Breast cancer electron intraoperative radiotherapy: assessment of preoperative selection factors from a retrospective analysis of 758 patients and review of literature.

PURPOSE: To report our experience with full-dose 21 Gy IORT in early breast cancer patients after breast-conserving surgery to define most important selection factors. METHODS: Seven hundred and fifty eight patients, subjected to conserving surgery and IORT, were retrospectively analyzed evaluating most important clinical outcomes. RESULTS: Median follow up was 5.2 years. Results from Cox analyses defined 2 groups of patients, "suitable" (age > 50 years, non lobular histology, tumour size ≤ 2 cm, pN0 or pNmic, ki67 ≤ 20%, non triple negative receptor status and G1-G2) and "unsuitable" for IORT, with a higher rate of breast related events moving from "suitable" to "unsuitable" group. The 5 year rate of IBR is 1.8% in suitable group with significant differences versus unsuitable (1.8 vs. 11.6%, p < 0.005). Same differences between two groups were evidenced in true local relapse (0.6 vs. 6.9%, p < 0.005) and in new ipsilateral BC (1.1 vs. 4.7%, p < 0.015). CONCLUSIONS: In our current practice we consider the following preoperative factors to select patients suitable for IORT: age > 50 years, absence of lobular histology, tumor size ≤ 2 cm, pN0 or pNmic, according to APBI consensus statement, including also ki67 ≤ 20%, non triple negative receptor status and G1-G2.

Effective penumbra and scalloping effect: a dosimetric study in multifield radiotherapy with multileaf collimator for prostate cancer treatment.

AIMS AND BACKGROUND: The aim of the study was to test whether the multileaf collimator can be used to replace divergent alloy blocks for field shaping and to evaluate the dosimetric impact of the scalloping effect and the effective penumbra in multifield isocentric configurations routinely used at our department to treat early stage prostate tumor in supine patients. Deviations between measurements and treatment planning system calculations are also discussed in order to estimate the accuracy of effective penumbra calculations carried out by the software in the presence of blocks or a multileaf collimator. METHODS: The multileaf collimator installed on a dual energy (6 and 18 MV) linear accelerator Varian CLINAC 2100 C/D is an add-on component positioned below the standard jaws, with 40 computer-controlled opposed pairs of tungsten leaves. Transmission, effective penumbra and scalloping measurements were performed with films placed at different depths in a (30 x 30 x 20 cm3) acrylic phantom. A laser scanning photodensitometer was used to obtain the optical density and the relative dose profile. Effective penumbra and scalloping effect measured data were tested on a software phantom; the phantom, automatically performed with the treatment planning system, was a regular parallelepiped measuring 30 x 30 x 20 cm3 and the acrylic electronic density value. RESULTS: For one multileaf collimator-shaped field, the width of effective penumbra was about 2 mm wider than penumbra for cerrobend blocks, at a 45 degrees angle between leaf motion direction and the field edge. Collimator rotation, automatically performed by the treatment planning system, by minimizing the sum of over- and underblocked areas, reduces the differences between the multileaf collimator and blocks. The differences between measured and treatment planning system calculated data were within the treatment planning system dose calculation accuracy limits, as recommended in ICRU Report No. 42. CONCLUSIONS: Penumbra and, for the multileaf collimator, scalloping effect values seem to depend on the gantry angle, i.e., on the fields path of entry. The values for even fields are higher than the those for odd fields, because the dose gradient at the target edges is steeper for a single field than for two opposite fields, and the interplay of doses from the individual beams increases the distance between the isodose levels. Therefore, in order to reduce scalloping and effective penumbra values, it would be better to rotate the collimators, above all in even-number field techniques. In particular, the six-field technique, used mostly in prostate treatment, shows the same effective penumbra values with the multileaf collimator, with proper collimator rotation, and in blocked fields.

[Screening for HIV-1 infection targeted to women at a center for sexually transmitted diseases (STD). Comparison between 2 periods of 5 years of work]. / Lo screening per l'infezione da HIV-1 mirato alle donne in un centro per le malattie sessualmente trasmesse (MST). Confronto tra due quinquenni di attività.

OBJECTIVE: To determine changes over time in the proportion of individuals requesting HIV-1 testing represented by women and in the HIV-1 prevalence among women attending a centre for sexually transmitted diseases (STD) in Rome Italy. METHODS: We analysed the computerised clinical records of all women undergoing HIV-1 testing in two five-year periods (i.e., 1985-89 and 1993-97). RESULTS: In the period 1985-89, 2,605 individuals underwent HIV-1 testing; 605 (23.2%) of these individuals were women. In the period 1993-97, 5,981 individuals were tested; 2,015 (33.7%) were women. When analysing the proportion of women tested by exposure category, there was an increase in the proportion of non-drug-using heterosexual women (75.5% in 1985-89 vs. 84.6% in 1993-97) and of women from geographical areas endemic for HIV (1.8% vs. 5.5%, respectively), where as there was a decrease in the proportion of tested women represented by intravenous drug users (12.4% vs. 2.7%). Overall, the prevalence of HIV-1 infection among women decreased (8.8% in 1985-89 vs. 5.0% in 1993-97). When considering specific exposure categories, the prevalence increased among partners of HIV-1 infected males (8.7% vs. 36.5%) and among women from endemic areas (2.8% vs. 9.3%). DISCUSSION AND CONCLUSIONS: The increased proportion of women requesting HIV-1 testing, especially those reporting at-risk heterosexual behaviour, suggests that women are generally more informed with regard to the risks of sexual transmission. However, the increase in HIV-1 prevalence among women with an HIV-1-infected partner and those from endemic areas suggests that programmes for preventing sexual transmission need to be improved.

Progesterone sensitive Interferon-gamma producing cells detected by ELISpot assay in autoimmune progesterone dermatitis.

Autoimmune progesterone dermatitis (APD) is a rare cutaneous disorder, characterized by recurrent polymorphous cutaneous and mucosal manifestations. It is considered to be caused by a hypersensitive reaction to endogenous progesterone. However, in vitro T-cell activity to this hormone has been described in few patients. Here we report the case of a 30-year-old woman with recurrent pruritic erythematous, and erythema multiforme-like eruptions localized to the genital area. Positive cutaneous reaction to intradermal progesterone injection suggested the diagnosis of APD. The analysis of cellular immune response to progesterone, investigated by the ELISpot assay, showed a significantly higher level of Interferon-gamma (IFN-gamma) producing cells in this patient compared with a control group comprising five asymptomatic women in the luteal phase of the menstrual cycle. Our results suggest that the ELISpot technique, together with clinical evaluations and assessment of allergies, could be useful in the diagnosis of APD.

[Dosimetric characterization of a multileaf collimator]. / Caratterizzazione dosimetrica di un collimatore multilamellare.

INTRODUCTION: We studied the dosimetric characteristics of a multileaf collimator (MLC) installed on a dual energy accelerator with 6 and 18 MV photon beams in the Radiotherapy Department of Mauriziano Umberto I Hospital in Turin initiating its use in clinical practice. In particular, measurements included transmission through and between the leaves and at the junction under closed-leaves, central axis percentage depth dose, output factors and effective penumbra. MATERIAL AND METHODS: The MLC installed on the dual energy (6 and 18 MV) linear accelerator Varian Clinac 2100 C/D used in our radiotherapy department is an add-on component positioned below the standard jaws; it consists of 40 computer-controlled opposed pairs of 5 cm thick tungsten leaves, each projecting a 1 cm width at the isocenter, and it provides a maximum treatment field of 40 x 40 cm2 at 100 cm SAD. Transmission, penumbra and scalloping values were measured with the standard radiographic film routinary used in our department. A laser scanning photodensitometer (WP102, Wellhofer) with a 450 microns spot was used to obtain the optical density and the relative dose profile. Radiographic films had been calibrated with an ionization chamber, by irradiating samples to known doses; this calibration was used to correct the film scanner readings to dose. Percentage depth doses were also measured in an automatic water phantom (WP600, Wellhofer) for irregular fields defined by either MLC or alloy blocks, in order to test the differences in the build-up region due to the presence of the acrylic accessory tray. Measured and calculated output factors were compared for some irregular fields defined by the MLC. This comparison tested the algorithm accuracy of our Treatment Planning System 3D CadPlan 3.1.1 Varian-Dosetek. RESULTS AND DISCUSSION: For both energies, approximately 2% of the incident radiation on the MLC is transmitted and an additional 0.5% leakage occurs between adjacent leaves. The leakage under closed-leaves junction is remarkable: about 25-33%. Relative depth dose curves are similar for two fields shaped by either MLC or conventional jaws. Skin dose with MLC-shaped field is less (3.5%) than the one with cerrobend block-shaped fields. The monitor unit calculation procedure used in our treatment planning system can be applied to the MLC (the difference is less than 1%). Effective penumbra in MLC-shaped irregular fields is on the average 11 mm, which is slightly wider (2-3 mm) than the conventional cerrobend blocks penumbra. Effective penumbra increases with depth, field width and leaves positioning. CONCLUSIONS: The MLC, if properly used (collimator rotation, jaws and leaves position, high number of fields), can be applied to conformal radiotherapy with good results. The MLC is better than conventional cerrobend blocks both to improve the treatment reproducibility and accuracy, and relative to dosimetric characteristics like dose transmission and skin dose. The use of MLC to modulate beam fluence (IMRT) will permit to modify beam intensity for improved shaping of the treated volume and to overcome the static therapy dosimetric limitations.

Cystic fibrosis and lens opacity.

Cystic fibrosis (CF) is a fairly common lethal genetic disease in whites, inherited via an autosomal recessive pattern. Several clinically evident anomalies of the eye such as xerophthalmia, papilledema, retinal alterations and optic neuropathy have been described. In the present study we investigated lens changes in 40 patients affected by CF, to relate the results to the stage of digestive insufficiency. Each patient underwent an accurate ocular examination including visual acuity, slit-lamp examination, and measurement of lens transparency with the Opacity Lens Meter 701. The results were compared with those of an age- and sex-matched control group. The comparison between the lens opacity values obtained in the CF patients and those measured in the control group showed a statistically significant difference; moreover, lens transparency was more decreased in patients with severe digestive insufficiency.

HLA typing and retinitis pigmentosa.

Retinitis pigmentosa is a disease whose pathogenesis remains largely obscure. A lot of evidences support the hypothesis that auto-immunity is involved, but no HLA antigen has ever been associated with retinitis pigmentosa. Ten patients with autosomal recessive retinitis pigmentosa were tissue typed for class I and II HLA antigens. The results of the study show a significant increase in the frequency of the antigens Cw4, Cw6 and DR11. High values of relative risk were found also for some class I antigens, but the size of the group of patients with these loci precluded a meaningful statistical analysis.

Diagnosis of pigmented skin lesions by dermoscopy: web-based training improves diagnostic performance of non-experts.

BACKGROUND: Dermoscopy has been shown to enhance the diagnosis of melanoma. However, use of dermoscopy requires training and expertise to be effective. OBJECTIVES: To determine whether an Internet-based course is a suitable tool in teaching dermoscopy, and to evaluate the diagnostic value of pattern analysis and diagnostic algorithms in colleagues not yet familiar with this technique. METHODS: Sixteen colleagues who were not experts in dermoscopy were asked to evaluate the dermoscopic images of 20 pigmented skin lesions using different diagnostic methods (i.e. pattern analysis, ABCD rule, seven-point checklist and Menzies' method), before and after an Internet-based training course on dermoscopy. Mean +/- SEM sensitivity, specificity and diagnostic accuracy, and kappa (kappa) intraobserver agreement were evaluated for each diagnostic method before and after training for the 16 participants. Differences between mean values were assessed by means of two-tailed Wilcoxon rank-sum tests. RESULTS: There was a considerable improvement in the dermoscopic melanoma diagnosis after the Web-based training vs. before. Improvements in sensitivity and diagnostic accuracy were significant for the ABCD rule and Menzies' method. Improvements in sensitivity were also significant for pattern analysis, whereas the sensitivity values were high for the seven-point checklist in evaluations both before and after training. No significant difference was found for specificity before and after training for any method. There was a significant improvement in the kappa intraobserver agreement after training for pattern analysis and the ABCD rule. For the seven-point checklist and Menzies' method there was already good agreement before training, with no significant improvement after training. CONCLUSIONS: We demonstrated that Web-based training is an effective tool for teaching dermoscopy.