Interplay between inter- and intraparticle interactions in bi-magnetic core/shell nanoparticles

The synthesis strategy and magnetic characterisation of two systems consisting of nanoparticles with core/shell morphology are presented: an assembly of hard/soft nanoparticles with cores consisting of magnetically hard cobalt ferrite covered by a magnetically soft nickel ferrite shell, and the inverse system of almost the same size and shape. We have successfully designed these nanoparticle systems by gradually varying the magnetic anisotropy resulting in this way in the modulation of the magnetic dipolar interactions between particles. Both nanoparticle systems exhibit high saturation magnetisation and display superparamagnetic behaviour at room temperature. We have shown strong exchange coupling at the core/shell interface of these nanoparticles systems which was also confirmed by mesoscopic modelling. Our results demonstrate the possibility of modulating magnetic anisotropy not only by chemical composition but also by adopting the proper nano-architecture.

D2 dissection improves disease-specific survival in advanced gastric cancer patients: 15-year follow-up results of the Italian Gastric Cancer Study Group D1 versus D2 randomised controlled trial

BACKGROUND

The extended lymphadenectomy (D2) was recently introduced in several guidelines as the optimal treatment for gastric cancer, based only on the 15-year follow-up results of the Dutch randomised trial, while the British Medical Research Council (MRC) study failed to demonstrate a survival benefit over the more limited D1 dissection. The Italian Gastric Cancer Study Group randomised controlled trial (RCT) was also undertaken to compare D1 versus D2 gastrectomy, and a tendency to improve survival in patients with advanced resectable disease (pT > 1N+) was documented despite negative results in the entire patient population. Now we present the 15-year follow-up results of survival and gastric cancer-related mortality.

METHODS

Between June 1998 and December 2006, eligible patients with gastric cancer who signed the informed consent were randomised at 5 centres to either D1 or D2 gastrectomy. Intraoperative randomisation was implemented centrally by phone call. Primary outcome was overall survival (OS); secondary end-points were disease-specific survival, postoperative morbidity and mortality. Analyses were by intention to treat. Strict quality control measures for surgery, lymph node removal, pathology and patient follow-up were implemented and monitored. Registration number: ISRCTN11154654 (http://www.controlled-trials.com).

FINDINGS

A total of 267 eligible patients were assigned to either D1 (133 patients) or D2 (134) procedure. Median follow-up time was 16.76 years. Analyses were done both in overall patient population and in pT > 1N+. One hundred patients (38.5) were alive without recurrence. OS and disease-specific survival (DSS) were very high in both arms. In overall population, they were not different between D1 and D2 arm (51.3% vs. 46.8% and 65% vs. 67% respectively, p = 0.31 and p = 0.94). DSS was significantly higher after D2 in pT > 1N+ patients (29.4% vs. 51.4%, p = 0.035). OS and DSS were better after D1 in patients older than 70 years (p = 0.003 and p = 0.006). DSS was higher after D1 also in early stages (p = 0.01).

INTERPRETATION

After 15-year follow up, despite no relevant difference in overall population, DSS and gastric cancer-related mortality of patients with advanced disease and lymph node metastases are improved by D2 procedure. Further data available from this trial suggest that D1 procedure should be preferably used in older patients and in early disease. As accurate detection of advanced diseases can be currently provided by adequate preoperative workup in referral centres, D2 procedure should be recommended in these cases.

FUNDING

Piedmont Regional fund for Finalized Healthy Research Project, Application 2003 for data collection.

Manual on the creation of quality indicators for population based cancer screening programs in Italy

Issue

In many countries the organized screening programs have been in the frontline in developing and implementing the evaluation of the quality of screening and of the entire process of care following a positive test. Over the years, the three Italian Screening Groups (GIS) have separately published indicators and standards concerning the programs for breast, cervical and colorectal cancers they were responsible for, thus hampering coherence, homogeneity. In addition, at local level, an increasing number of indicators have been observed with difficult to monitor all of them.

Description of the Problem

The Screening Indicators Manual, prepared by a multidisciplinary working group, represents the guidance agreed upon by the Italian Screening Network (ONS) and the three GIS on how to develop, implement, communicate and maintain a set of quality indicators for the evaluation of cancer screening programs.

Results

The Manual indicates that the three GIS must first constitute, with ONS, the common steering committee made of six-nine experts. The involvement of the public and the management of the conflicts of interests are foreseen. The conceptual framework distinguishes indicators of context, coverage and process. It is based on six dimensions: efficacy, efficiency, security, appropriateness, person centeredness, equity. There are four macro-processes: invitation; test, further assessment and diagnosis; treatment and follow-up; evaluation. The methods include: a survey of the existent indicators, their selection with the Delphi method, the evaluation of the completeness of the resulting indicators set, its integration, when needed, by means of a public call, and finally a new Delphi round. Appropriate standards, empirical or evidence based, are then identified. Last, indicators are assigned to core or library list based on priority.

Lessons

Select, define and measure an indicator is a way to understand what we are aiming at even more than provide the measure of how we do it.

Key messages

The creation of the Manual allows to build a coherent evaluation framework for the three screening programs. The Manual promotes the adoption of rigorous methods and make feasible the monitoring activity according to its purpose, level of observation and detail of information needed.

Aesthetic results following breast cancer surgery: A prospective study on 6515 cases from ten Italian Senonetwork breast centers

Breast cancer treatment has deeply changed in the last decades, since clinical and oncological cure cannot be achieved without patient's satisfaction in term of aesthetic outcomes. Several methods have been proposed to objectively assess these results. However, Italian breast centers have not yet agreed on measurable, reproducible and validated aesthetic outcome indicators to monitor their performance.

METHODS

The study was designed and conducted by Senonetwork, a not-for-profit association of Italian breast centers. Ten breast centers were selected based on specific eligibility criteria. This multicentre observational prospective study recruited 6515 patients with diagnosis of in situ or invasive breast cancer who underwent breast surgery in the years 2013-2016. Thirteen indicators of aesthetic results and of related quality of care were analyzed. Data collection and analysis were conducted using a common study database.

RESULTS

On average, seven out of ten centers were able to collect data on the proposed indicators with a proportion of missing values < 25%. By expert consensus based on study results, some seven indicators have been defined as "mandatory" while the remaining six have been defined as "recommended" because they require further refinement before they can be proposed for monitoring aesthetic outcomes or because there are doubts on the feasibility of data collection. The minimum standard is reached for 5 of 13 indicators. This finding and the wide range between centers reveal that there is ample room for improvement.

CONCLUSIONS

From the present study useful measurable aesthetic parameters have emerged, leading to the definition of target objectives that breast centers can use for benchmarking and improvement of quality of care.

Promoting Participation in a Population Screening Program for Breast and Cervical Cancer: A Randomized Trial of Different Invitation Strategies

Aims and background

Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.

Methods

Women eligible for invitation - 8385 for cervical and 8069 for breast cancer screening - listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A - letter signed by the GP, with a prefixed appointment; Group B - open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C - letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D - extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).

Results

Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).

Conclusions

Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored.

Practice of Early Diagnosis of Breast and Uterine Cervix Cancer in a Northern Italian Town

We studied the practice of screening for breast and uterine cervix cancer in Torino where, currently, no kind of organized program exists and two projects of population screening programs, based on pap smear and mammography, have been developed. Fifty-two percent (95% confidence limits (C.L.): 47%-58%) of women 18-69 years old had had a pap test or colposcopy in the absence of symptoms during their lifetime. Among them 50% had had their last pap test within 18 months of the interview, 77% within 3 and 1/2 years, and only 14% was screened 5 and 1/2 years before or earlier. Thirty percent of never-screened women (95% C.L.: 25-35%) would not accept any of the proposed modalities for screening. Overall, 15% of women had had a mammography for screening purposes. Among women 50 to 59 years old, 23% (95% C.L.: 17-30%) had had at least one mammography for screening purposes in their lifetime, but only 18% (95% C.L.: 13-24%) had had at least 1 screening test at age 50 or after. Half of ever-screened women age 50-69 years had had the last mammography within 2 and 1/2 years. Among all respondents in the same age group this figure was 11% (95% C.L.: 7-15%). Forty-one percent of respondents reported to currently practice BSE (95% C.L.: 36-45%), but this proportion dropped to 10% in the age group 19-39 years and to 4% among women 40-69 years old when only those who had 10-13 examinations each year and judged their performance to be good were considered. Thirty-nine percent (95% C.L.: 34-44%) had had a physical examination of the breast performed by a medical doctor in the absence of symptoms within the last 18 months. Thirty-five percent (95% C.L.: 31-38%) of all women had never had a mammography, did not practice BSE, and had never consulted a physician for control in the absence of symptoms. Analysis by age, birth cohort, education, marital status and place of birth is presented.

How Tumor Markers are used in the Routine Follow-up of Breast and Colorectal Cancer. A Survey of 29 Italian Hospitals

The impact of tumor markers on the outcome of several malignancies is still under debate. This relative uncertainty leads to a subjective approach to their use. Monitoring the use of tumor markers is a valuable tool to identify the need for educational policies. We conducted a survey to evaluate how tumor markers are routinely used in the follow-up of patients with breast, colorectal and ovarian carcinoma. The former two malignancies are considered in the present paper. We surveyed 35 Italian hospitals; 29 (83%, accounting for 26,622 hospital beds) filled in and returned the questionnaire. Overall, 467,361 tumor marker requests were scrutinized by the surveyed hospitals. We found a wide variability in the type and number of routinely used markers, the cutoff points chosen, and the clinical decisions taken on the basis of marker results. In addition, we observed a relative lack of communication between clinicians and clinical pathologists in around 50% of the surveyed hospitals. In these cases clinical information was not provided to the laboratory and methodological aspects were not communicated to clinicians. From the findings of the present study we conclude that the cooperation between clinicians and clinical pathologists must improve before guidelines for the use of tumor marker assays can be framed and the compliance with these guidelines can be checked. Request forms for tumor marker assays should therefore be designed to contain clinical information and the quality of filling in request forms with clinical data should be carefully monitored.

Focal compression of the upper left thoracic intersegmental arteries as a potential cause of spinal cord ischemia

BACKGROUND AND PURPOSE

This study was prompted by recurrent angiographic observations of focal stenoses involving the proximal segment of the left upper thoracic intersegmental arteries, a few centimeters distal to their origin. The purpose was to investigate the nature and prevalence of this anomaly.

MATERIALS AND METHODS

The existence of non-ostial thoracic intersegmental artery stenoses was evaluated in 50 angiograms; the contribution of stenosed branches to the anterior spinal artery was recorded. Angiograms performed in 3 patients with right-sided aortas were also reviewed. The topographic relationships of the upper thoracic intersegmental artery with surrounding structures were investigated in 3 cadavers.

RESULTS

Thirty-seven non-ostial stenoses were found in 26 patients (52%), predominantly on the left side (92%), between T3 and T8, most frequently at T4 and T5 (54%). Severe lesions were observed in 10% of cases. Patients with stenoses had fewer detectable anterior radiculomedullary arteries between T3 and T5 (35% versus 54%). Upper intersegmental artery stenoses, documented on the left side of all 3 specimens, appeared to be caused by the recurrent path of these intersegmental arteries related to the leftward position of the thoracic aorta, and by their course around reinforced paramedian longitudinal strands of the endothoracic fascia.

CONCLUSIONS

Upper thoracic intersegmental artery stenoses are frequent. They result from the leftward deviation of the descending aorta and the existence of a fixed point along the course of the intersegmental arteries related to the endothoracic fascia. Because contributors to the spinal vascularization often originate at similar levels, these stenoses may play a role in the susceptibility of the upper and midthoracic spinal cord to ischemia.

Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer

BACKGROUND

It is still unclear whether D2 lymphadenectomy improves the survival of patients with gastric cancer and should therefore be performed routinely or selectively. The aim of this multicentre randomized trial was to compare D2 and D1 lymphadenectomy in the treatment of gastric cancer.

METHODS

Between June 1998 and December 2006, patients with gastric adenocarcinoma were assigned randomly to either D1 or D2 gastrectomy. Intraoperative randomization was implemented centrally by telephone. Primary outcome was overall survival; secondary endpoints were disease-specific survival, morbidity and postoperative mortality.

RESULTS

A total of 267 eligible patients were allocated to either D1 (133 patients) or D2 (134) resection. Morbidity (12.0 versus 17.9 per cent respectively; P = 0.183) and operative mortality (3.0 versus 2.2 per cent; P = 0.725) rates did not differ significantly between the groups. Median follow-up was 8.8 (range 4.5-13.1) years for surviving patients and 2.4 (0.2-11.9) years for those who died, and was not different in the two treatment arms. There was no difference in the overall 5-year survival rate (66.5 versus 64.2 per cent for D1 and D2 lymphadenectomy respectively; P = 0.695). Subgroup analyses showed a 5-year disease-specific survival benefit for patients with pathological tumour (pT) 1 disease in the D1 group (98 per cent versus 83 per cent for the D2 group; P = 0.015), and for patients with pT2-4 status and positive lymph nodes in the D2 group (59 per cent versus 38 per cent for the D1 group; P = 0.055).

CONCLUSION

No difference was found in overall 5-year survival between D1 and D2 resection. Subgroup analyses suggest that D2 lymphadenectomy may be a better choice in patients with advanced disease and lymph node metastases.

REGISTRATION NUMBER

ISRCTN11154654 (http://www.controlled-trials.com).

The requirements of a specialist Breast Centre

INTRODUCTION

In recognition of the advances and evidence based changes in clinical practice that have occurred in recent years and taking into account the knowledge and experience accumulated through the voluntary breast unit certification programme, Eusoma has produced this up-dated and revised guidelines on the requirements of a Specialist Breast Centre (BC).

METHODS

The content of these guidelines is based on evidence from the recent relevant peer reviewed literature and the consensus of a multidisciplinary team of European experts. The guidelines define the requirements for each breast service and for the specialists who work in specialist Breast Centres.

RESULTS

The guidelines identify the minimum requirements needed to set up a BC, these being an integrated Breast Centre, dealing with a sufficient number of cases to allow effective working and continuing expertise, dedicated specialists working with a multidisciplinary approach, providing all services throughout the patients pathway and data collection and audit. It is essential that the BC also guarantees the continuity of care for patients with advanced (metastatic) disease offering treatments according to multidisciplinary competencies and a high quality palliative care service. The BC must ensure that comprehensive support and expertise may be needed, not only through the core BC team, but also ensure that all other medical and paramedical expertise that may be necessary depending on the individual case are freely available, referring the patient to the specific care provider depending on the problem.

CONCLUSIONS

Applying minimum requirements and quality indicators is essential to improve organisation, performance and outcome in breast care. Efficacy and compliance have to be constantly monitored to evaluate the quality of patient care and to allow appropriate corrective actions leading to improvements in patient care.

Pebbles and PebbleJuggler: software for accurate, unbiased, and fast measurement and analysis of nanoparticle morphology from transmission electron microscopy (TEM) micrographs

Pebbles is a user-friendly software program which implements an accurate, unbiased, and fast method to measure the morphology of a population of nanoparticles (NPs) from TEM micrographs. The morphological parameters of the projected NP shape are obtained by fitting intensity models to the TEM micrograph. Pebbles can be used either in automatic mode, where both fitting and validation are reliably carried out with minimal human intervention, and in manual mode, where the user has full control on the fitting and validation steps. Accuracy in diameter measurement has been shown to be ≲1%. When operated in automatic mode, Pebbles can be very fast. The effective speed of 1 NP s⁻¹ has been achieved in favorable cases (packed monolayer of NPs). Since Pebbles is based on a local modeling procedure, it successfully treats cases such as low contrast NPs, NPs with significant diffraction scattering, and inhomogeneous background which often make conventional thresholding procedures fail. Pebbles is accompanied by PebbleJuggler, a software program for the statistical analysis of the sets of best-fit NP models created by Pebbles. Effort has been devoted to make Pebbles and PebbleJuggler the most user-friendly and the least user-tedious we could. Pebbles and PebbleJuggler are available at http://pebbles.istm.cnr.it.

[Abdominal aortic aneurysms: diagnosis and endovascular therapy]

Abdominal aortic aneurysms are a common condition whose prognosis without treatment is poor because of the lethality in case of breakage. An early diagnosis is thus necessary by screening or symptoms recognition. Surgery is not the only option then, continuous monitoring and medical treatment being sometimes possible. If curative treatment is undertaken, endovascular technique is an alternative to open surgical repair but its indications are not yet fully established and endovascular grafts have not the same longevity as open surgery. A review of the indications for endovascular repair in patients operated at the Geneva University Hospital has been used to illustrate the importance of individualized care for each patient.

A few simple rules governing hydrogenation of graphene dots

We investigated binding of hydrogen atoms to small polycyclic aromatic hydrocarbons (PAHs)--i.e., graphene dots with hydrogen-terminated edges--using density functional theory and correlated wavefunction techniques. We considered a number of PAHs with three to seven hexagonal rings and computed binding energies for most of the symmetry unique sites, along with the minimum energy paths for significant cases. The chosen PAHs are small enough to not present radical character at their edges, yet show a clear preference for adsorption at the edge sites which can be attributed to electronic effects. We show how the results, as obtained at different levels of theory, can be rationalized in detail with the help of a few simple concepts derivable from a tight-binding model of the π electrons.

Sudden cardiac arrest in a marathon runner. A case report

Sudden cardiac death is a rare condition resulting from undetected cardiac abnormalities in athletes and non-athletes. Participant screening, immediate and advanced medical management can probably reduce mortality and ameliorate outcomes. In recent years, extracorporeal membrane oxygenation has emerged as a valuable therapeutic option in patients experiencing refractory cardiac arrest as a bridge to different types of outcome, including recovery, heart transplantation or ventricular assist device and organ donations. In this report we describe a case of a sudden cardiac arrest in a marathon runner treated with extracorporeal membrane oxygenation.

Role and efficacy of intraoperative evaluation of resection adequacy in conservative breast surgery

In the present study we considered the histology of 51 patients who have undergone breast conservative surgery and the related 54 re-excisions that were performed in the same surgical procedure or in delayed procedures, in order to evaluate the role of intraoperative re-excisions in completing tumor removal. In 13% of the cases the re excision obtained the resection of the target lesion. In this study, the occurrence of residual neoplastic lesions in intraoperative re-excisions (24%) is lower than in delayed re-excisions (62%; P = .03). The residual lesions that we could find with definitive histology of re excision specimens are related with lesions with ill defined profile. In 77% of the cases of re excision with tumoral residual the lesion was close to the new resection margin, thus the re-excisions couldn't achieve an adequate ablation of the neoplasm. Invasive or preinvasive nature of the main lesion resected for each case and the approach to the evaluation of the first resection specimen adequacy (surgical or radiological) don't affect the rate of tumoral residual in intraoperative re-excisions. In conclusion, our data are consistent with a low efficacy of intraoperative re excision in obtaining a complete removal of the tumor; intraoperative radiologic evaluation of the first resection specimen is however imperative in defining the effective removal of the target lesion.

Lymph-nodal ratio in gastric cancer staging system

AIM

Many studies have indicated that lymph node metastases and the depth of invasion of the primary tumor are the most reliable prognostic factors for patients with radically resected gastric cancer. Recently the ratio between metastatic and examined lymph nodes (n ratio) has been proposed as a new prognostic indicator. The aim of this study was to evaluate the prognostic value of n ratio in patients with gastric cancer.

METHODS

We retrospectively reviewed the data of 399 patients who had undergone radical resection for gastric carcinoma.

RESULTS

N ratio was significantly greater in patients with large and undifferentiated tumors. Moreover, it was significantly related to both the number and location of lymph node metastases. Survival curves showed that n ratio was strictly related to patients' survival. Multivariate analysis confirmed that it was an important independent prognostic indicator.

CONCLUSION

N ratio is useful to better evaluate the status of lymph node metastases in patients with gastric cancer submitted to radical surgery. Moreover it is a very important independent prognostic factor for gastric cancer.

Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer

BACKGROUND

A randomized clinical trial was performed to compare D1 and D2 gastrectomy in specialized Western centres. This paper reports short-term results.

METHOD

A total of 267 patients with gastric cancer were randomly assigned to either a D1 or a D2 procedure in five specialized centres. Based on the findings of the phase II trial and published phase III trials, a prespecified non-inferiority boundary at 12 per cent difference between groups was set regarding total morbidity.

RESULTS

In the intention-to-treat analysis, the overall morbidity rate after D2 and D1 dissections was 17.9 and 12.0 per cent respectively (P = 0.178), with a 95 per cent confidence interval of the difference of 0 to 13.0 per cent, slightly exceeding the prespecified non-inferiority limit. There was a single duodenal stump leak in the D2 arm (0.7 per cent). The postoperative 30-day mortality rate was 3.0 per cent after D1 and 2.2 per cent after D2 gastrectomy (P = 0.722).

CONCLUSION

In specialized centres the rate of complications following D2 dissection is much lower than in published randomized Western trials. D2 dissection, in an appropriate setting, can therefore be considered a safe option for the radical management of gastric cancer in Western patients.

REGISTRATION NUMBER

ISRCTN11154654 (http://www.controlled-trials.com).

Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer

BACKGROUND

A randomized clinical trial was performed to compare D1 and D2 gastrectomy in specialized Western centres. This paper reports short-term results.

METHOD

A total of 267 patients with gastric cancer were randomly assigned to either a D1 or a D2 procedure in five specialized centres. Based on the findings of the phase II trial and published phase III trials, a prespecified non-inferiority boundary at 12 per cent difference between groups was set regarding total morbidity.

RESULTS

In the intention-to-treat analysis, the overall morbidity rate after D2 and D1 dissections was 17.9 and 12.0 per cent respectively (P = 0.178), with a 95 per cent confidence interval of the difference of 0 to 13.0 per cent, slightly exceeding the prespecified non-inferiority limit. There was a single duodenal stump leak in the D2 arm (0.7 per cent). The postoperative 30-day mortality rate was 3.0 per cent after D1 and 2.2 per cent after D2 gastrectomy (P = 0.722).

CONCLUSION

In specialized centres the rate of complications following D2 dissection is much lower than in published randomized Western trials. D2 dissection, in an appropriate setting, can therefore be considered a safe option for the radical management of gastric cancer in Western patients.

REGISTRATION NUMBER

ISRCTN11154654 (http://www.controlled-trials.com).

Hormone replacement therapy may prevent the development of isolated pulmonary hypertension in patients with systemic sclerosis and limited cutaneous involvement

BACKGROUND

Isolated pulmonary hypertension (iPHT) is a near-fatal consequence of systemic sclerosis (SSc); in female patients, the risk of its development is increased during the post-menopausal period, when the protective effects of oestrogens on the endothelium decrease. In many animal and human models, hormone replacement therapy (HRT) and oestrogen administration proved efficacious in counteracting many mechanisms that might be implicated in the pathogenesis of iPHT. Accordingly, it has been hypothesized that HRT might help to prevent the development of iPHT.

METHODS

A retrospective cohort study was conducted on 61 SSc patients with the limited cutaneous form of the disease and no sign of pulmonary hypertension on echocardiogram (pulmonary artery pressure, PAP > 35 mmHg) at the time of menopause. All the patients had to be stably treated with calcium-channel blockers and not to have risk factors for secondary PHT throughout the duration of the observational period.

RESULTS

Twenty patients (32.8%) received HRT for a mean of 6.7 +/- 3.7 years. None of these patients developed iPHT after a mean of 7.2 +/- 3.5 years from menopause, whereas eight out of 41 patients not receiving HRT (19.5%) developed iPHT after a similar time period (7.5 +/- 3.9 years, p = 0.032). These rates were not explained by differences between the two groups with respect to autoantibodies, age, age at onset of SSc, diffusing capacity of the lung for carbon monoxide (DLCO) at menopause, or duration of therapy with calcium-channel blockers.

CONCLUSION

HRT administration may be effective in SSc post-menopausal women, preventing the development of iPHT.

XuvTools: free, fast and reliable stitching of large 3D datasets

Current biomedical research increasingly requires imaging large and thick 3D structures at high resolution. Prominent examples are the tracking of fine filaments over long distances in brain slices, or the localization of gene expression or cell migration in whole animals like Caenorhabditis elegans or zebrafish. To obtain both high resolution and a large field of view (FOV), a combination of multiple recordings ('tiles') is one of the options. Although hardware solutions exist for fast and reproducible acquisition of multiple 3D tiles, generic software solutions are missing to assemble ('stitch') these tiles quickly and accurately. In this paper, we present a framework that achieves fully automated recombination of tiles recorded at arbitrary positions in 3D space, as long as some small overlap between tiles is provided. A fully automated 3D correlation between all tiles is achieved such that no manual interaction or prior knowledge about tile positions is needed. We use (1) phase-only correlation in a multi-scale approach to estimate the coarse positions, (2) normalized cross-correlation of small patches extracted at salient points to obtain the precise matches, (3) find the globally optimal placement for all tiles by a singular value decomposition and (4) accomplish a nearly seamless stitching by a bleaching correction at the tile borders. If the dataset contains multiple channels, all channels are used to obtain the best matches between tiles. For speedup we employ a heuristic method to prune unneeded correlations, and compute all correlations via the fast Fourier transform (FFT), thereby achieving very good runtime performance. We demonstrate the successful application of the proposed framework to a wide range of different datasets from whole zebrafish embryos and C. elegans, mouse and rat brain slices and fine plant hairs (trichome). Further, we compare our stitching results to those of other commercially and freely available software solutions. The algorithms presented are being made available freely as an open source toolset 'XuvTools' at the corresponding author's website (http://lmb.informatik.uni-freiburg.de/people/ronneber), licensed under the GNU General Public License (GPL) v2. Binaries are provided for Linux and Microsoft Windows. The toolset is written in templated C++, such that it can operate on datasets with any bit-depth. Due to the consequent use of 64bit addressing, stacks of arbitrary size (i.e. larger than 4 GB) can be stitched. The runtime on a standard desktop computer is in the range of a few minutes. A user friendly interface for advanced manual interaction and visualization is also available.

Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction

The aim of this study was the evaluation of the impact of service screening programmes on breast cancer mortality in five regions of Italy. We conducted a matched case-control study with four controls for each case. Cases were defined as breast cancer deaths occurred not later than 31 December 2002. Controls were sampled from the local municipality list and matched by date of birth. Screening histories were assessed by the local, computerised, screening database and subjects were classified as either invited or not-yet-invited and as either screened or unscreened. There were a total of 1750 breast cancer deaths within the 50 to 74-year-old breast cancer cases and a total of 7000 controls. The logistic conditional estimate of the cumulative odds ratios comparing invited with not-yet-invited women was 0.75 (95% CI: 0.62-0.92). Restricting the analyses to invited women, the odds ratio of screened to never-respondent women corrected for self-selection bias was 0.55 (95% CI: 0.36-0.85). The introduction of breast cancer screening programmes in Italy is associated with a reduction in breast cancer mortality attributable to the additional impact of service screening over and above the background access to mammography.

The hormone replacement therapy opposed to low dose tamoxifen (HOT) study: safety data from an ongoing phase III trial

1514

Background: Primary prevention trials have shown that tamoxifen (T) lowers ER+ breast cancer (BC) incidence by 48%. While the IBIS I update showed mixed findings, the Italian trial showed an interesting positive risk/benefit ratio in T and hormone replacement therapy (HRT) users: fewer BC, endometrial cancer comparable to placebo, and no cardiovascular diseases (CVD) excess. In a phase II study, low dose T and HRT showed a safe gynecological profile and did not increase menopausal symptoms. Moreover low dose T maintains the same antiproliferative effects as the standard dose. To improve BC prevention and quality of life (QoL) in menopausal women we started a multicentric, phase III trial of low dose T in HRT users. Methods: current or de novo HRT users are randomized to T 5 mg/day or placebo for 5 yrs. The primary aim is the reduction of invasive or in situ BC. Secondary aims are: safety, gene polymorphisms (SNPs) correlated to BC risk and T activity. In a subgroup transvaginal ultrasound (TvUS) and endometrial biopsy is being performed after 3 years of treatment to monitor endometrial effects. Results: as of December 31 2006, 1870 women were enrolled, of which 21% were hysterectomized. Median age is 53 years (33–72), BMI is <25 in 66%, =25<30 in 26%, >30 in 8%. Current or de novo users are 80% and 20%. 84% participants have at least one follow-up visit. 128 subjects performed already the 3 years TvUS and endometrial biopsy: so far no atypical hyperplasia or cancer was found. A modest increase of menopausal symptoms was observed (hot flashes 42% vs 52%, night sweating 39% vs 44%). Drop-outs are 23%, of which 13% due to AE including: 21 cancers (12 invasive BC, 1 DCIS), 13 CVD (3 VTE), 9 gynecological (5 endometrial polyps). Conclusions: combination of low dose T and HRT has reasonable safety profile, we have reached almost 1,900 women on study and AE rate is very low. These unblinded findings support the safety of the association of HRT and T.

No significant financial relationships to disclose.

Mastectomy rates are decreasing in the era of service screening: a population-based study in Italy (1997-2001)

We enrolled all 2162 in situ and 21 148 invasive cases of breast cancer in 17 areas of Italy, diagnosed in 1997–2001. Rates of early cancer increased by 13.7% in the screening age group (50–69 years), and breast conserving surgery by 24.6%. Advanced cancer rates decreased by 19.4%, and mastectomy rates by 24.2%. Service screening did not increase mastectomy rates in the study population.

Periodic patterns of actin turnover in lamellipodia and lamellae of migrating epithelial cells analyzed by quantitative Fluorescent Speckle Microscopy

We measured actin turnover in lamellipodia and lamellae of migrating cells, using quantitative Fluorescent Speckle Microscopy. Lamellae disassembled at low rates from the front to the back. However, the dominant feature in their turnover was a spatially random pattern of periodic polymerization and depolymerization moving with the retrograde flow. Power spectra contained frequencies between 0.5 and 1 cycle/min. The spectra remained unchanged when applying Latrunculin A and Jasplakinolide in low doses, except that additional frequencies occurred beyond 1 cycle/min. Whereas Latrunculin did not change the rate of mean disassembly, Jasplakinolide halted it completely, indicating that the steady state and the dynamics of actin turnover are differentially affected by pharmacological agents. Lamellipodia assembled in recurring bursts at the leading edge and disassembled approximately 2.5 microm behind. Events of polymerization correlated spatially and temporally with transient formation of Arp2/3 clusters. In lamellae, Arp2/3 accumulation and polymerization correlated only spatially, suggesting an Arp2/3-independent mechanism for filament nucleation. To acquire these data we had to enhance the resolution of quantitative Fluorescent Speckle Microscopy to the submicron level. Several algorithmic advances in speckle image processing are described enabling the analysis of kinetic and kinematic activities of polymer networks at the level of single speckles.

Comparison of early performance indicators for screening projects within the European Breast Cancer Network: 1989–2000

In 1989 the European Breast Cancer Network (EBCN) was established by the first pilot projects for breast cancer screening, co-funded by the Europe Against Cancer programme. We report early performance indicators for these EBCN projects while taking into account their organizational setting. Out of 17 projects in the network, 10 projects from six European countries contributed aggregated data on number of invitations, screening examinations, and breast cancers detected over the period 1989-2000. Results were summarized separately for projects in centralized versus decentralized health care environments. The European Guidelines for quality assurance in mammography screening provided reference values for the performance indicators. The most prominent finding in this study was the higher participation rate in centralized versus decentralized projects (average participation in 1998: 74 versus 33%; P<0.001), whereas the invitation system and screening policy in these projects were similar. Detection rates and characteristics of cancers detected at initial and subsequent screening examinations showed no significant differences between centralized and decentralized projects. Even though early performance indicators for centralized versus decentralized projects were similar, the impact of breast screening on mortality from this disease at the population level will differ since the decentralized projects reach only part of the target population.

Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer

BACKGROUND

The need for further axillary treatment in patients with breast cancer with low-volume sentinel node (SN) involvement (micrometastases or smaller) is controversial.

METHODS

Twenty-five studies reporting on non-SN involvement associated with low-volume SN involvement were identified using Medline and a meta-analysis was performed.

RESULTS

The weighted mean estimate for the incidence of non-SN metastases after low-volume SN involvement is around 20 per cent, whereas this incidence is around 9 per cent if the SN involvement is detected by immunohistochemistry (IHC) alone. Subset analyses suggest that studies with axillary dissection after any type of SN involvement result in somewhat higher estimates than studies allowing omission of axillary clearance, as do studies with more detailed histological evaluation of the SN compared with those with a less intensive histological protocol. Higher-quality papers yield lower pooled estimates than lower-quality papers.

CONCLUSION

The risk of non-SN metastasis with a low-volume metastasis in the SN is around 10-15 per cent, depending on the method of detection of SN involvement. This should be taken into account when assessing the risk of omission of axillary dissection after a positive SN biopsy yielding micrometastatic or immunohistochemically positive SNs.

Two distinct actin networks drive the protrusion of migrating cells

Cell migration initiates by extension of the actin cytoskeleton at the leading edge. Computational analysis of fluorescent speckle microscopy movies of migrating epithelial cells revealed this process is mediated by two spatially colocalized but kinematically, kinetically, molecularly, and functionally distinct actin networks. A lamellipodium network assembled at the leading edge but completely disassembled within 1 to 3 micrometers. It was weakly coupled to the rest of the cytoskeleton and promoted the random protrusion and retraction of the leading edge. Productive cell advance was a function of the second colocalized network, the lamella, where actomyosin contraction was integrated with substrate adhesion.

Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer

Curative resection is the treatment of choice for potentially curable gastric cancer. Two major Western studies in the 1990s failed to show a benefit from D2 dissection. They showed extremely high postoperative mortality after D2 dissection, and were criticised for the potential inadequacy of the pretrial training in the new technique of D2 dissection, prior to the phase III studies being initiated. The inclusion of pancreatectomy and splenectomy in D2 dissection was associated with increased morbidity and mortality. Following these results, we started a phase II trial to evaluate the safety and efficacy of pancreas-preserving D2 dissection. The results of this trial regarding the safety of pancreas preserving D2 dissection were published in 1998. In this paper, we present the survival results of this phase II trial to confirm the rationale of carrying out a phase III study comparing D1 vs D2 dissection for curable gastric cancer. Italian patients with histologically proven gastric adenocarcinoma were registered in the Italian Gastric Cancer Study Group Multicenter trial. The study was carried out based on the General Rules of the Japanese Research Society for Gastric Cancer. A strict quality control system was achieved by a supervising surgeon of the reference centre who had stayed at the National Cancer Center Hospital, Tokyo, to learn the standard D2 gastrectomy and the postoperative management. The standard procedure entailed removal of the first and second tier lymph nodes. During total gastrectomy, the pancreas was preserved according to the Maruyama technique. Complete follow-up was available to death or 5 years in 100% of patients and the median follow-up time was 4.38 years. Out of 297 consecutive patients registered, 191 patients were enrolled in the study between May 1994 and December 1996. The overall morbidity rate was 20.9%. The postoperative in-hospital mortality was 3.1%. The overall 5-year survival rate among all eligible patients was 55%. Survival was strictly related to stage, depth of wall invasion, lymph node involvement and type of gastrectomy (distal vs total). Our results suggest a survival benefit for pancreas-preserving D2 dissection in Italian patients with gastric cancer if performed in experienced centres. A phase III trial among exclusively experienced centres is urgently needed.

Monitoring surgical treatment of screen-detected breast lesions in Italy

The object of this study was to assess quality of care and adherence to treatment guidelines of screen-detected lesions in Italy using a new audit system. Data on screen-detected cases surgically treated in 1997 were collected using a system (QT 2.3) developed within the Italian Group for Planning and Evaluating Mammographic Screening Programmes (GISMa) and the European Breast Cancer Screening Network. Results of 18 performance parameters were considered compared with the reference standards. In 1997, 515 lesions (335 invasive, 60 in situ and 120 benign) in 496 patients were collected from 14 departments in the Central and Northern area of Italy. The 18 indicators were analysed and grouped according to six quality objectives. Some results were good and others were excellent, such as intraoperative identification, breast conservation surgery, adequate axillary procedures and completeness of pathology reports, but most of them failed: waiting times, preoperative diagnosis, employment of frozen section on small lesions and avoiding axillary procedures in ductal carcinoma-in-situ. This work is a first attempt in Italy to evaluate and uniform the criteria adopted for quality control of breast cancer treatment, using a standardised system. Some results are good or excellent, the overall level of compliance with quality indicators is not satisfactory and corrective actions should be undertaken for a number of issues. A continuous monitoring should be performed and appropriate action taken in order to verify the effectiveness of the corrective actions and to provide screen-detected patients with the best quality of care.

Morbidity and mortality after D1 and D2 gastrectomy for cancer: interim analysis of the Italian Gastric Cancer Study Group (IGCSG) randomised surgical trial

BACKGROUND

The disadvantages of D2 gastrectomy have been mostly related to splenopancreatectomy. Unlike two large European trials, we have recently showed the safety of D2 dissection with pancreas preservation in a one-arm phase I-II trial. This new randomised trial was set up to compare post-operative morbidity and mortality and survival after D1 and D2 gastrectomy among the same experienced centres that participated into the previous trial.

METHODS

In a prospective multicenter randomised trial, D1 gastrectomy was compared to D2 gastrectomy. Central randomisation was performed following a staging laparotomy in 162 patients with potentially curable gastric cancer.

FINDINGS

Of 162 patients randomised, 76 were allocated to D1 and 86 to D2 gastrectomy. The two groups were comparable for age, sex, site, TNM stage of tumours, and type of resection performed. The overall post-operative morbidity rate was 13.6%. Complications developed in 10.5% of patients after D1 and in 16.3% of patients after D2 gastrectomy. This difference was not statistically significant (p<0.29). Reoperation rate was 3.4% after D2 and 2.6% after D1 resection. Post-operative mortality rate was 0.6% (one death); it was 1.3% after D1 and 0% after D2 gastrectomy.

INTERPRETATION

Our preliminary data confirm that in very experienced centres morbidity and mortality after extended gastrectomy can be as low as those showed by Japanese authors. They also suggest that D2 gastrectomies with pancreas preservation are not followed by significantly higher morbidity and mortality than D1 resections.

Recovery, visualization, and analysis of actin and tubulin polymer flow in live cells: a fluorescent speckle microscopy study

Fluorescent speckle microscopy (FSM) is becoming the technique of choice for analyzing in vivo the dynamics of polymer assemblies, such as the cytoskeleton. The massive amount of data produced by this method calls for computational approaches to recover the quantities of interest; namely, the polymerization and depolymerization activities and the motions undergone by the cytoskeleton over time. Attempts toward this goal have been hampered by the limited signal-to-noise ratio of typical FSM data, by the constant appearance and disappearance of speckles due to polymer turnover, and by the presence of flow singularities characteristic of many cytoskeletal polymer assemblies. To deal with these problems, we present a particle-based method for tracking fluorescent speckles in time-lapse FSM image series, based on ideas from operational research and graph theory. Our software delivers the displacements of thousands of speckles between consecutive frames, taking into account that speckles may appear and disappear. In this article we exploit this information to recover the speckle flow field. First, the software is tested on synthetic data to validate our methods. We then apply it to mapping filamentous actin retrograde flow at the front edge of migrating newt lung epithelial cells. Our results confirm findings from previously published kymograph analyses and manual tracking of such FSM data and illustrate the power of automated tracking for generating complete and quantitative flow measurements. Third, we analyze microtubule poleward flux in mitotic metaphase spindles assembled in Xenopus egg extracts, bringing new insight into the dynamics of microtubule assemblies in this system.

Computational analysis of F-actin turnover in cortical actin meshworks using fluorescent speckle microscopy

Fluorescent speckle microscopy (FSM) is a new imaging technique with the potential for simultaneous visualization of translocation and dynamic turnover of polymer structures. However, the use of FSM has been limited by the lack of specialized software for analysis of the positional and photometric fluctuations of hundreds of thousand speckles in an FSM time-lapse series, and for translating this data into biologically relevant information. In this paper we present a first version of a software for automated analysis of FSM movies. We focus on mapping the assembly and disassembly kinetics of a polymer meshwork. As a model system we have employed cortical F-actin meshworks in live newt lung epithelial cells. We lay out the algorithm in detail and present results of our analysis. The high spatial and temporal resolution of our maps reveals a kinetic cycling of F-actin, where phases of polymerization alternate with depolymerization in a spatially coordinated fashion. The cycle rates change when treating cells with a low dose of the drug latrunculin A. This shows the potential of this technique for future quantitative screening of drugs affecting the actin cytoskeleton. Various control experiments demonstrate that the algorithm is robust with respect to intensity variations due to noise and photobleaching and that effects of focus plane drifts can be eliminated by manual refocusing during image acquisition.

An economic evaluation of the optimal workload in treating surgical patients in a breast unit

A breast unit is a cancer centre specialised in the diagnosis and treatment of patients with breast cancer. The high level of specialised skills involved in running a breast unit makes it an expensive pattern of care. The European Society of Mastology (EUSOMA) recommends a minimum caseload of 150 cases sufficient to maintain expertise for each team member and to ensure cost-effective working of the breast unit. Specific economic analysis evaluating main diagnostic services (radiology and pathology) and treatment are needed. The present study assesses the activity level at which the breast unit represents good value for money in surgically-treated patients. Cost assessment is realised by defining a cost function according to the following assumptions: cost function input is personnel costs and technical equipment and output is the number of newly diagnosed cases of primary breast cancer admitted to the breast care unit each year. The increase from 50 new cancer cases per year to 100 will reduce average costs by almost 50%. Cost reduction is important up to a volume of 200 new cases per year. For economic investment to be justified, it is desirable that intake rises to at least 200 new cases per year. Our result is in-line with the EUSOMA recommendation.

How CA 125 is used in the routine follow-up of ovarian cancer: a survey of 29 Italian hospitals

Tumor markers are currently monitored on a routine basis. However, their impact on the course of a disease is still under debate. This relative uncertainty leads to a subjective approach to their use. In order to evaluate the range in the pattern of tumor marker application we carried out a survey on the follow-up of patients with ovarian, breast, and colorectal carcinomas. This report concerns only ovarian cancer. Preliminary results showed that the number of markers used, the cutoff point and, probably of major importance, the management of patients with positive tumor marker vary considerably. When evaluating the institutional setting of the surveyed hospitals, a relatively poor interaction between clinicians and the laboratory staff was found. Actually, in about half of the investigated centers, clinical information is not provided to the laboratory staff and methodological aspects are not reported to clinicians, too. The first step to increase the effectiveness of tumor markers is to improve cooperation between persons assaying the markers and those using them. This is a mandatory task in order to both enable the application of recommendations provided by guidelines and to provide the means to verify their rate of acceptance.

[Generic screening for breast cancer]

Following the cloning of BRCA1 and BRCA2 it has been suggested that genetic screening may be of benefit for women at high familial risk. To be able to assess whether this is the case more research is needed on the penetrance of the different mutations, their prevalence in the population, the biological and environmental factors affecting the development of cancer in mutation carriers and the natural history of genetically determined breast cancer. Furthermore, studies on the efficacy of preventive measures, on counselling and on psychological effects of testing are also needed.