Home-care educational interventions to prevent complications in patients with Ventricular Assist Devices: a systematic review

Background

The implantation of ventricular assist devices is the only effective alternative to cardiac transplantation in patients with chronic heart failure, in terms of survival and quality of life. However, their implantation can lead to physical and psychological complications, potentially preventable, especially in the long term, through patients' education. This research aimed to summarize the current best evidence on educational strategies towards patients after implantation of ventricular assist devices, in home-care setting, to reduce the major related complications, namely driveline infections, gastrointestinal bleeding and psychological complications.

Study Design

Systematic review.

Methods

Title and abstract selection, full-text screening, study quality assessment, and data extraction followed the PRISMA protocol and the Cochrane Handbook for Systematic Reviews of Interventions. The search was conducted through consultation of databases such as Medline, Scopus, EMBASE, and Web of Science, during the period from March 2022 to December 2022, in relation to English-language articles, from search strings processing and inclusion and exclusion criteria.

Results

Of the 1,231 items identified, 9 were selected because consistent with the inclusion criteria. The most effective educational interventions toward patients with ventricular assist devices were identified, delivered by multidisciplinary teams coordinated by a professional expert in management of ventricular assist devices, and regularly conducted. In particular, gastrointestinal bleeding and driveline infections could be prevented and reduced by complex, multimodal educational interventions, including telephone and app interventions. Educational strategies based on verbal instructions, hands-on demonstrations, innovative technologies, and active involvement of families/caregivers were particularly effective in preventing psychological complications.

Conclusions

Investing time and resources in educating patients with ventricular assist devices is mandatory, given the significant impact of educational outcomes on complications' reduction. Moreover, educational interventions geared towards patient's psychological well-being, brings positive outcomes on patient's compliance too, resulting in promising clinical outcomes. However, more in-depth research is needed, to support professionals in developing effective educational plans for such fragile and complex patients.

Is subareolar intraoperative biopsy still necessary to predict nipple involvement?

OBJECTIVE

To predict the occult tumor involvement of nipple-areola complex (NAC) using preoperative MR imaging and to investigate whether the intraoperative histopathological examination of the subareolar tissue is still necessary.

PATIENTS AND METHODS

Out of 712 patients submitted to nipple-sparing mastectomy (NSM) between 2014 and 2019, we selected 188 patients who underwent preoperative breast MRI. Breast MRI and intraoperative histopathological examination of the subareolar tissue were performed to predict NAC involvement at permanent pathology. All parameters were correlated with final pathological NAC assessment by univariate and multivariate analysis.

RESULTS

Forty-three patients (22.9%) had tumor involvement of the NAC. At univariate analysis, non-mass enhancement type (p = 0.009), multifocality/multicentricity (p = 0.002), median tumor size (p < 0.001), median tumor-NAC distance measured by MRI (p < 0.001), tumor-NAC distance ≤ 10 mm (p < 0.001) and tumor-NAC distance ≤ 20 mm (p < 0.001), and lymphovascular invasion (p = 0.001) were significantly correlated with NAC involvement. At multivariate analysis, only tumor-NAC distance ≤ 10 mm retained statistical significance. The sensitivity and specificity of MRI tumor-NAC distance ≤ 10 mm were 79.1% and 97.2% and those of intraoperative pathologic assessment were 74,4% and 100%, respectively.

CONCLUSIONS

Tumor-NAC distance is the only reliable MRI characteristic that can predict NAC involvement in breast cancer patients. Although several cut-offs showed promising performances, intraoperative pathologic assessment is still mandatory.

Abstract P1-11-03: Impact of scalp cooling device (SCD) in preventing alopecia in women undergoing chemotherapy for breast cancer

Background.

Alopecia (A) is a common and emotionally traumatic adverse effect for breast cancer (BC) patients (pts) undergoing chemotherapy (CT). Food and Drug Administration (FDA) cleared the DigniCap® SCD, for patients with breast cancer in 2015. This device was designed to reduce hair loss during chemotherapy. However, the impact of SCD in pts undergoing anthracycline and taxane-based sequential regimen is not entirely established. Thus, the aim of this analysis was to prospectively explore the role of SCD in a cohort of pts including also this regimen.

Methods.

From February 2016 to June 2018 patients with early/locally advanced breast cancer treated with neoadjuvant/adjuvant CT including anthracycline, taxane or both in sequential regimen were enrolled. The estimate of hair-loss was evaluated by photographs of the head using the Dean scale during and one month after the end of chemotherapy. Alopecia was graduated according to Dean scale: G0 = no A; G1 &lt; 25% A; G2 = 25–50% A; G3 = 50–75% A; G4 &gt; 75%. A score of 0-2 (≤ 50% hair loss) was defined as treatment success. Tolerability was defined as the percentage of patients who completed all chemotherapy cycles using the SCD. All patients received the Patient Symptoms Survey (self-reported). A database for individual data and information was appropriately fulfilled. Descriptive statistics was adopted.

Results.

Overall 121 pts were enrolled; 118 pts were evaluable for efficacy of Dignicap® SCD. Median age was 44 years (range: 24-74 years). CT regimens included docetaxel/cyclophosphamide (37 pts), epirubicin (90 mg/m2) and cyclophosphamide (600 mg/m2 iv) three weekly followed by 12 courses of paclitaxel (80 mg/m2 iv weekly) (84 pts). Alopecia all grade was showed in 52.5% (n=62): G1 in 35 pts (29.6%)and G2 in 23 pts (19.5%). No hair loss in 42 pts (35.6 %). Treatment success was seen in 103 pts (87.3%). Toxicity included grade 1/2 headache in 56 pts (47.4%), cervical discomfort in 36 pts (30.5%), pain of skin in one pts (8.5%). Discontinuation of SCD was seen in 28 pts (23.7%) primarily for headache G3 (4 pts – 3.4%), hair loss G3 in 15 pts (12.7%), discomfort in 8 pts (6.8%), use of head cover in one pt (0.8%).

Conclusions.

This prospective observational study suggests that SCD is effective in preventing A in a relevant number of patients (87.3%), undergoing also anthracyclines followed by taxanes regimen in sequential schedule.

Citation Format: Paris I, Accetta C, Carbognin L, Di Giorgio D, Magno S, Terribile D, Franceschini G, Sanchez M, Ferrandina G, Pasciuto T, Fulvi A, Scambia G, Masetti R. Impact of scalp cooling device (SCD) in preventing alopecia in women undergoing chemotherapy for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-03.

Role of DWI assessing nodal involvement and response to neoadjuvant chemotherapy in advanced breast cancer

OBJECTIVE

To explore the role of diffusion-weighted imaging (DWI) in the staging of axillary lymph nodes and the restaging after neoadjuvant chemotherapy (NAD) in advanced breast cancer.

PATIENTS AND METHODS

MRI examinations of forty-two patients diagnosed with advanced breast cancer addressed to NAD and axillary lymph node dissection (ALND) were reviewed. Apparent diffusion coefficients (ADC) of each visible node in DWI in the pathologic axilla (PA) and healthy axilla (HA) were measured at the time of diagnosis (t0) and after chemotherapy (t1); mean values of the ADC were calculated. Patients were classified as responders (R), non-responders (NR), macrometastasis (MA), micrometastasis (Mi).

RESULTS

Mean ADC was 0.92 ± 0.07 x 10-3 mm2/sec at t0 and 0.97 ± 0.06 x 10-3 mm2/sec at t1 (p = 0.284) in PA, 0.89 ± 0.06 x 10-3 mm2/sec at t0 and 0.92 ± 0.06 x 10-3 mm2/sec at t1 (p = 0.403) in HA, 0.95 ± 0.111 x 10-3 mm2/sec at t0 and 0.95 ± 0.14 x 10-3 mm2/sec at t1 (p = 0.954) in R group, 0.90 ± 0.09 x 10-3 mm2/sec at t0 and 0.97 ± 0.07 x 10-3 mm2/sec at t1 (p = 0.085) in NR group, 0.86 ± 0.10 x 10-3 mm2/sec at t0 and 0.99 ± 0.09 x 10-3 mm2/sec at t1 (p = 0.055) in MA, and 0.99 ± 0.23 x 10-3 mm2/sec at t0 and 0.95 ± 0.15 x 10-3 mm2/sec at t1 in Mi (p = 0.667).

CONCLUSIONS

Mean ADC between PA and HA, R and NR, MA and Mi did not significantly differ at t0 and t1 (p > 0.05). Variation in mean ADC between t0 and t1 was not significant in all groups (p > 0.05), except for a trend toward significance (p = 0.055) in MA. DWI has a potential role in restaging of macrometastatic axillary nodes after NAD.

New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient

The surgical management of breast cancer has undergone continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long, but constant, despite the controversies that appeared every time a new procedure came to light. Today, the aesthetic satisfaction of breast cancer patients coupled with the oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and cosmesis by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present work will highlight the new surgical treatment options increasingly efficacy and respectful of breast cancer patients.

Genetic determinants of HDL metabolism

Plasma high density lipoproteins (HDL) comprise a highly heterogeneous family of lipoprotein particles, with subclasses that can be separated and identified according to density, size, surface charge as well as shape and protein composition. There is evidence that these subclasses may differ in their functional properties. The individual plasma HDL cholesterol (HDL-C) level is generally taken as a snapshot of the steady-state concentration of all circulating HDL subclasses together, but this is insufficient to capture the structural and functional variation in HDL particles. HDL are continuously remodeled and metabolized in plasma and interstitial fluids, through the interaction with a large number of factors, including structural proteins, membrane transporters, enzymes, transfer proteins and receptors. Genetic variation in these factors can lead to essential changes in plasma HDL levels, and to remarkable changes in HDL particle density, size, surface charge, shape, and composition in lipids and apolipoproteins. This review discusses the impact of rare mutations and common variants in genes encoding factors involved in HDL remodeling and metabolism on plasma HDL-C levels and particle distribution. The study of the effects of human genetic variation in major players in HDL metabolism provides important clues on how individual factors modulate the formation, maturation, remodeling and catabolism of HDL.

Acquired lecithin:cholesterol acyltransferase deficiency as a major factor in lowering plasma HDL levels in chronic kidney disease

OBJECTIVES

It has been suggested that a low plasma high-density lipoprotein cholesterol (HDL-C) level contributes to the high cardiovascular disease risk of patients with chronic kidney disease (CKD), especially those undergoing haemodialysis (HD). The present study was conducted to gain further understanding of the mechanism(s) responsible for the low HDL-C levels in patients with CKD and to separate the impact of HD from that of the underlying CKD.

METHODS

Plasma lipids and lipoproteins, HDL subclasses and various cholesterol esterification parameters were measured in a total of 248 patients with CKD, 198 of whom were undergoing HD treatment and 40 healthy subjects.

RESULTS

Chronic kidney disease was found to be associated with highly significant reductions in plasma HDL-C, unesterified cholesterol, apolipoprotein (apo)A-I, apoA-II and LpA-I:A-II levels in both CKD cohorts (with and without HD treatment). The cholesterol esterification process was markedly impaired, as indicated by reductions in plasma lecithin:cholesterol acyltransferase (LCAT) concentration and activity and cholesterol esterification rate, and by an increase in the plasma preβ-HDL content. HD treatment was associated with a further lowering of HDL levels and impaired plasma cholesterol esterification. The plasma HDL-C level was highly significantly correlated with LCAT concentration (R = 0.438, P < 0.001), LCAT activity (R = 0.243, P < 0.001) and cholesterol esterification rate (R = 0.149, P = 0.031). Highly significant correlations were also found between plasma LCAT concentration and levels of apoA-I (R = 0.432, P < 0.001), apoA-II (R = 0.275, P < 0.001), LpA-I (R = 0.326, P < 0.001) and LpA-I:A-II (R = 0.346, P < 0.001).

CONCLUSION

Acquired LCAT deficiency is a major cause of low plasma HDL levels in patients with CKD, thus LCAT is an attractive target for therapeutic intervention to reverse dyslipidaemia, and possibly lower the cardiovascular disease risk in these patients.

Update on oncoplastic breast surgery

Oncoplastic surgery of the breast (OPS) has generated great excitement over the past years and has become an integrated component of the surgical treatment of breast cancer. Oncoplastic surgical procedures associate the best surgical oncologic principles to achieve wide tumor-free margins with the best principles of plastic surgery to optimize cosmetic outcomes. Thanks to oncoplastic techniques, the role of breast conserving surgery (BCS) has been extended to include a group of patients who would otherwise require mastectomy to achieve adequate tumor clearance. As OPS continues to gain acceptance and diffusion, an optimal and systematic approach to these techniques is becoming increasingly necessary. This article has the aim to review the essential principles and techniques associated with oncoplastic surgery, based on the data acquired through an extensive search of the PUBMED and MEDLINE database for articles published using the key words "breast cancer oncoplastic surgery". This review analyzes possible the advantages", classifications, indications, and the criteria for a proper selection of oncoplastic techniques to facilitate one's ability to master these procedures and make OPS a safe and an effective procedure.

The role of oxidized regenerate cellulose to prevent cosmetic defects in oncoplastic breast surgery

BACKGROUND

Breast conserving surgery (BCS) combined with postoperative radiotherapy has become the gold standard of locoregional treatment for the majority of patients with early-stage breast cancer, offering equivalent survival and improved body image and lifestyle scores as compared to mastectomy. In an attempt to optimize the oncologic safety and cosmetic results of BCS, oncoplastic procedures (OPP) have been introduced in recent years combining the best principles of surgical oncology with those of plastic surgery. However, even with the use of OPP, cosmetic outcomes may result unsatisfying when a large volume of parenchyma has to be removed, particularly in small-medium size breasts.

AIM

The aim of this article is to report our preliminary results with the use of oxidized regenerate cellulose (ORC) (Tabotamp fibrillar, Johnson & Johnson; Ethicon, USA) as an agent to prevent cosmetic defects in patients undergoing OPP for breast cancer and to analyze the technical refinements that can enhance its efficacy in optimizing cosmetic defects.

METHODS

Different OPP are selected based on the location and size of the tumor as well as volume and shape of the breast. After excision of the tumor, glandular flaps are created by dissection of the residual parenchyma from the pectoralis and serratus muscles and from the skin. After careful haemostasis, five layers of ORC are positioned on the pectoralis major in the residual cavity and covered by advancement of the glandular flaps. Two additional layers of ORC are positioned above the flaps and covered by cutaneous-subcutaenous flaps.

RESULTS

The use of ORC after OPP has shown promising preliminary results, indicating a good tolerability and positive effects on cosmesis.

CONCLUSIONS

This simple and reliable surgical technique may allow not only to reduce the rate of post-operative bleeding and infection at the surgical site but also to improve cosmetic results.

Diffusion-weighted imaging in breast cancer: relationship between apparent diffusion coefficient and tumour aggressiveness

AIM

To assess the utility of diffusion-weighted imaging in diagnosing and characterizing breast malignancy.

MATERIALS AND METHODS

From April 2006 to April 2009, all consecutive patients with breast cancer undergoing breast magnetic resonance imaging (MRI) and subsequent surgery in our hospital were enrolled in this study. MRI was performed using a 1.5 T MRI unit using a dedicated, bilateral, four-channel breast coil. The MRI protocol included a diffusion sequence acquired using b values of 0 and 1000 s/mm(2). For each malignant lesion the relationships between tumour grade and histology and the relative value of the apparent diffusion coefficient (ADC) were analysed.

RESULTS

There were 136 female patients with 162 lesions. Histology revealed 149 invasive carcinomas and 13 ductal carcinomas in situ. There were 34 grade 1, 61 grade 2, and 67 grade 3 lesions. The mean ADC value of all malignant lesions was 1.03×10(-3) mm(2)/s. The mean ADC values for invasive and in situ carcinomas were 1.03×10(-3) mm(2)/s and 1.05×10(-3) mm(2)/s, respectively. The mean ADC values for grade 1, 2, and 3 tumours were 1.25×10(-3) mm(2)/s, 1.02×10(-3) mm(2)/s, and 0.92×10(-3) mm(2)/s, respectively. A statistically significant (p<0.001) inverse correlation was disclosed between the ADC value and the tumour grading. The mean ADC value of the "less aggressive" group of disease (G1 and in situ lesions) was 1.19×10(-3) mm(2)/s, whereas the mean ADC value of the "more aggressive" group (G2-G3 invasive carcinomas) was 0.96×10(-3) mm(2)/s (p<0.001).

CONCLUSION

The study confirms the usefulness of diffusion imaging in assessing the aggressiveness of breast tumours. ADC appears to be a promising parameter in the evaluation of the degree of malignancy of breast cancer tissue.

High uptake of colonoscopy in first-degree relatives of patients with colorectal cancer in a healthcare region: a population-based, prospective study

BACKGROUND AND STUDY AIMS

A screening program in first-degree relatives (FDRs) of colorectal cancer (CRC) patients (index patients) was started in Trentino, Italy, to analyze factors that influence uptake of CRC screening among invited FDRs (first objective) and to describe colorectal findings among those undergoing colonoscopy (secondary objective).

PATIENTS AND METHODS

FDRs aged between 45 and 75 years were invited; exclusion criteria were: colonoscopy or barium enema in the preceding 5 years, a history of familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, inflammatory bowel diseases, and severe comorbidities. FDRs who were eligible but were not invited for screening because consent was not obtained from the index patients were considered as the control group. FDRs were invited by the education campaign targeted at the population at risk (both study and control groups); in the study group, interventions targeting individuals at risk (letters, phone calls, face-to-face counseling) were implemented.

RESULTS

Starting from 626 new index cases of diagnosed CRC, 725 FDRs were invited to counseling; 77.6 % of these attended for colonoscopy in the study group vs. 8 % in the control group ( P < 0.0001). Predictors of colonoscopy uptake were FDR age above 60 years [odds ratio (OR) 2.50, 95 %CI 1.72 - 3.62], complex family history (simple family history: one CRC at age above 60 years; complex family history: one CRC at age below 60 or two or more CRC; OR 1.54; 95 %CI 1.04 - 2.33) and living in a rural area (OR 1.64, 95 %CI 1.12 - 2.44). Of the 560 FDRs in the study group, 186 (33.8 %) had adenomas, and 48 (8.8 %) had advanced adenomas or cancer.

CONCLUSIONS

Interventions that target FDRs of patients with CRC, especially those younger than 60 years, with a complex family history of CRC and who live in a rural area, may improve uptake of CRC screening via colonoscopy.

Parametric analysis of the strength in the ''Toronto'' osseous-prosthesis system

AIM

The aim of this work is to analyze how the different distributions of the chewing load could be related to dental prosthesis fractures of the Toronto restoration via the fulfilment of a virtual parametric model. Moreover investigation about implant positions and perspectives in comparison with a virtual medial plane was made to evaluate the incidence of screw and prosthesis breakage.

METHODS

Finite element analysis of the lower jaw was performed to underline parameters and mechanical features of dental implants connected with the fractures of the prosthetic restoration. Jaw virtual model and 3D fixtures (Global Sweden and Martina) were created by Cosmos-Solid Works. Matlab was used to recreate the distribution of an unspecific chewing phase analyzing the overall load on the fixtures of the lower jaw.

RESULTS

Four virtual 3D models were performed with Matchad 14, for data analysis. The study investigated frontal and horizontal planes and vertical direction of the occlusal forces. Data results showed how position and perspective of fixtures strongly influenced the stress distribution upon the bone of the jaw; safeguard of prostheses elements like cantilever, passing screws, and dental implants are strictly related to a correct selection of the dental implant position.

CONCLUSIONS

The 3D geometry of the jaw is an important condition for the choice of position, number, diameter and length of dental implants used for Toronto prostheses. This study would suggest a virtual ''method'' to help the surgeon choosing a correct model for a prosthetic rehabilitation evaluating position, perspective, and stress distribution of the chewing strengths.

Conservative and radical oncoplastic approches in the surgical treatment of breast cancer

In the attempt to optimise the balance between the risk of local recurrence and the cosmetic outcomes in breast surgery, new surgical procedures, so-called oncoplastic techniques, have been introduced in recent years. The term oncoplastic surgery refers to surgery on the basis of oncological principles during which the techniques of plastic surgery are used, mostly for reconstructive and cosmetic reasons. The advantage of the oncoplastic surgery for breast cancer is the possibility of performing a wider excision of the tumour with a good cosmetic result. Oncoplastic surgery is a broad concept that can be used for several different combinations of oncological surgery and plastic surgery: excision of the tumour by reduction mammoplasty, tumour excision followed by remodelling mammoplasty, mastectomy with immediate reconstruction of the breast and partial mastectomy with reconstruction. Careful patient selection and preoperative planning are key components for the success of any oncoplastic operation for breast cancer. Accurate preoperative evaluation of the clinical and biological features of the tumour as well as of the morphological aspects of the breast allow the surgeon to make a decision if a conservative or radical approach is preferable and select the most effective oncoplastic surgical technique. In this review we summarise the indications, advantages and limitations of several oncoplastic procedures.

Conservative treatment of the central breast cancer with nipple-areolar resection: an alternative oncoplastic technique

Conservative surgery with radiation therapy is the standard treatment for early-stage breast cancer. Nevertheless, the patients with subareolar breast cancer have been often excluded from breast-conserving surgery and treated with mastectomy because of the unacceptable cosmetic effect associated with the resection of the nipple-areola complex (NAC), as well as oncologic concerns about multicentricity or multifocality associated with these tumours. We show a conservative "oncoplastic technique" in which the resection of the central portion of the breast, including the NAC, can allow a wide excision of the tumour with uninvolved margins of resection and good cosmetic results.

Solid breast mass characterisation: use of the sonographic BI-RADS classification

PURPOSE

The aim of this study was to assess the reliability of the sonographic Breast Imaging Reporting and Data System (BI-RADS) classification in differentiating benign from malignant breast masses.

MATERIALS AND METHODS

A total of 292 female patients with breast masses undergoing biopsy between November 2004 and March 2006 in our department were included in this study. All lesions were classified according to the sonographic BI-RADS lexicon. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) for the sonographic BI-RADS lexicon and PPV and NPV for each lesion category and each sonographic descriptor were calculated. The chi(2) test and the Fischer exact test were used to evaluate our results.

RESULTS

Univariate analysis showed a significant difference between malignant and benign groups with regard to morphology (p<0.001), horizontal-vertical diameter ratio<1 (p<0.002), orientation (p<0.001), noncircumscribed margins (p<0.001), echogenic halo (p<0.001), hypoechoic pattern (p=0.035), shadowing (p<0.001) and surrounding tissue alterations (p=0.001). The cumulative risk for malignancy was 64 and 10 times higher, respectively, in categories 5 and 4 than in category 3.

CONCLUSIONS

The sonographic BI-RADS lexicon is an important system for describing and classifying breast lesions.

Update in the treatment of locally advanced breast cancer: a multidisciplinary approach

Locally advanced breast cancer represents a wide variety of neoplasms and constitutes approximately 10%-20% of the newly diagnosed breast cancers. These cancers may have widely different clinical and biological characteristics. According to the American Joint Committee on Cancer (AJCC) staging system, all of stage III disease is considered locally advanced. The clinical treatment of locally advanced breast cancer is complex and should be tailored to the individual patient. In this paper we discuss the options of management of locally advanced breast cancer, focusing on a multidisciplinary approach through a combined-modality care involving surgery, radiotherapy and systemic therapy.

Management of locally advanced breast cancer. Mini-review

The term locally advanced breast cancer (LABC) encompasses a heterogeneous group of breast neoplasms; in the last revision of the American Joint Committee on Cancer (AJCC) staging system, all of stage III disease is considered locally advanced. LABC constitutes up to 20% of breast cancer in medically underserved populations in the United States and up to 75% of breast cancers in developing countries. The prognosis depends on tumor size, extent of lymph node involvement, and the presence or absence of an inflammatory component. The clinical management of LABC is complex and should be tailored to the individual patient. However, a multidisciplinary approach is always recommended combining surgery, radiotherapy and systemic therapy (chemotherapy and/or hormone therapy). In this paper, we discuss the possible options in the management of operable (stage IIIA) and inoperable (stage IIIB-IIIC) LABC.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

Background

Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.

Case presentation

We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.

Conclusion

To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

Epidemiologic evidence for high-density lipoprotein cholesterol as a risk factor for coronary artery disease

Plasma high-density lipoprotein cholesterol (HDL-C) is inversely related to coronary artery disease incidence in both women and men, with a proportionately increasing effect of HDL-C throughout the average (or slightly above average)-to-low concentration range. A substantial body of evidence from major epidemiologic studies has established that this coronary artery disease risk associated with HDL-C is entirely independent of plasma low-density lipoprotein cholesterol, other lipid parameters (triglycerides, total cholesterol), and other nonlipid risk factors. The coronary artery disease relative risk for patients with low levels of HDL-C in conjunction with low total cholesterol is also markedly higher than in patients with a profile of high levels of these 2 lipid parameters. Similarly, the risk associated with a low HDL-C level is of particular significance in patients with established coronary artery disease or with type 2 diabetes, and it is a more pertinent factor to consider when managing dyslipidemia.

Limited proteolysis of a disulfide-linked apoA-I dimer in reconstituted HDL

The apolipoprotein A-I(Milano) (apoA-I(M)) is a molecular variant of apoA-I characterized by the Arg(173)-->Cys substitution, leading to the formation of homodimers A-I(M)/A-I(M). Upon interaction with palmitoyloleoylphosphatidylcholine, A-I(M)/A-I(M) forms only two species of reconstituted HDL (rHDL) particles, with diameters of 7.8 and 12.5 nm. We used limited proteolysis to analyze the conformation of A-I(M)/A-I(M) in the two rHDL particles, in comparison with that of apoA-I in rHDL of similar size. ApoA-I in the small, 7.8-nm rHDL is degraded to a greater extent (50% after 6 h) than in the large rHDL (<10% degraded after 6 h). The protease susceptibility of A-I(M)/A-I(M) in small and large rHDL is instead remarkably the same, with A-I(M)/A-I(M) being much more sensitive to proteolytic digestion (50% degraded after 10 min) than apoA-I. The identification of the proteolytic fragments by immunoblotting, N-terminal sequencing, and molecular mass determination, shows that the N-terminus of both proteins is resistant to proteolysis, with six cleavage sites located in the central and carboxy-terminal portions of the molecules. Cleavage in the middle of apoA-I occurs at distinct sites in 7.8-nm (Lys(118)) and 12.7-nm (Arg(123)) rHDL, indicating a different conformation in small and large rHDL particles. The A-I(M)/A-I(M) instead adopts a unique and identical conformation in small and large rHDL, with the carboxy-terminal portion of the molecule being remarkably more accessible to the proteases than in apoA-I. This suggests the presence of a novel carboxy-terminal domain in A-I(M)/A-I(M), not organized in a compact structure and not shared by wild-type apoA-I, which may account for the unique functional properties of A-I(M)/A-I(M).

Development of a lipid-rich, soft plaque in rabbits, monitored by histology and intravascular ultrasound

Lipid rich, soft plaques in the clinic are a common forerunner to occlusive thrombus formation, even with modest arterial stenosis. Animal models of atherosclerosis, obtained by various methods, do not generally allow direct in vivo evaluation of the lesion and, furthermore, cannot be examined more than once. The aim of the study was the generation of a rabbit model of atherosclerosis, with morphological characteristics similar to human lipid-rich, soft atheromatous plaques, and the evaluation of the reliability of intravascular ultrasound (IVUS) technology in the study of the development of atherosclerotic lesions in this model. Briefly, New Zealand white rabbits undergo perivascular electrical injury at both common carotid arteries, together with a 1.5% cholesterol diet for up to 90 days. The lesioned arterial segments show progressive changes, from diffuse cellular mortality, to macrophage infiltration in the media, up to the final migration of macrophages to the neointima, resulting in bulky, eccentric, macrophage and lipid-rich lesions. At IVUS, the produced lesions clearly resemble those described as 'soft plaques' in the clinical setting, with minimal calcification and reduced echo-reflectivity versus the adventitial layer. Quantitative and morphometric analysis of plaques shows a significant correlation between histological and IVUS measurements at each time point. In conclusion, vascular injury in the common carotids of rabbits generates atherosclerotic lipid-rich, soft plaques, that can be properly assessed by the IVUS methodology. The easy accessibility of the arterial lesion allows serial IVUS investigations and the direct evaluation of a number of locally or generally delivered therapeutic agents.