Enhancing intraoperative tumor delineation with multispectral short-wave infrared fluorescence imaging and machine learning

SIGNIFICANCE

Fluorescence-guided surgery (FGS) provides specific real-time visualization of tumors, but intensity-based measurement of fluorescence is prone to errors. Multispectral imaging (MSI) in the short-wave infrared (SWIR) has the potential to improve tumor delineation by enabling machine-learning classification of pixels based on their spectral characteristics.

AIM

Determine whether MSI can be applied to FGS and combined with machine learning to provide a robust method for tumor visualization.

APPROACH

A multispectral SWIR fluorescence imaging device capable of collecting data from six spectral filters was constructed and deployed on neuroblastoma (NB) subcutaneous xenografts ( n = 6 ) after the injection of a NB-specific NIR-I fluorescent probe (Dinutuximab-IRDye800). We constructed image cubes representing fluorescence collected from ∼ 850 to 1450 nm and compared the performance of seven learning-based methods for pixel-by-pixel classification, including linear discriminant analysis, k -nearest neighbor classification, and a neural network.

RESULTS

The spectra of tumor and non-tumor tissue were subtly different and conserved between individuals. In classification, a combine principal component analysis and k -nearest-neighbor approach with area under curve normalization performed best, achieving 97.5% per-pixel classification accuracy (97.1%, 93.5%, and 99.2% for tumor, non-tumor tissue and background, respectively).

CONCLUSIONS

The development of dozens of new imaging agents provides a timely opportunity for multispectral SWIR imaging to revolutionize next-generation FGS.

Short-wave infrared imaging enables high-contrast fluorescence-guided surgery in neuroblastoma

Fluorescence-guided surgery is set to play a pivotal role in the intraoperative management of pediatric tumors. Short-wave infrared imaging (SWIR) has advantages over conventional near-infrared I (NIR-I) imaging with reduced tissue scattering and autofluorescence. Here, two NIR-I dyes (IRDye800CW and IR12), with long tails emitting in the SWIR range, were conjugated with a clinical-grade anti-GD2 monoclonal antibody (Dinutuximab-beta) to compare NIR-I and SWIR imaging for neuroblastoma surgery. A first-of-its-kind multispectral NIR-I/SWIR fluorescence imaging device was constructed to allow an objective comparison between the two imaging windows. Conjugates were first characterized in vitro. Tissue-mimicking phantoms, imaging specimens of known geometric and material composition, were used to assess the sensitivity and depth penetration of the NIR-I/SWIR device, showing a minimum detectable volume of ~0.9 mm3 and depth penetration up to 3 mm. In vivo, fluorescence imaging using the NIR-I/SWIR device showed a high tumor-to-background ratio (TBR) for both dyes, with anti-GD2-IR800 being significantly brighter than anti-GD2-IR12. Crucially, the system enabled higher TBR at SWIR wavelengths than at NIR-I wavelengths, verifying SWIR imaging enables high-contrast delineation of tumor margins. This work demonstrates that by combining the high-specificity of anti-GD2 antibodies with the availability and translatability of existing NIR-I dyes, along with the advantages of SWIR in terms of depth and tumor signal-to-background ratio, GD2-targeted NIR-I/SWIR-guided surgery could improve the treatment of neuroblastoma patients, warranting investigation in future clinical trials.

Dynamic Changes in Microvascular Density Can Predict Viable and Non-Viable Areas in High-Risk Neuroblastoma

Despite aggressive treatments, the prognosis of high-risk NB remains poor. Surgical oncology needs innovative intraoperative devices to help surgeons discriminate malignant tissue from necrotic and surrounding healthy tissues. Changes within the tumor vasculature could be used intraoperatively as a diagnostic tool to guide surgical resection. Here, we retrospectively analyzed the mean vascular density (MVD) of different NB subtypes at diagnosis and after induction chemotherapy using scanned histological samples. One patient was prospectively enrolled, and an ex vivo photoacoustic imaging (PAI) scan was performed on two representative sections to assess its capacity to discriminate different tumor regions. We found that post-chemotherapy, viable areas of differentiating NBs and ganglioneuroblastomas are associated with higher MVD compared to poorly differentiated NBs. Early necrotic regions showed higher MVD than late necrotic and viable regions. Finally, calcified areas showed significantly lower MVD than any other histological component. The acquired PAI images showed a good high-resolution ex vivo 3D delineation of NB margins. Overall, these results suggest that a high-definition preclinical imaging device such as PAI could potentially be exploited to guide surgical resection by identifying different vasculature signatures.

Shear wave elastography combined with electromyography to assess the effect of botulinum toxin on spastic dystonia following stroke: A pilot study

Background

Shear wave elastography (SWE) is a method for carrying out a quantitative assessment of the mechanical properties of soft tissues in terms of stiffness. In stroke survivors, the paretic muscles may develop hypertonia due to both neural-mediated mechanisms and structural alterations with consequent muscular fibrous-fatty remodeling.

Methods

Fourteen adult patients with spastic dystonia following stroke were recruited. Muscle hypertonia was assessed using the modified Ashworth scale (MAS). Muscle activation was measured by surface electromyography (sEMG) with the selected muscle in shortened (spastic dystonia) and stretched (dynamic stretch reflex) positions. SWE was performed on a selected paretic muscle and on the contralateral non-paretic one to calculate shear wave velocities (SWV) along and across muscular fibers. The modified Heckmatt scale (MHS) pattern was also determined. All evaluations were performed shortly before BoNT-A injections (T0) and one month later (T1).

Results

All SWV on paretic muscles were higher than contralateral non-paretic ones (p < 0.01). After BoNT-A injection, a significant reduction in MAS (p = 0.0018), spastic dystonia (p = 0.0043), and longitudinal SWE measurements, both in shortened (p = 0.001) and in stretched muscular conditions (p = 0.0029), was observed. No significant changes in SWV on non-paretic muscles were observed. Higher SWV resulted along the direction of muscular fibers vs. across them (p = 0.001). No changes resulted from the MHS evaluations after BoNT-A. There was a positive correlation between MHS scores and SWV values while the muscle was in the shortened position, but not with spastic dystonia recorded by sEMG.

Conclusions

This is the first study evaluating the effect of BoNT-A on muscle hypertonia following stroke, assessed by both SWE and sEMG. These findings support SWE as a useful method to disclose intrinsic muscular remodeling, independently of the effect of spastic dystonia, in particular, while muscles were assessed in a neutral position. SWE measurements of muscle stiffness cannot tell apart neural-mediated and intrinsic muscle hypertonia. Interestingly, when sEMG activity is very limited, as in spastic muscles kept in a shortened position, SWE can provide a measurement of stiffness due almost completely to intrinsic muscle changes. Alongside sEMG, SWE could aid clinicians in the assessment of responses to treatments.

P-774 Risks management in a donor program: application of Failure Mode and Effect Analysis from gamete matching to gamete thawing

Study question

Is failure mode and effects analysis (FMEA) a useful and effective method of risk assessment in a gamete donor program?

Summary answer

The analysis of the potential failures, their causes and effects significantly improved the safety strategies previously adopted in our gamete donor program.

What is known already

At present, in Italy, the donation of fresh gametes is possible, but almost unmanageable due to the lack of donors and the refund to donors forbidden by law. As a result, many IVF Italian Centers established agreements with foreign gametes cryo-banks in order to meet the huge demand for donation treatments. The exchange of personal sensitive data and gametes between the sending and receiving centers represents a crucial aspect in a donor cycle. Each stage of this process, from gamete request to gamete thawing, is not error-free. FMEA represents a strategy to identify and mitigate potential failures before they occur.

Study design, size, duration

Fifty-eight oocyte and 4 sperm donation cycles were performed at our IVF facility from September 2019 to January 2021. Gametes came from a single Spanish cryo-bank. FMEA represents a proactive risk evaluation tool useful to identify real or potential failures and to develop actions to minimize risks. FMEA was conducted, in January 2021, by a team consisting of 2 gynaecologists, 3 embryologists and 2 quality managers and repeated 8 months later.

Participants/materials, setting, methods

Processes were analyzed to identify and score the potential failure modes using the risk priority number (RPN) scoring system. The calculation has been obtained by multiplying 3 factors: severity, occurrence and detectability scored from 1-5. After calculating the criticality of each failure mode, an action plan was prepared and then effectiveness of new process was monitored. Finally, FMEA was repeated and the improved RPN after the corrective actions was calculated.

Main results and the role of chance

In our gamete donation program, we mapped four phases: gamete request, donor-recipient matching, gamete delivery and gamete thawing. All the steps presented multiple failures and 11 different potential failure modes had been identified. Failure modes as the incorrect transcription of the recipient data, the acceptance of a donor proposal not well-matched with recipients and the receipt of gametes unsuitable for the couple correlate to high-risk scores with 30 RPN. These events may have severe consequences such as an incorrect matching between donor and recipient, and the subsequent birth of a child from a mismatched donor. Although gamete request, donor-recipient matching and receiving gametes phases are mainly characterized by document checking, the introduction of witnessing by another physician or embryologist, reduced the risk by 50%. Therefore, the introduction of double checking by a second operator represents an essential control measure to avoid errors.

Limitations, reasons for caution

This study is influenced by the general limitations of the FMEA approach, such as different personal experiences and skills of the participants since failures may be unrecognized, underestimated or overstated.

Wider implications of the findings

Performing a risk assessment in a donor program represents a valid strategy to mitigate risks of incorrect matching and loss of traceability. Since errors in data record and acceptance of donor proposal may cause important down streaming consequences, the double witnessing is strongly encouraged.

Trial registration number

NA

P-408 IL-10 and IL-17 pathway enrichment in uterine fluid-derived extracellular vesicles (UF-EVs) is associated with failed implantation in women with recurrent implantation failure undergoing PGT-A

Study question

Can the UF-EVs transcriptome provide markers of implantation in women diagnosed with recurrent implantation failure (RIF)?

Summary answer

Enrichment in IL-10 and IL-17 pathway transcripts in UF-EVs of women with RIF might identify those at risk for negative outcome after euploid blastocyst transfer.

What is known already

Our group has recently found that transcriptomic changes occur in UF-EVs during the window of implantation and closely resemble those occurring in the endometrial tissue. Patients affected by RIF represent a debated and heterogeneous population of patients who currently undergo several investigations, empirical therapies and embryo transfer attempts, with inconclusive results. We investigated whether UF-EVs can provide markers to define subgroups of patients within the RIF population, to predict outcomes and tailor interventions.

Study design, size, duration

We herein present the first sub-analysis of our previous larger observational study on the human UF-EVs transcriptome (Giacomini et al., 2021). RIF was defined by &gt; 3 failed embryo transfers (ETs) with high quality embryos and patients affected by RIF and undergoing their first PGT-A cycle were enrolled (n = 19). Fertile women undergoing PGT-A+PGT-M for monogenic diseases and achieving successful implantation were used as controls (n = 29). PGT-A was performed by Next Generation Sequencing.

Participants/materials, setting, methods

RNA-Seq was performed on UF-EVs collected on day LH + 7 of the cycle preceding that of the blastocyst transfer. Differential Gene Expression (DGE) analysis was performed between RIF patients failing implantation (Group A) versus RIF patients achieving implantation (Group B) and between Group A and fertile controls achieving implantation (Group C). Pre-ranked gene set enrichment (GSEA) with WebGestalt was used for pathway enrichment analysis, with Normalized Enrichment Score (NES) indicating the strength of the enrichment.

Main results and the role of chance

RIF patients had a mean (± SD) age of 36.6 (± 3.4) and 5.1 ± 2.1 (mean ± SD) previous failed ETs. DGE comparisons between UF-EVs of RIF women who failed implantation (n = 10) showed 135 up- and 32 down-regulated genes compared to Group B, and 258 up- and 44 down-regulated genes compared to Group C, with 63 genes showing consistent significantly different ‘expression’ values in both comparisons. UF-EVs of Group A were enriched in transcripts belonging to the IL-17 pathway compared to both groups (Group A vs B, NES=2.2044, FDR &lt;0.0001; Group A vs C, NES=2.3584, FDR &lt;0.0001).Also transcripts belonging to the IL-10 pathway were enriched compared to both groups (Group A vs B NES=2.2741, FDR = 0.002; Group A vs C NES=2.2047, FDR &lt; 0.0001). Among genes enriched in both DGE comparisons, C-X-C motif chemokine ligand (CXCL)1, CXCL2, CXCL8, and prostaglandin-endoperoxide synthase 2 (PTGS2) belonged to both the IL-10 and IL-17 pathway. On multivariate analysis controlling for relevant confounders (i.e. number of previous failed ETs), expression levels of CXCL8 emerged as a significant negative predictor of implantation (OR 0.675, 95%CI 0.493-0.925, p = 0.01).

Limitations, reasons for caution

As the main limitation of our study, we collected UFs in the cycle immediately preceding (and not corresponding to) the euploid ET. This approach was considered the most appropriate in relation to the current paucity of data regarding the safety of UF aspiration in the same cycle of an ET.

Wider implications of the findings

UF-EVs represent a source of transcriptomic markers related to the endometrial immune profile in RIF patients. Enrichment in the IL-17 and IL-10 pathways in this population could define the subgroup who is at risk for implantation failure even after euploid ET and who could potentially benefit from tailored immunotherapies.

Trial registration number

not applicable

Fluorescence-Guided Surgery (FGS) during a Laparoscopic Redo Nissen Fundoplication: The First Case in Children

We present the first case of fluorescence-guided surgery (FGS) using indocyanine green (ICG) in a pediatric redo-Nissen fundoplication. The patient is a 17-year-old male with recurrent gastroesophageal symptoms who underwent primary antireflux surgery at 10 months of age. During the redo fundoplication, ICG was intravenously administered to help the visualization during the adhesiolysis between liver, stomach and right crus of the diaphragm and to spare small oesophageal vessels and the left gastric artery. In this case, FGS made the surgery easier than usual and likely reduced the risk of intra-operative complications. Therefore, we believe that this new technology should be regularly used in these types of complex intra-abdominal redo operations.

Long-term active problems in patients with cloacal exstrophy: A systematic review

BACKGROUND

Cloacal exstrophy (CE) is the most severe end of the Exstrophy-Epispadias Complex malformations spectrum. Improvements in postnatal management and well-established operative techniques have resulted in survival rates approaching 100%. This systematic review aims to define the prevalence of long-term active medical problems affecting CE patients after the first decade of life.

METHODS

PubMed/Medline, Embase, Scopus, and ISI Web of Knowledge databases were used for the literature search. Original articles related to medical, surgical, and psychosocial long-term problems in CE patients >10 years of age were included in the study. Quality assessment of the articles was performed through the Newcastle-Ottawa Scale. Prevalence estimates and 95% CI were assessed for each outcome.

RESULTS

Twelve studies were included. The most common long-term active problems identified were: urinary incontinence with a prevalence ranging from 9.1% to 85%; sexual function issues related to vaginal anomalies with a prevalence ranging from 8.3% to 71.3%, and uterine anomalies, with a prevalence from 14.3% to 71%; gender identity issues in 46, XY patients raised female had a prevalence from 11.1% to 66.7%. There is no documented history of paternity. Impairment of ambulatory capacity was recorded in 13.8% of patients. Only one paper studied psychological well-being, reporting significantly higher levels of depression among gender reassigned patients.

CONCLUSIONS

Teenagers and adults born with CE have well defined long-term problems compared to the general population. Recognition and expert management are crucial to improve care and quality of life during and after the transition into adulthood.

Indocyanine Green-Based Fluorescence-Guided Surgery in a Male Infant with Anorectal Malformation

Reconstructive techniques for complex anorectal malformations (ARMs) require intestinal pull-through on vascular pedicles. Traditionally, the visual inspection of the intestinal perfusion is the sole modality adopted to assess tissue viability. In this article, we report the case of a child with a rectourethral prostatic fistula, who had a Peña's descending colostomy with distal mucous fistula in the neonatal period and a posterior sagittal anorectoplasty at 6 months of life. The ARM repair was guided by indocyanine green (ICG), which was intravenously administered to evaluate the blood flow of the intestinal pull-through using the EleVision IR system (Medtronic Ltd, U.K.). ICG-based fluorescence-guided surgery helped to define the proximal resection margin, impacting intraoperative decision making, and no postoperative complications occurred. We envisage that this technology will become part of the armory of pediatric surgeons soon, by reducing the risk of intra- and postoperative complications.

Above and Beyond Robotic Surgery and 3D Modelling in Paediatric Cancer Surgery

Although the survival rates for children's cancers have more than doubled in the last few decades, the surgical practise has not significantly changed. Among the most recent innovations introduced in the clinic, robotic surgery and augmented reality are two of the most promising, even if they are not widespread. The increased flexibility of the motion, the magnification of the surgical field and the tremor reduction provided by robotic surgery have been beneficial to perform complex oncological procedures in children. Besides, augmented reality has been proven helpful in planning for tumour removal, facilitating early discrimination between cancer and healthy organs. Nowadays, research in the field of surgical oncology is moving fast, and new technologies and innovations wich will help to shape a new way to perform cancer surgery. Paediatric surgeons need to be ready to adopt these novel devices and intraoperative techniques to allow more radical tumour resections with fewer complications. This review aims to present the mechanism of action and indications of several novel technologies such as optical imaging surgery, high definition cameras, and intraoperative loco-regional treatments. We hope this will enhance early adoption and more research on how to employ technology for the benefit of children.

Image-guided surgery and novel intraoperative devices for enhanced visualisation in general and paediatric surgery: a review

Fluorescence guided surgery, augmented reality, and intra-operative imaging devices are rapidly pervading the field of surgical interventions, equipping the surgeon with powerful tools capable of enhancing the surgical visualisation of anatomical normal and pathological structures. There is a wide range of possibilities in the adult population to use these novel technologies and devices in the guidance for surgical procedures and minimally invasive surgeries. Their applications and their use have also been increasingly growing in the field of paediatric surgery, where the detailed visualisation of small anatomical structures could reduce procedure time, minimising surgical complications and ultimately improve the outcome of surgery. This review aims to illustrate the mechanisms underlying these innovations and their main applications in the clinical setting.

123I-Meta-Iodobenzylguanidine Single-Photon Emission Computerized Tomography/Computerized Tomography Scintigraphy in the Management of Neuroblastoma

Neuroblastoma is the most common pediatric extracranial solid tumor. High-risk neuroblastoma is the most frequent presentation with an overall survival of approximately 50%. ¹²³I-meta-iodobenzylguanidine (¹²³I-mIBG) scintigraphy in the assessment of the primary tumor and its metastases at diagnosis and after chemotherapy is a cornerstone imaging modality. In particular, the bulk of skeletal metastatic disease evaluated with ¹²³I-mIBG at diagnosis and the following chemotherapy has a prognostic value. Currently, single-photon emission computerized tomography/computerised tomography (SPECT/CT) is considered a fundamental part of ¹²³I-mIBG scintigraphy. ¹²³I-mIBG SPECT/CT is a highly specific and sensitive imaging biomarker and it has been the basis of all existing neuroblastoma trials requiring molecular imaging. The introduction of SPECT/CT has shown not only the heterogeneity of the mIBG uptake within the primary tumor but also the presence of completely mIBG nonavid metastatic lesions with mIBG-avid primary neuroblastomas. It is currently possible to semi-quantitatively assess tracer uptake with standardized uptake value, which allows a more precise evaluation of the tracer avidity and can help monitor chemotherapy response. The patchy mIBG uptake has consequences from a theranostic perspective and may partly explain the failure of some neuroblastomas to respond to ¹³¹I-mIBG molecular radiotherapy. Various positron emission tomography tracers, targeting different aspects of neuroblastoma cell biology, are being tested as possible alternatives to ¹²³I-mIBG.

Anti-Müllerian hormone concentration as an indicator of female general health status: a cross-sectional study

RESEARCH QUESTION

To evaluate the correlation between clinical and hormonal parameters and comorbidity burden in Caucasian women presenting for fertility treatment.

DESIGN

Monocentric cross-sectional study including a cohort of 3163 Caucasian women seeking medical care for fertility treatment. All patients underwent centralized laboratory testing for hormonal assessment. Complete clinical and laboratory data from the entire cohort were retrospectively analysed. Comorbidity burden score was assessed by the Charlson Comorbidity Index (CCI; categorized as 0 versus 1 versus ≥2).

RESULTS

Descriptive statistics and regression models tested the associations between clinical and laboratory parameters and CCI. Among the entire cohort of patients, a CCI = 0 was found in 2977 women (94.1%), and CCI = 1 and CCI ≥2 were found in 113 (3.6%) and 73 (2.3%) patients, respectively. Age (P = 0.009), gravidity (P = 0.001), anti-Müllerian hormone (AMH, P < 0.001) and TSH (P = 0.003) values were significantly different among CCI groups. In regression models, age at presentation and AMH emerged as independent indicators of CCI ≥ 1. Age at presentation <36 years (odds ratio [OR] 1.742, 95% confidence interval [CI] 1.284-2.364) and an AMH concentration ≤2.3 ng/ml (OR 1.864, 95% CI 1.29-2.69) were the most informative cut-off values for CCI ≥ 1 in the study population.

CONCLUSIONS

A younger age at presentation and lower AMH concentrations are significant independent indicators of decreased general health in women requiring clinical evaluation for fertility treatment. As observed for sperm parameters in men, AMH might serve as a proxy of women's general health status.

Global transcriptomic changes occur in uterine fluid-derived extracellular vesicles during the endometrial window for embryo implantation

STUDY QUESTION

Are uterine fluid-derived extracellular vesicles (UF-EVs) a 'liquid biopsy' reservoir of biomarkers for real-time monitoring of endometrial status?

SUMMARY ANSWER

The transcriptomic cargo of UF-EVs reflects the RNA profile of the endometrial tissue as well as changes between the non-receptive and the receptive phase, possibly supporting its use for a novel endometrial receptivity test.

WHAT IS KNOWN ALREADY

EVs have been previously isolated from uterine fluid, where they likely contribute to the embryo-endometrium crosstalk during implantation. Based on a meta-analysis of studies on endometrial tissue implantation-associated genes and the human exosomes database, 28 of the 57 transcripts considered as receptivity markers refer to proteins present in human exosomes. However, the specific transcriptomic content of receptive phase UF-EVs has yet to be defined.

STUDY DESIGN, SIZE, DURATION

Two experimental series were set up. First, we simultaneously sequenced RNA species derived from paired UF-EVs and endometrial tissue samples collected from physiologically cycling women. Second, we analyzed RNA species of UF-EVs collected during the non-receptive (LH + 2) and receptive (LH + 7) phase of proven fertile women and from the receptive (LH + 7) phase of a population of women undergoing ART and transfer of euploid blastocysts.

PARTICIPANTS/MATERIALS, SETTING, METHODS

For paired UF-endometrial tissue sampling, endometrial tissue biopsies were obtained with the use of a Pipelle immediately after UF collection performed by lavage of the endometrial cavity. Overall, n = 87 UF samples were collected and fresh-processed for EV isolation and total RNA extraction, while western blotting was used to confirm the expression of EV protein markers of the isolated vesicles. Physical characterization of UF-EVs was performed by Nanoparticle Tracking Analysis. To define the transcriptomic cargo of UF-EV samples, RNA-seq libraries were successfully prepared from n = 83 UF-EVs samples and analyzed by RNA-seq analysis. Differential gene expression (DGE) analysis was used to compare RNA-seq results between different groups of samples. Functional enrichment analysis was performed by gene set enrichment analysis with g:Profiler. Pre-ranked gene set enrichment analysis (GSEA) with WebGestalt was used to compare RNA-seq results with the gene-set evaluated in a commercially available endometrial receptivity array.

MAIN RESULTS AND THE ROLE OF CHANCE

A highly significant correlation was found between transcriptional profiles of endometrial biopsies and pairwise UF-EV samples (Pearson's r = 0.70 P < 0.0001; Spearman's ρ = 0.65 P < 0.0001). In UF-EVs from fertile controls, 942 gene transcripts were more abundant and 1305 transcripts less abundant in the LH + 7 receptive versus the LH + 2 non-receptive phase. GSEA performed to evaluate concordance in transcriptional profile between the n = 238 genes included in the commercially available endometrial receptivity array and the LH + 7 versus LH + 2 UF-EV comparison demonstrated an extremely significant and consistent enrichment, with a normalized enrichment score (NES)=9.38 (P < 0.001) for transcripts up-regulated in LH + 7 in the commercial array and enriched in LH + 7 UF-EVs, and a NES = -5.40 (P < 0.001) for transcripts down-regulated in LH + 7 in the commercial array and depleted in LH + 7 UF-EVs. When analyzing LH + 7 UF-EVs of patients with successful versus failed implantation after transfer of one euploid blastocyst in the following cycle, we found 97 genes whose transcript levels were increased and 64 genes whose transcript levels were decreased in the group of women who achieved a pregnancy. GSEA performed to evaluate concordance in transcriptional profile between the commercially available endometrial receptivity array genes and the comparison of LH + 7 UF-EVs of women with successful versus failed implantation, demonstrated a significant enrichment with a NES = 2.14 (P = 0.001) for transcripts up-regulated in the commercial array in the receptive phase and enriched in UF-EVs of women who conceived, and a not significant NES = -1.18 (P = 0.3) for transcripts down-regulated in the commercial array and depleted in UF-EVs. In terms of physical features, UF-EVs showed a homogeneity among the different groups analyzed except for a slight but significant difference in EV size, being smaller in women with a successful implantation compared to patients who failed to conceive after euploid blastocyst transfer (mean diameter ± SD 205.5± 22.97 nm vs 221.5 ± 20.57 nm, respectively, P = 0.014).

LARGE SCALE DATA

Transcriptomic data were deposited in NCBI Gene Expression Omnibus (GEO) and can be retrieved using GEO series accession number: GSE158958.

LIMITATIONS, REASONS FOR CAUTION

Separation of RNA species associated with EV membranes might have been incomplete, and membrane-bound RNA species-rather than the internal RNA content of EVs-might have contributed to our RNA-seq results. Also, we cannot definitely distinguish the relative contribution of exosomes, microvesicles and apoptotic bodies to our findings. When considering patients undergoing ART, we did not collect UFs in the same cycle of the euploid embryo transfer but in the one immediately preceding. We considered this approach as the most appropriate in relation to the novel, explorative nature of our study. Based on our results, a validation of UF-EV RNA-seq analyses in the same cycle in which embryo transfer is performed could be hypothesized.

WIDER IMPLICATIONS OF THE FINDINGS

On the largest sample size of human EVs ever analyzed with RNA-seq, this study establishes a gene signature to use for less-invasive endometrial receptivity tests. This report is indeed the first to show that the transcriptome of UF-EVs correlates with the endometrial tissue transcriptome, that RNA signatures in UF-EVs change with endometrial status, and that UF-EVs could serve as a reservoir for potential less-invasive collection of receptivity markers. This article thus represents a step forward in the design of less-invasive approaches for real-time monitoring of endometrial status, necessary for advancing the field of reproductive medicine.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by a competitive grant from European Society of Human Reproduction and Embryology (ESHRE Research Grant 2016-1). The authors have no financial or non-financial competing interests to disclose.

TRIAL REGISTRATION NUMBER

NA.

Novel Treatments and Technologies Applied to the Cure of Neuroblastoma

Neuroblastoma (NB) is the most common extracranial solid tumour in childhood, accounting for approximately 15% of all cancer-related deaths in the paediatric population1. It is characterised by heterogeneous clinical behaviour in neonates and often adverse outcomes in toddlers. The overall survival of children with high-risk disease is around 40-50% despite the aggressive treatment protocols consisting of intensive chemotherapy, surgery, radiation therapy and hematopoietic stem cell transplantation2,3. There is an ongoing research effort to increase NB's cellular and molecular biology knowledge to translate essential findings into novel treatment strategies. This review aims to address new therapeutic modalities emerging from preclinical studies offering a unique translational opportunity for NB treatment.

Comparison Between Diffusion-Weighted MRI and 123 I-mIBG Uptake in Primary High-Risk Neuroblastoma

Background

High‐risk neuroblastoma (HR‐NB) has a variable response to preoperative chemotherapy. It is not possible to differentiate viable vs. nonviable residual tumor before surgery.

Purpose

To explore the association between apparent diffusion coefficient (ADC) values from diffusion‐weighted magnetic resonance imaging (DW‐MRI), ¹²³I‐meta‐iodobenzyl‐guanidine (¹²³I‐mIBG) uptake, and histology before and after chemotherapy.

Study Type

Retrospective.

Subjects

Forty patients with HR‐NB.

Field Strength/Sequence

1.5T axial DW‐MRI (b = 0,1000 s/mm²) and T₂‐weighted sequences. ¹²³I‐mIBG scintigraphy planar imaging (all patients), with additional ¹²³I‐mIBG single‐photon emission computed tomography / computerized tomography (SPECT/CT) imaging (15 patients).

Assessment

ADC maps and ¹²³I‐mIBG SPECT/CT images were coregistered to the T₂‐weighted images. ¹²³I‐mIBG uptake was normalized with a tumor‐to‐liver count ratio (TLCR). Regions of interest (ROIs) for primary tumor volume and different intratumor subregions were drawn. The lower quartile ADC value (ADC_25prc) was used over the entire tumor volume and the overall level of ¹²³I‐mIBG uptake was graded into avidity groups.

Statistical Tests

Analysis of variance (ANOVA) and linear regression were used to compare ADC and MIBG values before and after treatment. Threshold values to classify tumors as viable/necrotic were obtained using ROC analysis of ADC and TLCR values.

Results

No significant difference in whole‐tumor ADC_25prc values were found between different ¹²³I‐mIBG avidity groups pre‐ (P = 0.31) or postchemotherapy (P = 0.35). In the “intratumor” analysis, 5/15 patients (prechemotherapy) and 0/14 patients (postchemotherapy) showed a significant correlation between ADC and TLCR values (P < 0.05). Increased tumor shrinkage was associated with lower pretreatment tumor ADC_25prc values (P < 0.001); no association was found with pretreatment ¹²³I‐mIBG avidity (P = 0.17). Completely nonviable tumors had significantly lower postchemotherapy ADC_25prc values than tumors with >10% viable tumor (P < 0.05). Both pre‐ and posttreatment TLCR values were significantly higher in patients with >50% viable tumor than those with 10–50% viable tumor (P < 0.05).

Data Conclusion

¹²³I‐mIBG avidity and ADC values are complementary noninvasive biomarkers of therapeutic response in HR‐NB.

Level of Evidence

4.

Technical Efficacy Stage

3.

Does Endometriosis Influence the Embryo Quality and/or Development? Insights from a Large Retrospective Matched Cohort Study

In vitro fertilization can be an effective tool to manage the endometriosis-associated infertility, which accounts for 10% of the strategy indications. Nevertheless, a negative effect of endometriosis on IVF outcomes has been suggested. The aim of this study was to evaluate the potential effect of endometriosis in the development of embryos at cleavege stage in assisted reproduction treatment cycles. A total of 429 cycles from women previously operated for moderate/severe endometriosis were compared with 851 cycles from non-affected women. Patients were matched by age, number of oocyte retrieved and study period. A total of 3818 embryos in cleavage stage have been analyzed retrospectively. Overall, no difference was found between women with and without endometriosis regarding the number of cleavage stage embryos obtained as well as the percentage of good/fair quality embryos. Excluding cycles in which no transfers were performed or where embryos were frozen in day three, no difference was observed for blastulation rate or the percentage of good/fair blastocysts obtained. Despite similar fertilization rate and number/quality of embryos, a reduction in ongoing pregnancy rate was observed in patients affected, possibly due to an altered endometrial receptivity or to the limited value of the conventional morphological evaluation of the embryo.

Safety of fertility treatments in women with systemic autoimmune diseases (SADs)

Introduction: Systemic Autoimmune Diseases (SADs) include systemic lupus erythematosus, antiphospholipid antibody syndrome, rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome, mixed connective tissue disease, idiopathic inflammatory myopathies and vasculitis. SADs often occur in women of childbearing age and can affect fertility. Both infertility treatments and fertility preservation techniques are thus often indicated. Areas covered: The literature regarding the safety of fertility-related drugs for both fertility preservation and infertility treatment in patients affected by SADs was reviewed. Based on current knowledge, all the options for fertility preservation should be contemplated in patients with SADs who are at risk for fertility loss, including GnRH analogue administration, oocyte/embryo vitrification and ovarian tissue cryopreservation. Similarly, if pregnancy is not contraindicated in a patient with a SAD, neither should be any fertility treatment. Expert opinion: Women with SADs should postpone conception until a stable disease has been achieved for at least 6 months. When infertility treatments are needed, women with antiphospholipid antibodies should receive concomitant anticoagulation. If in vitro fertilization/intra-cytoplasmic sperm injection and embryo transfer is required, ovarian hyperstimulation and the inherent risk of thrombosis should be eliminated by GnRH-agonist trigger and cycle segmentation. Counselling about adherence to anti-rheumatic therapy to prevent disease exacerbations is also critical.

Embryonic extracellular vesicles as informers to the immune cells at the maternal-fetal interface

Extracellular vesicle (EV) exchange is emerging as a novel method of communication at the maternal-fetal interface. The presence of the EVs has been demonstrated in the preimplantation embryo culture medium from different species, such as bovines, porcines and humans. Preimplantation embryo-derived EVs have been shown to carry molecules potentially able to modulate the local endometrial immune system. The non-classical major histocompatibility complex (MHC) class I molecule human leucocyte antigen (HLA)-G, the immunomodulatory molecule progesterone-induced blocking factor and some regulatory miRNAs species are contained in embryo-derived EV cargo. The implanted syncytiotrophoblasts are also well known to secrete EVs, with microvesicles exerting a mainly proinflammatory effect while exosomes in general mediate local immunotolerance. This review focuses on the current knowledge on the potential role of EVs released by the embryo in the first weeks of pregnancy on the maternal immune cells. Collectively, the data warrant further exploration of the dialogue between the mother and the embryo via EVs.

Recombinant LH administration in subsequent cycle after "unexpected" poor response to recombinant FSH monotherapy

Abstract Poor ovarian response (POR) is most frequently linked to the condition known as diminished ovarian reserve, but it can also occur in the absence of pathological ovarian reserve tests ("unexpected" POR). Because possible explanations include theca cells function deficiency, our aim was to evaluate the effect of r-LH administration in "unexpected" poor responders. A retrospective, single-centre, cohort study was conducted on 65 patients with AMH >0.5 ng/ml and/or AFC >5 with POR in their first cycle. Patients underwent a second IVF cycle with same protocol (long- or antagonist) and same starting dose of r-FSH used in the first cycle, plus daily addiction of 150 IU of r-LH from day 1. Compared to the first cycle, r-LH addition in the second cycle determined an increase in number of oocytes retrieved (p < 0.001), number of metaphase II oocytes (p < 0.05), E2 levels at hCG triggering (p < 0.001) and number of embryos transferred (p = 0.002). A 15% clinical pregnancy rate was also observed in the second cycle. Our results suggest that patients with non-pathological ovarian reserve tests and previous "unexpected" POR seem to benefit from r-LH addition in subsequent cycles without the need to increase the r-FSH starting dose, possibly due to an underlying occult theca cells deficiency.

[Vascular access for hemodialysis. Clinical experience]

Seventy-nine arteriovenous fistulas for periodic hemodialysis were created in 62 uremic patients: 64 primary vascular accesses and 15 salvage operations for malfunctioning fistulas. Sixty-three distal and 1 proximal arteriovenous fistulas between the radial artery and the cephalic vein, were created as primary vascular access. The utilization time of the primary arteriovenous fistulas was longer than 5 years in 34%, 3-4 years in 25% and 0-2 years in 41% of cases. Eleven fistulas evidenced thrombosis: a salvage operation (resection-anastomosis) was possible for 9 (89%). A salvage operation was possible for 100% of poor flow fistulas. The utilization's time of the salvage fistulas is longer than 5 years in 15%, 3-4 years in 15% and 0-2 years in 70% of cases.

The use of dura mater allograft in the surgical repair of large defects of the abdominal wall

The dura mater allograft is being used as an abdominal fascia substitute and major advantages are documented. It was used successfully in four patients at this institution, with a ten month follow-up period. Its strength, durability, tissue tolerance, flexibility, ease of handling, nonallergenic property, availability and stability in the presence of infection make it a good graft to be used in the repair of large abdominal hernias. We are quite convinced that long term follow-up results will verify the results of the animal experiments done by others and affirm the durability of the graft. In one patient, this graft has been shown to be adequate for placement in an infected bed and to have a definite resistance to infection. The results of incidental operative biopsy in another patient, have shown an excellent incorporation of the dura graft into the surrounding tissues. In our hands, the experience with the dura graft using monofilament sutures has been quite positive.