Multidisciplinary clinical guidelines in proactive monitoring, early diagnosis, and effective management of trastuzumab deruxtecan (T-DXd)-induced interstitial lung disease (ILD) in breast cancer patients.

Trastuzumab deruxtecan (T-DXd), a human epidermal growth factor receptor 2 (HER2)-directed antibody-drug conjugate (ADC), has altered the treatment landscape in breast cancer (BC), irrespective of the HR-receptor status. The use of the agent is increasing, despite the finding that exposure to T-DXd increases the risk of interstitial lung disease (ILD), particularly in BC patients. Although T-DXd-related ILD can be potentially severe and life-threatening, most low-grade cases can be treated safely using a multidisciplinary approach comprising early and accurate diagnosis, effective management, close monitoring, and the prompt administration of steroids. Additionally, increasing patients' education on ILD symptoms ensures close attention and enables prompt reporting, enhancing patient outcomes. It is recommended that predictive biomarkers are assessed in patients with risk factors for developing ILD. Currently, diagnostic criteria comprise newly identified pulmonary opacities, the relation of symptom onset to medication initiation, and the exclusion of other causes of ILD. The general condition of patients is weakened during the management of ILD (BC progression and corticosteroid treatment). Consequently, BC chemotherapy might be attenuated. This highlights the importance of preventing (high-grade) ILD, especially since its use is expanded. Identifying high-risk patients, diagnosing, and customizing treatment is, however, challenging and additional information on patient selection is often not fully clarified. In this paper, we provide updated multidisciplinary clinical guidance for patient selection, proactive monitoring, early diagnosis, and effectively management of T-DXd-induced ILD in HER2-positive BC patients. We describe the risk factors for developing ILD, patients' characteristics of ILD, and the histopathological and radiographic characteristics of ILD, including real-world clinical practice reports. These recommendations provide a structured step-by-step approach for managing each suspected BC-related ILD grade.

The Future of Breast Cancer Research in the Survivorship Field.

Prevalence of survivors of breast cancer has been steadily increasing in the last 20 years. Currently, more than 90% of women diagnosed with early-stage breast cancer are expected to be alive at 5 years from diagnosis thanks to early detection and breakthrough innovations in multimodal treatment strategies. Alongside this advancement in clinical outcomes, survivors of breast cancer might experience several specific challenges and present with unique needs. Survivorship trajectories after diagnosis and treatment of breast cancer can be significantly impacted by long-lasting and severe treatment-related side effects, including physical problems, psychological distress, fertility issues in young women, and impaired social and work reintegration, which add up to patients' individual risk of cancer recurrence and second primary malignancies. Alongside cancer-specific sequelae, survivors still present with general health needs, including management of chronic preexisting or ensuing conditions. Survivorship care should implement high-quality, evidence-based strategies to promptly screen, identify, and address survivors' needs in a comprehensive way and minimize the impact of severe treatment sequelae, preexisting comorbidities, unhealthy lifestyles, and risk of recurrence on quality of life. This narrative review focuses on core areas of survivorship care and discuss the state of the art and future research perspectives in key domains including selected long-term side effects, surveillance for recurrences and second cancers, well-being promotion, and specific survivors' needs.

Homologous Recombination Repair Deficiency and the Immune Response in Breast Cancer: A Literature Review.

The success of cancer immunotherapy with immune checkpoint blockade (ICB) has demonstrated the importance of targeting a preexisting immune response in a broad spectrum of tumors. This is particularly novel and relevant for less immunogenic tumors, such as breast cancer (BC), where the efficacy of ICB was more evident in the triple-negative (TNBC) subtype, in earlier stages, and in association with chemotherapy. Tumors harboring homologous recombination DNA repair (HRR) deficiency (HRD) are supposed to have a higher number of mutations, hence a higher tumor mutational burden, which could potentially make them more sensitive to immunotherapy. However, the mechanisms involved in ICB sensitivity and patient selection are still yet to be defined in BC: whether the innate system could play a role and how the adaptive immunity could be linked with HRR pathways are the two key points of debate that we will discuss in this article. The aim of this review was to close the loop between what was found in clinical trial results so far, go back to laboratory theory and preclinical results and point out what needs to be clarified from now on.

Scoring of tumor-infiltrating lymphocytes: From visual estimation to machine learning.

The extent of tumor-infiltrating lymphocytes (TILs), along with immunomodulatory ligands, tumor-mutational burden and other biomarkers, has been demonstrated to be a marker of response to immune-checkpoint therapy in several cancers. Pathologists have therefore started to devise standardized visual approaches to quantify TILs for therapy prediction. However, despite successful standardization efforts visual TIL estimation is slow, with limited precision and lacks the ability to evaluate more complex properties such as TIL distribution patterns. Therefore, computational image analysis approaches are needed to provide standardized and efficient TIL quantification. Here, we discuss different automated TIL scoring approaches ranging from classical image segmentation, where cell boundaries are identified and the resulting objects classified according to shape properties, to machine learning-based approaches that directly classify cells without segmentation but rely on large amounts of training data. In contrast to conventional machine learning (ML) approaches that are often criticized for their "black-box" characteristics, we also discuss explainable machine learning. Such approaches render ML results interpretable and explain the computational decision-making process through high-resolution heatmaps that highlight TILs and cancer cells and therefore allow for quantification and plausibility checks in biomedical research and diagnostics.

Immuno-oncology-101: overview of major concepts and translational perspectives.

Cancer immunotherapy is demonstrating impressive clinical benefit in different malignancies and clinical oncologists are increasingly turning their attention to immune-oncology. It is now well recognized that innate and adaptive immune cells infiltrating tumors are associated with clinical outcomes and responses to treatments, and can be harnessed to patients' benefit. Considerable advances have also been made in understanding how cancers escape from immune attack. Targeting of immunological escape processes regulated by the expression of immune checkpoint receptors and ligands and the down-modulation of tumor antigen presentation is the basis of immuno-oncology treatments. Despite recent achievements, there remain a number of unresolved issues in order to successfully implement cancer immunotherapy in many cancers. Importantly, clinical biomarkers are still needed for better optimization of emerging combination immunotherapies and better treatment tailoring. In this review, we summarize the function of innate and adaptive immune cells in anti-tumor immunity and the general mechanisms exploited by tumor cells to escape and inhibit immune responses as well as therapeutic strategies developed to overcome these mechanisms and discuss emerging biomarkers in immuno-oncology.

Antiviral activity and metal ion-binding properties of some 2-hydroxy-3-methoxyphenyl acylhydrazones.

Here we report on the results obtained from an antiviral screening, including herpes simplex virus, vaccinia virus, vesicular stomatitis virus, Coxsackie B4 virus or respiratory syncytial virus, parainfluenza-3 virus, reovirus-1 and Punta Toro virus, of three 2-hydroxy-3-methoxyphenyl acylhydrazone compounds in three cell lines (i.e. human embryonic lung fibroblast cells, human cervix carcinoma cells, and African Green monkey kidney cells). Interesting antiviral EC50 values are obtained against herpes simplex virus-1 and vaccinia virus. The biological activity of acylhydrazones is often attributed to their metal coordinating abilities, so potentiometric and microcalorimetric studies are here discussed to unravel the behavior of the three 2-hydroxy-3-methoxyphenyl compounds in solution. It is worth of note that the acylhydrazone with the higher affinity for Cu(II) ions shows the best antiviral activity against herpes simplex and vaccinia virus (EC50 ~ 1.5 µM, minimal cytotoxic concentration = 60 µM, selectivity index = 40).

Tumor-infiltrating lymphocytes in patients with HER2-positive breast cancer treated with neoadjuvant chemotherapy plus trastuzumab, lapatinib or their combination: A meta-analysis of randomized controlled trials.

BACKGROUND: A relationship between baseline tumor-infiltrating lymphocytes (TIL) and outcomes has been described in HER2-positive breast cancer. Nevertheless, the magnitude of this association and whether this effect differs based on the type of anti-HER2 agent remain controversial. This meta-analysis investigated the association between baseline TIL and pathologic complete response (pCR) rates in HER2-positive breast cancer patients treated with neoadjuvant chemotherapy plus trastuzumab and lapatinib either alone or in combination. METHODS: A literature search covering PubMed, Embase and the Cochrane library up to October 31, 2016 identified randomized, controlled trials investigating neoadjuvant chemotherapy plus trastuzumab and lapatinib either alone or in combination where published data for pCR based on pre-treatment TIL scores were available. Two subgroups were considered: high baseline TIL vs. non-high TIL, according to each study definition. Summary risk estimates (odds ratio) and 95% confidence intervals (CI) were calculated for pCR using pre-treatment TIL levels for each trial. Pooled analyses were conducted using random and fixed effects models. Interaction P-values were computed using a Monte Carlo permutation test. RESULTS: A total of 5 studies (N=1256 patients) were included. Overall, high TIL subgroup was associated with a significantly increased pCR rate (OR 2.46; 95% CI 1.36-4.43; P=0.003). No interaction was observed between TIL subgroup (high vs. non-high TIL) and response to anti-HER2 agent(s) (trastuzumab vs. lapatinib vs. their combination; P=0.747) and chemotherapy (anthracycline and taxanes vs. taxanes only; P=0.201). A stronger association between high TIL subgroup and pCR rates was observed when examining only the 4 studies using anthracycline- and taxane- based neoadjuvant chemotherapy and the 60% cut-off for high TIL (N=869, NeoALTTO excluded) with an OR of 2.88 (95% CI 2.03-4.08; P<0.001). CONCLUSIONS: In HER2-positive breast cancer, high baseline TIL are associated with increased pCR probability irrespective of neoadjuvant anti-HER2 agent(s) and chemotherapy regimens used.

Cercopithifilaria spp. in dogs in Sardinia Island (Italy).

A survey on Cercopithifilaria spp. was carried out on owned and kennelled dogs in Sardinia, Italy. A total of 180 dogs were sampled and tested by microscopic detection or PCR of dermal microfilariae in skin snip sediments. The overall prevalence for Cercopithifilaria spp. at both microscopy and molecular tests was 9.4 % (17/180), while 8.3 % (15/180) of dogs scored positive at microscopic detection of sediments only. Of the 225 microfilariae measured, 212 were identified as Cercopithifilaria bainae and the remaining as Cercopithifilaria sp. II. All samples were molecularly processed for specific amplification of cytochrome oxidase subunit 1 (cox1) and ribosomal 12S gene fragments. The Basic Local Alignment Search Tool analysis of the cox1 and 12S sequences here obtained showed a high nucleotide similarity (99 and 100 %, respectively) with those of C. bainae available in GenBank. In particular, cox1 haplotype I (HI; n=14), haplotype HXVIII (n=2), and a new haplotype, named HXIX (n=1), differing for a single polymorphism from HI, were detected. This study reports data on the occurrence, distribution, and genetic makeup of C. bainae and Cercopithifilaria sp. II infesting dogs in Sardinia, suggesting that these filarioids are spread in areas where Rhipicephalus sanguineus sensu lato ticks occur.

Epidemiology, chronobiology and taxonomic updates of Rhinoestrus spp. infestation in horses of Sardinia Isle, Western Mediterranean (Italy).

From January to December 2008, 265 horses slaughtered in Sardinia (Italy) were examined for the presence of Rhinoestrus spp. (Diptera: Oestridae) through the examination of the nasal cavities and pharynges. Larvae were detected in 49% of the horses, with a mean intensity of infestation of 16.09 and abundance of 7.95. A total of 2108 larvae were collected, 66% of which were classified in first instar (L1), 22% in second instar (L2) and 12% in third instar (L3). The most frequent localization of larvae was the ethmoid, while the less one the larynx. According to the dynamics of Rhinoestrus larval stages, three periods in the chronobiology can be considered, the diapause (September-February) characterized by an absolute prevalence of first larval stage; the active phase of the endogenous phase (February-September) with an increase in the percentages of L2 and L3, and the exit phase (May-September), pointed by a further increase of L1. Morphological examination of L3 larvae revealed the presence of the Rhinoestrus purpureus features in 8% of the examined larvae, of 8% of the Rhinoestrus usbekistanicus features, while in 84% of the larvae were evidenced intermediate features. Contrastingly biomolecular analysis of the COI gene of the larvae evidenced uniformity at genetic level, confirming the presence of a unique species in the Mediterranean area. The results of the present paper, reveal the wide diffusion of rhinoestrosis among Sardinian horses, and suggest the need for applying appropriate control measures. Chemotherapy should be very useful if administered during the diapause period, for reducing the presence of L1 stages and interrupting thus the life cycle of this myiasis.

Cystic echinococcosis in Sardinia: farmers' knowledge and dog infection in sheep farms.

Cystic Echinococcosis (CE) is one of the most widespread parasitic diseases in Sardinia, the second largest Mediterranean island where almost 3,558,000 milk sheep were raised extensively. The aim of this survey was to evaluate the level of farmers' knowledge on CE transmission, focusing on the role of human to facilitate the persistence of this zoonosis in Sardinia after 14 years after the last campaign against CE. The other goal of the survey is to update on presence of Echinococcus granulosus in its definitive hosts through three ELISA coproantigen tests. An interview was carried out with 172 farmers. The questionnaire was designed to include possible factors associated with the transmission of Echinococcosis: ownership and number of dogs, the use of anthelmintic drugs against dog cestode, frequency of anthelmintic treatment in dogs, home slaughtering and offal disposal. Individual faecal samples were retrieved from 300 dogs, and after a preliminary macroscopic examination to discover adult worms and/or proglottids, was submitted to copromicroscopic examination. Coproantigens were then extracted according to the protocol described by Allan et al. (1992), and subsequently stored at -20°C until use. Faecal soluble antigens from E. granulosus were detected using three different ELISA coproantigen assays: (a) the commercially produced Chekit Echinotest (Bommeli, Bern, CH) based on polyclonal antibodies against adult excretory/secretory (E/S) antigens; (b) a sandwich ELISA that uses rabbit polyclonal antibodies against adult E/S antigens and biotinylated monoclonal antibody EmA9 produced against adult Echinococcus multilocularis somatic extract (Malgor et al., 1997); and (c) a sandwich assay that uses monoclonal antibody EgC3 produced by immunization with adult E. granulosus E/S products (Casaravilla et al., 2005). Questionnaire results reveal that on all farms home-slaughtering was done, and offal was used as dog meal raw (17%) or after boiling (37%), discarded in the trash (23%), or buried superficially (15%). Most farmers (69%) declared to deworm their dogs, but only 10% used cestodicidal drugs. The coprological survey of 300 farm dogs using sedimentation, flotation and three different coproantigen (CA) ELISAs resulted in a faecal prevalence of 8.3% for taeniid eggs, while the CA tests gave prevalences of 3% (Chekit Echinotest, Bommeli), 6% (EmA9 sandwich ELISA) and 10% (EgC3 sandwich ELISA). Our results show that this is not only an educational problem, but also an economic one, stressing the need that future control plans should follow an integrative approach including veterinary and medical services, farmers, breeders' associations and the Government.

Cow's milk protein allergy.

Cow's milk protein allergy (CMPA) affects 2-7.5% of children; persistence in adulthood is uncommon since a tolerance develops in 51% of cases within 2 years and 80% within 3-4 years. CMPA is an immunological reaction to one or more milk proteins: α-lactalbumin, ß-lactoglobulin, casein, IgE or non-IgE associated, responsible of immediate or late onset symptoms. The suspicion of CMPA is based on detailed family and medical history, skin test, patch test, laboratory test, an elimination diet and food challenge. The general treatment for CMPA is dietary: elimination of cow's milk protein and introduction of extensively hydrolyzed whey or casein formula, amino acid formula, and soy formula. Extensively hydrolyzed whey or casein formula is recommended as first choice for infants in mild or moderate reactions, amino acid formula in severe CMPA and in cases with poor response to extensively hydrolysed whey or casein formula.

Effect of levetiracetam on cortical excitability: a transcranial magnetic stimulation study.

BACKGROUND AND PURPOSE: We studied the effect of levetiracetam (LEV), an anticonvulsant with a novel mechanism of action, on cortical excitability, measured using transcranial magnetic stimulation (TMS). For this purpose, 38 healthy volunteers were assessed in two TMS sessions, before and after an oral dose of 3000 mg LEV. METHODS: Resting motor threshold (RMT), intracortical facilitation (ICF) and intracortical inhibition (ICI), cortical silent period (CSP) threshold and duration and motor-evoked potential (MEP) amplitude were calculated. RESULTS: After treatment with LEV, RMT was increased (mean +/- SD: 63 +/- 14% of the maximum stimulator output) compared with baseline (58 +/- 11%). CSP threshold was decreased after LEV (54 +/- 10%; baseline, 57 +/- 11%). CSP duration was increased after LEV (116 +/- 37 ms; baseline: 102 +/- 33 ms). LEV did not affect ICF or ICI or mean MEP amplitude significantly. CONCLUSIONS: Our results indicate that LEV modulates some aspects of cortical excitability. Whereas the increase in the RMT most probably reflects the effect of LEV on ion channel activity, effects on the CSP might represent a modulation of GABA receptors at cortical and spinal level.

Neurological complications of porphyria.

The aim of this study was to evaluate and describe the importance of neurological complications in patients with a confirmed diagnosis of porphyria. Clinical details are presented for a cohort of 14 patients who presented with one of four categories of symptoms: seizures, polyneuropathy, transient sensory-motor symptoms and cognitive or behavioural abnormalities. Ascertainment of porphyria was often incidental and in many patients neurological complications preceded the definitive biochemical diagnosis. Porphyria is a group of diseases whose clinical picture is often complex and heterogeneous, but neurological complications are not uncommon. When indicated, differential diagnosis of neurological signs and symptoms should include porphyria, as the incidence of the disease is probably underestimated. Part of the clinical picture can be transient and it is often initially disregarded. A family history and recurrence of otherwise unexplained neurological symptoms should alert the clinician to a possible diagnosis of porphyria for patients with neurological presentations.

Changing Australian prescribing patterns for antiepileptic drugs in pregnancy and their possible consequences.

We report progress in the accumulation of data by the Australian Pregnancy Register over 64 months, confirming the rise in enrollment and the predominantly epileptic indication for taking antiepileptic drugs. Eighty percent of the enrollment was prospective. The focus of the current report is the observation that as a possible result of education and dissemination of information about the risks of exposure to high-dose valproate, there has been a decline in the drug's doses prescribed in Australia, as well as a decline in the proportion of patients prescribed this drug in pregnancy. The risk of teratogenicity associated with valproate in doses in excess of 1100 mg/day was confirmed, and the incidence of lamotrigine-related malformations was comparable to that associated with exposure to phenytoin and carbamazepine. Reporting of data for this paper took into account the 12 months follow-up period for each pregnancy outcome, thus in effect making the evaluation period 21 months for each pregnancy and its outcome.

Foetal malformations and seizure control: 52 months data of the Australian Pregnancy Registry.

The Australian Pregnancy Registry, affiliated European Register of Antiepileptic drugs in Pregnancy (EURAP), recruits informed consenting women with epilepsy on treatment with antiepileptic drugs (AEDs), those untreated, and women on AEDs for other indications. Enrolment is considered prospective if it has occurred before presence or absence of major foetal malformations (FMs) are known, or retrospective, if they had occurred after the birth of infant or detection of major FM. Telephone Interviews are conducted to ascertain pregnancy outcome and collect data about seizures. To date 630 women have been enrolled, with 565 known pregnancy outcomes. Valproate (VPA) above 1100 mg/day was associated with a significantly higher incidence of FMs than other AEDs (P < 0.05). This was independent of other AED use or potentially confounding factors on multivariate analysis (OR = 7.3, P < 0.0001). Lamotrigine (LTG) monotherapy (n = 65), has so far been free of malformations. Although seizure control was not a primary outcome, we noted that more patients on LTG than on VPA required dose adjustments to control seizures. Data indicate an increased risk of FM in women taking VPA in doses >1100 mg/day compared with other AEDs. The choice of AED for pregnant women with epilepsy requires assessment of balance of risks between teratogenicity and seizure control.

Current approaches to management of depression in Parkinson's Disease.

Depression is a common problem in patients affected by Parkinson's Disease (PD). In many cases, treatment with antidepressants is necessary, and the choice of the most suitable drug is often controversial, as many factors need to be considered that may complicate the development of the disease, including potential side effects of antidepressant therapy. Selective Serotonin Reuptake Inhibitors (SSRIs) and Tricyclic Antidepressants (TCAs) are the two major categories of antidepressants used. Tricyclics have been shown to be effective in most cases, but some side effects (orthostatic hypotension, sedation, cognitive and anticholinergic effects) may present problems. In contrast, SSRI appear to be better tolerated, but some reports indicate a potential worsening of the parkinsonism. Other recently introduced medications need further investigation. The main therapeutic strategies, as reported in the international literature according to efficacy and tolerability, interactions with antiparkinsonian or concomitant drugs and possible effects on worsening of PD, are presented.

Antimicrobial and mutagenic properties of organotin(IV) complexes with isatin and N-alkylisatin bisthiocarbonohydrazones.

A new series of ligands is synthesised starting from thiocarbonohydrazide and isatin (H(2)itc) or N-alkylisatin (methyl, H(2)mtc; butyl, H(2)btc; pentyl, H(2)ptc); the X-ray structure of H(2)mtc is discussed. The bis imine ligands are reacted with diorganotin(IV) compounds, obtaining monometallic complexes. In order to establish unequivocally their coordination geometry, the X-ray structures of (C(2)H(5))(2)Sn(Hmtc)Cl.THF (THF, tetrahydrofuran) and (C(6)H(5))Sn(Hptc)Cl(2) are determined. In (C(2)H(5))(2)Sn(Hmtc)Cl.THF, the ligand results monodeprotonated and, essentially, monodentate through the sulphur atom, while in (C(6)H(5))Sn(Hptc)Cl(2) the ligand is still monodeprotonated but SNO tridentate. The organotin(IV) complexes of isatin and N-methylisatin exhibit good antibacterial activity, better than that of the corresponding N-butyl and N-pentylisatin derivatives. Gram positive bacteria are the most sensitive microorganisms. No growth inhibition of fungi is detected up to the concentration of 100 microg/ml. H(2)mtc shows mutagenic activity with and without metabolic activation, whereas no mutagenicity is found for its organotin complexes and for the other compounds.

Hypertensive encephalopathy: antecedent to hippocampal sclerosis and temporal lobe epilepsy?

The authors describe three patients with refractory temporal lobe epilepsy (TLE) following an episode of hypertensive encephalopathy as their only identified antecedent event. All patients had typical MR features of hippocampal sclerosis (HS), and the two operated cases had typical HS histology and became seizure-free postoperatively. These cases suggest that hypertensive encephalopathy may be a rare form of initial precipitating injury, leading to TLE and HS.

Role of GABA(B) receptors in the sedative/hypnotic effect of gamma-hydroxybutyric acid.

The present study was aimed at identifying the receptor systems involved in the mediation of the sedative/hypnotic effect of gamma-hydroxybutyric acid (GHB) in DBA mice. Administration of the putative antagonist of the GHB binding site, 6,7,8,9-tetrahydro-5-hydroxy-5H-benzocyclohept-6-ylideneacetic acid (NCS-382; 50-500 mg/kg, i.p.), significantly increased the duration of loss of righting reflex induced by GHB (1000 mg/kg, i.p.). In contrast, the GABA(B) receptor antagonists, (2S)(+)-5,5-dimethyl-2-morpholineacetic acid (SCH 50911; 25-100 mg/kg, i.p.) and (3-aminopropyl)(cyclohexylmethyl)phosphinic acid (CGP 46381; 12.5-150 mg/kg, i.p.), completely prevented the sedative/hypnotic effect of GHB. SCH 50911 (100 and 300 mg/kg, i.p.) was also capable to readily reverse the sedative/hypnotic effect of GHB (1000 mg/kg, i.p.) in mice that had lost the righting reflex. SCH 50911 (100 mg/kg, i.p.) also completely abolished the sedative/hypnotic effect of the GABA(B) receptor agonist, baclofen. These results indicate that the sedative/hypnotic effect of GHB is mediated by the stimulation of GABA(B) receptors and add further support to the hypothesis that the GABA(B) receptor constitutes a central site of action of GHB.