Twenty Years of Advancements in a Radiotherapy Facility: Clinical Protocols, Technology, and Management.

BACKGROUND: Hypo-fractionation can be an effective strategy to lower costs and save time, increasing patient access to advanced radiation therapy. To demonstrate this potential in practice within the context of temporal evolution, a twenty-year analysis of a representative radiation therapy facility from 2003 to 2022 was conducted. This analysis utilized comprehensive data to quantitatively evaluate the connections between advanced clinical protocols and technological improvements. The findings provide valuable insights to the management team, helping them ensure the delivery of high-quality treatments in a sustainable manner. METHODS: Several parameters related to treatment technique, patient positioning, dose prescription, fractionation, equipment technology content, machine workload and throughput, therapy times and patients access counts were extracted from departmental database and analyzed on a yearly basis by means of linear regression. RESULTS: Patients increased by 121 ± 6 new per year (NPY). Since 2010, the incidence of hypo-fractionation protocols grew thanks to increasing Linac technology. In seven years, both the average number of fractions and daily machine workload decreased by -0.84 ± 0.12 fractions/year and -1.61 ± 0.35 patients/year, respectively. The implementation of advanced dose delivery techniques, image guidance and high dose rate beams for high fraction doses, currently systematically used, has increased the complexity and reduced daily treatment throughput since 2010 from 40 to 32 patients per 8 h work shift (WS8). Thanks to hypo-fractionation, such an efficiency drop did not affect NPY, estimating 693 ± 28 NPY/WS8, regardless of the evaluation time. Each newly installed machine was shown to add 540 NPY, while absorbing 0.78 ± 0.04 WS8. The COVID-19 pandemic brought an overall reduction of 3.7% of patients and a reduction of 0.8 fractions/patient, to mitigate patient crowding in the department. CONCLUSIONS: The evolution of therapy protocols towards hypo-fractionation was supported by the use of proper technology. The characteristics of this process were quantified considering time progression and organizational aspects. This strategy optimized resources while enabling broader access to advanced radiation therapy. To truly value the benefit of hypo-fractionation, a reimbursement policy should focus on the patient rather than individual treatment fractionation.

Oligorecurrent Prostate Cancer and Stereotactic Body Radiotherapy: Where Are We Now? A Systematic Review and Meta-analysis of Prospective Studies.

CONTEXT: The optimal management of oligometastatic prostate cancer (PCa) is still debated. OBJECTIVE: The purpose of the present systematic review and meta-analysis is to collect the available evidence to date to better define the role of stereotactic body radiotherapy (SBRT) in selected patients with oligorecurrent PCa. EVIDENCE ACQUISITION: Study methodology complied with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). All prospective studies including PCa patients with nodal and/or bone oligometastases (one to five lesions) were considered eligible. Heterogeneity between study-specific estimates was tested using chi-square statistics and measured with the I2 index. A pooled estimate was obtained by fitting both fixed-effect and DerSimonian and Laird random-effect model. EVIDENCE SYNTHESIS: Overall, six works (two randomized and the remainder observational) published between 2013 and 2020 were considered eligible. Globally, data from 445 patients were incorporated, of whom 396 were treated with SBRT (329 in observational studies and the remaining 67 in randomized ones). Regarding local progression-free survival (PFS), five studies reported values close to 100%, while one reported a value of 80% in the observation arm. The benefit in terms of biochemical PFS brought by SBRT was evident in all considered studies. Such a difference in cumulative probabilities between the intervention arm and the comparator arm is maintained even 24 mo after the baseline. All studies but one considered toxicity among the endpoints of interest. Most events were classified as either G1 or G2, and the only G ≥ 3 adverse event was reported in one trial. CONCLUSIONS: SBRT is highly cost effective, safe, and with an almost inexistent toxicity risk that makes it the perfect candidate for the optimal management of PCa oligometastatic patients. However, more solid data and a higher level of evidence are needed to affirm its role in the management of these patients. PATIENT SUMMARY: In this work, we reviewed available evidence on the use of stereotactic body radiotherapy in treating oligometastatic prostate cancer patients. We found good evidence that radiotherapy brings important benefits in overall treatment efficacy without major side effects.

Exploring miRNA Signature and Other Potential Biomarkers for Oligometastatic Prostate Cancer Characterization: The Biological Challenge behind Clinical Practice. A Narrative Review.

In recent years, a growing interest has been directed towards oligometastatic prostate cancer (OMPC), as patients with three to five metastatic lesions have shown a significantly better survival as compared with those harboring a higher number of lesions. The efficacy of local ablative treatments directed on metastatic lesions (metastases-directed treatments) was extensively investigated, with the aim of preventing further disease progression and delaying the start of systemic androgen deprivation therapies. Definitive diagnosis of prostate cancer is traditionally based on histopathological analysis. Nevertheless, a bioptic sample-static in nature-inevitably fails to reflect the dynamics of the tumor and its biological response due to the dynamic selective pressure of cancer therapies, which can profoundly influence spatio-temporal heterogeneity. Furthermore, even with new imaging technologies allowing an increasingly early detection, the diagnosis of oligometastasis is currently based exclusively on radiological investigations. Given these premises, the development of minimally-invasive liquid biopsies was recently promoted and implemented as predictive biomarkers both for clinical decision-making at pre-treatment (baseline assessment) and for monitoring treatment response during the clinical course of the disease. Through liquid biopsy, different biomarkers, commonly extracted from blood, urine or saliva, can be characterized and implemented in clinical routine to select targeted therapies and assess treatment response. Moreover, this approach has the potential to act as a tissue substitute and to accelerate the identification of novel and consistent predictive analytes cost-efficiently. However, the utility of tumor profiling is currently limited in OMPC due to the lack of clinically validated predictive biomarkers. In this scenario, different ongoing trials, such as the RADIOSA trial, might provide additional insights into the biology of the oligometastatic state and on the identification of novel biomarkers for the outlining of true oligometastatic patients, paving the way towards a wider ideal approach of personalized medicine. The aim of the present narrative review is to report the current state of the art on the solidity of liquid biopsy-related analytes such as CTCs, cfDNA, miRNA and epi-miRNA, and to provide a benchmark for their further clinical implementation. Arguably, this kind of molecular profiling could refine current developments in the era of precision oncology and lead to more refined therapeutic strategies in this subset of oligometastatic patients.

Computer-Assisted Classification Patterns in Autoimmune Diagnostics: The AIDA Project.

Antinuclear antibodies (ANAs) are significant biomarkers in the diagnosis of autoimmune diseases in humans, done by mean of Indirect ImmunoFluorescence (IIF) method, and performed by analyzing patterns and fluorescence intensity. This paper introduces the AIDA Project (autoimmunity: diagnosis assisted by computer) developed in the framework of an Italy-Tunisia cross-border cooperation and its preliminary results. A database of interpreted IIF images is being collected through the exchange of images and double reporting and a Gold Standard database, containing around 1000 double reported images, has been settled. The Gold Standard database is used for optimization of a CAD (Computer Aided Detection) solution and for the assessment of its added value, in order to be applied along with an Immunologist as a second Reader in detection of autoantibodies. This CAD system is able to identify on IIF images the fluorescence intensity and the fluorescence pattern. Preliminary results show that CAD, used as second Reader, appeared to perform better than Junior Immunologists and hence may significantly improve their efficacy; compared with two Junior Immunologists, the CAD system showed higher Intensity Accuracy (85,5% versus 66,0% and 66,0%), higher Patterns Accuracy (79,3% versus 48,0% and 66,2%), and higher Mean Class Accuracy (79,4% versus 56,7% and 64.2%).

Fuzzy technique for microcalcifications clustering in digital mammograms.

BACKGROUND: Mammography has established itself as the most efficient technique for the identification of the pathological breast lesions. Among the various types of lesions, microcalcifications are the most difficult to identify since they are quite small (0.1-1.0 mm) and often poorly contrasted against an images background. Within this context, the Computer Aided Detection (CAD) systems could turn out to be very useful in breast cancer control. METHODS: In this paper we present a potentially powerful microcalcifications cluster enhancement method applicable to digital mammograms. The segmentation phase employs a form filter, obtained from LoG filter, to overcome the dependence from target dimensions and to optimize the recognition efficiency. A clustering method, based on a Fuzzy C-means (FCM), has been developed. The described method, Fuzzy C-means with Features (FCM-WF), was tested on simulated clusters of microcalcifications, implying that the location of the cluster within the breast and the exact number of microcalcifications are known.The proposed method has been also tested on a set of images from the mini-Mammographic database provided by Mammographic Image Analysis Society (MIAS) publicly available. RESULTS: The comparison between FCM-WF and standard FCM algorithms, applied on both databases, shows that the former produces better microcalcifications associations for clustering than the latter: with respect to the private and the public database we had a performance improvement of 10% and 5% with regard to the Merit Figure and a 22% and a 10% of reduction of false positives potentially identified in the images, both to the benefit of the FCM-WF. The method was also evaluated in terms of Sensitivity (93% and 82%), Accuracy (95% and 94%), FP/image (4% for both database) and Precision (62% and 65%). CONCLUSIONS: Thanks to the private database and to the informations contained in it regarding every single microcalcification, we tested the developed clustering method with great accuracy. In particular we verified that 70% of the injected clusters of the private database remained unaffected if the reconstruction is performed with the FCM-WF. Testing the method on the MIAS databases allowed also to verify the segmentation properties of the algorithm, showing that 80% of pathological clusters remained unaffected.

Mammographic images segmentation based on chaotic map clustering algorithm.

BACKGROUND: This work investigates the applicability of a novel clustering approach to the segmentation of mammographic digital images. The chaotic map clustering algorithm is used to group together similar subsets of image pixels resulting in a medically meaningful partition of the mammography. METHODS: The image is divided into pixels subsets characterized by a set of conveniently chosen features and each of the corresponding points in the feature space is associated to a map. A mutual coupling strength between the maps depending on the associated distance between feature space points is subsequently introduced. On the system of maps, the simulated evolution through chaotic dynamics leads to its natural partitioning, which corresponds to a particular segmentation scheme of the initial mammographic image. RESULTS: The system provides a high recognition rate for small mass lesions (about 94% correctly segmented inside the breast) and the reproduction of the shape of regions with denser micro-calcifications in about 2/3 of the cases, while being less effective on identification of larger mass lesions. CONCLUSIONS: We can summarize our analysis by asserting that due to the particularities of the mammographic images, the chaotic map clustering algorithm should not be used as the sole method of segmentation. It is rather the joint use of this method along with other segmentation techniques that could be successfully used for increasing the segmentation performance and for providing extra information for the subsequent analysis stages such as the classification of the segmented ROI.

Surgical treatment of chronic acromioclavicular dislocation with biologic graft vs synthetic ligament: a prospective randomized comparative study.

BACKGROUND: Acromioclavicular (AC) dislocation involves complete loss of articular contact; it is defined as chronic when it follows conservative management or unsuccessful surgical treatment. MATERIALS AND METHODS: The study compared the clinical and radiographic outcomes of AC joint stabilization performed in 40 patients with chronic dislocation using a biological allograft (group A) or a synthetic ligament (group B). Demographic data included: M/F: 25/15; mean age: 35 ± 3.2 years; previous surgery in 11 patients, including Weaver-Dunn (3), coracoacromial ligament repair (4), stabilization with K-wires (4). Dislocation was type III in 14 (35 %) and type IV in 26 (65 %) patients. Clinical assessment was with the Constant-Murley score (pre- and postoperative) and with the modified UCLA score. Enrollment started in January 2004 and was completed in March 2008. Patients were evaluated at 1 and 4 years. Postoperative X-rays were examined to assess joint stability in the coronal and axial planes, coracoclavicular ossification, and signs of AC joint osteoarthritis and distal clavicular osteolysis. RESULTS: The "biological" group achieved significantly better clinical scores than the "synthetic" group at both 1 and 4 years. Poor subjective satisfaction and lower clinical scores were found in the 3 patients (1 from group A and 2 from group B) who experienced complete postoperative dislocation. No significant correlations were found with other radiographic parameters. CONCLUSIONS: The biological graft afforded better clinical and radiographic outcomes than the synthetic ligament in patients with chronic AC joint instability. Fixation to the clavicle constitutes the main weakness of both approaches and needs improving.

Correlation between radiographic risk for glenoid component loosening and clinical scores in shoulder arthroplasty.

Glenoid component loosening is the weak point in the failure of total shoulder arthroplasty (TSA). In this study we analyse the radiographic risk factors observed on 86 cemented polyethylene glenoid components and their relationship with clinical signs at a mean follow-up of 5.8 years. Clinical assessment included Simple Shoulder Test (SST) and Constant-Murley score. Radiograms were taken to detect periprosthetic radiolucency, tilt, medial displacement and polyethylene thinning. Pearson's correlation coefficient and Spearman's rank correlation coefficient were calculated for statistical analysis. In 61 patients (71%) lucent lines were less than 2 mm wide (grade 2) and in 6 cases (7%) they were >or=2 mm wide (grade 3 and 4). Thinning of the polyethylene was found in 11 cases (13%), glenoid tilt in 6 cases (7%) and medial migration of the component in 5 cases (6%). Complete glenoid prosthetic loosening was found in 3 cases (3.5%) associated with polyethylene wear and glenoid bone loss. The Constant-Murley score associated with radiolucency grade 3 and 4 was less than 45% (38.39 +/- 8.9) (p < 0.05), while a score less than 56% (30.72 +/- 8.7) was found in patients with glenoid tilt and medial migration (p < 0.01). The mean SST score was 4.8 +/- 2.8 in case of glenoid tilt and migration of the component (p < 0.01). Removal of the glenoid component and conversion to hemiarthroplasty or reverse prostheses is suggested in painful glenoid loosening. An exhaustive analysis of radiograms is essential to detect early and late complications or risk factors of glenoid loosening.

A massive lesion detection algorithm in mammography.

A new algorithm for massive lesion detection in mammography is presented. The algorithm consists in three main steps: 1) reduction of the dimension of the image to be processed through the identification of regions of interest (roi) as candidates for massive lesions; 2) characterization of the RoI by means of suitable feature extraction; 3) pattern classification through supervised neural networks. Suspect regions are detected by searching for local maxima of the pixel grey level intensity. A ring of increasing radius, centered on a maximum, is considered until the mean intensity in the ring decreases to a defined fraction of the maximum. The ROIS thus obtained are described by average, variance, skewness and kurtosis of the intensity distributions at different fractions of the radius. A neural network approach is adopted to classify suspect pathological and healthy pattern. The software has been designed in the framework of the INFN (Istituto Nazionale Fisica Nucleare) research project GPCALMA (Grid Platform for Calma) which recruits physicists and radiologists from different Italian Research Institutions and hospitals to develop software for breast cancer detection.