Breast cancer highlights from 2023: Knowledge to guide practice and future research

This narrative work highlights a selection of published work from 2023 with potential implications for breast cancer practice. We feature publications that have provided new knowledge immediately relevant to patient care or for future research. We also highlight guidelines that have reported evidence-based or consensus recommendations to support practice and evaluation in breast cancer diagnosis and treatment. The scope of selected highlights represents various domains and disciplines in cancer control, from prevention to treatment of early and advanced breast cancer.

Evaluating the ability of an artificial-intelligence cloud-based platform designed to provide information prior to locoregional therapy for breast cancer in improving patient's satisfaction with therapy: The CINDERELLA trial

BACKGROUND

Breast cancer therapy improved significantly, allowing for different surgical approaches for the same disease stage, therefore offering patients different aesthetic outcomes with similar locoregional control. The purpose of the CINDERELLA trial is to evaluate an artificial-intelligence (AI) cloud-based platform (CINDERELLA platform) vs the standard approach for patient education prior to therapy.

METHODS

A prospective randomized international multicentre trial comparing two methods for patient education prior to therapy. After institutional ethics approval and a written informed consent, patients planned for locoregional treatment will be randomized to the intervention (CINDERELLA platform) or controls. The patients in the intervention arm will use the newly designed web-application (CINDERELLA platform, CINDERELLA APProach) to access the information related to surgery and/or radiotherapy. Using an AI system, the platform will provide the patient with a picture of her own aesthetic outcome resulting from the surgical procedure she chooses, and an objective evaluation of this aesthetic outcome (e.g., good/fair). The control group will have access to the standard approach. The primary objectives of the trial will be i) to examine the differences between the treatment arms with regards to patients' pre-treatment expectations and the final aesthetic outcomes and ii) in the experimental arm only, the agreement of the pre-treatment AI-evaluation (output) and patient's post-therapy self-evaluation.

DISCUSSION

The project aims to develop an easy-to-use cost-effective AI-powered tool that improves shared decision-making processes. We assume that the CINDERELLA APProach will lead to higher satisfaction, better psychosocial status, and wellbeing of breast cancer patients, and reduce the need for additional surgeries to improve aesthetic outcome.

ESO-ESMO fifth international consensus guidelines for breast cancer in young women (BCY5)

We dedicate this manuscript in memory of a dear friend and colleague Bella Kaufman. The fifth International Consensus Symposium for Breast Cancer in Young Women (BCY5) took place virtually in October 2020, organized by the European School of Oncology (ESO) and the European Society of Medical Oncology (ESMO). Consensus recommendations for the management of breast cancer in young women were updated from BCY4 with incorporation of new evidence to inform the guidelines. Areas of research priorities as well as specificities in different geographic and minority populations were identified. This manuscript summarizes the ESO-ESMO international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

Aim

Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario.

Methods

A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology.

Results

The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR.

Conclusions

The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR

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Autologous breast reconstruction is increasingly preferred over implants in the setting of radiation therapy.

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Use of patient-reported outcomes is endorsed.

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Shape and size of reconstructed breasts can hinder radiotherapy planning.

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There is a need for randomised phase III trials.

Imitation learning for improved 3D PET/MR attenuation correction

The assessment of the quality of synthesised/pseudo Computed Tomography (pCT) images is commonly measured by an intensity-wise similarity between the ground truth CT and the pCT. However, when using the pCT as an attenuation map (μ-map) for PET reconstruction in Positron Emission Tomography Magnetic Resonance Imaging (PET/MRI) minimising the error between pCT and CT neglects the main objective of predicting a pCT that when used as μ-map reconstructs a pseudo PET (pPET) which is as similar as possible to the gold standard CT-derived PET reconstruction. This observation motivated us to propose a novel multi-hypothesis deep learning framework explicitly aimed at PET reconstruction application. A convolutional neural network (CNN) synthesises pCTs by minimising a combination of the pixel-wise error between pCT and CT and a novel metric-loss that itself is defined by a CNN and aims to minimise consequent PET residuals. Training is performed on a database of twenty 3D MR/CT/PET brain image pairs. Quantitative results on a fully independent dataset of twenty-three 3D MR/CT/PET image pairs show that the network is able to synthesise more accurate pCTs. The Mean Absolute Error on the pCT (110.98 HU ± 19.22 HU) compared to a baseline CNN (172.12 HU ± 19.61 HU) and a multi-atlas propagation approach (153.40 HU ± 18.68 HU), and subsequently lead to a significant improvement in the PET reconstruction error (4.74% ± 1.52% compared to baseline 13.72% ± 2.48% and multi-atlas propagation 6.68% ± 2.06%).

FLAIR-only joint volumetric analysis of brain lesions and atrophy in clinically isolated syndrome (CIS) suggestive of multiple sclerosis

Background

MRI assessment in multiple sclerosis (MS) focuses on the presence of typical white matter (WM) lesions. Neurodegeneration characterised by brain atrophy is recognised in the research field as an important prognostic factor. It is not routinely reported clinically, in part due to difficulty in achieving reproducible measurements. Automated MRI quantification of WM lesions and brain volume could provide important clinical monitoring data. In general, lesion quantification relies on both T1 and FLAIR input images, while tissue volumetry relies on T1. However, T1-weighted scans are not routinely included in the clinical MS protocol, limiting the utility of automated quantification.

Objectives

We address an aspect of this important translational challenge by assessing the performance of FLAIR-only lesion and brain segmentation, against a conventional approach requiring multi-contrast acquisition. We explore whether FLAIR-only grey matter (GM) segmentation yields more variability in performance compared with two-channel segmentation; whether this is related to field strength; and whether the results meet a level of clinical acceptability demonstrated by the ability to reproduce established biological associations.

Methods

We used a multicentre dataset of subjects with a CIS suggestive of MS scanned at 1.5T and 3T in the same week. WM lesions were manually segmented by two raters, ‘manual 1′ guided by consensus reading of CIS-specific lesions and ‘manual 2′ by any WM hyperintensity. An existing brain segmentation method was adapted for FLAIR-only input. Automated segmentation of WM hyperintensity and brain volumes were performed with conventional (T1/T1 + FLAIR) and FLAIR-only methods.

Results

WM lesion volumes were comparable at 1.5T between ‘manual 2′ and FLAIR-only methods and at 3T between ‘manual 2′, T1 + FLAIR and FLAIR-only methods. For cortical GM volume, linear regression measures between conventional and FLAIR-only segmentation were high (1.5T: α = 1.029, R² = 0.997, standard error (SE) = 0.007; 3T: α = 1.019, R² = 0.998, SE = 0.006). Age-associated change in cortical GM volume was a significant covariate in both T1 (p = 0.001) and FLAIR-only (p = 0.005) methods, confirming the expected relationship between age and GM volume for FLAIR-only segmentations.

Conclusions

FLAIR-only automated segmentation of WM lesions and brain volumes were consistent with results obtained through conventional methods and had the ability to demonstrate biological effects in our study population. Imaging protocol harmonisation and validation with other MS phenotypes could facilitate the integration of automated WM lesion volume and brain atrophy analysis as clinical tools in radiological MS reporting.

Residual Glandular Breast Tissue After Mastectomy: A Systematic Review

BACKGROUND

The goal of mastectomy is remove all of the glandular breast tissue (BGT) without compromising skin flaps viability. The purpose of this systematic review was to localize and/or estimate the amount of residual BGT (rBGT) after mastectomy and to identify factors that could be related to rBGT and/or residual disease.

METHODS

We conducted a PubMed search. The report was subdivided according to the method used to evaluate the presence of rBGT. A total of 16 publications were included in our final report. Two main methods for identifying rBGT included imaging (i.e., MRI scan) and histological evaluation at the time of mastectomy.

RESULTS

The rate of rBGT was reported in up to 100% of the patients and was found to be associated mainly with the type of surgical resection, indication, and surgeon's expertise. Residual breast tissue can be found in all areas of the remaining chest wall, mostly in the skin-flaps, and more frequently underneath the nipple-areola complex.

European Guidelines on the Organisation of Breast Centres and Voluntary Certification Processes

BACKGROUND

EUSOMA undertook the commitment of defining the requirements for a specialist breast centre, which has become the reference document for the implementation of breast centres.

SUMMARY

The EUSOMA requirements for a specialist breast centre give clear indications regarding the requisite caseload, dedicated team composition (core and non-core team), organisation, availability of services and equipment throughout the patient pathway, quality control, and application of a multidisciplinary approach. The minimum number of cases is 150 newly diagnosed breast cancer cases per year. Based on the EUSOMA requirements, a voluntary and accredited certification scheme has been developed. In Europe, other voluntary certification schemes are available, such as those developed by the German Cancer Society and German Society for Breast Disease, the National Cancer Peer Review Programme in the UK, and the "label de qualité" established by the Swiss Anticancer League and the Swiss Senology Society. The European Commission Initiative on Breast Cancer (ECIBC) has overseen the development of a European Quality Assurance Scheme.

KEY MESSAGES

Nearly 20 years after the initial publication of the EUSOMA requirements, ensuring that all breast cancer patients in Europe are treated only in certified breast centres should be considered a high priority and eventually achieved through collaborative efforts.

Geometric and dosimetric evaluations of atlas-based segmentation methods of MR images in the head and neck region

Owing to its excellent soft-tissue contrast, magnetic resonance (MR) imaging has found an increased application in radiation therapy (RT). By harnessing these properties for treatment planning, automated segmentation methods can alleviate the manual workload burden to the clinical workflow. We investigated atlas-based segmentation methods of organs at risk (OARs) in the head and neck (H&N) region using one approach that selected the most similar atlas from a library of segmented images and two multi-atlas approaches. The latter were based on weighted majority voting and an iterative atlas-fusion approach called STEPS. We built the atlas library from pre-treatment T1-weighted MR images of 12 patients with manual contours of the parotids, spinal cord and mandible, delineated by a clinician. Following a leave-one-out cross-validation strategy, we measured the geometric accuracy by calculating Dice similarity coefficients (DSC), standard and 95% Hausdorff distances (HD and HD95), and the mean surface distance (MSD), whereby the manual contours served as the gold standard. To benchmark the algorithm, we determined the inter-observer variability (IOV) between three observers. To investigate the dosimetric effect of segmentation inaccuracies, we implemented an auto-planning strategy within the treatment planning system Monaco (Elekta AB, Stockholm, Sweden). For each set of auto-segmented OARs, we generated a plan for a 9-beam step and shoot intensity modulated RT treatment, designed according to our institution's clinical H&N protocol. Superimposing the dose distributions on the gold standard OARs, we calculated dose differences to OARs caused by delineation differences between auto-segmented and gold standard OARs. We investigated the correlations between geometric and dosimetric differences. The mean DSC was larger than 0.8 and the mean MSD smaller than 2 mm for the multi-atlas approaches, resulting in a geometric accuracy comparable to previously published results and within the range of the IOV. While dosimetric differences could be as large as 23% of the clinical goal, treatment plans fulfilled all imposed clinical goals for the gold standard OARs. Correlations between geometric and dosimetric measures were low with R2  <  0.5. The geometric accuracy and the ability to achieve clinically acceptable treatment plans indicate the suitability of using atlas-based contours for RT treatment planning purposes. The low correlations between geometric and dosimetric measures suggest that geometric measures alone are not sufficient to predict the dosimetric impact of segmentation inaccuracies on treatment planning for the data utilised in this study.

Geometric and dosimetric evaluations of atlas-based segmentation methods of MR images in the head and neck region

Owing to its excellent soft-tissue contrast, magnetic resonance (MR) imaging has found an increased application in radiation therapy (RT). By harnessing these properties for treatment planning, automated segmentation methods can alleviate the manual workload burden to the clinical workflow. We investigated atlas-based segmentation methods of organs at risk (OARs) in the head and neck (H&N) region using one approach that selected the most similar atlas from a library of segmented images and two multi-atlas approaches. The latter were based on weighted majority voting and an iterative atlas-fusion approach called STEPS. We built the atlas library from pre-treatment T1-weighted MR images of 12 patients with manual contours of the parotids, spinal cord and mandible, delineated by a clinician. Following a leave-one-out cross-validation strategy, we measured the geometric accuracy by calculating Dice similarity coefficients (DSC), standard and 95% Hausdorff distances (HD and HD95), and the mean surface distance (MSD), whereby the manual contours served as the gold standard. To benchmark the algorithm, we determined the inter-observer variability (IOV) between three observers. To investigate the dosimetric effect of segmentation inaccuracies, we implemented an auto-planning strategy within the treatment planning system Monaco (Elekta AB, Stockholm, Sweden). For each set of auto-segmented OARs, we generated a plan for a 9-beam step and shoot intensity modulated RT treatment, designed according to our institution's clinical H&N protocol. Superimposing the dose distributions on the gold standard OARs, we calculated dose differences to OARs caused by delineation differences between auto-segmented and gold standard OARs. We investigated the correlations between geometric and dosimetric differences. The mean DSC was larger than 0.8 and the mean MSD smaller than 2 mm for the multi-atlas approaches, resulting in a geometric accuracy comparable to previously published results and within the range of the IOV. While dosimetric differences could be as large as 23% of the clinical goal, treatment plans fulfilled all imposed clinical goals for the gold standard OARs. Correlations between geometric and dosimetric measures were low with R²  <  0.5. The geometric accuracy and the ability to achieve clinically acceptable treatment plans indicate the suitability of using atlas-based contours for RT treatment planning purposes. The low correlations between geometric and dosimetric measures suggest that geometric measures alone are not sufficient to predict the dosimetric impact of segmentation inaccuracies on treatment planning for the data utilised in this study.

Bullseye's representation of cerebral white matter hyperintensities

BACKGROUND AND PURPOSE

Visual rating scales have limited capacities to depict the regional distribution of cerebral white matter hyperintensities (WMH). We present a regional-zonal volumetric analysis alongside a visualization tool to compare and deconstruct visual rating scales.

MATERIALS AND METHODS

3D T1-weighted, T2-weighted spin-echo and FLAIR images were acquired on a 3T system, from 82 elderly participants in a population-based study. Images were automatically segmented for WMH. Lobar boundaries and distance to ventricular surface were used to define white matter regions. Regional-zonal WMH loads were displayed using bullseye plots. Four raters assessed all images applying three scales. Correlations between visual scales and regional WMH as well as inter and intra-rater variability were assessed. A multinomial ordinal regression model was used to predict scores based on regional volumes and global WMH burdens.

RESULTS

On average, the bullseye plot depicted a right-left symmetry in the distribution and concentration of damage in the periventricular zone, especially in frontal regions. WMH loads correlated well with the average visual rating scores (e.g. Kendall's tau [Volume, Scheltens]=0.59 CI=[0.53 0.62]). Local correlations allowed comparison of loading patterns between scales and between raters. Regional measurements had more predictive power than global WMH burden (e.g. frontal caps prediction with local features: ICC=0.67 CI=[0.53 0.77], global volume=0.50 CI=[0.32 0.65], intra-rater=0.44 CI=[0.23 0.60]).

CONCLUSION

Regional-zonal representation of WMH burden highlights similarities and differences between visual rating scales and raters. The bullseye infographic tool provides a simple visual representation of regional lesion load that can be used for rater calibration and training.

Performance of grain sorghum hybrids under drought stress using GGE biplot analyses

The objective of this study was to estimate the adaptability and stability of grain sorghum hybrids grown under post-flowering water stress and non-stress conditions. The trials were carried out in Nova Porteirinha-MG during the season of 2014 and 2015, and in Teresina-PI in the 2014 season. Twenty-nine-grain sorghum hybrids were evaluated, in a randomized complete block design, with three replications. Plots consisted of four lines with 3 m long. The grain yield data were submitted to the individual variance analysis, having considered the effects of the hybrids as fixed and the other effects as random. The joint analysis was carried out, and when the interaction genotypes x environments was significant, the grain yield data were submitted to the adaptability and stability analysis by the GGE biplot method. A substantial reduction in the grain yield in environments with water stress was found. The highest yielding hybrids under water stress conditions in Nova Porteirinha-MG were 50A50, AG1080, AG1090, DKB550, DKB590, Jade, and BM737, and the highest yielding hybrids under the water stress in Teresina-PI were 1G282, 1G244, and A9721R. Considering all environments, the highest yielding hybrids were 1G282, DKB540, A9721R, 1G100, and AG1090.

Evaluation of a multi-atlas CT synthesis approach for MRI-only radiotherapy treatment planning

BACKGROUND AND PURPOSE

Computed tomography (CT) imaging is the current gold standard for radiotherapy treatment planning (RTP). The establishment of a magnetic resonance imaging (MRI) only RTP workflow requires the generation of a synthetic CT (sCT) for dose calculation. This study evaluates the feasibility of using a multi-atlas sCT synthesis approach (sCTa) for head and neck and prostate patients.

MATERIAL AND METHODS

The multi-atlas method was based on pairs of non-rigidly aligned MR and CT images. The sCTa was obtained by registering the MRI atlases to the patient's MRI and by fusing the mapped atlases according to morphological similarity to the patient. For comparison, a bulk density assignment approach (sCTbda) was also evaluated. The sCTbda was obtained by assigning density values to MRI tissue classes (air, bone and soft-tissue). After evaluating the synthesis accuracy of the sCTs (mean absolute error), sCT-based delineations were geometrically compared to the CT-based delineations. Clinical plans were re-calculated on both sCTs and a dose-volume histogram and a gamma analysis was performed using the CT dose as ground truth.

RESULTS

Results showed that both sCTs were suitable to perform clinical dose calculations with mean dose differences less than 1% for both the planning target volume and the organs at risk. However, only the sCTa provided an accurate and automatic delineation of bone.

CONCLUSIONS

Combining MR delineations with our multi-atlas CT synthesis method could enable MRI-only treatment planning and thus improve the dosimetric and geometric accuracy of the treatment, and reduce the number of imaging procedures.

Identification of sorghum hybrids with high phenotypic stability using GGE biplot methodology

The aim of this study was to identify sorghum hybrids that have both high yield and phenotypic stability in Brazilian environments. Seven trials were conducted between February and March 2011. The experimental design was a randomized complete block with 25 treatments and three replicates. The treatments consisted of 20 simple pre-commercial hybrids and five witnesses of grain sorghum. Sorghum genotypes were analyzed by the genotype main effects + genotype environment interaction (GGE) biplot method if significant genotype x environment interaction, adaptability, and phenotypic stability were detected. GGE biplot methodology identified two groups of environments, the first composed of Água Comprida-MG, Montividiu-GO, and Vilhena- RO and the second of Guaíra-SP and Sete Lagoas-MG. The BRS 308 and 1G282 genotypes were found to have high grain yield, adaptability, and phenotypic stability and are thus indicated for cultivation in the first and second groups of environments, respectively.

Imaging the accumulation and suppression of tau pathology using multiparametric MRI

Mouse models of Alzheimer's disease have served as valuable tools for investigating pathogenic mechanisms relating to neurodegeneration, including tau-mediated and neurofibrillary tangle pathology-a major hallmark of the disease. In this work, we have used multiparametric magnetic resonance imaging (MRI) in a longitudinal study of neurodegeneration in the rTg4510 mouse model of tauopathy, a subset of which were treated with doxycycline at different time points to suppress the tau transgene. Using this paradigm, we investigated the sensitivity of multiparametric MRI to both the accumulation and suppression of pathologic tau. Tau-related atrophy was discernible from 5.5 months within the cortex and hippocampus. We observed markedly less atrophy in the treated rTg4510 mice, which was enhanced after doxycycline intervention from 3.5 months. We also observed differences in amide proton transfer, cerebral blood flow, and diffusion tensor imaging parameters in the rTg4510 mice, which were significantly less altered after doxycycline treatment. We propose that these non-invasive MRI techniques offer insight into pathologic mechanisms underpinning Alzheimer's disease that may be important when evaluating emerging therapeutics targeting one of more of these processes.

Breast cancer under age 40: a different approach

Breast cancer (BC) under age 40 is a complex disease to manage due to the additionally fertility-related factors to be taken in consideration. More than 90% of young patients with BC are symptomatic. Women<40 years are more likely to develop BC with worse clinicopathological features and more aggressive subtype. This has been frequently associated with inferior outcomes. Recently, the prognostic significance of age<40 has been shown to differ according to the BC subtype, being associated with worst recurrence-free survival (RFS) and overall survival (OS) for luminal BC. The biology of BC<40 has also been explored through analysis of large genomic data set, and specific pathways overexpressed in these tumors have been identified which can lead to the development of targeted therapy in the future. A multidisciplinary tumor board should determine the optimal locoregional and systemic management strategies for every individual patient with BC before the start of any therapy including surgery. This applies to both early (early breast cancer (EBC)) and advanced (advanced breast cancer (ABC)) disease, before the start of any therapy. Mastectomy even in young patients confers no overall survival advantage when compared to breast-conserving treatment (BCT), followed by radiotherapy. Regarding axillary approach, indications are identical to other age groups. Young age is one of the most important risk factors for local recurrence after both breast-conserving surgery (BCS) and mastectomy, associated with a higher risk of distant metastasis and death. Radiation after BCS reduces local recurrence from 19.5 to 10.2% in BC patients 40 years and younger. The indications for and the choice of systemic treatment for invasive BC (both early and advanced disease) should not be based on age alone but driven by the biological characteristics of the individual tumor (including hormone receptor status, human epidermal growth factor receptor 2 (HER-2) status, grade, and proliferative activity), disease stage, and patient's comorbidities. Recommendations regarding the use of genomic profiles such as MammaPrint, Oncotype Dx, and Genomic grade index in young women are similar to the general BC population. Especially in the metastatic setting, patient preferences should always be taken into account, as the disease is incurable. The best strategy for these patients is the inclusion into well-designed, independent, prospective randomized clinical trials. Metastatic disease should always be biopsied whenever feasible for histological confirmation and reassessment of biology. Endocrine therapy is the preferred option for hormone receptor-positive disease (HR+ve), even in presence of visceral metastases, unless there is concern or proof of endocrine resistance or there is a need for rapid disease response and/or symptom control. Recommendations for chemotherapy (CT) should not differ from those for older patients with the same characteristics of the metastatic disease and its extent. Young age by itself should not be an indication to prescribe more intensive and combination CT regimens over the sequential use of monotherapy. Poly(ADP-ribose) polymerase inhibitors (PARP inhibitors) represent an important group of promising drugs in managing patients with breast cancer susceptibility gene (BRCA)-1- or BRCA-2-associated BC. Specific age-related side effects of systemic treatment (e.g., menopausal symptoms, change in body image, bone morbidity, cognitive function impairment, fertility damage, sexual dysfunction) and the social impact of diagnosis and treatment (job discrimination, taking care for children) should also be carefully addressed when planning systemic long-lasting therapy, such as endocrine therapy. Survivorship concerns for young women are different compared to older women, including issues of fertility, preservation, and pregnancy.

In vivo imaging of tau pathology using multi-parametric quantitative MRI

As the number of people diagnosed with Alzheimer's disease (AD) reaches epidemic proportions, there is an urgent need to develop effective treatment strategies to tackle the social and economic costs of this fatal condition. Dozens of candidate therapeutics are currently being tested in clinical trials, and compounds targeting the aberrant accumulation of tau proteins into neurofibrillary tangles (NFTs) are the focus of substantial current interest. Reliable, translatable biomarkers sensitive to both tau pathology and its modulation by treatment along with animal models that faithfully reflect aspects of the human disease are urgently required. Magnetic resonance imaging (MRI) is well established as a valuable tool for monitoring the structural brain changes that accompany AD progression. However the descent into dementia is not defined by macroscopic brain matter loss alone: non-invasive imaging measurements sensitive to protein accumulation, white matter integrity and cerebral haemodynamics probe distinct aspects of AD pathophysiology and may serve as superior biomarkers for assessing drug efficacy. Here we employ a multi-parametric array of five translatable MRI techniques to characterise the in vivo pathophysiological phenotype of the rTg4510 mouse model of tauopathy (structural imaging, diffusion tensor imaging (DTI), arterial spin labelling (ASL), chemical exchange saturation transfer (CEST) and glucose CEST). Tau-induced pathological changes included grey matter atrophy, increased radial diffusivity in the white matter, decreased amide proton transfer and hyperperfusion. We demonstrate that the above markers unambiguously discriminate between the transgenic group and age-matched controls and provide a comprehensive profile of the multifaceted neuropathological processes underlying the rTg4510 model. Furthermore, we show that ASL and DTI techniques offer heightened sensitivity to processes believed to precede detectable structural changes and, as such, provides a platform for the study of disease mechanisms and therapeutic intervention.

Guidelines for time-to-event end point definitions in breast cancer trials: results of the DATECAN initiative (Definition for the Assessment of Time-to-event Endpoints in CANcer trials)†

BACKGROUND

Using surrogate end points for overall survival, such as disease-free survival, is increasingly common in randomized controlled trials. However, the definitions of several of these time-to-event (TTE) end points are imprecisely which limits interpretation and cross-trial comparisons. The estimation of treatment effects may be directly affected by the definitions of end points. The DATECAN initiative (Definition for the Assessment of Time-to-event Endpoints in CANcer trials) aims to provide recommendations for definitions of TTE end points. We report guidelines for randomized cancer clinical trials (RCTs) in breast cancer.

PATIENTS AND METHODS

A literature review was carried out to identify TTE end points (primary or secondary) reported in publications of randomized trials or guidelines. An international multidisciplinary panel of experts proposed recommendations for the definitions of these end points based on a validated consensus method that formalize the degree of agreement among experts.

RESULTS

Recommended guidelines for the definitions of TTE end points commonly used in RCTs for breast cancer are provided for non-metastatic and metastatic settings.

CONCLUSION

The use of standardized definitions should facilitate comparisons of trial results and improve the quality of trial design and reporting. These guidelines could be of particular interest to those involved in the design, conducting, reporting, or assessment of RCT.

Selection indices to identify drought-tolerant grain sorghum cultivars

Twenty-five cultivars of grain sorghum [Sorghum bicolor (L.) Moench] were examined under both drought stress and normal conditions in 4 experiments. In each condition, genotypes were evaluated in a factorial experiment using a randomized complete block design with 3 replications. Eight drought tolerance indices including stability tolerance index, mean productivity (MP), geometric MP, harmonic mean, stress susceptibility index, tolerance index, yield index, and yield stability index were estimated for each genotype based on grain yield under drought (Ys) and irrigated conditions (Yp). The results indicated that there were positive and significant correlations among Yp and Ys with geometric MP, MP, harmonic mean, and stability tolerance index, indicating that these factors are better predictors of Yp and Ys than tolerance index, stress susceptibility index, yield stability index, and yield index. Based on adjusted means at Yp and Ys, indices geometric MP, MP, harmonic mean, and stability tolerance index, unweighted pair group method with arithmetic mean cluster and biplot analysis, the most tolerant cultivars were '9929020', '9929034', and 'N 95B'.

Stability and adaptability of grain sorghum hybrids in the off-season

We analyzed productivity data obtained from experiments on grain sorghum conducted in 7 locations of its cultivation in Brazil. A total of 25 hybrids were analyzed, of which 22 were pre-commercial and 3 were cultivars. The Wricke and Purchase et al. methods were highly consistent in identifying individuals with low contributions to genotype x environment interactions. The Lin and Binns method proved to be easily applicable and interpretable but it was not efficient in detecting individuals with specific adaptations. An additive main effect and multiplicative interaction (AMMI) model indicated the suitability of cultivar 1G282 for the cities of Guaíra, Sete Lagoas, and Vilhena, and hybrids 0307087 and 0307091 for the southeast of Goiás. The associations of the Eberhart and Russell method with AMMI indicated that 0307071, 0307131, 0307511, and 0307651 showed adaptability to favorable environments. Hybrid 0009061 stood out as the most adaptable and stable cultivar.

Long-term cosmetic changes after breast-conserving treatment of patients with stage I-II breast cancer and included in the EORTC 'boost versus no boost' trial

BACKGROUND

In breast cancer treated with breast-conserving radiotherapy, the influence of the boost dose on cosmetic outcome after long-term follow-up is unknown.

PATIENTS AND METHODS

We included 348 patients participating in the EORTC 'boost versus no boost' mega trial with a minimum follow-up of 6 years. Digitalised pictures were analysed using specific software, enabling quantification of seven relative asymmetry features associated with different aspects of fibrosis.

RESULTS

After 3 years, we noted a statistically significantly poorer outcome for the boost patients for six features compared with those of the no boost patients. Up to 9 years of follow-up, results continued to worsen in the same magnitude for the both patient groups. We noted the following determinants for poorer outcome: (i) boost treatment, (ii) larger excision volumes, (iii) younger age, (iv) tumours located in the central lower quadrants of the breast and (v) a boost dose administered with photons.

CONCLUSIONS

A boost dose worsens the change in breast appearance in the first 3 years. Moreover, the development of fibrosis associated with whole-breast irradiation, as estimated with the relative asymmetry features, is an ongoing process until (at least) 9 years after irradiation.

Tuberculosis screening in Portuguese healthcare workers using the tuberculin skin test and the interferon-gamma release assay

The prevalence of latent tuberculosis (TB) infection (LTBI) and the incidence of active tuberculosis in healthcare workers (HCWs) in a Portuguese hospital were examined. This cross-sectional study comprises 4,735 hospital workers screened between May 2005 and September 2008. Tuberculin skin test (TST) and interferon-gamma release assay (IGRA) were used simultaneously in 1,219 HCWs (25.7%). Radiographs were taken in symptomatic HCWs or in test-positive HCWs. The tests were repeated annually or bi-annually depending on risk assessment. IGRA was positive in 32.6% and TST in 74.2% of the HCWs. Years spent in healthcare were a risk factor for a positive IGRA, but not for a positive TST. Repeated bacillus Calmette-Guérin vaccination increased the probability of TST+/IGRA- discordance (35.4% versus 54.4%, respectively). In those tested three times with TST during the study period (n = 59), the mean diameter of TST increased from 5 to 7 to 10 mm. Within 3 yrs, 31 HCWs were diagnosed with active TB (annual incidence rate 191 out of 100,000 people). In eight HCWs with active TB, TST and IGRA were performed at the time of diagnosis and each test was positive. TB burden in HCWs in Portugal is high. With IGRA, the number of radiographs needed to exclude active TB could have been reduced by about half without missing a case of active TB. Therefore IGRA should be introduced into TB screening programmes.

[Influence of the grade of anxiety and level of cortisol on post-surgical recovery]

INTRODUCTION

The objective is to analyze the influence of several biological and/or psychological factors on postsurgery recovery.

METHOD

Our sample was made up of 42 inpatients waiting for surgery. The day before the intervention, they filled out Spielbergers' State/Trait Anxiety Inventory (STAI) and sample of saliva was collected at 8:00 in order to determine cortisol concentration. Recovery was codified as <<good>> or <<poor>> using the Moix criteria (1995).

RESULTS

Patients with higher scores on the STAI had higher levels of salivary cortisol and their recovery was worse compared with patients with low anxiety.

CONCLUSIONS

Our results confirm the relationship between specific psychological variables, cortisol levels and the characteristics of the surgery recovery process of the patients.

The use of a breast symmetry index for objective evaluation of breast cosmesis

The cosmetic result after breast surgery is an important marker in clinical studies. Most authors used subjective scales to judge breast cosmesis. However, inter-observer discrepancies are very high and the use of such subjective scales for prospective trials is highly disputed. In this study we present for the first time a new invented breast symmetry index (BSI). This BSI is calculated by subtracting the size and the shape between both breasts (frontal view and side view). The BSI is measured with a software system called breast analysing tool (BAT) from digital photographs. The photographs of 27 patients have been analysed with this software by different physicians to evolve inter-observer reproducibility. The Harris scale for subjective cosmetic analyses has been correlated with the BSI. In our study the inter-observer reproducibility was excellent (Pearson correlation r=0.9; p<0.05) and the BSI was able to significantly differentiate between good and bad cosmesis (BSI values from 0%d to 30%d is good, BSI>30%d is bad cosmesis). Thus the BSI may be used for clinical studies.

Role of viruses and atypical bacteria in asthma exacerbations among children in Oporto (Portugal)

BACKGROUND

Upper respiratory tract infections are known to be a significant precipitant of acute asthma exacerbations. The aim of this study was to evaluate seasonal trends and the role of these pathogens in asthma exacerbations in school-aged children from Oporto (Portugal).

METHODS

Nasal aspirates were collected from children aged 6 to 12 years old with asthma exacerbations attended in the Pediatric Emergency Department one day per week from January 1 to December 31, 2003. Demographic data, severity of asthma and asthma exacerbations, and current treatment were recorded. Samples were obtained through nasal wash with 1 ml saline and were processed by immunofluorescence assays (respiratory syncytial virus, adenovirus, parainfluenza and influenza virus), retrotranscription polymerase chain reaction (rhinovirus) and polymerase chain reaction (enterovirus, Chlamydia pneumoniae and Mycoplasma pneumoniae).

RESULTS

In 54 eligible children, 37 nasal samples were obtained. Infectious agents were detected in 78 % of the patients. Rhinovirus was detected in 70.3 %, Mycoplasma pneumoniae in 16.2 %, enterovirus in 10.8 %, and Chlamydia pneumoniae in 2.7 %. Coinfection was identified in 21.6 % of the samples. There was no significant correlation between current treatment status, severity of asthma or exacerbations and the isolated agents. Two distinct peaks of asthma exacerbation were found, 40.5 % in spring and 32.4 % in autumn [corrected] The highest number of cases was recorded in March and the lowest in August and January. Rhinoviruses was detected in 27 % of the cases in autumn and in 24.3 % in spring [corrected]

CONCLUSIONS

These results confirm the previously reported high frequency of rhinovirus detection in asthma exacerbations in children and provide evidence that asthma exacerbations and rhinovirus infections follow a seasonal pattern, occurring mostly in spring and autumn. The findings also underscore the frequency of Mycoplasma pneumoniae detection, and emphasize the importance of this agent as a possible trigger of asthma exacerbations.

Alternate response preparation in a visuomotor serial task

The preparation of a particular motor pattern is related to the information available that enables the actor to predict the correct response to a forthcoming stimulus. In many situations, however, prediction is not possible. In such cases, the individual can guess the probable parameters of the next stimulus. The authors attempted to establish the bias in the motor intention for movement and its interaction with a possible memory trace of the stimulus-response mapping produced by the preceding stimulus. Two letters were presented bilaterally, and participants (N=21) had to discriminate the target letter and respond with the compatible hand. The present findings support the existence of a memory trace of the previous stimulus-response mapping.

Gender differences in event-related potentials during visual-spatial attention

The aim of present work is to test possible gender differences in the ERPs to the standards during the performance of a visual-spatial attention task. The sample: 20 subjects (10 women) aged 18-24. Electrodes: F3, F4, C3, C4, P3, P4, T5, T6, O1, O2. ANOVA tests were computed with the following factors: attention, gender, visual field, hemisphere, and electrodes. Results showed that men presented higher amplitudes in P1 and in P3b than did women, and women presented higher amplitudes in the temporal N1 than did men. For the P3, the amplitude in frontal-central regions for the attended condition was higher in men than in women, and men presented a gender-specific right frontal functional asymmetry that was not present in women. Since these components are related with the modulation of visual processing by the effect of spatial attention, the intra- and inter-gender differences obtained suggest possible differences in the processing of visual information in both genders. However, the fact that the brain generators could have a different orientation is also a possible explanation for the differences obtained in the ERPs in both genders.

Temporal evolution of alpha and beta bands during visual spatial attention

Event-related potentials (ERPs) are an electrophysiological index of various cognitive processes such as attention. However, this kind of analysis does not allow observation of differences in the spectral content taking place during a sensory, cognitive or motor task. The goal of the present work was to compute the temporal dynamics of EEG oscillations using a technique called temporal spectral evolution (TSE). The electroencephalogram (EEG) was recorded during the presentation of flashed stimuli that were randomly presented to the left or right visual field. Subjects were asked to pay attention, alternately in different blocks of trials, to the left or to the right to detect an infrequent target. The results showed a decrease in the alpha band in a time window of 375-500 ms and an increase in the beta band at 500-875 ms after stimulus onset, for both attended and unattended stimuli. Statistical analysis showed that the decrease in alpha and the increase in beta were more marked during the attentional condition. In conclusion, these results demonstrate that the decrease in alpha band and the increase in beta band are electrophysiological markers of visual spatial attention.

[Temporal spectral evolution of electroencephalogram. Methodology and applications]

INTRODUCTION

The event related potentials (ERPs) allow to study the evolution of the cerebral electric activity related with the diverse sensorial, motors and cognitive processes. However, the ERPs and the spectral analyses based in Fast Fourier Transform, are not able to show the variations along the time of the spectral content of the electroencephalogram (EEG).

OBJECTIVE

The present work will show the necessary methodology to obtain the temporal dynamics of the frequency (TSE) in the EEG, a technique described by Salmelin and Hari (1994) that allows the analysis of the modulations of any spectral band along the time.

SUBJECTS AND METHODS

The presented data correspond to the electroencephalographic registration of 20 human subjects during an experiment of visual spatial attention.

RESULTS

The modulations of the ERPs differ of the observed by the spectral techniques in latency and topography. Likewise, comparing different spectral techniques is proven that the TSE allows to define with more temporal precision the variations on the spectral content.

CONCLUSION

The application of the TSE technique to the same EEG signal that is used for obtaining the ERPs, allows the inclusion of the variable time in the spectral analysis of the EEG, what can be crucial to understand the physiological bases of some neuropathologies.

Current source density analysis of CNV during temporal gap paradigm

The present report studied the contingent negative variation during Gap and Non-Gap conditions using visual stimulation and manual responses. The reaction times during the Gap condition were facilitated compared with those of the Non-Gap condition. The contingent negative variation component was obtained during the preparatory period from electrodes placed at 58 scalp sites for both Gap and Non-Gap conditions. The comparison between both conditions: Gap and non-gap did not show statistically significant differences during the preparatory period. The topography of the voltage and current source density maps showed three different foci: (i) an early negativity centred in electrodes overlying the supplementary motor area and cingulate motor areas, (ii) an activation over the primary motor cortex contralateral to the finger movement, and (iii) a bilateral activation on posterior sites. All these results suggest that the facilitation induced by the warning stimuli occurs in neural circuits that would be recruited for the subsequent processing of the imperative stimulus. The facilitation of the reaction times during the gap condition with respect to non-gap condition must be justified by neural events occurring during the gap period.

Frequency analysis of the EEG during spatial selective attention

In this study, we recorded the event-related potentials (ERPs) elicited by stimuli appearing at attended and unattended locations. The voltage amplitudes and latencies of the P1, N1, P2, N2 and P3 visual components showed statistically significant differences in the attended condition with respect to the unattended one. The power spectral density of the EEG following stimulus onset was calculated. The difference between the spectral densities of the attended and unattended conditions was computed. Statistically significant differences were found in the decrease of alpha (9-11 Hz) and the increase of beta (15-17 Hz) frequencies during the attention condition with respect to the unattended condition. These results suggest that the arrival of a visual stimulus during the attended condition generates a complex reorganization of neuronal activity in both time and frequency domains.

[Hormone replacement therapy and cancer of the breast. 2. Should a woman with cancer of the breast receive hormone replacement therapy?]

The common menopausal symptoms of a growing number of women treated for breast cancer poses difficult therapeutic decisions to the Gynaecologist. It has been extensively demonstrated that hormonal replacement therapy (HRT) is the most effective treatment of such symptoms, as well as protecting women from cardiovascular disease, osteoporosis and increased mortality related to these disorders. However, breast cancer is classically considered a contraindication to HRT. In this paper we review the existing evidence regarding the influence of HRT on breast cancer. A computerized bibliographical search (MEDLINE) of literature in the English-language literature published in the last 15 years was conducted, followed by a hand search of references found in these papers. Evidence on the response of breast cancer cells to HRT is derived from animal studies, tissue growth system experiments, indirect epidemiological data and clinical data. While the bulk of experimental evidence points towards a proliferative effect of estrogen on breast cancer cells, almost all clinical reports have found no adverse effects of HRT on these patients. In our opinion, currently existing evidence does not justify the denial of HRT to breast cancer patients whose quality of life is at stake. Such is the case of women with intense menopausal symptoms unresponsive to alternative therapies. This opinion is shared by numerous other authors and a small number of eminent institutions. We believe it is safer to avoid HRT, in asymptomatic women as long-term regimens would be needed for protection against cardiovascular disease and osteoporosis, and the risks of such regimens have yet to be evaluated. We also believe that large randomized trials are now ethically justified and greatly needed to obtain safer data on this subject.