What does "Advanced" mean in 2023? reflecting on 10 years of the ESTRO advanced Skills in modern radiotherapy course

The roles and responsibilities of radiation therapists (RTTs) are many and varied. Professional expectations are influenced by the technology available, as well as the level of autonomy RTTs have in their daily practice. This professional range requires RTTs to possess a unique set of ever evolving skills, posing challenges from an educational perspective. Teaching these "advanced skills" has been the ambition the ESTRO Advanced Skills in Modern Radiotherapy course. In the 10th year of this course, the Faculty look back and reflect on how our programme has evolved and what it has achieved.

CANTO: Skin Toxicities Evaluation of a Multicenter Large Prospective Cohort of Irradiated Patients for Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Skin damage is a common toxicity during oncology management. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients treated for an early breast cancer (BC).

MATERIALS/METHODS

CANTO (NCT01993498) is a prospective, multicentric, clinical cohort study of 11 400 patients with stage I-III BC, treated in 26 French cancer centers. In this study, we will evaluate the 8561 patients during their overall management for a BC. We are focus on specifical skin toxicities: Erythema, fibrosis, telangiectasia and skin color (CTCAE v4.0). These toxicities were assessed at 3-6 (M0), 12 (M12), 36 (M36), 60 (M60) months.

RESULTS

The prevalence of toxicities of interest varied over time, so at M0, 30.4% of patients had erythema while 17.7% of patients had fibrosis. At M12, M36 and M60, the prevalence of erythema decreased from 5.5 % to 2.5 % then to 2 %, respectively, while fibrosis remained stable at about 19 %. The prevalence of telangiectasia increased from 0.8 % to 7 % from M0 to M60. While the modification of skin color was 51.1 % at M0, and 10.6 % at M60. After adjustments, at M0, there was a statistically significant association between the onset of cutaneous erythema and obesity, the presence of axillary dissection, the type of surgery the age of the patient as well as the tumor phenotype RH+/HER2+ [OR: 0.79 [0.67; 0.93]]. Concerning fibrosis, a statistically significant association was found, at M12, with the age of the patient, obesity, tumor grade, Charlson score, type of surgery and mitotic index. Obesity and the age of the patient represent at M12 and M36 a risk significantly associated with the onset of telangiectasia. Concerning the modification of skin color at M12, we find a link between the age of the patient, obesity, tobacco consumption, tumor grade, Charlson score, type of surgery, and alcohol consumption [OR: 0.69 [0.51; 0.91]].

CONCLUSION

In this study we identified several risk factors for acute and late skin toxicity. The knowledge of its predictive factors allows a personalized management of the patient by adapting our treatments and our monitoring according to these different factors.

[Breast cancer radiation therapy: Current questions in 2023]

Radiation therapy is a corner stone of breast cancer treatment as it has been shown postoperatively that it improves local control and overall survival. In recent years, multidisciplinary therapeutic strategies have evolved considerably for early-stage breast cancer, both surgically and in terms of systemic treatments or radiation therapy. Each of these developments affects other treatment components and open up new questions allowing even more personalized treatments. Essentially normofractionated a few years ago, breast radiation therapy is today very largely moderately or even ultra hypofractionated. De-escalation of the surgery of the axilla has changed the indications for lymph node radiation therapy keeping similar efficacy with reduced toxicity. Indications for radiation therapy after neoadjuvant chemotherapy remain based on pre-chemotherapy staging pending the results of ongoing randomized studies. The addition of a boost to the tumor bed significantly reduces the risk of local recurrence, but the magnitude of this benefit decreases with increasing age. The main risk factors for local recurrence are young age, the associated extended ductal in situ component, hormone receptor negative and high-grade status. The results of the simultaneous integrated boost (SIB) seem similar with normo- or moderately hypofractionated radiation therapy regimen.

Insights on the carbon footprint of radiotherapy in France

The French healthcare system is responsible for 8% of the national footprint. Achieving a net zero emissions scenario will require a 4-5 fold decrease of carbon emissions in the coming years. The carbon footprint of radiation therapy has not been specifically studied to date. In this review we summarize the content of the carbon footprint dedicated session at the annual meeting of the French society of radiation oncology (SFRO). We discuss the French healthcare system carbon footprint and its major drivers and our work on the estimation of the carbon footprint of external beam radiation therapy in the French setting. We developed a dedicated methodology to estimate the carbon footprint related to radiation therapies, and describe the main drivers of emissions based on a single centre as an example, namely patient's rides, accelerators acquisition and maintenance and data storage. Based on the carbon footprint calculated in our centres, we propose mitigation strategies and an estimation of their respective potential. Our results may be extrapolated to other occidental settings by adapting emission factors (kilograms of carbon per item or euro) to other national settings. External beam radiation therapy has a major carbon footprint that may be mitigated in many ways that may impact how radiation therapy treatments are delivered, as well as the national organization of the radiotherapy sector. This needs to be taken into account when thinking about the future of radiotherapy.

[Targeted systemic treatments and locoregional radiotherapy for breast cancer: Can we expect a benefit from the potentiation of local treatment?]

Breast cancer is the first most common cancer worldwide, and radiation therapy has a major role to play in locoregional adjuvant treatment. In recent years, we have seen the emergence of adjuvant targeted systemic therapies improving the prognosis of patients at high risk of recurrence. Practices concerning combinations of targeted therapies and locoregional radiation therapy for non-metastatic breast cancers often remain heterogeneous due to the low level of evidence and lack of validated recommendations. This literature review covers immunotherapy, CDK 4/6 inhibitors, PARP inhibitors and anti-Her2 therapies. Combining these targeted systemic therapies with radiation therapy could potentiate local treatment. The optimal therapeutic sequence and fractionation for maximum synergistic effect remain to be defined. However, while efficacy may be enhanced, radiosensitization of healthy tissue may also lead to increased toxicity. It appears possible to continue immunotherapy, trastuzumab, pertuzumab, TDM-1 or lapatinib during locoregional breast and lymph node irradiation. PARP inhibitors and CDK4/6 inhibitors are still to be suspended, due to the lack of data in the adjuvant setting and their short half-life, which does not necessitate prolonged discontinuation. As with the new antibody-drug conjugates, prospective data are needed in conjunction with adjuvant radiation therapy.

[Clinical research in private sector: Which strategic analysis?]

Clinical research in private practice has significantly increased in recent years and has become crucial for the attractiveness of centres both for patients who can access innovative treatments and molecules and for participating physicians. The responsiveness, the size and reduced number of interlocutors, flexibility, and decision-making autonomy of private practitioners are strengths in the strategic analysis of clinical research in the private sector. However, the varied medical activity allowing for broader recruitment, location of practice, and administrative time related leadership roles can become weakness in terms of quality and time dedicated to this research activity, which still relies heavily on strong individual involvement. Collaborations, which develop when clinical research in private centres is dynamic, are sources of opportunities, growth, and progress, allowing participation in various ambitious projects that can benefit patients in these facilities. Recent administrative and legislative complexities for trial integration and competition with academic structures can threaten this important clinical research activity for private practices, requiring reflection on its valorisation and promotion to ensure its sustainability.

[Real world data in radiotherapy: A data farming project by Unitrad]

The aim of the data farming project by the Unitrad group is to produce and use large quantities of structured real-life data throughout radiotherapy treatment. Starting in 2016, target real world data were selected at expert consensus conferences and regularly updated, then captured in MOSAIQ© as the patient was treated. For each partner institution, the data was then stored in a relational database, then extracted and used by researchers to create real world knowledge. This production was carried out in a multicentre, coordinated fashion. When necessary, the raw data was shared according to the research projects, in compliance with regulations. Feedack was provided at each stage, enabling the system to evolve flexibly and rapidly, using the "agile" method. This work, which is constantly evolving, has led to the creation of health data warehouses focused on data of interest in radiotherapy, and the publication of numerous academic studies. It forms part of the wider context of the exploitation of real-life data in cancerology. Unitrad data farming is a collaborative project for creating knowledge from real-life radiotherapy data, based on an active network of clinicians and researchers.

[Five-fraction radiotherapy for breast cancer]

Extreme hypofractionation in adjuvant breast radiotherapy currently generates a lot of interest. We propose here a synthesis of hypofractionation trials and present the DESTHE COL and DESTHE GR projects, encouraged by the French National Cancer Institute (INCa), which experiment care pathways in order to deploy effective strategies to de-escalate the therapeutics and to reduce sequelae after cancer treatment.

The Helico Maze Detects Early Impairment of Reference Memory at Three Months of Age in the 5XFAD Mouse Model of Alzheimer’s Disease

Background: The 5XFAD model of Alzheimer’s disease (AD) bearing five familial mutations of Alzheimer’s disease on human APP and PSEN1 transgenes shows deposits of amyloid-β peptide (Aβ) as early as 2 months, while deficits in long-term memory can be detected at 4 months using the highly sensitive olfactory-dependent tests that we previously reported. Objective: Given that detecting early dysfunctions in AD prior to overt pathology is of major interest in the field, we sought to detect memory deficits at earlier stages of the disease in 3-month-old male 5XFAD mice. Methods: To this end, we used the Helico Maze, a behavioral task that was recently developed and patented. This device allows deeper analysis of learning and subcategories of hippocampal-dependent long-term memory using olfactory cues. Results: Eight male 5XFAD and 6 male wild-type (WT: C57Bl6 background) mice of 3 months of age were tested in the Helico Maze. The results demonstrated, for the first time, a starting deficit of pure reference long-term memory. Interestingly, memory impairment was clearly correlated with Aβ deposits in the hippocampus. While we also found significant differences in astrogliosis between 5XFAD and WT mice, this was not correlated with memory abilities. Conclusion: Our results underline the efficiency of this new olfactory-dependent behavioral task, which is easy to use, with a small cohort of mice. Using the Helico Maze may open new avenues to validate the efficacy of treatments that target early events related to the amyloid-dependent pathway of the disease and AD progression.

P09.04.B The importance of treatment tolerability for people with glioma: registry review and qualitative findings from the COBra Study

Background

Gliomas are the commonest form of primary brain tumour, accounting for 80% of malignant brain tumours. Gliomas represent a heterogeneous group of cancers with variable outcomes, traditionally graded from I to IV (least to most aggressive). The poor prognosis of some glioma patients and high symptom burden has led to a growing emphasis on their quality of survival. Maintaining cognitive function, physical function and other health-related quality of life aspects throughout the disease trajectory are key considerations, particularly for patients with aggressive forms of glioma. It is therefore important that glioma intervention studies collect data aligned with patient priorities that enables assessment of the net clinical benefit of treatments and facilitates informed decision-making. In particular, and of increasing recognition, is the importance of monitoring the incidence of adverse events during and after the course of an intervention, and understanding their impact upon patients, and patients’ own assessment of, tolerability.

Material and Methods

A trial registry review, a systematic review of the qualitative literature and semi-structured interviews with patients and caregivers were undertaken. Outcomes were extracted from these sources to formulate a longlist during the development of a core outcome set for glioma interventional trials (the COBra study).

Results

The registry review (n=91), systematic review (n=21) and semi-structured interviews (n=19) identified many important outcomes and concepts, one of which was tolerability. Tolerability, adverse events, toxicity or safety was reported to be collected as an outcome in 46 trials. Outcomes related to tolerability were identified from 7 articles included in the systematic review. Themes related to tolerability emerged from the qualitative interviews. These included tolerability of side effects of treatment; trade-offs of side effects versus potential benefits in deciding on, and willingness to, undertake further treatment; and self-directed strategies for coping.

Conclusion

There is a growing acknowledgement of the importance of treatment tolerability in the wider field of cancer research. In glioma research specifically, its significance is yet to be reflected in outcomes collected in trials. Our qualitative findings indicate tolerability is of high significance to patients and those close to them. Participants reported how their preconceptions and experience of tolerability influenced treatment decisions and treatment uptake. However, outcomes related to tolerability were collected in just over half of trials in our sample. Tolerability and items relating to the patients’ experience of adverse events should be collected and reported in trial findings to reflect patients’ priorities and enable informed treatment decisions.

MT5-MMP promotes neuroinflammation, neuronal excitability and Aβ production in primary neuron/astrocyte cultures from the 5xFAD mouse model of Alzheimer’s disease

Background

Membrane-type matrix metalloproteinase 5 (MT5-MMP) deficiency in the 5xFAD mouse model of Alzheimer's disease (AD) reduces brain neuroinflammation and amyloidosis, and prevents deficits in synaptic activity and cognition in prodromal stages of the disease. In addition, MT5-MMP deficiency prevents interleukin-1 beta (IL-1β)-mediated inflammation in the peripheral nervous system. In this context, we hypothesized that the MT5-MMP/IL-1β tandem could regulate nascent AD pathogenic events in developing neural cells shortly after the onset of transgene activation.

Methods

To test this hypothesis, we used 11–14 day in vitro primary cortical cultures from wild type, MT5-MMP−/−, 5xFAD and 5xFAD/MT5-MMP−/− mice, and evaluated the impact of MT5-MMP deficiency and IL-1β treatment for 24 h, by performing whole cell patch-clamp recordings, RT-qPCR, western blot, gel zymography, ELISA, immunocytochemistry and adeno-associated virus (AAV)-mediated transduction.

Results

5xFAD cells showed higher levels of MT5-MMP than wild type, concomitant with higher basal levels of inflammatory mediators. Moreover, MT5-MMP-deficient cultures had strong decrease of the inflammatory response to IL-1β, as well as decreased stability of recombinant IL-1β. The levels of amyloid beta peptide (Aβ) were similar in 5xFAD and wild-type cultures, and IL-1β treatment did not affect Aβ levels. Instead, the absence of MT5-MMP significantly reduced Aβ by more than 40% while sparing APP metabolism, suggesting altogether no functional crosstalk between IL-1β and APP/Aβ, as well as independent control of their levels by MT5-MMP. The lack of MT5-MMP strongly downregulated the AAV-induced neuronal accumulation of the C-terminal APP fragment, C99, and subsequently that of Aβ. Finally, MT5-MMP deficiency prevented basal hyperexcitability observed in 5xFAD neurons, but not hyperexcitability induced by IL-1β treatment.

Conclusions

Neuroinflammation and hyperexcitability precede Aβ accumulation in developing neural cells with nascent expression of AD transgenes. MT5-MMP deletion is able to tune down basal neuronal inflammation and hyperexcitability, as well as APP/Aβ metabolism. In addition, MT5-MMP deficiency prevents IL-1β-mediated effects in brain cells, except hyperexcitability. Overall, this work reinforces the idea that MT5-MMP is at the crossroads of pathogenic AD pathways that are already incipiently activated in developing neural cells, and that targeting MT5-MMP opens interesting therapeutic prospects.

Radiotherapy of breast cancer

Adjuvant radiotherapy is an essential component of the treatment of breast cancer. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. A boost dose over the tumour bed is required if the patient is younger than 50 years-old. Partial breast irradiation could be routinely proposed as an alternative to whole breast irradiation, but only in selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3-T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neoadjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3-T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra- and infraclavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Hypofractionation regimens (42.5Gy in 16 fractions, or 41,6Gy en 13 or 40Gy en 15) are equivalent to conventional irradiation and must prescribe after tumorectomy in selected patients. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with or after radiotherapy.

MT5-MMP controls APP and β-CTF/C99 metabolism through proteolytic-dependent and -independent mechanisms relevant for Alzheimer's disease

We previously discovered the implication of membrane-type 5-matrix metalloproteinase (MT5-MMP) in Alzheimer's disease (AD) pathogenesis. Here, we shed new light on pathogenic mechanisms by which MT5-MMP controls the processing of amyloid precursor protein (APP) and the fate of amyloid beta peptide (Aβ) as well as its precursor C99, and C83. We found in human embryonic kidney cells (HEK) carrying the APP Swedish familial mutation (HEKswe) that deleting the C-terminal non-catalytic domains of MT5-MMP hampered its ability to process APP and release the soluble 95 kDa form (sAPP95). Catalytically inactive MT5-MMP variants increased the levels of Aβ and promoted APP/C99 sorting in the endolysosomal system, likely through interactions of the proteinase C-terminal portion with C99. Most interestingly, the deletion of the C-terminal domain of MT5-MMP caused a strong degradation of C99 by the proteasome and prevented Aβ accumulation. These discoveries reveal new control of MT5-MMP over APP by proteolytic and non-proteolytic mechanisms driven by the C-terminal domains of the proteinase. The targeting of these non-catalytic domains of MT5-MMP could, therefore, provide new insights into the therapeutic regulation of APP-related pathology in AD.

Deficiency in MT5-MMP Supports Branching of Human iPSCs-Derived Neurons and Reduces Expression of GLAST/S100 in iPSCs-Derived Astrocytes

For some time, it has been accepted that the β-site APP cleaving enzyme 1 (BACE1) and the γ-secretase are two main players in the amyloidogenic processing of the β-amyloid precursor protein (APP). Recently, the membrane-type 5 matrix metalloproteinase (MT5-MMP/MMP-24), mainly expressed in the nervous system, has been highlighted as a new key player in APP-processing, able to stimulate amyloidogenesis and also to generate a neurotoxic APP derivative. In addition, the loss of MT5-MMP has been demonstrated to abrogate pathological hallmarks in a mouse model of Alzheimer’s disease (AD), thus shedding light on MT5-MMP as an attractive new therapeutic target. However, a more comprehensive analysis of the role of MT5-MMP is necessary to evaluate how its targeting affects neurons and glia in pathological and physiological situations. In this study, leveraging on CRISPR-Cas9 genome editing strategy, we established cultures of human-induced pluripotent stem cells (hiPSC)-derived neurons and astrocytes to investigate the impact of MT5-MMP deficiency on their phenotypes. We found that MT5-MMP-deficient neurons exhibited an increased number of primary and secondary neurites, as compared to isogenic hiPSC-derived neurons. Moreover, MT5-MMP-deficient astrocytes displayed higher surface area and volume compared to control astrocytes. The MT5-MMP-deficient astrocytes also exhibited decreased GLAST and S100β expression. These findings provide novel insights into the physiological role of MT5-MMP in human neurons and astrocytes, suggesting that therapeutic strategies targeting MT5-MMP should be controlled for potential side effects on astrocytic physiology and neuronal morphology.

[Postoperative radiotherapy after immediate breast reconstruction]

Immediate breast reconstruction versus delayed breast reconstruction improves quality of life of breast cancer patients undergoing total mastectomy without impacting oncologic outcomes. Two types of immediate reconstruction are possible, implant-based reconstruction or autologous reconstruction. These reconstructions interpose a tissue in the operating bed, which modifies target volume definition compared to a wall without reconstruction Post mastectomy radiotherapy increases the rate of postoperative complications for both surgical procedures. Recent guidelines were published about target volume definition in the post mastectomy setting after implant-based reconstruction. Guidelines about target volume definition after autologous reconstruction are still awaited. The aim of our work is to present the different surgical procedures for immediate breast reconstruction, their complications, and the definition of the postmastectomy target volume.

[Retrospective study on the intensification of hypofractionated radiotherapy: The organizational change]

Objectif de l’étude

Le processus de réalisation de la radiothérapie externe est une chaine d’étapes dans laquelle chacune d’entre elles est réalisée seulement si la précédente a été complétée. Le développement des pratiques d’hypofractionnement ces dernières années a tendance à augmenter la charge de travail des étapes de préparation à une irradiation et à diminuer le nombre de séances par patient. Cette étude rétrospective vise à analyser l’évolution de ces pratiques dans un centre de lutte contre le cancer et d’en apprécier les enjeux organisationnels.

Matériel et méthodes

L’ensemble des données de gestion des dossiers de radiothérapie ont été extraites du système d’information de radiothérapie. Les séances de radiothérapie ont été identifiées par patient et par code CIM (Classification internationale des maladies). Le taux de remplissage des appareils de traitement a été calculé avec les données réelles du département de radiothérapie.

Résultats

De 2015 à 2019, une augmentation du nombre de scanographies (+16 %), du nombre de patients pris en charge (+11,6 %) et du volume d’heures disponibles pour les traitements (+12 %) ont été observées. Aussi, une diminution du nombre total de séances de radiothérapie (−5 %), de la moyenne de séances réalisées par séquence de traitement (−19 %), du taux de remplissage des appareils (−7 %) et de la moyenne de séances réalisées par patients traités des tumeurs malignes des bronches et du poumon (−38 %), des organes digestifs (−37 %), secondaires (−19 %) du sein (−15 %) et de la prostate (−15 %) ont été observées. Le nombre de séances administrées par séquence de traitement entre 2015 et 2019 a diminué significativement pour les patients des classes d’âge [20–69 ans] (p < 0,001) et [> 70 ans] (p < 0,001).

Conclusion

Un paradoxe apparait entre l’augmentation du nombre total de patients pris en charge et la diminution du taux de remplissage des appareils de traitement. Ce transfert de charge de travail a un impact sur la qualité et la sécurité des soins et sur les stratégies d’organisation et d’investissement. Il a également un impact économique lié au modèle de remboursement basé sur la tarification à la séance. Une réorganisation des services de radiothérapie s’avère inéluctable.

Matrix Metalloproteinases as New Targets in Alzheimer's Disease: Opportunities and Challenges

Although matrix metalloproteinases (MMPs) are implicated in the regulation of numerous physiological processes, evidence of their pathological roles have also been obtained in the last decades, making MMPs attractive therapeutic targets for several diseases. Recent discoveries of their involvement in central nervous system (CNS) disorders, and in particular in Alzheimer's disease (AD), have paved the way to consider MMP modulators as promising therapeutic strategies. Over the past few decades, diverse approaches have been undertaken in the design of therapeutic agents targeting MMPs for various purposes, leading, more recently, to encouraging developments. In this article, we will present recent examples of inhibitors ranging from small molecules and peptidomimetics to biologics. We will also discuss the scientific knowledge that has led to the development of emerging tools and techniques to overcome the challenges of selective MMP inhibition.

0817 Abnormal REM Sleep Atonia Control In Patients With Chronic Post-traumatic Stress Disorder

Introduction

Post-traumatic stress disorder (PTSD) is characterized by persistent mental and emotional stress following one or more significant physical or psychological traumatic incidents earlier in life. Vivid recall of the events, including traumatic nightmares, and prominent sleep disturbance are usual in PTSD. Previous studies have suggested that PTSD may share some clinical features with idiopathic REM sleep behavior disorder (iRBD) including altered REM sleep without atonia (RSWA) levels. Our group has previously found evidence for altered RSWA control in patients with psychiatric disease, including a pilot sample of PTSD patients with iRBD. We aimed to comparatively analyze RSWA levels between patients with PTSD, PTSD and RBD (PTSD+RBD), iRBD, and controls.

Methods

We selected 18 PTSD, 18 PTSD+RBD, 15 iRBD, and 51 healthy control patients matched for age and sex from the Mayo Clinic Center for Sleep Medicine’s polysomnography database for RSWA quantification. RSWA amounts in the submentalis (SM) and anterior tibialis (AT) were quantitatively analyzed as a percentage of REM sleep duration, in accordance with previously published methods. Non-parametric analyses were performed to compare RSWA, patient demographics, and PSG data across groups. Significance was set at p &lt; 0.016.

Results

Patients with PTSD had significantly higher RSWA than controls in all RSWA density measures (p &lt; 0.016 for all). All measures of RSWA, excluding average SM duration, were significantly greater in PTSD+RBD patients compared with controls (p &lt; 0.016 for all). Within the PTSD group, patients on antidepressants did not have significantly higher RSWA in any of the measures. PTSD+RBD patients had significantly higher SM Phasic, AT Any, SM+AT Any, and Tonic RSWA measures than PTSD patients (p &lt; 0.016 for all).

Conclusion

PTSD patients have significantly higher RSWA than controls, with PTSD+RBD patients having higher RSWA levels than PTSD patients. These data provide the first evidence for abnormal RSWA control in patients with chronic PTSD. This provides evidence of a unique biology in PTSD that could imply a future risk for neurodegenerative disease in PTSD similar to RBD patients. Further prospective studying will need to be performed on patients with PTSD to understand the unique biology.

Support

 

Donecopride, a Swiss army knife with potential against Alzheimer's disease

BACKGROUND AND PURPOSE

We recently identified donecopride as a pleiotropic compound able to inhibit AChE and to activate 5-HT₄ receptors. Here, we have assessed the potential therapeutic effects of donecopride in treating Alzheimer's disease (AD).

EXPERIMENTAL APPROACH

We used two in vivo animal models of AD, transgenic 5XFAD mice and mice exposed to soluble amyloid-β peptides and, in vitro, primary cultures of rat hippocampal neurons. Pro-cognitive and anti-amnesic effects were evaluated with novel object recognition, Y-maze, and Morris water maze tests. Amyloid load in mouse brain was measured ex vivo and effects of soluble amyloid-β peptides on neuronal survival and neurite formation determined in vitro.

KEY RESULTS

In vivo, chronic (3 months) administration of donecopride displayed potent anti-amnesic properties in the two mouse models of AD, preserving learning capacities, including working and long-term spatial memories. These behavioural effects were accompanied by decreased amyloid aggregation in the brain of 5XFAD mice and, in cultures of rat hippocampal neurons, reduced tau hyperphosphorylation. In vitro, donecopride increased survival in neuronal cultures exposed to soluble amyloid-β peptides, improved the neurite network and provided neurotrophic benefits, expressed as the formation of new synapses.

CONCLUSIONS AND IMPLICATIONS

Donecopride acts like a Swiss army knife, exhibiting a range of sustainable symptomatic therapeutic effects and potential disease-modifying effects in models of AD. Clinical trials with this promising drug candidate will soon be undertaken to confirm its therapeutic potential in humans.

[Prophylactic nodal radiotherapy for breast cancer]

Adjuvant radiotherapy is a key treatment in early-stage breast cancer. The meta-analysis by the Early Breast Cancer Trialist's Collaborative Group (EBCTCG) has demonstrated a decreased risk of locoregional relapse and death after whole-breast radiotherapy. Prophylactic lymph nodes irradiation in breast cancer has also proven to be beneficial in several therapeutic trials. At a time when three-dimensional conformal radiotherapy has become the standard procedure and with the development of intensity-modulated radiation therapy, defining nodal volumes is essential and practices should be harmonized to assess and compare the efficiency and toxicity of radiotherapy. Furthermore, the indication of lymph nodes irradiation has to take into account the risk/benefit balance as expanding the irradiated volume can increase radio-induced toxicity. Selection of patients receiving this treatment is essential. The aim of this update is to define nodal volumes, to precise the indications of their irradiation and to present the expected benefits as well as the potential side effects.

Long-Term Pantethine Treatment Counteracts Pathologic Gene Dysregulation and Decreases Alzheimer's Disease Pathogenesis in a Transgenic Mouse Model

The low-molecular weight thiol pantethine, known as a hypolipidemic and hypocholesterolemic agent, is the major precursor of co-enzyme A. We have previously shown that pantethine treatment reduces amyloid-β (Aβ)-induced IL-1β release and alleviates pathological metabolic changes in primary astrocyte cultures. These properties of pantethine prompted us to investigate its potential benefits in vivo in the 5XFAD (Tg) mouse model of Alzheimer's disease (AD).1.5-month-old Tg and wild-type (WT) male mice were submitted to intraperitoneal administration of pantethine or saline control solution for 5.5 months. The effects of such treatments were investigated by performing behavioral tests and evaluating astrogliosis, microgliosis, Αβ deposition, and whole genome expression arrays, using RNAs extracted from the mice hippocampi. We observed that long-term pantethine treatment significantly reduced glial reactivity and Αβ deposition, and abrogated behavioral alteration in Tg mice. Moreover, the transcriptomic profiles revealed that after pantethine treatment, the expression of genes differentially expressed in Tg mice, and in particular those known to be related to AD, were significantly alleviated. Most of the genes overexpressed in Tg compared to WT were involved in inflammation, complement activation, and phagocytosis and were found repressed upon pantethine treatment. In contrast, pantethine restored the expression of a significant number of genes involved in the regulation of Αβ processing and synaptic activities, which were downregulated in Tg mice. Altogether, our data support a beneficial role for long-term pantethine treatment in preserving CNS crucial functions altered by Aβ pathogenesis in Tg mice and highlight the potential efficiency of pantethine to alleviate AD pathology.

Emerging Alternative Proteinases in APP Metabolism and Alzheimer's Disease Pathogenesis: A Focus on MT1-MMP and MT5-MMP

Processing of amyloid beta precursor protein (APP) into amyloid-beta peptide (Aβ) by β-secretase and γ-secretase complex is at the heart of the pathogenesis of Alzheimer’s disease (AD). Targeting this proteolytic pathway effectively reduces/prevents pathology and cognitive decline in preclinical experimental models of the disease, but therapeutic strategies based on secretase activity modifying drugs have so far failed in clinical trials. Although this may raise some doubts on the relevance of β- and γ-secretases as targets, new APP-cleaving enzymes, including meprin-β, legumain (δ-secretase), rhomboid-like protein-4 (RHBDL4), caspases and membrane-type matrix metalloproteinases (MT-MMPs/η-secretases) have confirmed that APP processing remains a solid mechanism in AD pathophysiology. This review will discuss recent findings on the roles of all these proteinases in the nervous system, and in particular on the roles of MT-MMPs, which are at the crossroads of pathological events involving not only amyloidogenesis, but also inflammation and synaptic dysfunctions. Assessing the potential of these emerging proteinases in the Alzheimer’s field opens up new research prospects to improve our knowledge of fundamental mechanisms of the disease and help us establish new therapeutic strategies.

Metalloproteinases in nervous system function and pathology: introduction

This multi-author review in CMLS includes ten articles that provide an update of current knowledge on the role of metalloproteinases in the physiology and pathology of the central nervous system. The collection covers a wide range of situations in which matrix metalloproteinases, adamalysins and meprins are regulated and in turn regulate substrates or signalling pathways involved in: nervous system development, learning and memory, neuroinflammation, degeneration and repair after traumatic and ischemic injury or neurodegenerative mechanisms underlying retinopathies, psychiatric and neurodegenerative disorders. The authors also argue that these proteinases can be considered in some cases as biomarkers or potential therapeutic targets for diseases of the nervous system. Overall, metalloproteinases are placed among the key factors that can help us better understand the cellular and molecular processes that govern neuropathophysiology and implement the strategies that result from this knowledge to open up much-needed treatment opportunities.

The Assisi Think Tank Meeting Survey of post-mastectomy radiation therapy in ductal carcinoma in situ: Suggestions for routine practice

BACKGROUND

Risk factors for local recurrence after mastectomy in ductal carcinoma in situ (DCIS) emerged as a grey area during the second "Assisi Think Tank Meeting" (ATTM) on Breast Cancer.

AIM

To review practice patterns of post-mastectomy radiation therapy (PMRT) in DCIS, identify risk factors for recurrence and select suitable candidates for PMRT.

METHODS

A questionnaire concerning DCIS management, focusing on PMRT, was distributed online via SurveyMonkey.

RESULTS

142 responses were received from 15 countries. The majority worked in academic institutions, had 5-20 years work-experience and irradiated <5 DCIS patients/year. PMRT was more given if: surgical margins <1 mm, high-grade, multicentricity, young age, tumour size >5 cm, skin- or nipple- sparing mastectomy. Moderate hypofractionation was the most common schedule, except after immediate breast reconstruction (57% conventional fractionation).

CONCLUSIONS

The present survey highlighted risk factors for PMRT administration, which should be further evaluated.

Partial versus whole breast irradiation: Side effects, patient satisfaction and costs

PURPOSE

Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs.

MATERIALS AND METHODS

Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy.

RESULTS

When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions.

CONCLUSION

In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.

Atrial Fibrillation in Heart Failure Patients with Preserved or Reduced Ejection Fraction. Prognostic significance of Rhythm control strategy with Catheter Ablation

Introduction

Atrial fibrillation (AF) and heart failure (HF) often coexist with an increase in morbidity and mortality. AF catheter ablation (CA) has proved to be a safe and efficient option for HF patients, but long-term evolution and prognosis remain uncertain. The aim is to assess the efficacy and safety of CA in HF patients with AF, and analyze HF long-term evolution.

Methods

We prospectively analyzed consecutive patients with AF and congestive HF or left ventricular ejection fraction (EF) less than 45%, who underwent CA of AF between 2011 and 2016. We excluded patients who did not complete one year of follow-up.

Results

Seventy-nine patients were included. Mean age was 62.1 years, 72.4% were men, 67.2% had hypertension and 8.6% were diabetics. Mean EF was 49%, left atrial area was 26.5 cm2 and mean CHA2DS2-VASc score was 2. 70.6% were on NYHA FC II-III.The recurrence rate of AF was 60%, and after a second CA the rate decreased to 27.8%. Only persistent AF prior to the procedure was identified as independent predictor of recurrence. There was a significant NYHA FC improvement in the sinus rhythm (SR) group vs those with recurrence (63.6% vs 36.4%; p=0.047). None of the patients in SR were hospitalized, whereas six with recurrence were hospitalized due to HF (0% vs. 18.2%; p = 0.07). The rate of complications was 9.1%.

Conclusions

Catheter ablation of atrial fibrillation in heart failure presents an adequate success rate, improving symptoms and reducing rehospitalizations due to heart failure.

Updated results on catheter ablation of ventricular arrhythmias arising from the papillary muscles of the left ventricle

BACKGROUND

Catheter ablation of ventricular arrhythmias (VAs) arising from the left ventricle`s (LV) papillary muscles (PM) is challenging. In this study we present results of catheter ablation using multiple energy sources and image-based approaches.

METHODS

Fifty-three patients (49 ± 17 years old; 34% females; median LV ejection fraction 53 ± 11%) underwent catheter cryoablation or radiofrequency (RF) ablation with non-contact force sensing (Non-CFS) catheters and cardiac computed tomography integration (CTII) into the electroanatomical mapping system or contact force sensing RF (CFS RF) ablation catheters and intracardiac echo-facilitated 3D electroanatomical mapping. Ventricular arrhythmias foci were mapped at either the anterolateral (ALPM) or posteromedial papillary muscles (PMPM). Ablation was performed using an 8-mm cryoablation catheter (CRYO); a Non-CFS 4-mm open-irrigated RF catheter; or a CFS RF 3.5-mm open-irrigated tip catheter, via transmitral or transaortic approach.

RESULTS

Acute success rate was 83% for Non-CFS RF/CTII; 100% for CRYO/CTII (n = 16) and CFS RF/ICE3D (n = 14) (P = 0.03). Catheter stability was achieved in all patients treated with Cryo/CTII. VA recurrence at 12 months follow-up was 48% (n = 11) for Non-CFS RF/CTII; 19% (n = 3) for CRYO/CTII; and 7% (n = 1) for CFS RF/ICE3D (P = 0.02).

CONCLUSIONS

Non-CFS/CTII was associated with an increased risk of recurrence of the clinical arrhythmia. Ablation with either CFS RF/ICE3D or CRYO/CTII showed high acute success rates and low recurrence rates during follow-up. Cryoablation provided stable contact and was less arrhythmogenic.