Robustness analysis of surface-guided DIBH left breast radiotherapy: personalized dosimetric effect of real intrafractional motion within the beam gating thresholds

PURPOSE

The robustness of surface-guided (SG) deep-inspiration breath-hold (DIBH) radiotherapy (RT) for left breast cancer was evaluated by investigating any potential dosimetric effects due to the residual intrafractional motion allowed by the selected beam gating thresholds. The potential reduction of DIBH benefits in terms of organs at risk (OARs) sparing and target coverage was evaluated for conformational (3DCRT) and intensity-modulated radiation therapy (IMRT) techniques.

METHODS

A total of 192 fractions of SGRT DIBH left breast 3DCRT treatment for 12 patients were analyzed. For each fraction, the average of the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift") during beam-on was evaluated and applied to the original plan isocenter. The dose distribution for the treatment beams with the new isocenter point was then calculated and the total plan dose distribution was obtained by summing the estimated perturbed dose for each fraction. Then, for each patient, the original plan and the perturbed one were compared by means of Wilcoxon test for target coverage and OAR dose-volume histogram (DVH) metrics. A global plan quality score was calculated to assess the overall plan robustness against intrafractional motion of both 3DCRT and IMRT techniques.

RESULTS

Target coverage and OAR DVH metrics did not show significant variations between the original and the perturbed plan for the IMRT techniques. 3DCRT plans showed significant variations for the left descending coronary artery (LAD) and the humerus only. However, none of the dose metrics exceeded the mandatory dose constraints for any of the analyzed plans. The global plan quality analysis indicated that both 3DCRT and IMRT techniques were affected by the isocenter shifts in the same way and, generally, the residual isocenter shifts more likely tend to worsen the plan in all cases.

CONCLUSION

The DIBH technique proved to be robust against residual intrafractional isocenter shifts allowed by the selected SGRT beam-hold thresholds. Small-volume OARs located near high dose gradients showed significant marginal deteriorations in the perturbed plans with the 3DCRT technique only. Global plan quality was mainly influenced by patient anatomy and treatment beam geometry rather than the technique adopted.

Disparities in Acute Radiation-Related Pain and Dermatitis between Black and White Patients with Early-Stage Breast Cancer Receiving Adjuvant Radiation Following Breast Conserving Surgery

PURPOSE/OBJECTIVE(S)

Historically, black patients with cancer experience poor clinical outcomes and low quality of life due to inadequate screening and management of cancer-related treatment toxicities. There are limited data documenting racial disparities in acute radiation-related toxicities (ARRTs) for patients with early-stage breast cancer. Therefore, we compared ARRTs between Black (B) and White (W) patients receiving adjuvant radiation following breast conserving surgery (BCS).

MATERIALS/METHODS

This retrospective analysis included 317 patients with stage 0/1 breast cancer treated with adjuvant radiation between October 2019 and February 2022. 29% (N = 81) were B and 71% (N = 236) were W, with an average age of 65 (range: 32-88) for both. We abstracted weekly on-treatment-visit clinical notes (OTVs) completed by a nurse and radiation oncologist who utilized the Common Terminology Criteria for Adverse (CTCAE) v4.0 to evaluate each patient's pain score (scaled 0-10, 0 = no pain and 10 = worst), radiation dermatitis (RD; Grade 0-4), as well as non-CTCAE descriptors of pain and presence of hyperpigmentation or pruritus. We compared onset and severity of pain and rates of RD and pruritus between B and W patients.

RESULTS

The proportion reporting pain was significantly lower among B vs. W patients (43.8% vs. 63.6%; P = 0.002). Of patients qualitatively reporting pain, B patients were significantly more likely to have their pain scored as 0 than W patients (24.3% vs. 11.7%; P = 0.024). B patients had significantly lower median pain scores than W patients (P = 0.010), with a median score of 3 (interquartile range [IQR]: 0-5.5) vs. 5 (IQR: 4-8). B patients had a significantly longer time to pain identification than W patients (P = 0.027), with median time to pain of 10th fraction (IQR: 4-13.5) vs. 8th fraction (IQR: 4-11). Radiation dermatitis was graded as 0 (50.6% vs 8.5%; P<0.001), 1 (44.4% vs 82.6%; P<0.001), 2 (14.8% vs 15.3%, P = NS), and 3 (3.7% vs 0.4%; P = 0.023), with no grade 4 RD, amongst B and W patients, respectively. Of note, B patients experiencing mild hyperpigmentation were graded as 0. We found no statistically significant differences in incidence of pruritus.

CONCLUSION

Qualitative and quantitative analyses of ARRTs based on CTCAE v4.0 show discordance in pain scores and radiation dermatitis. The underscoring of pain amongst B patients suggests possible cultural hesitancy to report pain or implicit biases in evaluating pain suggesting the need for alternative ways to discuss and score pain in B patients. Our data suggests that CTCAE does not effectively assess radiation dermatitis in B patients. There are no descriptors of hyperpigmentation in grading of radiation dermatitis in CTCAE, which may lead to underreporting in dark-skinned individuals. Better assessment tools are needed to document ARRTs to ensure appropriate evaluation and treatment across all racial groups.

The JAK1/2 inhibitor ruxolitinib in patients with COVID-19 triggered hyperinflammation: the RuxCoFlam trial

Dysregulated hyperinflammatory response is key in the pathogenesis in patients with severe COVID-19 leading to acute respiratory distress syndrome and multiorgan failure. Whilst immunosuppression has been proven to be effective, potential biological targets and optimal timing of treatment are still conflicting. We sought to evaluate efficacy and safety of the Janus Kinase 1/2 inhibitor ruxolitinib, employing the previously developed COVID-19 Inflammation Score (CIS) in a prospective multicenter open label phase II trial (NCT04338958). Primary objective was reversal of hyperinflammation (CIS reduction of ≥25% at day 7 in ≥20% of patients). In 184 patients with a CIS of ≥10 (median 12) ruxolitinib was commenced at an initial dose of 10 mg twice daily and applied over a median of 14 days (range, 2-31). On day 7, median CIS declined to 6 (range, 1-13); 71% of patients (CI 64-77%) achieved a ≥25% CIS reduction accompanied by a reduction of markers of inflammation. Median cumulative dose was 272.5 mg/d. Treatment was well tolerated without any grade 3-5 adverse events related to ruxolitinib. Forty-four patients (23.9%) died, all without reported association to study drug. In conclusion, ruxolitinib proved to be safe and effective in a cohort of COVID-19 patients with defined hyperinflammation.

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The COVID 19 has produced a renewal of the working conditions likely to affect mental health, a professional risk that psychosocial risks (RPS) helps to prevent. The article links stress, one of the components of this legal regime in training, and teleworking, the solution chosen to protect workers. To characterize an RPS, stress must be pathogenic. An essential question arises: how to avoid it?As an extension, on the one hand, of the various sources of RPS law applicable to telework, it is, on the other hand, to assess the instruments available to the actors required to optimize risk prevention. Although RPS law continues to increase security for mental health, some tracks are proposed for the benefit of teleworkers.

Treatment discontinuation following low-dose TKIs in 248 chronic myeloid leukemia patients: Updated results from a campus CML real-life study

TKIs long-term treatment in CML may lead to persistent adverse events (AEs) that can promote relevant morbidity and mortality. Consequently, TKIs dose reduction is often used to prevent AEs. However, data on its impact on successful treatment-free remission (TFR) are quite scarce. We conducted a retrospective study on the outcome of CML subjects who discontinued low-dose TKIs from 54 Italian hematology centers participating in the Campus CML network. Overall, 1.785 of 5.108 (35.0%) regularly followed CML patients were treated with low-dose TKIs, more frequently due to relevant comorbidities or AEs (1.288, 72.2%). TFR was attempted in 248 (13.9%) subjects, all but three while in deep molecular response (DMR). After a median follow-up of 24.9 months, 172 (69.4%) patients were still in TFR. TFR outcome was not influenced by gender, Sokal/ELTS risk scores, prior interferon, number and last type of TKI used prior to treatment cessation, DMR degree, reason for dose reduction or median TKIs duration. Conversely, TFR probability was significantly better in the absence of resistance to any prior TKI. In addition, patients with a longer DMR duration before TKI discontinuation (i.e., >6.8 years) and those with an e14a2 BCR::ABL1 transcript type showed a trend towards prolonged TFR. It should also be emphasized that only 30.6% of our cases suffered from molecular relapse, less than reported during full-dose TKI treatment. The use of low-dose TKIs does not appear to affect the likelihood of achieving a DMR and thus trying a treatment withdrawal, but might even promote the TFR rate.

Surface-guided DIBH radiotherapy for left breast cancer: impact of different thresholds on intrafractional motion monitoring and DIBH stability

PURPOSE

To compare two left breast cancer patient cohorts (tangential vs. locoregional deep-inspiration breath-hold - DIBH treatment) with different predefined beam gating thresholds and to evaluate their impact on motion management and DIBH stability.

METHODS

An SGRT-based clinical workflow was adopted for the DIBH treatment. Intrafractional monitoring was performed by tracking both the respiratory signal and the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift"). Beam gating tolerances were 5 mm/4 mm for the SGRT shifts and 5 mm/3 mm for the gating window amplitude for breast tangential and breast + lymph nodes locoregional treatments, respectively. A total of 24 patients, 12 treated with a tangential technique and 12 with a locoregional technique, were evaluated for a total number of 684 fractions. Statistical distributions of SGRT shift and respiratory signal for each treatment fraction, for each patient treatment, and for the two population samples were generated.

RESULTS

Lateral cumulative distributions of SGRT shifts for both locoregional and tangential samples were consistent with a null shift, whereas longitudinal and vertical ones were slightly negative (mean values < 1 mm). The distribution of the percentage of beam on time with SGRT shift > 3 mm, > 4 mm, or > 5 mm was extended toward higher values for the tangential sample than for the locoregional sample. The variability in the DIBH respiration signal was significantly greater for the tangential sample.

CONCLUSION

Different beam gating thresholds for surface-guided DIBH treatment of left breast cancer can impact motion management and DIBH stability by reducing the frequency of the maximum SGRT shift and increasing respiration signal stability when tighter thresholds are adopted.

End-to-end test for lung SBRT: An Italian multicentric pilot experience

PURPOSE

Set up a lung SBRT end-to-end (e2e) test and perform a multicentre validation.

MATERIAL AND METHODS

A group of medical physicists from four hospitals and the Italian Institute of Ionizing Radiation Metrology designed the present e2e test. One sub-group set up the test, while another tested its feasibility and ease of use. A satisfaction questionnaire was used to collect user feedback. Each participating centre (PC) received the ADAM breathing phantom, a microDiamond detector and radiochromic films. Following the e2e protocol, each PC performed its standard internal procedure for simulating, planning, and irradiating the phantom. Each PC uploaded its planning and treatment delivery data in a shared Google Drive. A single centre analyzed all the data.

RESULTS

The e2e test was successfully performed by all PCs. Participants' comments indicated that ADAM was well suited to the purpose and the protocol well described. All PCs performed the test in static and dynamic modes. The ratio between measured and planned point dose obtained by PC1, PC2, PC3, PC4 was: 0.99, 0.96, 1.01 and 1.01 (static track) and 0.99, 1.02, 1.01 and 0.94 (dynamic track). The gamma passing rates (3 % global, 3 mm) between planned and measured dose maps were 98.5 %, 94.0 %, 99.1 % and 94.0 % (static track) and 99.5 %, 96.5 %, 86.0 % and 94.5 % (dynamic track) for PC1, PC2, PC3 and PC4, respectively.

CONCLUSIONS

An e2e test for lung SBRT has been proposed and tested in a multicentre framework. The results and user feedback prove the validity of the proposed e2e test.

The web of laughter: frontal and limbic projections of the anterior cingulate cortex revealed by cortico-cortical evoked potential from sites eliciting laughter

According to an evolutionist approach, laughter is a multifaceted behaviour affecting social, emotional, motor and speech functions. Albeit previous studies have suggested that high-frequency electrical stimulation (HF-ES) of the pregenual anterior cingulate cortex (pACC) may induce bursts of laughter-suggesting a crucial contribution of this region to the cortical control of this behaviour-the complex nature of laughter implies that outward connections from the pACC may reach and affect a complex network of frontal and limbic regions. Here, we studied the effective connectivity of the pACC by analysing the cortico-cortical evoked potentials elicited by single-pulse electrical stimulation of pACC sites whose HF-ES elicited laughter in 12 patients. Once these regions were identified, we studied their clinical response to HF-ES, to reveal the specific functional target of pACC representation of laughter. Results reveal that the neural representation of laughter in the pACC interacts with several frontal and limbic regions, including cingulate, orbitofrontal, medial prefrontal and anterior insular regions-involved in interoception, emotion, social reward and motor behaviour. These results offer neuroscientific support to the evolutionist approach to laughter, providing a possible mechanistic explanation of the interplay between this behaviour and emotion regulation, speech production and social interactions. This article is part of the theme issue 'Cracking the laugh code: laughter through the lens of biology, psychology and neuroscience'.

Statins and Left Ventricular Ejection Fraction Following Doxorubicin Treatment

BACKGROUND

Statins taken for cardiovascular indications by patients with breast cancer and lymphoma during doxorubicin treatment may attenuate left ventricular ejection fraction (LVEF) decline, but the effect of statins on LVEF among patients with no cardiovascular indications is unknown.

METHODS

A double-blind, placebo-controlled, 24-month randomized trial of 40 mg of atorvastatin per day administered to patients with breast cancer and lymphoma receiving doxorubicin was conducted within the National Cancer Institute Community Oncology Research Program across 31 sites in the United States. At pretreatment and then 6 and 24 months after initiating doxorubicin, we assessed left ventricular (LV) volumes, strain, mass, and LVEF through cardiac magnetic resonance imaging, along with cognitive function and serum markers of inflammation. The primary outcome was the difference in 24-month LVEF between placebo and treatment groups, adjusted for pretreatment LVEF.

RESULTS

A total of 279 participants were enrolled in the trial. Participants had a mean (±SD) age of 49±12 years; 92% were women; and 83% were White. The mean (±SD) LVEF values were 61.7±5.5% before treatment and 57.4±6.8% at 24 months in the placebo group and 62.6±6.4% before treatment and 57.7±5.6% at 24 months in the atorvastatin group. On the basis of a multiple imputed data set for missing data and adjusted for each individual's pretreatment LVEF, 24-month declines in LVEF averaged 3.3±0.6 percentage points and 3.2±0.7 percentage points, for those randomly assigned to placebo versus statins, respectively (P=0.93). Across both treatment arms, similar percentages of individuals experienced changes of more than 10 percentage points in LVEF, LV strain, LV mass, cognition, and inflammation biomarkers, including among those with greater than 90% drug compliance.

CONCLUSIONS

In patients with breast cancer and lymphoma with no existing indication for statin therapy, prospective statin administration did not affect LVEF declines 2 years after doxorubicin. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01988571.).

Family Pediatrician and Public Health collaboration, an alliance to increase vaccination coverage: an experience with MenB vaccination in Italy

BACKGROUND

Invasive Meningococcal Disease is a severe disease mainly affecting infants and young children. Most infections are caused by serogroups A, B, C, W, X, and Y. In the last 10 years, serogroup B has been the main cause of Invasive Meningococcal Disease in Europe. Recent data resulting from an observational study conducted in Italy show a significant reduction in the number of Invasive Meningococcal Disease cases due to Neisseria meningitidis B after the introduction of vaccine 4CMenB. Thus, the Naples Team of Federation of Italian Primary Care Pediatricians and the Public Health Department started an active collaboration focused on vaccination process management (named "Progetto Via") with the aim of increasing Meningococcal B vaccination coverage.

STUDY DESIGN

Source of data is the regional platform "GE.VA.". Every Primary care Pediatrician uses daily to record vaccination activity. This platform is integrated with data entered by operators of the District/Vaccination Center.

METHODS

Time: January 2019 - December 2019. The Federation of Italian Primary Care Pediatricians/Naples organized a meeting to identify six coordinators. The pediatricians could choose to counsel in their own offices and send children to the vaccination center or to counsel and vaccinate directly in their own clinics.

RESULTS

A total of 78 pediatricians took part in the project: 46 did only counseling and 32 did both counseling and vaccination in their medical clinic. Data obtained show an overall average vaccination coverage growth of about 13% in the first 4 months of the survey, and a further growth of about 11% in the following seven months, with a total growth in the entire period of 24%. The pediatricians' counseling is essential to recover non-compliant subjects, considering both the relationship of trust with the families and the visits already scheduled as an ideal moment for vaccinations' status check.

CONCLUSIONS

The project highlights how an effective collaboration between family pediatricians and the Local Health Authority becomes valuable in getting closer to reach the Ministerial goal of 95%. Vaccination coverage increased significantly when family pediatricians supported the activity of vaccine centers in distress in many regional situations. The trust relationship, the hourly availability and the capillary network of family pediatricians' clinics were key elements for the success of this project and were also recognized by parents.

Randomized trial of atorvastatin during and following receipt of doxorubicin for breast cancer and lymphoma (WF-98213)

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Background: Statins taken for cardiovascular (CV) indications by breast cancer (BC) and lymphoma survivors during doxorubicin (DOX) treatment may attenuate left ventricular ejection fraction (LVEF) decline, but statin impact among these survivors with no CV indications is unknown. Methods: In 279 patients from 31 cancer centers, we conducted a double blind, placebo-controlled, 24-month randomized trial of 40mg/day atorvastatin among those receiving DOX for BC or lymphoma. At pretreatment, six and 24 months after initiating DOX for BC or lymphoma, we assessed LV volumes, strain, mass, and LVEF (via cardiac magnetic resonance), cognitive function and serum markers of inflammation. Using a linear model adjusted for pretreatment measures, our primary analysis assessed change in LVEF over time by randomization group. Results: Participants were aged 49±12 years; 92% women, 83% white race. The mean pooled LVEF decline from pretreatment to 24 months was 62.2±6.0% to 57.6±6.3% (p < 0.001). Adjusting for pretreatment LVEF, 24-month declines in LVEF averaged 3.5±0.5% and 3.3±0.5% respectively for placebo vs statins (p = 0.83). Both randomized groups were similar for: incidence of > 10% change in LVEF, LV strain, LV mass, cognition and inflammation biomarkers, including among those > 90% study drug compliant (p > 0.05 for all). Conclusions: In BC and lymphoma survivors with no existing indication for statin therapy, prospective statin administration does not appear to impact LVEF declines two years after doxorubicin. Clinical trial information: NCT01988571. [Table: see text]

Potential of supervised machine learning algorithms for estimating the impact of water efficient scenarios on solids accumulation in sewers

Understanding the negative effects of widespread implementation of optimal water efficient solutions may have on existing centralised sewer systems is still limited - one of these effects is the accumulation of solids in sewer pipes. Predicting these effects requires setting up and simulating complex detailed hydraulic sewer network models. Often, precise details of the sewer network layout and diurnal patterns of the wastewater flows are not available, limiting the applicability of using model predictions for such phenomena. In this study, the applicability of supervised machine learning (ML) algorithms for the development of a simplified surrogate model to predict solid accumulation in sewer pipes was investigated. A large number of highly variable sewer networks were synthetically generated and used to produce results that can be generalizable within the limitations of the current study. A hydrodynamic sewer model was set up and simulated for each synthetic sewer network and various scenarios in which different water-efficient solutions were considered. Simulation results indicated that the most impacts are expected to occur in the upstream part of the sewer networks, and that with 50% reduction in (waste-)water flows, 3-20% more pipes are expected to accumulate solids. It was further found that ML algorithms can be used to successfully predict locations of solids accumulation in sewer pipes without using hydrodynamic models. A simple tool based on the findings of this study, sparing the need to conduct complex hydraulic simulations, was developed. It allows the user to enter a set of pipe characteristics and the proportion of flow that is reduced due to the implementation of water efficient solutions, and it predicts whether the pipe will accumulate solids or not. The study results and the proposed ML algorithms can support the implementation of optimal water-efficient solutions that will promote designing and managing the water sensitive cities of the future.

Simultaneous stereo-EEG and high-density scalp EEG recordings to study the effects of intracerebral stimulation parameters

BACKGROUND

Cortico-cortical evoked potentials (CCEPs) recorded by stereo-electroencephalography (SEEG) are a valuable tool to investigate brain reactivity and effective connectivity. However, invasive recordings are spatially sparse since they depend on clinical needs. This sparsity hampers systematic comparisons across-subjects, the detection of the whole-brain effects of intracortical stimulation, as well as their relationships to the EEG responses evoked by non-invasive stimuli.

OBJECTIVE

To demonstrate that CCEPs recorded by high-density electroencephalography (hd-EEG) provide additional information with respect SEEG alone and to provide an open, curated dataset to allow for further exploration of their potential.

METHODS

The dataset encompasses SEEG and hd-EEG recordings simultaneously acquired during Single Pulse Electrical Stimulation (SPES) in drug-resistant epileptic patients (N = 36) in whom stimulations were delivered with different physical, geometrical, and topological parameters. Differences in CCEPs were assessed by amplitude, latency, and spectral measures.

RESULTS

While invasively and non-invasively recorded CCEPs were generally correlated, differences in pulse duration, angle and stimulated cortical area were better captured by hd-EEG. Further, intracranial stimulation evoked site-specific hd-EEG responses that reproduced the spectral features of EEG responses to transcranial magnetic stimulation (TMS). Notably, SPES, albeit unperceived by subjects, elicited scalp responses that were up to one order of magnitude larger than the responses typically evoked by sensory stimulation in awake humans.

CONCLUSIONS

CCEPs can be simultaneously recorded with SEEG and hd-EEG and the latter provides a reliable descriptor of the effects of SPES as well as a common reference to compare the whole-brain effects of intracortical stimulation to those of non-invasive transcranial or sensory stimulations in humans.

Who Has Access to Livestock Vaccines? Using the Social-Ecological Model and Intersectionality Frameworks to Identify the Social Barriers to Peste des Petits Ruminants Vaccines in Karamoja, Uganda

Access to veterinary services is important in Karamoja, northeastern part of Uganda, as livestock is a primary source of livelihood. Gender is often overlooked in animal health programs, let alone intersectionality. However, given the socio-cultural intricacies of Karamoja, ignoring these factors may hinder animal vaccination practices, limiting the success of programs designed to control and prevent animal diseases, such as peste des petits ruminants (PPR). The study used qualitative research methods, including focus group discussions, individual interviews, and key informant interviews in a participatory research approach to investigate the constraints faced by livestock keepers when accessing vaccines. The study was carried out in Abim, Amudat, Kotido, and Moroto, four districts in the Karamoja Subregion of Uganda. A modified version of the socio-ecological model (SEM) blended with an intersectional approach were used as frameworks to analyze underlying individual, social and structural determinants of vaccine access with intersecting factors of social inequalities. The results show there are seven intersecting factors that influence access to vaccination the most. These are: gender, ethnicity, geographic location, age, physical ability, marital status, and access to education. The impact of these intersections across the different levels of the SEM highlight that there are vast inequalities within the current system. Access to vaccines and information about animal health was most limited among women, widows, the elderly, the disabled, geographically isolated, and those with unfavorable knowledge, attitudes, and practices about vaccination. Cultural norms of communities were also important factors determining access to PPR vaccines. Norms that burden women with household chores and beliefs that women cannot manage livestock, combined with gender-based violence, leaves them unable to participate in and benefit from the livestock vaccine value chain. Trainings and sensitization on gendered intersectional approaches for those involved in the distribution and delivery of vaccines are necessary to avoid exacerbating existing inequalities in Karamoja.

Pathologic complete response (pCR) to neoadjuvant treatment with or without atezolizumab in triple negative, early high-risk and locally advanced breast cancer. NeoTRIP Michelangelo randomized study

BACKGROUND

High-risk triple negative breast cancers (TNBC) are characterized by poor prognosis, rapid progression to metastatic stage and onset of resistance to chemotherapy, thus representing an area in need of new therapeutic approaches. PD-L1 expression is an adaptive mechanism of tumour resistance to tumour infiltrating lymphocytes, which in turn are needed for response to chemotherapy. Overall, available data support the concept that blockade of PD-L1/PD-1 check-point may improve efficacy of classical chemotherapy.

PATIENTS AND METHODS

Two-hundred-eighty patients with TNBC were enrolled in this multicentre study (NCT002620280) and randomized to neoadjuvant carboplatin AUC 2 and nab-paclitaxel 125 mg/m² iv on days 1 and 8, without (N = 142) or with (N = 138) atezolizumab 1200 mg iv on day 1. Both regimens were given q3 weeks for 8 cycles before surgery and 4 cycles of an adjuvant anthracycline regimen. The primary aim of the study is to compare event-free survival, an important secondary aim was the rate of pathological complete remission (pCR defined as absence of invasive cells in breast and lymph nodes). The primary population for all efficacy endpoints is the intention-to-treat population.

RESULTS

The intention-to-treat analysis revealed that pCR rate after treatment with atezolizumab (48.6%) did not reach statistical significance compared to no atezolizumab [44.4%: odds ratio (OR) 1.18; 95% CI 0.74-1.89; P = 0.48]. Treatment-related adverse events were similar with either regimen except for a significantly higher overall incidence of serious adverse events and liver transaminases abnormalities with atezolizumab.

CONCLUSIONS

The addition of atezolizumab to nab-paclitaxel and carboplatin did not significantly increase the rate of pCR in women with TNBC. In multivariate analysis the presence of PD-L1 expression was the most significant factor influencing rate of pCR (OR 2.08). Continuing follow up for the event-free survival is ongoing, and molecular studies are under way.

Beyond the Gender of the Livestock Holder: Learnings from Intersectional Analyses of PPR Vaccine Value Chains in Nepal, Senegal, and Uganda

Simple Summary

The peste des petits ruminants (PPR) is one of the deadliest viral diseases of small ruminants and is endemic in Africa, the Middle East, and Asia. While PPR vaccination programs exist in these contexts, many factors restrict their reach and effectiveness, which go beyond the often cited financial, technological, and logistical constraints. This paper examines these less investigated factors, in particular the role of gender norms and other social and cultural factors, in affecting which livestock keepers are unable to access PPR vaccines and which groups are less reached by the vaccine distribution systems. Across three countries selected for our study, we find that, overall, women derive fewer benefits from the system than men; in addition, belonging to certain ethnic groups, being of low caste, or living in remote regions are additional markers of exclusion and marginalization from accessing livestock vaccines.

Abstract

The peste des petits ruminants (PPR) is a deadly viral disease of small ruminants, which are an important source of livelihood for hundreds of millions of poor smallholders throughout Africa, the Middle East, and Asia. PPR vaccination efforts often focus on overcoming financial, technological, and logistical constraints that limit their reach and effectiveness. This study posits that it is equally important to pay attention to the role of gender and other intersecting social and cultural factors in determining individual and groups’ ability to access PPR vaccines or successfully operate within the vaccine distribution system. We compare three study contexts in Nepal, Senegal, and Uganda. Qualitative data were collected through a total of 99 focus group discussions with men and women livestock keepers and animal health workers, 83 individual interviews, and 74 key informant interviews. Our findings show that there are not only important gender differences, but also interrelated structures of inequalities, which create additional sites of exclusion. However, these intersections are not generalizable across contexts—except for the intersection of gender and geographic remoteness, which is salient across vaccine distribution systems in the three countries—and social markers such as caste, ethnicity, and livelihood are associated with vulnerability only in specific settings. In order to address the distinct needs of livestock keepers in given settings, we argue that an intersectional analysis combined with context-dependent vaccination approaches are critical to achieving higher vaccination rates and, ultimately, PPR disease eradication by 2030.

Oncolytic ImmunoViroTherapy: A long history of crosstalk between viruses and immune system for cancer treatment

Cancer Immunotherapy relies on harnessing a patient's immune system to fine-tune specific anti-tumor responses and ultimately eradicate cancer. Among diverse therapeutic approaches, oncolytic viruses (OVs) have emerged as a novel form of cancer immunotherapy. OVs are a naturally occurring or genetically modified class of viruses able to selectively kill cancer cells, leaving healthy cells unharmed; in the last two decades, the role of OVs has been redefined to act beyond their oncolytic activity. Indeed, the immunogenic cancer cell death mediated by OVs induces the release of tumor antigens that in turn induces anti-tumor immunity, allowing OVs to act as in situ therapeutic cancer vaccines. Additionally, OVs can be engineered for intratumoral delivery of immunostimulatory molecules such as tumor antigens or cytokines to further enhance anti-tumor response. Moreover, OVs can be used in combination with other cancer immunotherapeutic approaches such as Immune Checkpoint Inhibitors and CAR-T cells. The current review first defines the three main mechanisms of action (MOA) of OVs currently used in cancer therapy that are: i) Oncolysis, ii) OV-induced cancer-specific immune activation, and iii) Exploiting pre-existing anti-viral immunity to enhance cancer therapy. Secondly, we focus on how OVs can induce and/or improve anti-cancer immunity in a specific or unspecific fashion, highlighting the importance of these approaches. Finally, the last part of the review analyses OVs combined with other cancer immunotherapies, revising present and future clinical applications.

T-DM1 versus pertuzumab, trastuzumab and a taxane as first-line therapy of early-relapsed HER2-positive metastatic breast cancer: an Italian multicenter observational study

Background

The current standard first-line treatment of human epidermal growth factor receptor 2 (HER2)-positive (+) metastatic breast cancer is the combination of pertuzumab, trastuzumab and a taxane (P + T + taxane), while standard second-line is ado-trastuzumab-emtansine (T-DM1). The registration trial of pertuzumab, however, did not include early-relapsing patients, defined as patients experiencing tumor relapse ≤12 months from the end of (neo)adjuvant anti-HER2 therapy. Conversely, the pivotal trial of T-DM1 included some patients relapsing ≤6 months after the end of (neo)adjuvant trastuzumab. Thus, a proportion of early-relapsing patients are currently eligible to receive T-DM1 as first-line treatment. Nevertheless, no direct comparison exists between the two regimens in this clinical setting.

Patients and methods

We retrospectively compared T-DM1 versus P + T + taxane as first-line treatment in two cohorts of early-relapsing patients in an Italian ‘real-world’ setting, involving 14 public health care institutions. The primary endpoint was progression-free survival. Secondary endpoints included patients' characterization, overall survival and post-progression survival. Univariate and multivariate analyses were carried out. All tests were two-sided and a P ≤ 0.05 was considered statistically significant.

Results

Among 1252 screened patients, 75 met the inclusion criteria. Forty-four (58.7%) received P + T + taxane and 31 (41.3%) received T-DM1. The two cohorts showed similar characteristics of aggressiveness and no significant differences in treatment history. T-DM1, compared with P + T + taxane was associated with worse progression-free survival (adjusted hazard ratio: 2.26, 95% confidence interval: 1.13-4.52, P = 0.021) and overall survival (adjusted hazard ratio: 3.95, 95% confidence interval: 1.38-11.32, P = 0.010), irrespective of previous (neo)adjuvant treatment, age, hormone receptors status, time-to-relapse (≤6 months or within 6-12 months) and presence of visceral/brain metastases. No differences were observed in post-progression survival (P = 0.095).

Conclusions

Our study suggests superiority for P + T + taxane over T-DM1 as up-front treatment of early-relapsing HER2+ metastatic breast cancer, which merits further assessment in larger and prospective trials.

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This is the first study comparing pertuzumab + trastuzumab + taxane (P + T + taxane) with T-DM1 in early-relapsing HER2+ MBC.

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The majority of early-relapsing HER2+ MBC have high-grade, node-positive, large primary tumors.

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First-line T-DM1 compared with P + T + taxane is associated with worse progression-free survival.

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First-line T-DM1 compared with P + T + taxane is associated with worse overall survival.

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Post-progression survival does not differ between the two treatments cohorts.

Focal lesions induce large-scale percolation of sleep-like intracerebral activity in awake humans

Focal cortical lesions are known to result in large-scale functional alterations involving distant areas; however, little is known about the electrophysiological mechanisms underlying these network effects. Here, we addressed this issue by analysing the short and long distance intracranial effects of controlled structural lesions in humans. The changes in Stereo-Electroencephalographic (SEEG) activity after Radiofrequency-Thermocoagulation (RFTC) recorded in 21 epileptic subjects were assessed with respect to baseline resting wakefulness and sleep activity. In addition, Cortico-Cortical Evoked Potentials (CCEPs) recorded before the lesion were employed to interpret these changes with respect to individual long-range connectivity patterns. We found that small structural ablations lead to the generation and large-scale propagation of sleep-like slow waves within the awake brain. These slow waves match those recorded in the same subjects during sleep, are prevalent in perilesional areas, but can percolate up to distances of 60 mm through specific long-range connections, as predicted by CCEPs. Given the known impact of slow waves on information processing and cortical plasticity, demonstrating their intrusion and percolation within the awake brain add key elements to our understanding of network dysfunction after cortical injuries.

Improving dose delivery accuracy with EPID in vivo dosimetry: results from a multicenter study

PURPOSE

To investigate critical aspects and effectiveness of in vivo dosimetry (IVD) tests obtained by an electronic portal imaging device (EPID) in a multicenter and multisystem context.

MATERIALS AND METHODS

Eight centers with three commercial systems-SoftDiso (SD, Best Medical Italy, Chianciano, Italy), Dosimetry Check (DC, Math Resolution, LCC), and PerFRACTION (PF, Sun Nuclear Corporation, SNC, Melbourne, FL)-collected IVD results for a total of 2002 patients and 32,276 tests. Data are summarized for IVD software, radiotherapy technique, and anatomical site. Every center reported the number of patients and tests analyzed, and the percentage of tests outside of the tolerance level (OTL%). OTL% was categorized as being due to incorrect patient setup, incorrect use of immobilization devices, incorrect dose computation, anatomical variations, and unknown causes.

RESULTS

The three systems use different approaches and customized alert indices, based on local protocols. For Volumetric Modulated Arc Therapy (VMAT) treatments OTL% mean values were up to 8.9% for SD, 18.0% for DC, and 16.0% for PF. Errors due to "anatomical variations" for head and neck were up to 9.0% for SD and DC and 8.0% for PF systems, while for abdomen and pelvis/prostate treatments were up to 9%, 17.0%, and 9.0% for SD, DC, and PF, respectively. The comparison among techniques gave 3% for Stereotactic Body Radiation Therapy, 7.0% (range 4.7-8.9%) for VMAT, 10.4% (range 7.0-12.2%) for Intensity Modulated Radiation Therapy, and 13.2% (range 8.8-21.0%) for 3D Conformal Radiation Therapy.

CONCLUSION

The results obtained with different IVD software and among centers were consistent and showed an acceptable homogeneity. EPID IVD was effective in intercepting important errors.

Eribulin in combination with bevacizumab as second-line treatment for HER2-negative metastatic breast cancer progressing after first-line therapy with paclitaxel and bevacizumab: a multicenter, phase II, single arm trial (GIM11-BERGI)

Background

We evaluated the efficacy and safety of the nontaxane microtubule dynamics inhibitor eribulin plus the humanized anti-VEGF monoclonal antibody bevacizumab in a novel second-line chemotherapy scheme in HER2-negative metastatic breast cancer (MBC) patients progressing after first-line paclitaxel and bevacizumab.

Patients and methods

This is a multicenter, single-arm, Simon's two-stage, phase II study. The primary endpoint was the overall response rate, considered as the sum of partial and complete response based on the best overall response rate (BORR). The secondary endpoints were progression-free survival (PFS), overall survival (OS), and clinical benefit rate.

Results

A total of 58 of the 61 patients enrolled in the study were evaluable for efficacy. The BORR was 24.6% (95% CI 14.5-37.3). The clinical benefit rate was 32.8% (95% CI 21.3-46.0). The median PFS was 6.2 months (95% CI 4.0-7.8), and median OS was 14.8 months (95% CI 12.6-22.8). Overall, adverse events (AEs) were clinically manageable and the most common AEs were fatigue, paresthesia, and neutropenia. Quality of life was well preserved in most patients.

Conclusions

The results of this study suggest that second-line therapy with bevacizumab in combination with eribulin has a meaningful clinical activity and may represent a potential therapeutic option for patients with HER2-negative MBC.

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Bevacizumab + chemotherapy improved progression-free survival in HER2-negative metastatic breast cancer (MBC) patients.

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Eribulin monotherapy improved overall survival in patients with anthracycline- and taxane-pretreated MBC.

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The GIM11-BERGI trial assessed the efficacy and safety of eribulin + bevacizumab as second-line treatment for HER2-MBC.

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Eribulin + bevacizumab showed to be a safe and active treatment after progression to first-line paclitaxel + bevacizumab.

Standardization of lower extremity quantitative lymphedema measurements and associated patient-reported outcomes in gynecologic cancers

Practice changing standardization of lower extremity lymphedema quantitative measurements with integrated patient reported outcomes will likely refine and redefine the optimal risk-reduction strategies to diminish the devastating limb-related dysfunction and morbidity associated with treatment of gynecologic cancers. The National Cancer Institute (NCI), Division of Cancer Prevention brought together a diverse group of cancer treatment, therapy and patient reported outcomes experts to discuss the current state-of-the-science in lymphedema evaluation with the potential goal of incorporating new strategies for optimal evaluation of lymphedema in future developing gynecologic clinical trials.