The clonal evolution of two distinct T315I-positive BCR-ABL1 subclones in a Philadelphia-positive acute lymphoblastic leukemia failing multiple lines of therapy: a case report

BACKGROUND: The treatment of Philadelphia chromosome-positive Acute Lymphoblastic Leukemia (Ph+ ALL) patients who harbor the T315I BCR-ABL1 mutation or who have two or more mutations in the same BCR-ABL1 molecule is particularly challenging since first and second-generation Tyrosine Kinase Inhibitors (TKIs) are ineffective. Ponatinib, blinatumomab, chemotherapy and transplant are the currently available options in these cases. CASE PRESENTATION: We here report the case of a young Ph+ ALL patient who relapsed on front-line dasatinib therapy because of two independent T315I-positive subclones, resulting from different nucleotide substitutions -one of whom never reported previously- and where additional mutant clones outgrew and persisted despite ponatinib, transplant, blinatumomab and conventional chemotherapy. Deep Sequencing (DS) was used to dissect the complexity of BCR-ABL1 kinase domain (KD) mutation status and follow the kinetics of different mutant clones across the sequential therapeutic approaches. CONCLUSIONS: This case presents several peculiar and remarkable aspects: i) distinct clones may acquire the same amino acid substitution via different nucleotide changes; ii) the T315I mutation may arise also from an 'act' to 'atc' codon change; iii) the strategy of temporarily replacing TKI therapy with chemo or immunotherapy, in order to remove the selective pressure and deselect aggressive mutant clones, cannot always be expected to be effective; iv) BCR-ABL1-mutated sub-clones may persist at very low levels (undetectable even by Deep Sequencing) for long time and then outcompete BCR-ABL1-unmutated ones becoming dominant even in the absence of any TKI selective pressure

Aspectos morfológicos da punção aspirativa de mama

A punção aspirativa por agulha fina (PAAF) de mama tem sido amplamente utilizada pela facilidade da técnica que, além de não dispendiosa, fornece resultados rápidos com boa acuidade diagnóstica. A análise de nosso material de punção aspirativa de mama permitiu a caracterização de alguns aspectos morfológicos importantes para o diagnóstico das lesões mais freqüentes

Efeitos da intervenção fisioterapêutica nas respostas sensoriais e funcionais de diabéticos neuropatas

The purpose of this study was to elaborate and apply a physical therapy treatment for diabetic neuropathic patients, comparing their sensorial, motor and functional responses before and after treatment to those of a healthy control group. Ten healthy subjects (CG) and 10 neuropathic diabetes patients (DG) clinically diagnosed were studied. Motor, functionaland sensorial evaluations were performed pre and post-intervention in both groups. Treatment was individually applied in 45-minute sessions twice a week, during 5 weeks. Therapy program consisted in stretching exercises for hamstrings, triceps surae and tibialis anterior muscles, actively-resisted exercises for intrinsic and extrinsic foot and ankle muscles, practice of daily activities and feet self-care orientations. Data were statistically analysed. When comparing DG post treatment data to DG-pre and CG, thermal sensitivity showed improvement in heel, hallux, lateral and medial forefoot; DG ankle dorsiflexion and eversion ROM reached values similar to those of CG's; DG showed significant improvement in ankle extension and inversion; and DG-post reached the same muscular functions observed in CG in intrinsic feet muscles, tibialis anterior and triceps surae. The physical therapy treatment showed effective in reducing distal numbness, tingling and pricking and it was also effective in preventing muscle function and mobility limitations in diabetic neuropathic patients.O objetivo foi elaborar e aplicar um tratamento fisioterapêutico para diabéticos neuropatas e comparar suas respostas sensoriais, motoras e funcionais, pré e pós-intervenção, com um grupo de sujeitos não-diabéticos assintomáticos. Participaram do estudo 10 sujeitos controle (GC) e 10 diabéticos neuropatas (GD) diagnosticados clinicamente. Realizou-se uma avaliação motora, funcional e sensorial nos dois grupos pré e pós-intervenção. O tratamento foi aplicado individualmente duas vezes por semana, por 45 minutos, durante 5 semanas. Foram feitos alongamentos de cadeia posterior e tibial anterior; exercícios ativos resistidos para musculatura intrínseca do pé e tornozelo; treino de atividades de vida diária e fornecidas orientações de autocuidado com os pés. Os dados foram analisados estatisticamente. Comparando-se os dados do GD pós-tratamento com os do GC, verificou-se melhora na sensibilidade térmica nas regiões de calcanhar, hálux, antepé lateral e medial; a amplitude ativa de dorsiflexão e eversão do tornozelo igualou-se à do GC; houve melhora significativa da extensão e inversão do pé; e o GD alcançou funções musculares (musculatura intrínseca do pé,tríceps sural e tibial anterior) semelhantes às do GC. Em diabéticos neuropatas, o tratamento fisioterapêutico proposto mostrou-se eficaz na atenuação dos sintomas dormência, formigamento e queimação, além de contribuir para a mobilidade e prevenção de limitações de função muscular

The Seascape of Demersal Fish Nursery Areas in the North Mediterranean Sea, a First Step Towards the Implementation of Spatial Planning for Trawl Fisheries

The identification of nursery grounds and other essential fish habitats of exploited stocks is a key requirement for the development of spatial conservation planning aimed at reducing the adverse impact of fishing on the exploited populations and ecosystems. The reduction in juvenile mortality is particularly relevant in the Mediterranean and is considered as one of the main prerequisites for the future sustainability of trawl fisheries. The distribution of nursery areas of 11 important commercial species of demersal fish and shellfish was analysed in the European Union Mediterranean waters using time series of bottom trawl survey data with the aim of identifying the most persistent recruitment areas. A high interspecific spatial overlap between nursery areas was mainly found along the shelf break of many different sectors of the Northern Mediterranean indicating a high potential for the implementation of conservation measures. Overlap of the nursery grounds with existing spatial fisheries management measures and trawl fisheries restricted areas was also investigated. Spatial analyses revealed considerable variation depending on species and associated habitat/depth preferences with increased protection seen in coastal nurseries and minimal protection seen for deeper nurseries (e.g. Parapenaeus longirostris 6%). This is partly attributed to existing environmental policy instruments (e.g. Habitats Directive and Mediterranean Regulation EC 1967/2006) aiming at minimising impacts on coastal priority habitats such as seagrass, coralligenous and maerl beds. The new knowledge on the distribution and persistence of demersal nurseries provided in this study can support the application of spatial conservation measures, such as the designation of no-take Marine Protected Areas in EU Mediterranean waters and their inclusion in a conservation network. The establishment of no-take zones will be consistent with the objectives of the Common Fisheries Policy applying the ecosystem approach to fisheries management and with the requirements of the Marine Strategy Framework Directive to maintain or achieve seafloor integrity and good environmental status.Versión del editor4,411

INCB84344-201: Ponatinib and steroids in frontline therapy for unfit patients with Ph+ acute lymphoblastic leukemia

Tyrosine kinase inhibitors have improved survival for patients with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). However, prognosis for old or unfit patients remains poor. In the INCB84344-201 (formerly GIMEMA LAL 1811) prospective, multicenter, phase 2 trial, we tested the efficacy and safety of ponatinib plus prednisone in newly diagnosed patients with Ph+ ALL 6560 years, or unfit for intensive chemotherapy and stem cell transplantation. Forty-four patients received oral ponatinib 45 mg/d for 48 weeks (core phase), with prednisone tapered to 60 mg/m2/d from days-14-29. Prophylactic intrathecal chemotherapy was administered monthly. Median age was 66.5 years (range, 26-85). The primary endpoint (complete hematologic response [CHR] at 24 weeks) was reached in 38/44 patients (86.4%); complete molecular response (CMR) in 18/44 patients (40.9%) at 24 weeks. 61.4% of patients completed the core phase. As of 24 April 2020, median event-free survival was 14.31 months (95% CI 9.30-22.31). Median overall survival and duration of CHR were not reached; median duration of CMR was 11.6 months. Most common treatment-emergent adverse events (TEAEs) were rash (36.4%), asthenia (22.7%), alanine transaminase increase (15.9%), erythema (15.9%), and \u3b3-glutamyltransferase increase (15.9%). Cardiac and vascular TEAEs occurred in 29.5% (grade 653, 18.2%) and 27.3% (grade 653, 15.9%), respectively. Dose reductions, interruptions, and discontinuations due to TEAEs occurred in 43.2%, 43.2%, and 27.3% of patients, respectively; 5 patients had fatal TEAEs. Ponatinib and prednisone showed efficacy in unfit patients with Ph+ ALL; however, a lower ponatinib dose may be more appropriate in this population. This trial was registered at www.clinicaltrials.gov as #NCT01641107

European Association of Nuclear Medicine Focus 5:Consensus on Molecular Imaging and Theranostics in Prostate Cancer

BACKGROUND: In prostate cancer (PCa), questions remain on indications for prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging and PSMA radioligand therapy, integration of advanced imaging in nomogram-based decision-making, dosimetry, and development of new theranostic applications.OBJECTIVE: We aimed to critically review developments in molecular hybrid imaging and systemic radioligand therapy, to reach a multidisciplinary consensus on the current state of the art in PCa.DESIGN, SETTING, AND PARTICIPANTS: The results of a systematic literature search informed a two-round Delphi process with a panel of 28 PCa experts in medical or radiation oncology, urology, radiology, medical physics, and nuclear medicine. The results were discussed and ratified in a consensus meeting.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Forty-eight statements were scored on a Likert agreement scale and six as ranking options. Agreement statements were analysed using the RAND appropriateness method. Ranking statements were analysed using weighted summed scores.RESULTS AND LIMITATIONS: After two Delphi rounds, there was consensus on 42/48 (87.5%) of the statements. The expert panel recommends PSMA PET to be used for staging the majority of patients with unfavourable intermediate and high risk, and for restaging of suspected recurrent PCa. There was consensus that oligometastatic disease should be defined as up to five metastases, even using advanced imaging modalities. The group agreed that [177Lu]Lu-PSMA should not be administered only after progression to cabazitaxel and that [223Ra]RaCl2 remains a valid therapeutic option in bone-only metastatic castration-resistant PCa. Uncertainty remains on various topics, including the need for concordant findings on both [18F]FDG and PSMA PET prior to [177Lu]Lu-PSMA therapy.CONCLUSIONS: There was a high proportion of agreement among a panel of experts on the use of molecular imaging and theranostics in PCa. Although consensus statements cannot replace high-certainty evidence, these can aid in the interpretation and dissemination of best practice from centres of excellence to the wider clinical community.PATIENT SUMMARY: There are situations when dealing with prostate cancer (PCa) where both the doctors who diagnose and track the disease development and response to treatment, and those who give treatments are unsure about what the best course of action is. Examples include what methods they should use to obtain images of the cancer and what to do when the cancer has returned or spread. We reviewed published research studies and provided a summary to a panel of experts in imaging and treating PCa. We also used the research summary to develop a questionnaire whereby we asked the experts to state whether or not they agreed with a list of statements. We used these results to provide guidance to other health care professionals on how best to image men with PCa and what treatments to give, when, and in what order, based on the information the images provide.</p

European Association of Nuclear Medicine Focus 5 : Consensus on Molecular Imaging and Theranostics in Prostate Cancer

Funding/Support and role of the sponsor: This research was funded by the EANM and supported by unrestricted grants from Advanced Accelerator Applications—a Novartis company, Monrol, Spectrum Dynamics Medical Ltd., Blue Earth Diagnostics, GE HealthCare, ITM Isotope Technologies Munich SE, Siemens Healthineers, and Telix Pharmaceuticals. These sponsors had no direct or indirect influence on the programme and content of the EANM Focus 5 meeting and the writing or content of this consensus statement. Acknowledgements: We would like to thank Evelyn Mansutti, Susanne Koebe, Andrea Csismazia, Jutta Peter, Petra Neubauer, Andreas Felser, and Henrik Silber (all from EANM) for project management. We also acknowledge all who participated in EANM Focus 5 meeting and especially the patients who participated in clinical and research projects, making it possible to inform expert opinion.Peer reviewe

Large-Scale Spatio-Temporal Patterns of Mediterranean Cephalopod Diversity

Species diversity is widely recognized as an important trait of ecosystems’ functioning and resilience. Understanding the causes of diversity patterns and their interaction with the environmental conditions is essential in order to effectively assess and preserve existing diversity. While diversity patterns of most recurrent groups such as fish are commonly studied, other important taxa such as cephalopods have received less attention. In this work we present spatio-temporal trends of cephalopod diversity across the entire Mediterranean Sea during the last 19 years, analysing data from the annual bottom trawl survey MEDITS conducted by 5 different Mediterranean countries using standardized gears and sampling protocols. The influence of local and regional environmental variability in different Mediterranean regions is analysed applying generalized additive models, using species richness and the Shannon Wiener index as diversity descriptors. While the western basin showed a high diversity, our analyses do not support a steady eastward decrease of diversity as proposed in some previous studies. Instead, high Shannon diversity was also found in the Adriatic and Aegean Seas, and high species richness in the eastern Ionian Sea. Overall diversity did not show any consistent trend over the last two decades. Except in the Adriatic Sea, diversity showed a hump-shaped trend with depth in all regions, being highest between 200–400 m depth. Our results indicate that high Chlorophyll a concentrations and warmer temperatures seem to enhance species diversity, and the influence of these parameters is stronger for richness than for Shannon diversityVersión del editor4,411

Cohort profile : demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe

Purpose: The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports. Participants: Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at. Findings to date: This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be ‘markedly ill’, ‘severely ill’ or ‘among the most extremely ill’ by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year. Future plans: Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared. Trial registration number: NCT03013595