed excess cancer incidence in responders for all cancers combined and for cancers of the thyroid and prostate. Methodological dissimilarities included recruitment strategies, source of cohort members, demographic characteristics, overlap between cohorts, assessment of WTC and other occupational exposures and confounders, methods and duration of follow-up, approaches for statistical analysis, and latency analyses.

CONCLUSIONS

The presence of three cohorts strengthens the effort of identifying and quantifying the cancer risk; the heterogeneity in design might increase sensitivity to the identification of cancers potentially associated with exposure. The presence and magnitude of an increased cancer risk remains to be fully elucidated. Continued long-term follow up with minimal longitudinal dropout is crucial to achieve this goal.

Association between personal exposure to ambient metals and respiratory disease in Italian adolescents: a cross-sectional study

Background

Release of ambient metals during ferroalloy production may be an important source of environmental exposure for nearby communities and exposure to these metals has been linked to adverse respiratory outcomes. We sought to characterize the association between personal air levels of metals and respiratory health in Italian adolescents living in communities with historic and current ferroalloy activity.

Methods

As part of a study in the industrial province of Brescia, Italy, 410 adolescents aged 11–14 years were recruited. Participants were enrolled from three different communities with varying manganese (Mn) levels: Bagnolo Mella which has current ferroalloy activity, Valcamonica, which has historic ferroalloy activity and Garda Lake which has no history of ferroalloy activity. Particulate matter <10 μm in diameter (PM₁₀) was collected for 24 h in filters using personal sampling. Mn, nickel (Ni), zinc (Zn), chromium (Cr) and iron (Fe) were measured in filters using x-ray fluorescence. Data on respiratory health was collected through questionnaire. Data for 280 adolescents were analyzed using a modified Poisson regression, and risk ratios were calculated for an interquartile (IQR) range increase in each pollutant.

Results

In adjusted models including PM₁₀ as a co-pollutant, we found significant associations between concentrations of Mn (RR: 1.09, 95 % CI [1.00, 1.18] per 42 ng/m³ increase), Ni (RR: 1.11, 95 % CI [1.03, 1.21] per 4 ng/m³ increase) and Cr (RR: 1.08, 95 % CI [1.06, 1.11] per 9 ng/m³ increase) and parental report of asthma. We also found significant associations between increased Mn and Ni and increased risk of asthma medication use in the past 12 months (RR: 1.13, 95 % CI [1.04, 1.29] and (RR: 1.13, 95 % CI [1.01, 1.27] respectively).

Conclusions

Our findings suggest that exposure to ambient Mn, Ni and Cr may be associated with adverse respiratory outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0173-9) contains supplementary material, which is available to authorized users.

Impact of ferromanganese alloy plants on household dust manganese levels: implications for childhood exposure

Adolescents living in communities with ferromanganese alloy plant activity have been shown to exhibit deficits in olfactory and fine motor function. Household dust may serve as an important manganese (Mn) exposure pathway to children, though dust Mn concentrations have not previously been measured to assess household contamination from ferromanganese alloy plant emissions. Here we determined the association between dust concentrations and surface loadings of Mn and other metals (Al, Cd, Cr, Cu, Fe, Pb, and Zn) in indoor and outdoor household dust from three Italian communities that differ by history of ferromanganese alloy plant activity: Bagnolo Mella, with an active ferromanganese alloy plant (n=178 households); Valcamonica, with historically active plants (n=166); and Garda Lake, with no history of ferromanganese plant activity (n=99). We also evaluated Mn levels in other environmental (soil, airborne particulates) and candidate biomarker (blood, hair, saliva, fingernails) samples from children within the households. Household dust Mn concentrations and surface loadings were significantly different between the three sites, with levels highest in Bagnolo Mella (outdoor median Mn concentration=4620, range 487-183,000µg/g), intermediate in Valcamonica (median=876, range 407-8240µg/g), and lowest in Garda Lake (median=407, range 258-7240µg/g). Outdoor dust Mn concentrations in Bagnolo Mella, but not the other communities, were significantly inversely related with distance from the plant (R(2)=0.6630, P<0.0001). Moreover, outdoor dust Mn concentrations and loadings were highly predictive of but significantly higher than indoor dust Mn concentrations and loadings by ~2 to ~7-fold (Mn concentrations) and ~7 to ~20-fold (Mn loadings). Finally, both indoor and outdoor dust Mn concentrations and outdoor dust Mn loading values were highly significantly correlated with both soil and air Mn concentrations, and with children's hair and fingernail Mn concentrations, but weakly or not associated with saliva or blood Mn levels. Given the evidence associating elevated Mn exposure with neurological impairments in children, these data support that dust Mn levels should be reduced in contaminated environments to protect the health of resident children.

Abstract 280: Cancer risk in World Trade Center rescue and recovery workers

Objective: The purpose of this investigation was to evaluate cancer incidence in responders during the first 7 years after 11 September 2001.

Methods: Cancers among 20,984 consented participants in the WTC Health Program were identified through linkage to state tumor registries in New York, New Jersey, Connecticut, and Pennsylvania. The follow-up lasted until 2008. Standardized incidence ratios (SIRs) were calculated to compare cancers diagnosed in responders to predicted numbers for the general population. Multivariate regression models were used to estimate associations with degree of exposure.

Results: A total of 575 cancers were diagnosed in 552 individuals. Increases above registry-based expectations were noted for all cancer sites combined (SIR = 1.15; 95% CI: 1.06, 1.25), thyroid cancer (SIR = 2.39; 95% CI: 1.70, 3.27), prostate cancer (SIR = 1.21; 95% CI: 1.01, 1.44), combined hematopoietic and lymphoid cancers (SIR = 1.36; 95% CI: 1.07, 1.71), and soft tissue cancers (SIR = 2.26; 95% CI: 1.13, 4.05). When restricted to 302 cancers diagnosed ≥ 6 months after enrollment, the SIR for all cancers decreased to 1.06 (95% CI: 0.94, 1.18), but thyroid and prostate cancer diagnoses remained greater than expected. All cancers combined were increased in very highly exposed responders and among those exposed to significant amounts of dust, compared with responders who reported lower levels of exposure.

Conclusion: Estimates should be interpreted with caution given the short follow-up and long latency period for most cancers, the intensive medical surveillance of this cohort, and the small numbers of cancers at specific sites. However, our findings highlight the need for continued follow-up and surveillance of WTC responders. The follow-up of the cohort is currently being updated and efforts are being made to improve the assessment of exposure to carcinogens related to WTC experience.

Citation Format: Paolo Boffetta, Samara Solan, Sylvan Wallenstein, Roberto Lucchini, Philip Landrigan. Cancer risk in World Trade Center rescue and recovery workers. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 280. doi:10.1158/1538-7445.AM2014-280

Thyroid anaplastic carcinoma: the impact of multimodality treatment on survival. The experience of a referral center for endocrine surgery

AIM

Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis.

METHODS

We retrospectively reviewed 79 consecutive patients treated between 1996 and 2012. We analysed the multimodality treatment of ATC considering the impact of surgery and radiotherapy on survival.

RESULTS

Patients were divided in groups A and B (tumor less and larger than 5 cm). Surgery was carried out in 44 patients, radiotherapy in 48 patients. Tracheostomy and endoprosthesis were used respectively in 48.1% and in 25.3% of patients. The mean survival was 5.35 (± 3.2) months with no significant difference in group A vs. group B. Considering patients undergone surgery, significant impact on survival was observed comparing A vs. B (P=0.013). Combination of surgery and radiotherapy significantly improves outcome comparing A vs. B (P=0.017). Improvement in survival compared to no treatment at all was observed in both groups respectively for surgery (P=0.001 and P=0.0001) and radiotherapy (P=0.047 and P=0.0001).

CONCLUSION

Although the severity of prognosis of ATC, multimodality treatment still significantly improves local control of the disease achieving acceptable survival in selected patients and adequate palliation of symptoms for the others. Surgery is still a fundamental treatment.

Diesel and silica monitoring at two sites following hurricane sandy

Following Hurricane Sandy, which hit New York City and New Jersey in October 2012, industrial hygienists from the Mount Sinai and Belleview/New York University occupational medicine clinics conducted monitoring for diesel exhaust and silica in lower Manhattan and Rockaway Peninsula. Average daytime elemental carbon levels at three stations in lower Manhattan on December 4, 2012, ranged from 9 to18 μg/m(3). Sub-micron particle counts at various times on the same day were over 200,000 particles per cubic centimeter on many streets in lower Manhattan. In Rockaway Peninsula on December 12, 2012, all average daytime elemental carbon levels were below a detection limit of approximately 7 μg/m(3). The average daytime crystalline silica dust concentration was below detection at two sites on Rockaway Peninsula, and was 0.015 mg/m(3) quartz where sand was being replaced on the beach. The daily average levels of elemental carbon and airborne particulates that we measured are in the range of levels that have been found to cause respiratory effects in sensitive subpopulations like asthmatic patients after 2 hr of exposure. Control of exposure to diesel exhaust must be considered following natural disasters where diesel-powered equipment is used in cleanup and recovery. Although peak silica exposures were not likely captured in this study, but were reported by a government agency to have exceeded recommended guidelines for at least one cleanup worker, we recommend further study of silica exposures when debris removal operations or traffic create visible levels of suspended dust from soil or sand.

Differentiated thyroid tumors: surgical indications

Thyroid gland tumors represent 1% of malignant tumors. In Italy their incidence is in constant growth. The aggressiveness depends on the histological type. The relative non-aggressive grade of different forms of tumors is the basis for discussing the treatment of choice: total thyroidectomy vs lobectomy with or without lymphadenectomy of the sixth level in the absence of metastasis. Authors report about their experience, and they advocate, given the high percentage of multicentric forms, total thyroidectomy as treatment of choice.

Health technology assessment and thyroid surgery

The growth of technological innovation, the request for assistance, the rising patient's expectations and the interest of the industry have led to a rise in the cost of health care systems. In this context the role of the National Health System is not to delay the development or adoption of new technologies, but rather to drive the development selecting priorities and promoting its use. Health Technology Assessment (HTA) is a multidisciplinary and multidimensional approach for analyzing the medical-clinical, social, organizational, economic, ethical and legal implications of a technology (devices, drugs, procedures) through the assessment of multiple parameters such as effectiveness, safety, costs of the social and organizational impact. A health technology assessment is a comprehensive, systematic evaluation of the prerequisites for estimating the consequences of using health technology. Main characteristic of HTA is that the problem is tackled using an approach focused on four main elements: - technology; - patient; - organization; - economy. The authors have applied the HTA method for the analysis of the ultrasonic focus dissector on thyroid surgery. They compared the cost of the surgical procedure using the ultrasonic dissector and without it in a case study of 440 patients who underwent thyroidectomy.

Metal fractionation in soils and assessment of environmental contamination in Vallecamonica, Italy

Metal contamination was investigated in soils of the Vallecamonica, an area in the northern part of the Brescia province (Italy), where ferroalloy industries were active for a century until 2001. The extent in which emissions from ferroalloy plants affected metal concentration in soils is not known in this area. In this study, the geogenic and/or anthropogenic origin of metals in soils were estimated. A modified Community Bureau of Reference sequential chemical extraction method followed by inductively coupled plasma optical emission spectroscopy (ICP-OES) analyses were employed to evaluate the potential bioavailability of Al, Cd, Mn, Fe, Cr, Zn, and Pb in soils. Principal component analysis (PCA) was used to assess the relationships among metal sources in soil samples from different locations. This approach allowed distinguishing of different loadings and mobility of metals in soils collected in different areas. Results showed high concentrations and readily extractability of Mn in the Vallecamonica soils, which may suggest potential bioavailability for organisms and may create an environmental risk and potential health risk of human exposure.

[Symptoms and upper limb work-related musculo-skeletal disorders among 173 supermarket cashiers]

BACKGROUND

Cashiers in supermarket chains have long been considered at risk for the development of work related musculo-skeletal disorders of the upper limbs (UL-WMSDs). The aim of this study was to assess the prevalence of UL-WMSDs among workers operating supermarket cash tills and, after clinical tests, their frequency.

METHODS

A standardized questionnaire was given to a random group of 173 workers in order to collect information regarding symptoms in the upper limbs (pain and parasthesia). Among the 111 workers who reached a "positive clinical history threshold" we selected a random sample of subjects to undergo clinical tests (professional medical care, ultrasound examination, electro-neurographic examination).

RESULTS

64% of the workers had a positive clinical history for UL-WMSDs. The most frequently reported disorder was pain, especially in the shoulder, while 37% of workers suffered from one or more disorders of the upper limbs. Clinical tests were performed on 51 workers (47 women) whose average length of service was 20 years and 2/3 were part-time workers; a total of 43 UL-WMSDs (59%) were diagnosed in 30 workers, including 13 (30.2%) cases of compressive neuropathies, 13 cases of hand/elbow tendinitis (30.2%) and 17 cases of shoulder tendinitis (39.5%). The average age of these 30 subjects was 47 years, with a length of service of 23 years, mostly part-time workers.

CONCLUSIONS

We found a high prevalence of general disorders and cases of UL-WMSDs among the workers investigated, including part-time workers and workers who were not working exclusively as cashiers. The study also revealed a poor health surveillance programme to identify/ UL-WMSDs that should be the responsibility of the occupational physician and a consequent underestimation of risk and lack of the information needed to adopt preventive measures.

The neurobehavioral impact of manganese: results and challenges obtained by a meta-analysis of individual participant data

Results from a meta-analysis of aggregated data provoked a new analysis using individual data on the neuropsychological performance of occupationally exposed workers. Data from eight studies examining 579 exposed and 433 reference participants were included, 28 performance variables analyzed. The performance scores were adjusted for well-known individual-level covariates; the influence of possible, but unknown study-level covariates was attenuated by means of a z-normalization. Associations between performance and exposure were estimated by ANOVAs and ANCOVAs, the latter representing multi-level models. Four cognitive and motor performance variables each indicated significantly lower performances of exposed individuals when confounding was considered; slowed motor performances and deficits in attention and short-term memory were found. Performance on a single test was significantly related to the biomarker manganese in blood. The outcomes on susceptibility were weak. The slowing of responses was the most distinct feature of performances of exposed workers. It remains unclear, whether this result is related to the employed tests or provides important information about early stages of the neurotoxic impairment. More specific cognitive tests need to be employed to answer this question. The lack of dose-response relationships was related to features of the biomarker: it does not reflect the Mn in brain responsible for changes in performances.