Recognizing the Emergent and Submerged Iceberg of the Celiac Disease: ITAMA Project-Global Strategy Protocol

Coeliac disease (CD) is frequently underdiagnosed with a consequent heavy burden in terms of morbidity and health care costs. Diagnosis of CD is based on the evaluation of symptoms and anti-transglutaminase antibodies IgA (TGA-IgA) levels, with values above a tenfold increase being the basis of the biopsy-free diagnostic approach suggested by present guidelines. This study showcased the largest screening project for CD carried out to date in school children (n=20,000) aimed at assessing the diagnostic accuracy of minimally invasive finger prick point-of-care tests (POCT) which, combined with conventional celiac serology and the aid of an artificial intelligence-based system, may eliminate the need for intestinal biopsy. Moreover, this study delves deeper into the "coeliac iceberg" in an attempt to identify people with disorders who may benefit from a gluten-free diet, even in the absence of gastrointestinal symptoms, abnormal serology and histology. This was achieved by looking for TGA-IgA mucosal deposits in duodenal biopsy. This large European multidisciplinary health project paves the way to an improved quality of life for patients by reducing the costs for diagnosis due to delayed findings of CD and to offer business opportunities in terms of diagnostic tools and support.

Idiopathic sterile pyogranuloma in three domestic cats

Pyogranulomatous inflammation has been extensively described in cats, in particular in cases of feline infectious peritonitis and also associated with Mycobacteria, Actinomyces, Nocardia, Rhodococcus and fungal infections. Idiopathic sterile pyogranulomatous dermatitis has also been described. In this case series we describe the clinical presentation, histopathology and outcome of three cases of feline idiopathic sterile steroid-responsive pyogranuloma with different presentation and different locations of the lesion, but with the common feature of having a mass with no superficial skin involvement.

Prospective clinical trial of masitinib mesylate treatment for advanced stage III and IV canine malignant melanoma

OBJECTIVE

To investigate efficacy of masitinib mesylate for the treatment of advanced malignant melanoma in dogs.

MATERIALS AND METHODS

Prospective clinical trial on 17 dogs with stage III and IV malignant melanoma (two digital, one anal and 14 oral mucosal). Only dogs with advanced gross disease for which the owner declined conventional treatment or dogs with progressive tumour despite conventional treatment were included.

RESULTS

There was a partial response in two dogs, stable disease in seven and tumour progression in eight dogs. Median survival time for all 17 dogs was 119 days (range 21-255). Masitinib was generally well-tolerated but grade 2 anaemia, grade 1 neutropenia, grade 1 diarrhoea and grade 2 anorexia were observed in one dog each.

CLINICAL SIGNIFICANCE

There was only mild effectiveness in end-stage disease, indicating that masitinib mesylate is not an appropriate sole-agent option for treatment of advanced malignant melanoma in dogs.

Abstract OT3-04-02: Neoadjuvant Her2-targeted therapy +/- immunotherapy with pembrolizumab (neoHIP): An open label randomized phase II trial

Background: In preclinical models HER2-directed therapy administered with checkpoint blockade is synergistic. Clinically, trastuzumab administered with pembrolizumab-mediated checkpoint blockade in trastuzumab-resistant HER2-positive metastatic breast cancer was safe and demonstrated modest activity. However, because checkpoint blockade can confer improved responses when administered earlier in the course of disease, trastuzumab with pembrolizumab administered in the curative-intent, treatment-naive setting may confer life-long, tumor-specific immunity and ultimately, improve cure rates. Moreover, the potential synergy of trastuzumab and pembrolizumab with paclitaxel may overcome the need for dual HER2-blockade. The neo-HIP study is a randomized, multicenter, phase II, open-label trial to evaluate the efficacy and safety of weekly paclitaxel, trastuzumab plus pertuzumab (THP) vs weekly THP plus pembrolizumab (THP-K) vs a HER2 monotherapy regimen (TH-K) as neoadjuvant treatment in patients with HER2-positive early stage invasive breast cancer.

Methods:Patients ≥18 years old with previously untreated, non-metastatic, stage II-III, HER2-positive (by ASCO/CAP guidelines) breast cancer are eligible. Patients with inflammatory breast cancer or bilateral primary tumors are excluded. Adequate organ function and ECOG PS 0-1 are required. Approximately 174 patients will be randomly assigned to 1 of 3 arms with stratification by clinical nodal status (positive vs. negative) and hormone receptor status (positive vs. negative). In arm A, patients will receive T at 80mg/m2 weekly for 12 weeks, H at 8mg/Kg (1 loading dose) and then 6mg/Kg IV every 3 weeks x 3 doses, P at 840mg (1 loading dose) and then 420mg/Kg IV every 3 weeks x 3 doses (THP). In arm B, patients will receive the same regimen as arm A with the addition of pembrolizumab 200mg IV every 3 weeks x 4 doses (THP-K). In arm C, patients will receive the same regimen as arm B, but without pertuzumab (TH-K). Definitive surgery will be 3-6 weeks after the last treatment dose. After surgery, patients in all arms willbe treated per the treating physician's discretion. After completion of post-operative chemotherapy, patients will receive radiotherapy per local clinical standard and those patients whose tumors are hormone-receptor positive will receive hormone therapy as per local standard-of-care. The purpose of this phase II study is to identify whether Arm B (THP-K) and/or Arm C (TH-K) demonstrate a clinically significant improvement in pCR rate when compared with Arm A (THP). The primary end point is pCR rate in the breast and axilla (ypT0/Tis ypN0). Secondary end points include pCR rate by ypT0ypN0 and ypT0/Tis, residual cancer burden index, event free survival, breast conserving surgery rate, safety and overall survival. Exploratory correlative studies will characterize the immunologic responses to the interventions and explore potential predictors of efficacy and toxicity.

Citation Format: McArthur HL, Leal JHS, DiLauro Abaya C, Basho R, Coleman H, Shiao S, Knott S, Tighiouart M, Dadmanesh F, Giuliano A, Verma S. Neoadjuvant Her2-targeted therapy +/- immunotherapy with pembrolizumab (neoHIP): An open label randomized phase II trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-04-02.

Abstract P4-16-01: A randomized, double-blind, placebo-controlled trial of testosterone (T) for aromatase inhibitor-induced arthralgias (AIA) in postmenopausal women: Alliance A221102

Background: Aromatase inhibitors are a mainstay hormone receptor-positive breast cancer treatment. AIA occur in up to 50% of patients (pts), adversely affecting quality of life and treatment compliance. A small phase II clinical trial of oral testosterone unedeconate appeared to improve AIA over placebo (P), with no significant androgenic side effects. The current study was performed to confirm these findings.

Methods: This randomized P-controlled trial enrolled postmenopausal women on adjuvant anastrozole or letrozole and experiencing moderate-to-severe AIA (≥5 on 0-10 scale). Pts were initially randomized to receive a subcutaneous pellet containing T 120 mg + anastrozole 8 mg (T+AIpellet) or P at the end of the first week on study (after obtaining baseline hot flash data) and at 3 months (mo). Due to slow accrual, the protocol was amended to change the route of delivery to topical T or P applied to the skin once daily for 6 mo. Baseline and monthly questionnaires were administered, including: Modified Brief Pain Inventory for aromatase arthralgia (BPI-AIA), prolife of mood states (POMS), the menopause specific quality of life questionnaire (MENQOL), a hot flash diary, the hot flash related daily interference scale (HFRDIS) and a symptom experience questionnaire. The primary endpoint was intra-patient change in joint pain at 3 mo, compared using a two-sample t-test.

Results: 227 pts were accrued between 9/1/2013-11/29/2017. 55 pts were randomized prior to the protocol amendment and received T+AIpellet or P. Baseline characteristics were balanced between arms, with the exceptions of median weight, BMI, hemoglobin (all higher in T arm), and breast tenderness, dissatisfaction with personal life/depression, and skin changes (all higher in P arm). Compared to baseline, there were no significant differences between T and P in average pain or joint stiffness at 3 (p=0.483) or 6 mo (p=0.573). Average pain was significantly lower each month compared to baseline, irrespective of treatment arm. There were no significant differences in any other items evaluated by BPI-AIA, POMS, MENQOL, hot flash diary or HFRDIS. Similarly, there were no substantial differences in toxicity. A subset analysis of the 55 pts randomized to receive T+AIpellet or P identified significant reductions in average pain scores with T+AIpellet during the first month (p=0.038), but not thereafter. T+AIpellet pts had significantly more reduction in reported % of baseline hot flash frequency (p=0.034) and score (p=0.031), nausea (p=0.019), fatigue (p=0.042), mood swings (p=0.026), hand/feet swelling (p=0.009), stress urinary incontinence (p=0.039) and changes in appearance, texture or tone of their skin (p=0.0083), than pts on P.

Conclusions: Overall, T did not improve AIA or menopausal symptoms compared to P. While there was significant improvement in AIA over the study period, T did not facilitate this process. However, T+AIpellet was associated with improvement in short-term AIA and several menopausal symptoms compared to P, suggesting that subcutaneous T combined with anastrozole may be superior to transdermal T alone.

Support: UG1CA189823, U10CA180820, U10CA189809; ClinicalTrials.gov Identifier: NCT01573442

Citation Format: Leon-Ferre RA, Le-Rademacher J, Terstriep S, Glaser R, Novotni P, Giuliano A, Copur MS, Jones C, Page S, Mitchell W, Birrell SN, Loprinzi CL. A randomized, double-blind, placebo-controlled trial of testosterone (T) for aromatase inhibitor-induced arthralgias (AIA) in postmenopausal women: Alliance A221102 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-01.

Abstract P2-09-07: Preoperative pembrolizumab (Pembro) with radiation therapy (RT) in patients with operable triple-negative breast cancer (TNBC)

Background: Radiation therapy (RT) induces immune-mediated cell death and could generate a rich supply of tumor antigens if administered in the pre-operative, curative-intent setting. The addition of PD-1 mediated checkpoint blockade to pre-operative RT could thus, generate robust anti-tumor immune responses, induce long-term tumor-specific memory, and ultimately, improve cure rates. This study aims to establish the safety of pre-operative pembrolizumab (pembro)-mediated immune modulation with a RT “boost” equivalent in patients with operable triple negative breast cancer (TNBC) for whom lumpectomy and adjuvant RT are planned (NCT03366844). Serial research biopsies permit interrogation of conventional biomarkers including tumor infiltrating lymphocytes (TILs) and novel immune correlates as potential predictors of response to pembro alone versus pembro with RT.

Methods: Ten women with operable, primary TNBC >2cm for whom breast-conserving therapy is planned are being enrolled in this single-institution pilot study. Study treatment consists of 1 cycle of pre-operative pembro (200 mg IV) alone, followed 3 weeks later by a RT boost (24 Gy/3 fractions) to the primary breast tumor concurrently with pembro (+/- 5 days). Curative-intent, standard-of-care, neoadjuvant chemotherapy (NAC) or breast-conserving surgery is then undertaken within 8 weeks of study enrollment (i.e. within 5 weeks of pembro #2). Adjuvant RT is administered per standard-of-care after surgery, but without a boost dose. Research blood and fresh tumor biopsies are obtained at baseline and after cycles 1 and 2 of pembro. Co-primary endpoints are: 1) safety/tolerability, as defined by the number of patients who do not necessitate a delay in standard-of-care chemotherapy or surgery and 2) change in TIL score. Secondary endpoints include safety/toxicity up to 19 weeks after study enrollment, pCR rates and disease-free survival. Correlative analysis will include single-cell RNA sequencing of the tumor immune infiltrate and multispectral immunohistochemistry

Results: Seven patients enrolled between 12/19/17 and 7/1/18. As of 7/1/18, 5 patients have completed the experimental pembro/RT phase of the trial and are currently completing standard-of-care NAC; 1 patient is currently being treated in the experimental pembro/RT phase; and 1 patient with a cT2N0 tumor at baseline achieved a pathologic complete response (pCR, ypT0/Tis ypN0) after completing the experimental pembro/RT phase followed by anthracycline- and taxane-based NAC. No grade 3 or 4 toxicities have been observed during pembro/RT in the 6 patients completing the experimental phase to date. Three additional patients will be enrolled

Conclusions: This is the first trial of curative-intent, pre-operative checkpoint blockade with RT in breast cancer and the strategy appears to be well tolerated to date. At the time of presentation, safety, change in TIL score, and pCR rates for all patients completing the experimental and NAC phases of the study will be reported.

Citation Format: McArthur HL, Basho R, Shiao SL, Park D, Mita M, Chung A, Arnold B, Martin C, Dang C, Karlan S, Knott S, Giuliano A, Ho A. Preoperative pembrolizumab (Pembro) with radiation therapy (RT) in patients with operable triple-negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-07.

Public Prevention Plans to Manage Climate Change and Respiratory Allergic Diseases. Innovative Models Used in Campania Region (Italy): The Twinning Aria Implementation and the Allergy Safe Tree Decalogue

In recent years, climate change has been influenced by air pollution, and this destructive combination has justifiably sounded an alarm for nations and many institutional bodies worldwide. Official reports state that the emission of greenhouse gases produced by human activity are growing, and consequently also the average temperature. The World Health Organization (WHO) believes that health effects expected in the future due to climate change will be dramatic, and has invited international groups to investigate potential remedies. A task force has been established by the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC), with the aim to actively work on correlation between pollution and climate change. The Task Force provided prevention tools to suggest city leaders how to improve the health conditions of allergic people in public urban parks. The "Allergy Safe Tree Decalogue" suggests the preparation and maintenance of public low allergy-impact greenery. Through the Twinning ARIA project, the Division for the Promotion and Enhancement of Health Innovation Programs of Campania Region (Italy), sought to promote the implementation of the project in the regional Health System. The main objective will be to investigate the current use and usefulness of mobile phone Apps in the management of allergic respiratory disease, through Mobile Airways Sentinel networK (MASK), the Phase 3 of the ARIA initiative, based on the freely available MASK App (the Allergy Diary, Android and iOS platforms). The effects of these prevention activities will be registered and compared with monitoring efforts thanks to the Aerobiology Units, located throughout the Campania area. A joint effort between researchers and public administrations for the implementation of prevention plans coherently with the two models proposed in a specific area, i.e. the Decalogue for public administrations and the MASK Allergy Diary app for individual patients suffering from allergy, will be implemented as a pilot.

Abstract P3-08-04: Withdrawn

This abstract was withdrawn by the authors.

Abstract P6-09-06: Updating the AJCC TNM staging system a summary of changes

This abstract was withdrawn by the authors.

Abstract P6-17-05: A corrole nanobiologic crosses the blood-brain-barrier and recognizes triple negative breast cancer: Implications for targeting brain metastases

Patients with breast cancer metastases to the brain on average survive less than one year. These tumors tend to be resistant to current therapies, and the majority of targeted therapeutics are unable to breach the blood brain barrier (BBB) to reach these tumors, thus improved alternatives are urgently needed.

Elevated cell surface levels of the human epidermal growth factor receptor subunit 3 (HER3) is associated with metastatic breast tumors, including those that spread to the brain. Elevated HER3 is also associated with resistance to a number of targeted therapies currently used in the clinic, including inhibitors of EGFR (lapatinib), HER2 (lapatinib, trastuzumab, T-DM1), HER2-3 (pertuzumab), and combination therapy.

Whereas a number of targeted therapies are currently used to combat peripheral breast tumors, the delivery of these molecules to brain metastases is limited by the blood brain barrier (BBB). This is exemplified by HER2+ breast tumors that metastasize to the brain: these tumors, while targetable outside of the central nervous system (CNS) by HER2 antibodies such as trastuzumab, are unreachable by these same antibodies because the HER2 subunit, though present on the brain endothelium, does not mediate antibody transcytosis across the blood vessel wall.

HER3, on the other hand, undergoes rapid transcytosis across the brain endothelium upon ligand binding, which normally occurs to mediate the delivery of neuregulin growth factors for neural growth and maintenance. We have developed a self-assembling nanobiological particle, HerMn, which uses HER3 as a portal for targeted entry of toxic molecules into tumor cells.

HerMn is a 10-20 nm diameter serum-stable particle comprised of a HER3-targeted cell penetration protein non-covalently assembled with a sulfonated manganese(III) corrole (S2Mn or Mn-corrole). Tumor-targeted toxicity by HerMn occurs by mitochondria membrane disruption and superoxide-mediated damage to the cytoskeleton. HerMn can also elicit tumor-selective detection by magnetic resonance imaging (MRI) due to the paramagnetic property of the corrole. HerMn distributes to the brain after systemic injection in mice, in addition to showing preferential homing and toxicity to subcutaneous tumors expressing the HER2-3 dimer. Interestingly, the Mn corrole is known to exhibit neuroprotective effects due to its antioxidant activity on normal tissue. Consistent with this, we have found that HerMn supports human cardiac cell survival ex vivo. Our studies interrogating the therapeutic potential of HerMn suggest that this nanobiologic bears the capacity for targeting toxicity to brain-metastatic breast tumors while sparing off-target tissue due to both its targeting capacity and ability to provide beneficial protective effects to normal tissue such as the brain and heart.

Citation Format: Medina-Kauwe L, Sims J, Taguiam M, Hanson C, Alonso-Valenteen F, Cui X, Wagner S, Sorasaenee K, Moats R, Marban E, Chung A, Gray H, Gross Z, Giuliano A. A corrole nanobiologic crosses the blood-brain-barrier and recognizes triple negative breast cancer: Implications for targeting brain metastases. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-17-05.

Abstract P3-07-37: Quantitative analysis of T cell and macrophage immune markers in Her2-positive breast cancer

Purpose/Objectives:

Her2-neu positive breast cancers have a good overall prognosis with the advent of Her2-directed therapies such as trastuzumab. However, despite the increased efficacy with Her-2-directed therapies 20-30% of patients still have local and/or distant failure despite being Her-2 amplified on pathology. The etiology of this local failure remains unknown. Recent evidence has suggested that there may be immune factors that contribute to the progression of breast cancer and the response to therapy so we undertook a study to examine the relationship between immune-based markers and traditional pathologic and clinical markers of outcome.

Materials/Methods:

Paraffin-embedded sections were generation and clinical records were reviewed for 88 patients, age ≥ 18 years, with pathologically-proven Her2-neu+ breast cancer who were treated at a single institution from 01/2001 to 12/2013. Single-color immunohistochemical staining was performed for CK5/6, CK14 and EGFR and scored by a breast pathologist. Adjacent sections were also then stained for CD45, CD4, CD8 and CD68 using a multi-color immunohistochemical approach. Slides were scanned using the Vectra Automated Quantitative Pathology Imaging System and analyzed using an in-house algorithm to quantitate the number of immune cells within the tumor, tumor margin and within 2 mm outside the tumor. We then compared the level of CK5/6, CK14, EGFR with the number of immune cells. The number of different immune cells were also analyzed with respect to other clinical parameters including age, tumor size, nodal status, hormone receptor status, time to progression, progression-free survival and overall survival.

Results:

At a median follow-up of 66.5 months, 20 (22.7%) patients had progressed. We found that the number of CD45+ leukocytes at the margin correlates with the expression of CK5/6 (p = 0.015) which predicted for local failure. Further, we found that the ratio of CD8 to CD4 cells within the tumor and margin highly correlates with the expression of the hormone receptors (p = 0.01).

Conclusions:

Our preliminary results suggest that immune markers may be important predictors of a basal-like phenotype as defined by CK5/6 expression in Her2+ breast cancers which itself correlated with significantly higher local failure. Further higher CD8 to CD4 ratios were highly correlated with hormone receptor expression, particularly PR expression suggesting that in the Her2+ population the more favorable prognosis for the "triple-positive" subtype of Her2+ cancers may be in part due to a more favorable immune microenvironment.

Citation Format: Shiao SL, Gertych A, Ma Z, Zhang X, Burnison CM, Mirhadi AJ, Giuliano A, Knudsen BS, Chung A. Quantitative analysis of T cell and macrophage immune markers in Her2-positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-37.

Abstract P6-13-10: Therapeutic efficacy of HER3-targeted nanobiologics on resistant tumors

Elevated cell surface levels of the human epidermal growth factor receptor subunit 3 (HER3) are associated with resistance to a number of signal-blocking breast cancer treatments, including inhibitors of EGF-R (lapatinib), HER2 (lapatinib, trastuzumab, T-DM1), HER2-3 (pertuzumab), and combination therapy. Additionally, HER3 elevation has been identified on "untarget-able" tumors such as triple-negative breast cancer (TNBC), including TNBC with acquired resistance to EGF-R inhibition. Patients with such refractory tumors currently have limited treatment options and a poor prognosis. Moreover, as up to 70% of cases resist or acquire resistance to signal-blocking therapies, an alternative approach addressing this important clinical problem has the potential for significant clinical impact.

We have developed a protein construct, HerPBK10, which self-assembles with a variety of payloads (including nucleic acids, chemotherapy agents, and imaging agents) and uses HER3 as a portal for targeted entry into cells. In contrast to receptor-targeted antibodies and tyrosine kinase inhibitors currently used in the clinic, HerPBK10 circumvents the need to modulate signaling by inducing rapid entry of toxic molecules into tumor cells through receptor-mediated endocytosis and membrane penetration.

We have previously shown that nanobiological particles formed between HerPBK10 and therapeutic payloads can elicit targeted toxicity to HER2+ tumors due to the prevalence of HER2-3 heterodimers on the tumor cell surface, while sparing heart and liver tissue. The particles that form (20-40 nm dia.) exhibit stability in serum and no detectable immunogenicity. Here we show that such particles resolve breast tumor cells with acquired resistance to HER2 and/or EGFR inhibitors in contrast to trastuzumab, pertuzumab, and combination treatment. Additionally, therapeutic efficacy is augmented on resistant over parental tumor cells, due in part to the elevated HER3 expression associated with resistance to these inhibitors. Our studies in preclinical models show that these nanoparticles ablate the growth of tumors with both acquired and pre-existing resistance to trastuzumab. Moreover, we have found that signal-inhibitors currently used in the clinic, such as trastuzumab, effectively augment the efficacy of our nanobiologic on both naïve and inherently-resistant breast tumor cells, in part through induced elevation of HER3. Thus, current targeted molecules such as trastuzumab or lapatinib may act as adjuvants to enhance tumor cell-sensitivity to HerPBK10-particles. Such an approach may address the tumor-heterogeneity associated with resistance, and corner tumors for attack by our particles.

Citation Format: Medina-Kauwe L, Sims J, Taguiam M, Hanson C, Alonso-Valenteen F, Cui X, Chung A, Gray H, Gross Z, Giuliano A. Therapeutic efficacy of HER3-targeted nanobiologics on resistant tumors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-10.

Analysis of persistence of human papillomavirus infection in men evaluated by sampling multiple genital sites

OBJECTIVE

Although human papillomavirus (HPV) infection has been studied extensively in women, data on male infection are limited. The purpose of this study was to investigate persistence of HPV infection at multiple genital sites in men and to define potential associations with socio-behavioural characteristics.

PATIENTS AND METHODS

Penile, urethral and seminal specimens were tested by the INNO-LiPA HPV system (Innogenetics) and a PCR assay. Persistence was defined as the detection of same HPV type at ≥ 2 consecutive visits. The Kaplan-Meier method and the log-rank test were applied to estimate the likelihood of persistence.

RESULTS

A total of 50 men (median age: 33 years) were followed for a median of 14.7 months. Altogether, 49%, 36%, 26% and 11% of baseline HPV-positive men had 6-, 12-, 18- and 24-month persistent infection with any HPV type, respectively. The 6-, 12- and 18- month persistence was more common for oncogenic HPV infections; 24-month persistence was similar. The median duration of persistence was 21.7 months for any HPV. The median duration of persistence for any HPV type was significantly longer in the penile sample (22.5 months, 95% CI: 18.3-26.7) than the semen sample (15.3 months, 95% CI: 14.5-16.1).

CONCLUSIONS

Over a third of type-specific HPV infections in men remained persistent over a 24-month period. The median duration of HPV infection was longer in penile samples compared to seminal samples. As being increasing the attention of HPV vaccination as a potential preventive approach also for men, it is imperative to obtain additional insight on natural history of HPV infection in men, particularly as far as incidence and duration are concerned.

Web-Based STAR E-Learning Course Increases Empathy and Understanding in Dementia Caregivers: Results from a Randomized Controlled Trial in the Netherlands and the United Kingdom

BACKGROUND

The doubling of the number of people with dementia in the coming decades coupled with the rapid decline in the working population in our graying society is expected to result in a large decrease in the number of professionals available to provide care to people with dementia. As a result, care will be supplied increasingly by untrained informal caregivers and volunteers. To promote effective care and avoid overburdening of untrained and trained caregivers, they must become properly skilled. To this end, the European Skills Training and Reskilling (STAR) project, which comprised experts from the domains of education, technology, and dementia care from 6 countries (the Netherlands, Sweden, Italy, Malta, Romania, and the United Kingdom), worked together to create and evaluate a multilingual e-learning tool. The STAR training portal provides dementia care training both for informal and formal caregivers.

OBJECTIVE

The objective of the current study was to evaluate the user friendliness, usefulness, and impact of STAR with informal caregivers, volunteers, and professional caregivers.

METHODS

For 2 to 4 months, the experimental group had access to the STAR training portal, a Web-based portal consisting of 8 modules, 2 of which had a basic level and 6 additional modules at intermediate and advanced levels. The experimental group also had access to online peer and expert communities for support and information exchange. The control group received free access to STAR after the research had ended. The STAR training portal was evaluated in a randomized controlled trial among informal caregivers and volunteers in addition to professional caregivers (N=142) in the Netherlands and the United Kingdom. Assessments were performed with self-assessed, online, standardized questionnaires at baseline and after 2 to 4 months. Primary outcome measures were user friendliness, usefulness, and impact of STAR on knowledge, attitudes, and approaches of caregivers regarding dementia. Secondary outcome measures were empathy, quality of life, burden, and caregivers' sense of competence.

RESULTS

STAR was rated positively by all user groups on both usefulness and user friendliness. Significant effects were found on a person-centered care approach and on the total score on positive attitudes to dementia; both the experimental and the control group increased in score. Regarding empathy, significant improvements were found in the STAR training group on distress, empathic concern, and taking the perspective of the person with dementia. In the experimental group, however, there was a significant reduction in self-reported sense of competence.

CONCLUSIONS

The STAR training portal is a useful and user-friendly e-learning method, which has demonstrated its ability to provide significant positive effects on caregiver attitudes and empathy.

Impact of Consensus Guidelines by the Society of Surgical Oncology and the American Society for Radiation Oncology on Margins for Breast-Conserving Surgery in Stages 1 and 2 Invasive Breast Cancer

BACKGROUND

This study aimed to evaluate the impact that the release of consensus guidelines for margins in breast-conserving surgery (BCS) had on re-excision rates.

METHODS

A retrospective review examined a prospectively maintained database of patients who had operable invasive breast cancer treated with BCS at the authors' institution. The patients were divided into two groups: (1) those with a diagnosis determined from 1 July 2011 to 31 July 2013 (before release of the guidelines) and (2) those with a diagnosis determined from 1 February 2014 to 31 July 2014 (after release of the guidelines). The groups were evaluated with respect to patient and tumor characteristics, re-excision rates, and reasons for re-excision.

RESULTS

A total of 846 cases of BCS were managed: 597 in group 1 and 249 in group 2. Re-excision rates were significantly reduced after release of the consensus guidelines (p = 0.03). Re-excisions were performed for 115 (19 %) of 597 patients in group 1 and 32 (13 %) of 249 patients in group 2. After release of the guidelines, re-excisions were performed for positive margins, as defined by the consensus statement, in 25 (78 %) of 32 cases. The two groups did not differ significantly in terms of age, tumor size, grade, nodal status, estrogen receptor status, progesterone receptor status, or human epidermal growth factor receptor 2 status. Group 1 had more tumors of mixed ductal and lobular histology than group 2, and group 2 had more lobular tumors than group 1 (p = 0.02).

CONCLUSIONS

The consensus guidelines on margins for BCS were applied for 78 % of the patients who underwent re-excision and resulted in a significant reduction in re-excision rates.

Metastatic anal sac carcinoma with hypercalcaemia and associated hypertrophic osteopathy in a dog

A seven-year-old male neutered Irish setter was treated for a metastatic anal sac adenocarcinoma (ASAC) and hypercalcaemia by complete surgical excision of the primary tumour and partial excision of the sublumbar lymph nodes. Further enlargement of the sublumbar lymph nodes was linked to recurrent hypercalcaemia 3 months after surgical treatment. Medical treatment with Toceranib and Clodronate showed modest results in the treatment of the tumour and the hypercalcaemia. Radiotherapy of the sublumbar lymph nodes and later concurrent carboplatin chemotherapy resulted in partial tumour remission with marked reduction in size of the lymph nodes and normalization of the calcaemia. Unfortunately, concurrently with subsequent relapse of the hypercalaemia, the dog developed hypertrophic osteopathy (HO) and lumbar spinal metastasis and the dog was euthanized. To the authors' knowledge, this is the second case of metastatic apocrine gland carcinoma of the anal sac associated with HO and the first case that describe the development of HO late in the stage of the disease.

Metastatic anal sac carcinoma with hypercalcaemia and associated hypertrophic osteopathy in a dog

A seven-year-old male neutered Irish setter was treated for a metastatic anal sac adenocarcinoma (ASAC) and hypercalcaemia by complete surgical excision of the primary tumour and partial excision of the sublumbar lymph nodes. Further enlargement of the sublumbar lymph nodes was linked to recurrent hypercalcaemia 3 months after surgical treatment. Medical treatment with Toceranib and Clodronate showed modest results in the treatment of the tumour and the hypercalcaemia. Radiotherapy of the sublumbar lymph nodes and later concurrent carboplatin chemotherapy resulted in partial tumour remission with marked reduction in size of the lymph nodes and normalization of the calcaemia. Unfortunately, concurrently with subsequent relapse of the hypercalaemia, the dog developed hypertrophic osteopathy (HO) and lumbar spinal metastasis and the dog was euthanized. To the authors’ knowledge, this is the second case of metastatic apocrine gland carcinoma of the anal sac associated with HO and the first case that describe the development of HO late in the stage of the disease.

Sentinel lymph node mapping in breast cancer: a critical reappraisal of the internal mammary chain issue

Although, like the axilla, the internal mammary nodes (IMNs) are a first-echelon nodal drainage site in breast cancer, the importance of their treatment has long been debated. Seminal randomized trials have failed to demonstrate a survival benefit from surgical IMN dissection, and several retrospective studies have shown that IMNs are rarely the first site of recurrence. However, the recent widespread adoption of sentinel lymph node (SLN) biopsy has stimulated a critical reappraisal of such early results. Furthermore, the higher proportion of screening-detected cancers, improved imaging and techniques (i.e., lymphoscintigraphy for radioguided SLN biopsy) make it possible to visualize lymphatic drainage to the IMNs. The virtually systematic application of adjuvant systemic and/or loco-regional radiotherapy encourages re-examination of the significance of IMN metastases. Moreover, randomized trials testing the value of postmastectomy irradiation and a meta-analysis of 78 randomized trials have provided high levels of evidence that local-regional tumor control is associated with long-term survival improvements. This benefit was limited to trials that used systemic chemotherapy, which was not routinely administered in the earlier studies. However, the contribution from IMN treatment is unclear. Lymphoscintigraphic studies have shown that a significant proportion of breast cancers have primary drainage to the IMNs, including approximately 30% of medial tumors and 15% of lateral tumors. In the few studies where IMN biopsy was performed, 20% of sentinel IMNs were metastatic. The risk of IMN involvement is higher in patients with medial tumors and positive axillary nodes. IMN metastasis has prognostic significance, as recognized by its inclusion in the American Joint Committee on Cancer staging criteria, and seems to have similar prognostic importance as axillary nodal involvement. Although routine IMN evaluation might be indicated, it has not been routinely performed, perhaps because IMN drainage with lymphoscintigraphy is more difficult to demonstrate than axillary drainage. This difference is due to technical reasons and not the absence of lymphatics to the IMN. Recent anatomical studies have confirmed a model of breast lymphatic drainage that comprises superficial, deep and perforating systems. The superficial system drains to the axilla, usually to a lymph node posterior to the pectoralis minor muscle. The deep system drains to the axilla and also anastomoses with the perforating system which drains to the IMNs. The perforating system does not connect with the superficial system. The prevalence of IMN drainage tends to reflect the method of lymphoscintigraphy, where peritumoral (deep lymphatic system) injections have a much higher likelihood of IMN drainage than subareolar or subdermal (superficial lymphatic system) injections. The fused SPECT/CT images represent a further technical solution to increase the identification of IMNs and consequently can significantly reduce the false negative rate of sentinel lymph node biopsy. Before mature results from current and future randomized trials assessing the benefit of IMN irradiation become available, lymphoscintigraphy and IMNs biopsy may be used to guide decisions regarding systemic and local-regional treatment. However, even in patients with visualized primary IMN drainage, the potential benefit of treatment should be balanced against the risk of added morbidity.

Thermophilic two-phase anaerobic digestion of source-sorted organic fraction of municipal solid waste for bio-hythane production: effect of recirculation sludge on process stability and microbiology over a long-term pilot-scale experience

A two-stage thermophilic anaerobic digestion process for the concurrent production of hydrogen and methane through the treatment of the source-sorted organic fraction of municipal solid waste was carried out over a long-term pilot scale experience. Two continuously stirred tank reactors were operated for about 1 year. The results showed that stable production of bio-hythane without inoculum treatment could be obtained. The pH of the dark fermentation reactor was maintained in the optimal range for hydrogen-producing bacteria activity through sludge recirculation from a methanogenic reactor. An average specific bio-hythane production of 0.65 m(3) per kg of volatile solids fed was achieved when the recirculation flow was controlled through an evaporation unit in order to avoid inhibition problems for both microbial communities. Microbial analysis indicated that dominant bacterial species in the dark fermentation reactor are related to the Lactobacillus family, while the population of the methanogenic reactor was mainly composed of Defluviitoga tunisiensis. The archaeal community of the methanogenic reactor shifted, moving from Methanothermobacter-like to Methanobacteriales and Methanosarcinales, the latter found also in the dark fermentation reactor when a considerable methane production was detected.

Co-digestion of livestock effluents, energy crops and agro-waste: feeding and process optimization in mesophilic and thermophilic conditions

In this study the optimization of the biogas yield from anaerobic co-digestion of manures and energy crops was carried out using four pilot scale CSTRs under different operating conditions. The effect on biogas yield of the partial substitution of energy crops with agro-waste was also investigated. For each substrate used during the continuous trials, BMP batch assays were also carried out to verify the maximum methane yield theoretically obtainable. Continuous operation results indicated that the co-digestion of manures, energy crops and agro-waste was viable at all operating conditions tested, with the greatest specific gas production of 0.54 m(3)/kg VS(fed) at an organic load rate of 2 kg TVS/m(3)(r)d consisting of 50% manure, 25% energy crops and 25% agro-waste on VS basis. No significant differences were observed between high and low loaded reactors suggesting the possibility of either improving the OLR in existing anaerobic reactors or reducing the design volumes of new reactors.

Topographic distribution of visual and somesthesic unitary responses in the Pul-LP complex of the cat

An electrophysiological analysis of field potentials and unitary responses evoked by visual, acoustic and somesthesic stimuli in thalamic associative nuclei was performed in 'encéphale isolé' cats. Photic responses were particularly pronounced in the pulvinar nucleus (Pul) including its inferior division, while in lateralis posterior (LP) and, to a lesser extent, in the posterior nuclear group (PO) a prevalence of somesthesic responses was found. Only a few units were influenced by the acoustic (clicks) stimulation. Unitary convergence and interaction was a characteristic common to all divisions of Pul-LP complex. Areas of different functional significance can therefore be traced into the associative thalamic posterior nuclei, according to their modal sensitivity. The topographic functional organization is in partial agreement with the distribution of afferent connections shown by previous anatomical studies.

Two-phase thermophilic anaerobic digestion process for biohythane production treating biowaste: preliminary results

This paper deals with the optimization of a two-phase anaerobic process treating biowaste for hydrogen and methane production. Neither physical nor chemical pre-treatments were used to optimize the process. The work was carried out at pilot scale, using two CSTRs (200 and 380 L working volume respectively) both maintained at thermophilic temperature (55 C) and fed semi-continuously with biowaste. The experiment was divided into three periods; during the first two periods the organic loading rate was maintained at 20 kg TVS/m3 d and the hydraulic retention time was changed from 6.6 to 3.3 days, while in the last period the digestate of the second reactor was recirculated to the first reactor in order to buffer the system and control pH at levels around 5. The HRT was maintained at 3.3 days and the OLR was decreased at 16.5 kg TVS/m3 d. The best yield was obtained in the last period where a specific hydrogen production of 50.9 L/kg VSfed was reached, with a H2 content in biogas from the first reactor of 36%. The methanogenic stage after the hydrogen conversion reached a specific biogas production of 0.62 m3/kg VSfed and an overall organic removal above 70%, without any stability problem. The overall biogas production was some 1.5 m3 per day with a gas composition of 10% H2 and 50% CH4.

Treatment of focal idiopathic hyperhidrosis with Botulinum Toxin Type A: clinical predictive factors of relapse-free survival

BACKGROUND

No material about the identification of predictive clinical factors of therapeutic response to Botulinum Toxin Type A (BTX-A) in focal idiopathic hyperhidrosis has been found.

OBJECTIVE

To evaluate if age, sex, extension rate of hyperhidrotic area, localization, disease-related impairment of life quality, number of previous local, non-invasive treatments different from BTX-A, and duration of disease, may affect the relapse-free survival (RFS) after a BTX-A treatment in palmar and axillary focal idiopathic hyperhidrosis.

METHODS

Forty-one patients suffering from palmar hyperhidrosis, and 38 patients suffering from axillary hyperhidrosis received intradermal injections of BTX-A. All patients were clinically screened before and after treatment; they were followed for 15 months after it, according to Hyperhidrosis Disease Severity Scale (HDSS), Minor's test, and DLQI test, to state disease severity, and disease-related impairment of quality of life.

RESULTS

The duration of therapeutic effect of BTX-A is not significantly influenced by age (P = 0.783), sex (P = 0.762), extension of hyperhidrotic area (P = 0.770), site of involvement (P = 0.402), disease-induced impairment of life quality (P = 0.745), number of previous therapies (P = 0.730), or site of involvement (P = 0.402). In palmar idiopathic hyperhidrosis, patients with a longer disease history show a shorter duration of RFS after a treatment with BTX-A (P = 0.01).

CONCLUSIONS

Patients suffering from palmar hyperhidrosis have a longer lasting disease, and a length of disease more than 20 years in these patients influences the RFS after BTX-A treatment.

Angiogenesis in psoriatic skin and its modifications after administration of etanercept: videocapillaroscopic, histological and immunohistochemical evaluation

Several studies suggest that microangiopathy plays a crucial role in the pathogenesis of psoriasis. TNFalpha up-regulates the genetic transcription of VEGF, a pro-angiogenetic cytokine over-expressed in psoriatic skin, which promotes micrangiopathic modifications in psoriatic plaque. Etanercept is a chimeric protein used in the treatment of psoriasis and other immunomediated disorders, which blocks inflammatory response by interfering in the binding of TNF-alpha to its receptors. Starting from this data, we retain that etanercept can improve microangiopathy in psoriatic skin by reducing the synthesis of pro-angiogenetic chemokine VEGF. The aims of the study are: to verify the effect of etanercept on cutaneous en plaque capillaries in vivo using intra-vital videocapillaroscopy analysis, to evaluate the relation between the en plaque videocapillaroscopic pattern and the immunohistochemical cutaneous expression of VEGF in psoriasis, and finally to correlate all these in data with clinical disease activity. Eighteen patients (10 male and 8 female, mean age 51, range 21-60) suffering from stable, en plaque type psoriasis, involving at least 10 percent of body surface area (BSA), and not responsive to conventional therapy were included in the study. All the enrolled patients received etanercept 50mg/twice/week, subcutaneously, for 12 weeks, and were carefully followed up for clinical response with PASI score and DLQI index both before (T0) and after 12 weeks (T12) of treatment with etanercept. A well demarcated psoriatic plaque of the extensor surface of upper extremities was chosen to perform an intra-vital videocapillaroscopy analysis (IVCP), and a skin biopsy for immunohistochemical study both at T0 and T12 in all the included patients, in order to evaluate the presence of microangiopathy and its modification after therapy. All the patients experienced a clinical improvement of cutaneous disease with a significant decrease of PASI score (p<0.0001) and DLQI level (p<0.0001), throughout the twelve weeks of treatment. On IVCP analysis, microangiopathy dramatically decreased (p<0.0001), this modification being significantly related with PASI and DLQI decrease at T12. Immunohistochemical expression of VEGF decreased significantly from T0 to T12 (p<0.0001), and was related with a reduction of psoriatic microangiopathy at T12. The results of our videocapillaroscopic and immunohistochemical investigation confirm that the therapeutic potentiality of etanercept is based also on its capability to promote the regression of psoriatic microangiopathy. Moreover, according to these considerations, videocapillaroscopic evaluation of psoriatic plaque, both before and after treatment with etancercept, may be a useful tool to objectively demonstrate its effect on microcirculation.