Longitudinal changes of the femoral bone mineral density from first to third trimester of pregnancy: bone health assessment by means of non-ionizing REMS technology.

BACKGROUND: Throughout the pregnancy, there is a substantial transfer of calcium from the maternal skeleton to the fetus, which leads to a transient net reduction of the maternal bone mineral density. AIMS: To assess longitudinally the changes in the bone mineral density at the femoral neck between the first and third trimester of pregnancy in a cohort of healthy participants using Radiofrequency Echographic Multi Spectrometry (REMS) technology. METHODS: Prospective, cohort study conducted at the University hospital of Parma, Italy between July 2022 and February 2023. We recruited healthy participants with an uncomplicated singleton pregnancy before 14 completed weeks of gestation. All included participants were submitted to a sonographic examination of the femoral neck to assess the bone mineral density (and the corresponding Z-score values) using REMS at 11-13 and 36-38 weeks of pregnancy. The primary outcome was the change in the bone mineral density values at the maternal femoral neck between the first and third trimester of pregnancy. RESULTS: Over a period of 7 months, a total of 65 participants underwent bone mineral density measurement at the femoral neck at first and third trimester of the pregnancy using REMS. A significant reduction of the bone mineral density at the femoral neck (0.723 ± 0.069 vs 0.709 ± 0.069 g/cm2; p < 0.001) was noted with a mean bone mineral density change of - 1.9 ± 0.6% between the first and third trimester of pregnancy. At multivariable linear regression analysis, none of the demographic or clinical variables of the study population proved to be independently associated with the maternal bone mineral density changes at the femoral neck. CONCLUSIONS: Our study conducted on a cohort of healthy participants with uncomplicated pregnancy demonstrates that there is a significant reduction of bone mineral density at femoral neck from early to late gestation.

Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years.

BACKGROUND: Accurate estimation of the imminent fragility fracture risk currently represents a challenging task. The novel Fragility Score (FS) parameter, obtained during a Radiofrequency Echographic Multi Spectrometry (REMS) scan of lumbar or femoral regions, has been developed for the non-ionizing estimation of skeletal fragility. AIMS: The aim of this study was to assess the performance of FS in the early identification of patients at risk for incident fragility fractures with respect to bone mineral density (BMD) measurements. METHODS: Data from 1989 Caucasians of both genders were analysed and the incidence of fractures was assessed during a follow-up period up to 5 years. The diagnostic performance of FS to discriminate between patients with and without incident fragility fracture in comparison to that of the BMD T-scores measured by both Dual X-ray Absorptiometry (DXA) and REMS was assessed through ROC analysis. RESULTS: Concerning the prediction of generic osteoporotic fractures, FS provided AUC = 0.811 for women and AUC = 0.780 for men, which resulted in AUC = 0.715 and AUC = 0.758, respectively, when adjusted for age and body mass index (BMI). For the prediction of hip fractures, the corresponding values were AUC = 0.780 for women and AUC = 0.809 for men, which became AUC = 0.735 and AUC = 0.758, respectively, after age- and BMI-adjustment. Overall, FS showed the highest prediction ability for any considered fracture type in both genders, resulting always being significantly higher than either T-scores, whose AUC values were in the range 0.472-0.709. CONCLUSION: FS displayed a superior performance in fracture prediction, representing a valuable diagnostic tool to accurately detect a short-term fracture risk.

Pulse-Echo Measurements of Bone Tissues. Techniques and Clinical Results at the Spine and Femur.

The aim of this chapter is to review the available pulse-echo approaches for the quantitative evaluation of bone health status, with a specific application to the assessment of possible osteoporosis presence and to the fracture risk prediction. Along with a review of the main in-vivo imaging approaches for skeletal robustness evaluation and fracture risk assessment, further understanding into Radiofrequency Echographic Multi Spectrometry (REMS), an ultrasound-based method measuring clinically relevant bone districts (i.e. lumbar vertebrae and proximal femur), is provided, and the further potentialities of this technology are discussed.Currently, the bone mineral density (BMD) provided by dual X-ray absorptiometry (DXA) is considered an established indicator for osteoporosis status assessment and fracture risk prediction, however, in order to obtain more accurate results, an additional step beyond BMD would be necessary, which means including data on bone quality for an improved evaluation of the disease and its consequences.REMS is a technology which allows both osteoporosis diagnosis, through the BMD estimation, and the prediction of fracture risk, through the computation of the Fragility Score; both measures are obtained by the automatic processing of unfiltered ultrasound signals acquired in correspondence of anatomical reference sites.

Human Hepatocarcinoma Cell Targeting by Glypican-3 Ligand Peptide Functionalized Silica Nanoparticles: Implications for Ultrasound Molecular Imaging.

Silica nanoparticles (SiNPs) are widely studied nanomaterials for their potential employment in advanced biomedical applications, such as selective molecular imaging and targeted drug delivery. SiNPs are generally low cost and highly biocompatible, can be easily functionalized with a wide variety of functional ligands, and have been demonstrated to be effective in enhancing ultrasound contrast at clinical diagnostic frequencies. Therefore, SiNPs might be used as contrast agents in echographic imaging. In this work, we have developed a SiNPs-based system for the in vitro molecular imaging of hepatocellular carcinoma cells that express high levels of glypican-3 protein (GPC-3) on their surface. In this regard, a novel GPC-3 targeting peptide was designed and conjugated to fluorescent silica nanoparticles. The physicochemical properties, acoustic behavior, and biocompatibility profile of the functionalized SiNPs were characterized; then binding and uptake of both naked and functionalized SiNPs were analyzed by laser scanning confocal microscopy and transmission electron microscopy in GPC-3 positive HepG2 cells, a human hepatocarcinoma cell line. The results obtained showed that GPC-3-functionalized fluorescent SiNPs significantly enhanced the ultrasound contrast and were effectively bound and taken up by HepG2 cells without affecting their viability.

New perspectives in echographic diagnosis of osteoporosis on hip and spine.

Currently, the accepted "gold standard" method for bone mineral density (BMD) measurement and osteoporosis diagnosis is dual-energy X-ray absorptiometry (DXA). However, actual DXA effectiveness is limited by several factors, including intrinsic accuracy uncertainties and possible errors in patient positioning and/or post-acquisition data analysis. DXA employment is also restricted by the typical issues related to ionizing radiation employment (high costs, need of dedicated structures and certified operators, unsuitability for population screenings). The only commercially-available alternative to DXA is represented by "quantitative ultrasound" (QUS) approaches, which are radiation-free, cheaper and portable, but they cannot be applied on the reference anatomical sites (lumbar spine and proximal femur). Therefore, their documented clinical usefulness is restricted to calcaneal applications on elderly patients (aged over 65 y), in combination with clinical risk factors and only for the identification of healthy subjects at low fracture risk. Literature-reported studies performed some QUS measurements on proximal femur, but their clinical translation is mostly hindered by intrinsic factors (e.g., device bulkiness). An innovative ultrasound methodology has been recently introduced, which performs a combined analysis of B-mode images and corresponding "raw" radiofrequency signals acquired during an echographic scan of the target reference anatomical site, providing two novel parameters: Osteoporosis Score and Fragility Score, indicative of BMD level and bone strength, respectively. This article will provide a brief review of the available systems for osteoporosis diagnosis in clinical routine contexts, followed by a synthesis of the most promising research results on the latest ultrasound developments for early osteoporosis diagnosis and fracture prevention.

[Translational perspectives in molecular imaging: methodological evolution and nanostructured materials]. / Prospettive traslazionali dell'imaging molecolare: evoluzione delle metodiche e materiali nanostrutturati.

Molecular imaging techniques play an increasingly important role in the deep understanding of pathologies. They represent a direct spotlight on the molecular correlates of diseases and can be used for assessing earlier the state of health and decide the treatment of each patient in a personalized way. This article will show the basis of several imaging techniques, and give examples on the application and development of molecular imaging tracers. Particular attention will be pointed on the use of nanostructured materials, that has a promising role in the finding of new tracers, on the use of novel methodological approaches (multimodality, theranostics, pretargeting) and on the possibility of translational applications.

Automatic measurement of head-perineum distance during intrapartum ultrasound: description of the technique and preliminary results.

OBJECTIVES: To evaluate the accuracy and reliability of a new ultrasound technique for the automatic assessment of the head-perineum distance (HPD) during childbirth. METHODS: HPD was measured on a total of 40 acquisition sessions in 30 laboring women both automatically by an innovative algorithm and manually by trained sonographers, assumed as gold standard. RESULTS: A significant correlation was found between manual and automatic measurements (Intra-CC = 0.994). High values of the coefficient of determination (r2=0.98) and low residual errors: RMSE = 2.01 mm (4.9%) were found. CONCLUSION: The automatic algorithm for the assessment of the HPD represents a reliable technique.

A new standard scoring for interstitial pneumonia based on quantitative analysis of ultrasonographic data: A study on COVID-19 patients.

OBJECTIVE: To assess the effectiveness of 3 novel lung ultrasound (LUS)-based parameters: Pneumonia Score and Lung Staging for pneumonia staging and COVID Index, indicating the probability of SARS-CoV-2 infection. METHODS: Adult patients admitted to the emergency department with symptoms potentially related to pneumonia, healthy volunteers and clinical cases from online accessible databases were evaluated. The patients underwent a clinical-epidemiological questionnaire and a LUS acquisition, following a 14-zone protocol. For each zone, a Pneumonia score from 0 to 4 was assigned by the algorithm and by an expert operator (kept blind with respect to the algorithm results) on the basis of the identified imaging signs and the patient Lung Staging was derived as the highest observed score. The output of the operator was considered as the ground truth. The algorithm calculated also the COVID Index by combining the automatically identified LUS markers with the questionnaire answers and compared with the nasopharyngeal swab results. RESULTS: Overall, 556 patients were analysed. A high agreement between the algorithm assignments and the expert operator evaluations was observed, both for Pneumonia Score and Lung Staging, with the latter having sensitivity and specificity over 92% both in the discrimination between healthy/sick patients and between sick patients with mild/severe pneumonia. Regarding the COVID Index, an area under the curve of 0.826 was observed for the classification of patients with/without SARS-CoV-2. CONCLUSION: The proposed methodology allowed the identification and staging of patients suffering from pneumonia with high accuracy. Moreover, it provided the probability of being infected by SARS-CoV-2.

First assessment of bone mineral density in healthy pregnant women by means of Radiofrequency Echographic Multi Spectrometry (REMS) technology.

OBJECTIVE: The maternal bone structure is the largest calcium reserve for the fetus during pregnancy, and this is claimed to lead to a bone mineral density (BMD) reduction in pregnant women. The primary outcome of the present work was to assess the BMD in a group of healthy pregnant women. STUDY DESIGN: In this prospective case - control observational study, a non-consecutive group of pregnant women with uncomplicated pregnancy at or >37 weeks were enrolled at the unit of Obstetrics and Gynecology, University of Parma, from February to December 2020. The study subjects were submitted to a sonographic examination of the proximal femur with Radiofrequency Echographic Multi Spectrometry (REMS) technology to quantify the BMD of the femur. The BMD values obtained in the study group were compared with those of a control group of non-pregnant women matched for age, ethnicity and pre-pregnant body mass index (BMI). RESULTS: Overall, 78 pregnant women at 39.1 ±â€¯1.5 weeks were assessed. Compared with non-pregnant women, the femoral BMD values measured in pregnancy using REMS were significant lower (0.769 ±â€¯0.094 g/cm2 vs 0.831 ±â€¯0.101 g/cm2, p = 0.0001) with a mean BMD reduction of 8.1%. The femoral neck BMD presented a positive correlation with the pre-pregnant BMI (p = 0.0004) and a negative correlation with the maternal age (p < 0.0001). In addition, a lower femoral neck BMD in Caucasian ethnicity compared with non-Caucasian was noted (p < 0.0001). CONCLUSION: In this exploratory and proof of concept study, for the first time, a decreased BMD has been objectively demonstrated in pregnant compared with non-pregnant women by means of REMS technology. New studies are required to assess the longitudinal changes of maternal bone density throughout the pregnancy.

Use of the Resection Map system as guidance during hepatectomy.

BACKGROUND: The objective of this work is to evaluate a new concept of intraoperative three-dimensional (3D) visualization system to support hepatectomy. The Resection Map aims to provide accurate cartography for surgeons, who can therefore anticipate risks, increase their confidence and achieve safer liver resection. METHODS: In an experimental prospective cohort study, ten consecutive patients admitted for hepatectomy to three European hospitals were selected. Liver structures (portal veins, hepatic veins, tumours and parenchyma) were segmented from a recent computed tomography (CT) study of each patient. The surgeon planned the resection preoperatively and read the Resection Map as reference guidance during the procedure. Objective (amount of bleeding, tumour resection margin and operating time) and subjective parameters were retrieved after each case. RESULTS: Three different surgeons operated on seven patients with the navigation aid of the Resection Map. Veins displayed in the Resection Map were identified during the surgical procedure in 70.1% of cases, depending mainly on size. Surgeons were able to track resection progress and experienced improved orientation and increased confidence during the procedure. CONCLUSIONS: The Resection Map is a pragmatic solution to enhance the orientation and confidence of the surgeon. Further studies are needed to demonstrate improvement in patient safety.

Full experimental modelling of a liver tissue mimicking phantom for medical ultrasound studies employing different hydrogels.

Tissue mimicking phantoms have been widely reported to be an important tool for development, optimisation and performance testing of ultrasound-based diagnostic techniques. In particular, modern applications of tissue mimicking phantoms often include characterisation of the nonlinear behaviour of experimental ultrasound contrast agents. In such cases, the tissue-mimicking materials should be chosen not only based on the values of their density, speed of sound and attenuation coefficient, but also considering their effect on the appearance of "native harmonics" due to nonlinear distortion of ultrasound signal during propagation. In a previous paper it was demonstrated that a cellulose-based hydrogel is suitable to simulate nonlinear acoustical behaviour of liver tissue for thicknesses up to 8 cm. In this paper we present the experimental characterisation of the nonlinear acoustical behaviour of a different polyethylene glycol diacrylate (PEGDA)-based hydrogel, in order to assess whether and how it can improve the performances and overcome some limitations of the cellulose-based hydrogel as liver tissue-mimicking material. Samples of pig liver tissue, cellulose-based hydrogel and PEGDA-based hydrogel were insonified in a through-transmission set-up, employing 2.25-MHz pulses with different mechanical index (MI) values. Second harmonic and first harmonic amplitudes were extracted from the spectra of received signals and their difference was then used to compare sample behaviours. Obtained results show how a new more accurate and combined experimental model of linear and nonlinear acoustical behaviour of liver tissue is feasible. In fact, a further confirmation of the cellulose-based hydrogel effectiveness to precisely simulate the liver tissue for penetration depths up to 8 cm was provided, and it was also shown that the employment of the PEGDA-based hydrogel can extend the range of useful tissue-mimicking material thicknesses up to 11 cm, moreover allowing a considerable improvement of the time stability and behaviour reliability of the corresponding manufactured phantoms.

Quantification of venous blood signal contribution to BOLD functional activation in the auditory cortex at 3 T.

Most modern techniques for functional magnetic resonance imaging (fMRI) rely on blood-oxygen-level-dependent (BOLD) contrast as the basic principle for detecting neuronal activation. However, the measured BOLD effect depends on a transfer function related to neurophysiological changes accompanying electrical neural activation. The spatial accuracy and extension of the region of interest are determined by vascular effect, which introduces incertitude on real neuronal activation maps. Our efforts have been directed towards the development of a new methodology that is capable of combining morphological, vascular and functional information; obtaining new insight regarding foci of activation; and distinguishing the nature of activation on a pixel-by-pixel basis. Six healthy volunteers were studied in a parametric auditory functional experiment at 3 T; activation maps were overlaid on a high-resolution brain venography obtained through a novel technique. The BOLD signal intensities of vascular and nonvascular activated voxels were analyzed and compared: it was shown that nonvascular active voxels have lower values for signal peak (P<10(-7)) and area (P<10(-8)) with respect to vascular voxels. The analysis showed how venous blood influenced the measured BOLD signals, supplying a technique to filter possible venous artifacts that potentially can lead to misinterpretation of fMRI results. This methodology, although validated in the auditory cortex activation, maintains a general applicability to any cortical fMRI study, as the basic concepts on which it relies on are not limited to this cortical region. The results obtained in this study can represent the basis for new methodologies and tools that are capable of adding further characterization to the BOLD signal properties.

Experimental investigations of nonlinearities and destruction mechanisms of an experimental phospholipid-based ultrasound contrast agent.

OBJECTIVES: We sought to characterize the acoustical behavior of the experimental ultrasound contrast agent BR14 by determining the acoustic pressure threshold above which nonlinear oscillation becomes significant and investigating microbubble destruction mechanisms. MATERIALS AND METHODS: We used a custom-designed in vitro setup to conduct broadband attenuation measurements at 3.5 MHz varying acoustic pressure (range, 50-190 kPa). We also performed granulometric analyses on contrast agent solutions to accurately measure microbubble size distribution and to evaluate insonification effects. RESULTS: Attenuation did not depend on acoustic pressure less than 100 kPa, indicating this pressure as the threshold for the appearance of microbubble nonlinear behavior. At the lowest excitation amplitude, attenuation increased during insonification, while, at higher excitation levels, the attenuation decreased over time, indicating microbubble destruction. The destruction rate changed with pressure amplitude suggesting different destruction mechanisms, as it was confirmed by granulometric analysis. CONCLUSIONS: Microbubbles showed a linear behavior until 100 kPa, whereas beyond this value significant nonlinearities occurred. Observed destruction phenomena seem to be mainly due to gas diffusion and bubble fragmentation mechanisms.

Comparison between the use of the Joel-Cohen incision and its modification during Stark's cesarean section.

OBJECTIVE: A comparative evaluation between the Joel-Cohen incision and its modification for the Stark's cesarean section (CS). MATERIALS AND METHODS: In a retrospective study, 477 women who underwent a Stark's CS were evaluated: 204 with the Joel-Cohen incision (JC) and 273 with a modified Joel-Cohen incision (MJC). All patients were checked for the following parameters: febrile morbidity, the need for painkillers, duration of hospital stay, and ultrasound examination for blood collection (BC) on the third postoperative day. The collections, when diagnosed were divided into three groups: (1) in the abdominal wall, (2) in the pouch of Douglas, and (3) in the lower uterine segment (LUS). Those included in the study were low-risk primiparae at term, presenting for CS for breech presentation, macrosomia, and on demand, and who had combined spinal-epidural anesthesia. Statistical evaluation was performed using SAS/V12 software. RESULTS: There were no statistical differences between the two groups with regard to febrile morbidity, duration of need for painkillers, and hospital stay. Statistically more blood collections were found in the MJC incision group (5.4% in the abdominal wall, 12.4% in the pouch of Douglas, and 11.7% in the LUS) than in the classical JC incision group (3.9% in the abdominal wall, 10.2% in the pouch of Douglas, and 8.8% in the LUS), however without any clinical significance. CONCLUSIONS: The routine use of the classical JC incision during the Stark's CS seems to be more rational, and causes fewer blood collections.

Major osteoporotic fragility fractures: Risk factor updates and societal impact.

Osteoporosis is a silent disease without any evidence of disease until a fracture occurs. Approximately 200 million people in the world are affected by osteoporosis and 8.9 million fractures occur each year worldwide. Fractures of the hip are a major public health burden, by means of both social cost and health condition of the elderly because these fractures are one of the main causes of morbidity, impairment, decreased quality of life and mortality in women and men. The aim of this review is to analyze the most important factors related to the enormous impact of osteoporotic fractures on population. Among the most common risk factors, low body mass index; history of fragility fracture, environmental risk, early menopause, smoking, lack of vitamin D, endocrine disorders (for example insulin-dependent diabetes mellitus), use of glucocorticoids, excessive alcohol intake, immobility and others represented the main clinical risk factors associated with augmented risk of fragility fracture. The increasing trend of osteoporosis is accompanied by an underutilization of the available preventive strategies and only a small number of patients at high fracture risk are recognized and successively referred for therapy. This report provides analytic evidences to assess the best practices in osteoporosis management and indications for the adoption of a correct healthcare strategy to significantly reduce the osteoporosis burden. Early diagnosis is the key to resize the impact of osteoporosis on healthcare system. In this context, attention must be focused on the identification of high fracture risk among osteoporotic patients. It is necessary to increase national awareness campaigns across countries in order to reduce the osteoporotic fractures incidence.

An Advanced Quantitative Echosound Methodology for Femoral Neck Densitometry.

The aim of this paper was to investigate the clinical feasibility and the accuracy in femoral neck densitometry of the Osteoporosis Score (O.S.), an ultrasound (US) parameter for osteoporosis diagnosis that has been recently introduced for lumbar spine applications. A total of 377 female patients (aged 61-70 y) underwent both a femoral dual X-ray absorptiometry (DXA) and an echographic scan of the proximal femur. Recruited patients were sub-divided into a reference database used for ultrasound spectral model construction and a study population for repeatability assessments and accuracy evaluations. Echographic images and radiofrequency signals were analyzed through a fully automatic algorithm that performed a series of combined spectral and statistical analyses, providing as a final output the O.S. value of the femoral neck. Assuming DXA as a gold standard reference, the accuracy of O.S.-based diagnoses resulted 94.7%, with k = 0.898 (p < 0.0001). Significant correlations were also found between O.S.-estimated bone mineral density and corresponding DXA values, with r(2) up to 0.79 and root mean square error = 5.9-7.4%. The reported accuracy levels, combined with the proven ease of use and very good measurement repeatability, provide the adopted method with a potential for clinical routine application in osteoporosis diagnosis.

Automatic Echographic Detection of Halloysite Clay Nanotubes in a Low Concentration Range.

Aim of this work was to investigate the automatic echographic detection of an experimental drug delivery agent, halloysite clay nanotubes (HNTs), by employing an innovative method based on advanced spectral analysis of the corresponding "raw" radiofrequency backscatter signals. Different HNT concentrations in a low range (5.5-66 × 1010 part/mL, equivalent to 0.25-3.00 mg/mL) were dispersed in custom-designed tissue-mimicking phantoms and imaged through a clinically-available echographic device at a conventional ultrasound diagnostic frequency (10 MHz). The most effective response (sensitivity = 60%, specificity = 95%), was found at a concentration of 33 × 1010 part/mL (1.5 mg/mL), representing a kind of best compromise between the need of enough particles to introduce detectable spectral modifications in the backscattered signal and the necessity to avoid the losses of spectral peculiarity associated to higher HNT concentrations. Based on theoretical considerations and quantitative comparisons with literature-available results, this concentration could also represent an optimal concentration level for the automatic echographic detection of different solid nanoparticles when employing a similar ultrasound frequency. Future dedicated studies will assess the actual clinical usefulness of the proposed approach and the potential of HNTs for effective theranostic applications.

Quality assurance in radiotherapy. How to improve the effectiveness and completeness of an electronic patient's chart.

A checking form was introduced in order to test the completeness of electronic and paper patient's charts in a radiotherapy department which had introduced record-and-verify system (RVS) and to improve tha staff performance. The chosen items for the electronic chart were 9 and 5 for paper chart. 223 patients were reviewed in two phases. The data analysis was based on a scoring method, attributing a positive score (+1) to the operator's good behaviour, a negative score (-1) to the lack of data input and a neutral score (0) to the inapplicable situation. The average global score increased from 0.4 to 0.7: in A (lowest complexity) category from 0.37 to 0.64, in B category from 0.4 to 0.89, in C category from 0.48 to 0.61.

A novel ultrasound methodology for estimating spine mineral density.

We investigated the possible clinical feasibility and accuracy of an innovative ultrasound (US) method for diagnosis of osteoporosis of the spine. A total of 342 female patients (aged 51-60 y) underwent spinal dual X-ray absorptiometry and abdominal echographic scanning of the lumbar spine. Recruited patients were subdivided into a reference database used for US spectral model construction and a study population for repeatability and accuracy evaluation. US images and radiofrequency signals were analyzed via a new fully automatic algorithm that performed a series of spectral and statistical analyses, providing a novel diagnostic parameter called the osteoporosis score (O.S.). If dual X-ray absorptiometry is assumed to be the gold standard reference, the accuracy of O.S.-based diagnoses was 91.1%, with k = 0.859 (p < 0.0001). Significant correlations were also found between O.S.-estimated bone mineral densities and corresponding dual X-ray absorptiometry values, with r(2) values up to 0.73 and a root mean square error of 6.3%-9.3%. The results obtained suggest that the proposed method has the potential for future routine application in US-based diagnosis of osteoporosis.

Fractionations in radiotherapy of brain metastases.

AIMS AND BACKGROUND: The aim of this study was to evaluate different fractionations for radiotherapy of brain metastases. METHODS: One hundred and twenty-five patients treated with whole brain cobalt therapy (WBRT) were examined to evaluate the effect on survival and quality of life of three different dose fractionations (2 Gy x 25, 3 Gy x 10 and 4 Gy x 5). Fractionation was evaluated in relation to mean survival, single or multiple lesions, presence of extracranial metastases, primary tumor control and neurological status before and after treatment. Kaplan-Meier analysis of survival and univariate and multivariate analysis of these factors were performed. Twenty-six (21%) patients were treated with 2 Gy x 25, 48 patients (38%) with 3 Gy x 10 and 42 patients (33%) with 4 Gy x 5. The other 9 patients were treated with unusual fractionations. RESULTS: In 66% of patients an improvement in neurological status after radiotherapy was recorded. Patients with controlled primary tumors had a better mean survival, 8.6 months, if they had no extracranial metastases. The six-month survival was 21% in the 4 Gy x 5 group, 36% in the 3 Gy x 10 group, and 21% in the 2 Gy x 25 group; the results for one-year actuarial survival were highly similar in the three fractionation groups (5%, 11% and 6%, respectively). CONCLUSIONS: The use of 5 x 4 Gy fractionation may be appropriate in lung cancer patients, where no significant difference in 6- and 12-month survival was observed with respect to the other fractionation groups despite the most unfavorable prognosis of these patients and the lower biological effectiveness of this fractionation with respect to the other schedules.