Metastatic breast cancer: an updating

This article reports on recent advances on metastatic breast cancer. Detection, prognostic factors, predictors of response to therapy and therapy, with particular regard to targeted therapies, were examined.

DETECTION

Unlike current guidelines that yet do not routinely recommend intensive clinical-instrumental post-operative follow-up of breast cancer patients, relatively large data collected in the last decades have shown that an intensive post-operative follow-up with 'dynamic evaluation' of a suitable tumour marker panel precedes a few months as average the clinical and/or instrumental sign of a pending relapse in most relapsed patients and largely limits the use of the common instrumental examinations.

PROGNOSIS AND THERAPY PREDICTORS

Disease-free interval (DFI)<or=24 months, adjuvant chemotherapy, liver and distant soft tissue involvement or DFI>24 months and disease confined to bony skeleton are prognostic factors more often correlated with relatively poor or prolonged survival, respectively. Estrogen receptor (ER) expression in primary tumour and at the relapse correlates strongly with response to salvage hormone therapy and data from large trials showed that 38-59% of ER and/or PR+ post-menopausal patients had clinical benefit from first line tamoxifen or aromatase inhibitors. An inverse correlation of ER with epidermal growth factor receptor (EGFR) has been found. The co-expression of HER-2/neu and/or elevated serum HER-2/neu protein level were associated with a low rate and shorter duration of response of ER+ patients to first line hormone therapy. Accordingly, ER-EGFR- compared with ER-EGFR+ tumours are usually more responsive to endocrine therapy. High class III beta-tubulin expression or fall in insulin-like growth factor binding protein-3 (IGFBP-3) from baseline levels have been found to significantly predict resistance to chemotherapeutic agents.

THERAPY

Liposomes as carrier of doxorubicin (Caelix, Evacet, Myocet) is one approach to decrease the anthracycline-related cardiac toxicity. Weekly paclitaxel or docetaxel and oral formulation of vinorelbine and 5-fluorouracil (5-FU) (capecitabine) provide new effective and well tolerated options that reach greater dose intensity and cumulative dose than with the conventional schedules. As to the so called 'tailored' or targeted therapies, the more potent and highly selective third generation of aromatase inhibitors (letrozole, anastrozole, exemestane) targeting ER+ tumours by estrogen deprivation, challenge tamoxifen as current standard first line therapy in postmenopausals. One pilot study showed that stimulation of cellular immunity by the addition of beta-interferon-interleukin-2 sequence in patients on clinical benefit on first line tamoxifen significantly prolonged median overall survival (OS) and duration of response compared to that observed in similar patients only treated with tamoxifen. Trastuzumab, a humanised monoclonal antibody to extracellular domain of HER-2, plus conventional chemotherapy has become a standard of care for women with overexpressing HER-2 tumours. Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor (VEGF) that in refractory metastatic breast cancer doubled the response rate of capecitabine although it did not affect survival. Finally, the so called 'oligometastatic' and a few stage IV diseases are conditions amenable to be rendered with no evidence of disease (NED) after local surgery and/or radiation. In both, as well as in complete responders to chemotherapy, minimal residual disease (m.r.d.) likely continues to be present. Recent data suggest that 'biological' therapy (immunomodulators and/or retinoids with or without hormone therapy), might be suitable to be successfully tested in these patients as maintenance treatment given soon after local intervention or chemotherapy.

Effects of green and black tea on hepatic xenobiotic metabolizing systems in the male F344 rat

1. The induction of phase I and II enzymes in the liver of the male F344 rat drinking 2% (w/v) solutions of green or black tea for 6 weeks was investigated. Also studied were glutathione (GSH) and cyst(e)ine in blood, liver and kidney, as well as serum cholesterol, HDL cholesterol, triglycerides, and total and free testosterone. 2. The total carbon monoxide-discernible liver P450, b5 and NADPH-cytochrome c(P450) reductase activities were similar in all groups. 3. There were significant increases in liver of rat drinking green or black tea of P4501A1, 1A2 and 2B1 activities, but no change in P4502E1 and 3A4 activities. Of the phase II enzymes, UDP-glucuronyltransferase was increased, but glutathione S-transferase was not. 4. Serum GSH was higher in the group administered black tea, but GSH and cyst(e)ine in other groups was at control levels. Serum cholesterol was lower in rat given black compared with green tea. Triglycerides had a declining trend after green and black tea exposure compared with water controls. Free and total testosterone were not affected. 5. Thus, beverages widely used by man altered host biochemistry as regards specific phase I and II enzymes in liver of rat and specific serum parameters.

Carbogen and nicotinamide combined with unconventional radiotherapy in glioblastoma multiforme: a new modality treatment

PURPOSE

A new radiotherapy schedule to treat glioblastoma multiforme after surgery, combining nicotinamide and carbogen.

METHODS AND MATERIALS

We analyzed 36 patients with glioblastoma multiforme treated after surgery with radiotherapy, Nicotinamide and Carbogen as follows: 7 patients were treated with accelerated fractionation: two fractions/day, 1.5 cGy/fraction, 6 h interval, 5 days/week, total dose 60 Gy in 4 weeks; 8 patients were treated with the same irradiation scheduling plus Nicotinamide at the dose of 4 g and 2 g in capsules, respectively, 1 h before the first and the second irradiation fraction; 21 patients were treated with accelerated radiotherapy, Nicotinamide, and Carbogen (inhaled 10 min before radiotherapy and during the whole course of irradiation). On the basis of surgical removal our patients were subdivided in three groups: totally resected, with residual tumor <50%, or >50%. Radiotherapy with accelerated fractionation was completed in the scheduled time without side effects on the whole group of patients and Carbogen inhalation did not cause significant change of cardiopulmonar parameters. The toxicity observed was predominant in the gastrointestinal tract and was related to Nicotinamide.

RESULTS

The median survival time (M.S.T.) was 10 months, as reported by others authors with conventional treatment, but in patients without surgical residual tumor and submitted to the complete treatment schedule, the survival at 35 months was around 25%.

CONCLUSIONS

We conclude that this method is feasible with acceptable toxicity; analyzing the survival curves appears to be a trend towards an improvement in survival in the subgroup of patients with gross total removal treated with the combination of Carbogen, Nicotinamide, and accelerated fractionation.

Basal knowledge in the field of pediatric nephrology and its enhancement following specific training of ChatGPT-4 "omni" and Gemini 1.5 Flash

BACKGROUND

We aimed to evaluate the baseline performance and improvement of ChatGPT-4 "omni" (ChatGPT-4o) and Gemini 1.5 Flash (Gemini 1.5) in answering multiple-choice questions related to pediatric nephrology after specific training.

METHODS

Using questions from the "Educational Review" articles published by Pediatric Nephrology between January 2014 and April 2024, the models were tested both before and after specific training with Portable Data Format (PDF) and text (TXT) file formats of the Educational Review articles removing the last page containing the correct answers using a Python script. The number of correct answers was recorded.

RESULTS

Before training, ChatGPT-4o correctly answered 75.2% of the 1395 questions, outperforming Gemini 1.5, which answered 64.9% correctly (p < 0.001). After training with PDF files, ChatGPT-4o's accuracy increased to 77.8%, while Gemini 1.5 improved significantly to 84.7% (p < 0.001). Training with TXT files showed similar results, with ChatGPT-4o maintaining 77.8% accuracy and Gemini 1.5 further improving to 87.6% (p < 0.001).

CONCLUSIONS

The study highlights that while ChatGPT-4o has strong baseline performance, specific training does not significantly enhance its accuracy. Conversely, Gemini 1.5, despite its lower initial performance, shows substantial improvement with training, particularly with TXT files. These findings suggest Gemini 1.5's superior ability to store and retrieve information, making it potentially more effective in clinical applications, albeit with a dependency on additional data for optimal performance.

Multiple Shape Coexistence in ^{110,112}Cd

From detailed spectroscopy of ^{110}Cd and ^{112}Cd following the β^{+}/electron-capture decay of ^{110,112}In and the β^{-} decay of ^{112}Ag, very weak decay branches from nonyrast states are observed. The transition rates determined from the measured branching ratios and level lifetimes obtained with the Doppler-shift attenuation method following inelastic neutron scattering reveal collective enhancements that are suggestive of a series of rotational bands. In ^{110}Cd, a γ band built on the shape-coexisting intruder configuration is suggested. For ^{112}Cd, the 2^{+} and 3^{+} intruder γ-band members are suggested, the 0_{3}^{+} band is extended to spin 4^{+}, and the 0_{4}^{+} band is identified. The results are interpreted using beyond-mean-field calculations employing the symmetry conserving configuration mixing method with the Gogny D1S energy density functional and with the suggestion that the Cd isotopes exhibit multiple shape coexistence.

Gut microbiota and COVID-19: An intriguing pediatric perspective

Gastrointestinal (GI) involvement has been reported in approximately 50% of patients with coronavirus disease 2019 (COVID-19), which is due to the pathogenic role of inflammation and the intestinal function of the angiotensin-converting enzyme 2 and its receptor. Accumulating adult data has pointed out that gut dysbiosis might occur in these patients with a potential impact on the severity of the disease, however the role of gut microbiota in susceptibility and severity of COVID-19 disease in children is still poorly known. During the last decades, the crosstalk between gut and lung has been largely recognized resulting in the concept of "gut-lung axis" as a central player in modulating the development of several diseases. Both organs are involved in the common mucosal immune system (including bronchus-associated and gut-associated lymphoid tissues) and their homeostasis is crucial for human health. In this framework, it has been found that the role of GI dysbiosis is affecting the homeostasis of the gut-liver axis. Of note, a gut microbiome imbalance has been linked to COVID-19 severity in adult subjects, but it remains to be clarified. Based on the increased risk of inflammatory diseases in children with COVID-19, the potential correlation between gut microbiota dysfunction and COVID-19 needs to be studied in this population. We aimed to summarize the most recent evidence on this striking aspect of COVID-19 in childhood.

Unveiling Artificial Intelligence's Power: Precision, Personalization, and Progress in Rheumatology

This review examines the increasing use of artificial intelligence (AI) in rheumatology, focusing on its potential impact in key areas. AI, including machine learning (ML) and deep learning (DL), is revolutionizing diagnosis, treatment personalization, and prognosis prediction in rheumatologic diseases. Specifically, AI models based on convolutional neural networks (CNNs) demonstrate significant efficacy in analyzing medical images for disease classification and severity assessment. Predictive AI models also have the ability to forecast disease trajectories and treatment responses, enabling more informed clinical decisions. The role of wearable devices and mobile applications in continuous disease monitoring is discussed, although their effectiveness varies across studies. Despite existing challenges, such as data privacy concerns and issues of model generalizability, the compelling results highlight the transformative potential of AI in rheumatologic disease management. As AI technologies continue to evolve, further research will be essential to address these challenges and fully harness the potential of AI to improve patient outcomes in rheumatology.

Transplant-Acquired Food Allergy in Children

BACKGROUND

Organ transplantation in children is a vital procedure for those with end-stage organ failure, but it has been linked to the development of post-transplant allergies, especially food allergies. This phenomenon, known as transplant-acquired food allergy (TAFA), is becoming increasingly recognized, though its mechanisms remain under investigation. Pediatric transplant recipients often require lifelong immunosuppressive therapy to prevent graft rejection, which can alter immune function and heighten the risk of allergic reactions. Our review aimed to gather the latest evidence on TAFA.

METHODS

We conducted a PubMed search from 25 June to 5 July 2024, using specific search terms, identifying 143 articles. After screening, 36 studies were included: 24 retrospective studies, 1 prospective study, 2 cross-sectional researches, and 9 case reports/series.

RESULTS

Most studies focused on liver transplants in children. The prevalence of food allergies ranged from 3.3% to 54.3%. Tacrolimus, alongside corticosteroids, was the most commonly used immunosuppressive therapy. In addition to food allergies, some patients developed atopic dermatitis, asthma, and rhinitis. Allergic symptoms typically emerged within a year post-transplant, with common allergens including milk, eggs, fish, nuts, soy, wheat, and shellfish. Both IgE-mediated and non-IgE-mediated reactions were observed, with treatment often involving the removal of offending foods and the use of adrenaline when necessary.

CONCLUSIONS

Consistent immunological monitoring, such as skin prick tests and IgE level assessments, is essential for early detection and management of allergies in these patients. Understanding the link between transplantation and allergy development is crucial for improving long-term outcomes for pediatric transplant recipients.

Severe Asthma in School-Age Children: An Updated Appraisal on Biological Options and Challenges in This Age Group

This review examines the growing role of biological therapies in managing severe asthma in children aged 6-11 years. Severe asthma, characterized by persistent symptoms and frequent exacerbations, presents significant challenges in pediatric care. Biologic treatments, including mepolizumab, omalizumab, and dupilumab, provide targeted interventions for patients with high eosinophilic inflammation or allergic asthma (T2-high asthma). Alongside their therapeutic benefits, the review evaluates the safety profiles of these biologics, highlighting potential side effects and the necessity for monitoring during long-term use. Cost considerations and treatment adherence also emerge as important challenges that need to be addressed in clinical practice. Additionally, the review emphasizes the need for identifying patients who would derive the most benefit from biologic therapies, advocating for the development of biomarkers to aid in treatment decisions. Emerging biologics, such as tezepelumab, are introduced as promising alternatives with the potential to target upstream inflammatory pathways, offering hope for treating T2-low asthma forms, which currently lack effective treatment options in children.

[Mammographic control after quadrantectomy and radiation therapy]

The efficacy of combined surgery and radiation therapy in the treatment of breast cancer has increased the use of mammography in the follow-up to detect early recurrences. The authors report their experience in the follow-up of 43 breast cancers after treatment with local excision, axillary dissection, and irradiation. Mammography was performed at 6.12, and 24 months. The radiological findings were: 38/43 (88.3%) breasts with abnormal mammographic patterns, skin thickening in 36/43 (83.7%) cases, breast retraction in 16/43 (37.2%), architectural distortion in 17/43 (39.5%), increased parenchymal density in 33/43 (76.7%), calcifications in 6/43 (13.9%), and a mass in 10/43 (23.2%) cases. The authors describe histologic changes, corresponding to mammographic findings, and evolution of the treated breasts. Suspicious findings were microcalcifications in one case and a mass in 6 cases (4 of them at 6 months and 2 at 12). Excisional biopsy, performed in the above 7 patients, confirmed recurrence in 4 cases. In 3 cases with negative pathology, where the malignant nature of the lesion could not be demonstrated, we observed: a cluster of microcalcifications undistinguishable from neoplasm in 1 case and spiculated nodules with architectural distortion in the extant 2 cases. Further limitations of mammography were due to radiological density of the breast in one case, and to its minimal size in another--these elements delayed both correct interpretation of mammographic findings and final diagnosis. The low agreement between mammography and histology proved the difficulty of both analysis and evaluation of abnormal post-irradiation breast tissue. The authors, in agreement with literature reports, suggest the schedule for clinical and mammographic follow-up.

Supplementation with Anti-inflammatory Nutraceutical Products in the Management of Chronic Pelvic Pain: A Narrative Review

Chronic pelvic pain is a chronic syndrome that affects patients’ life quality and expectancy as far as bladder, bowel and sexual functioning are compromised. So far treatment options are limited since pharmaceutical research has not provided any specific drug therapy to manage chronic pelvic pain. Nutraceutical products represent useful tools to supply this lack of medications. The aim of this narrative review is to provide some insight from a neuroscience perspective on the nutraceuticals’ use as adjuvant therapy in chronic pelvic pain. A review of the literature, between 2001 and 2019 on PMC and PubMed was performed in order to identify studies proving safety and efficacy of nutraceuticals in chronic pelvic pain. Inclusion criteria were nutraceutical compounds, namely curcumin, quercetin, bromelain, and diseases known for causing chronic pelvic pain. Nineteen studies were selected. Quercetin demonstrates to inhibit mast-cells, pro-inflammatory cytokines and regulate cell proliferation; curcumin suppresses inflammatory cytokines expression, inhibits invasion, angiogenesis of endometrial lesions. Bromelain resulted in a reduction of painkiller rescue doses required in endometriosis. Pre-clinical studies show promising effects of nutraceutical supplementation with selected enzymes and antioxidant compounds in patients suffering from chronic pelvic pain. Positive weak evidence suggests efficacy of these products in use as antiinflammatory and analgesic medications for chronic pelvic pain treatment.

Biomarkers in Atopic Dermatitis in Children: A Comprehensive Review

Atopic dermatitis (AD) is a chronic inflammatory skin disorder with significant implications for patient quality of life and a well-documented association with the atopic march. Recent advancements in biomarker research have unveiled critical insights into AD pathogenesis, diagnosis, prognosis, and therapeutic monitoring. This comprehensive review evaluates the utility of emerging biomarkers, including cytokines, chemokines, genetic markers, and microbiome-related components, in understanding the disease mechanisms and stratifying patient care. The role of minimally invasive diagnostic techniques, such as tape stripping and RNA monitoring, is highlighted, offering innovative approaches to pediatric populations. Furthermore, this review explores the biomarkers that predict disease progression, therapeutic response, and comorbidities, including food allergies and asthma. Personalized treatment strategies based on endotype-specific biomarkers are discussed as a future direction for improving clinical outcomes. Despite promising findings, the integration of biomarkers into routine practice necessitates further validation through large-scale studies. This work underscores the transformative potential of biomarker-driven approaches in enhancing the management of AD in children and its associated conditions.

[The echographic picture of the breast following quadrantectomy and radiation therapy]

Our experience moved from the clinical relevance of an eventual positive role of US in the follow-up of breast cancers treated with conservative therapy. This trial was suggested by the more and more frequent use of conservative therapy an by the diagnostic difficulties offered by the breasts treated with surgery and radiation therapy. Aim of the study is to analyze the diagnostic value of US in the identification of local relapse in a group of 60 patients with breast carcinoma (stages I and II) treated with conservative therapy. The patients were studied for at least 2 years following treatment, with clinical, US, and mammographic controls at 6, 12, and 24 months. The following clinical problems were considered: 1) study of the US patterns of the morphological and structural changes induced by conservative treatment; 2) observation of US and mammographic agreement in case of local relapse; 3) role of US in the follow-up of this kind of patients. US patterns and results at 6 months follow: cutaneous scar (60/60 cases), skin thickening (55/60), architectural distortion (asymmetry and amputation of the glandular cone, intramammary scar) (52/60), volumetric changes in the treated breast (50/60), skin asymmetry and retraction (50/60), "parenchymal fibrosis" (48/60), mass (8/60) and calcifications (3/60). As for the very few relapses (4 cases), US failed to reveal a ductal carcinoma which presented as microcalcifications. In our experience, US is a complementary exam to clinical and radiologic investigations, especially in the period immediately following therapy and in case of particular clinical problems, such as increased breast volume, mastitis, and appearance of a nodule.

[A decade's experience with electron radiotherapy]

The experience related to 1170 patients treated with electron beam between 1979-1988 at Radiation Therapy Department in Pisa is reported. Beam dosimetry and dose distribution in tissue, patients contour and other parameters have been analysed as main important factors to optimise this technique. Electron beam therapy offers important contributions to the management of peculiar types of cancer because of the radiotherapy treatments optimisation and the reduced normal tissue reactions.

A miRNA-Based Approach in Autosomal Dominant Polycystic Kidney Disease: Challenges and Insights from Adult to Pediatric Evidence

Autosomal dominant polycystic kidney disease (ADPKD) represents the most common inherited kidney disorder leading to kidney failure in a significant percentage of patients over time. Although previously considered as an adult disease, robust evidence demonstrated that clinical manifestations might occur during childhood and adolescence. Therefore, early identification and treatment of the disease are of cardinal importance for pediatricians to ensure the best long-term outcomes. To date, licensed treatment options are limited but promising potential therapeutic targets are emerging. Among these, an intriguing pathophysiological role for microRNAs as small molecules with a critical role in regulating gene expression has been considered possible in ADPKD. Indeed, numerous circulating microRNAs have been found to be dysregulated in ADPKD, suggesting their potential role as biomarkers and therapeutic targets. Based on this background, further detailed insights into the mechanisms of miRNAs contributing to ADPKD development might pave the way for their effective application as a targeted treatment in young patients with ADPKD. We aimed to summarize the most recent evidence in this fascinating research area, providing a comprehensive overview of the current landscape of specific microRNAs in ADPKD as a potential innovative therapeutic strategy for these young patients.