Sergiu Scobioala

Up-regulation of nestin in the infarcted myocardium potentially indicates differentiation of resident cardiac stem cells into various lineages including cardiomyocytes.

To identify proteins involved in cardiac regeneration, a proteomics approach was applied. A total of 26 proteins, which displayed aberrant expression in mouse hearts infarcted through ligation of the left anterior descending coronary artery, were identified. These included the intermediate filament protein nestin, which was up‐regulated in the infarct border zone. Corresponding changes were observed for its mRNA. Nestin mRNA was also up‐regulated in hearts from 17 of 19 patients with end‐stage heart failure, including 4 with acute myocardial infarction in comparison with 8 donor hearts. Immunofluorescence confo‐cal laser scanning microscopy revealed that nestin is expressed, on the one hand, in small proportions of cardiomyocytes, endothelial cells, smooth muscle cells, neuronal cells, and fibroblasts. On the other hand, it was found to be coexpressed with the stem cell markers c‐kit, Sca‐1, Mdr‐1, and Abcg2 in small interstitial cells. In infarcted hearts from chimeric mice transplanted with bone marrow from enhanced green fluorescent protein (EGFP) transgenic mice, less than 1% of nestin‐positive cells coexpressed EGFP, although EGFP‐positive cells were abundant in these. Consequently, enhanced expression of nestin in the injured myocardium might reflect spontaneous regenerative processes supposedly based on the differentiation of resident cardiac stem cells into diverse cardiac cell types. Scobioala, S., Klocke, R., Kuhlmann, M., Tian, W., Hasib, L., Milting, H., Koenig, S., Stelljes, M., El‐Banayosy, A., Tenderich, G., Michel, G., Breithardt, G., Nikol, S. Up‐regulation of nestin in the infarcted myocardium potentially indicates differentiation of resident cardiac stem cells into various lineages including cardiomyo‐cytes. FASEB J. 22, 1021–1031 (2008)

Granulocyte Colony-Stimulating Factor (G-CSF) for Cardio- and Cerebrovascular Regenerative Applications

The cytokine granulocyte colony-stimulating factor (G-CSF) is produced by numerous cell types including immune and endothelial cells. G-CSF binding to its receptor G-CSF-R which belongs to the cytokine receptor type I family depends on the interaction of alpha-helical motifs of the former and two fibronectin type III as well as an immunoglobulin-like domain of the latter. It activates several signalling transduction pathways including PI3K/Akt, Jak/Stat and MAP kinase, thereby promoting survival, proliferation, differentiation and mobilisation of haematopoietic stem and progenitor cells. Accordingly, recombinant human (rh)G-CSF has been extensively used in clinical haematology and oncology to enable bone marrow transplantation or to treat chemotherapy-associated neutropenia. Using animal models it has been recently shown that G-CSF, alone or in combination with other cytokines such as stem cell factor (SCF), causes an accumulation of bone marrow-derived cells in the infarcted heart which, however, do not differentiate into cardiac cells. Nevertheless, since beneficial effects on structural and functional properties were observed in animal models of cardiac, brain and hindlimb ischaemia other mechanisms of G-CSF action must be operative. Recent evidence suggests paracrine effects mediated by the immigrated bone marrow-derived cells and/or direct effects of the cytokine on resident G-CSF-R expressing cells. In both cases these may include promotion of cellular survival, proliferation and differentiation. First clinical studies in patients with myocardial infarction, heart failure and stroke have been accomplished and are reviewed in this paper.

Total Skin Electron Beam for Primary Cutaneous T-cell Lymphoma.

PURPOSE Recent trials with low-dose total skin electron beam (TSEB) therapy demonstrated encouraging results for treating primary cutaneous T-cell lymphoma (PCTCL). In this study, we assessed the feasibility of different radiation doses and estimated survival rates of different pathologic entities and stages. METHODS AND MATERIALS We retrospectively identified 45 patients with PCTCL undergoing TSEB therapy between 2000 and 2015. Clinical characteristics, treatment outcomes, and toxicity were assessed. RESULTS A total of 49 courses of TSEB therapy were administered to the 45 patients. There were 26 pathologically confirmed cases of mycosis fungoides (MF) lymphoma, 10 cases of Sézary syndrome (SS), and 9 non-MF/SS PCTCL patients. In the MF patients, the overall response rate (ORR) was 92% (50% complete remission [CR]), 70% ORR in SS patients (50% CR), and 89% ORR in non-MF/SS patients (78% CR). The ORR for MF/SS patients treated with conventional dose (30-36 Gy) regimens was 92% (63% CR) and 75% (25% CR) for low-dose (<30-Gy) regimens (P=.09). In MF patients, the overall survival (OS) was 77 months with conventional dose regimens versus 14 months with low-dose regimens (P=.553). In SS patients, the median OS was 48 versus 16 months (P=.219), respectively. Median event-free survival (EFS) for MF in conventional dose patients versus low-dose patients was 15 versus 8 months, respectively (P=.264) and 19 versus 3 months for SS patients (P=.457). Low-dose regimens had shorter treatment time (P=.009) and lower grade 2 adverse events (P=.043). A second TSEB course was administered in 4 MF patients with 100% ORR. There is a possible prognostic impact of supplemental/boost radiation (P<.001); adjuvant treatment (P<.001) and radiation tolerability (P=.021) were detected. CONCLUSIONS TSEB therapy is an efficacious treatment modality in the treatment of several forms of cutaneous T-cell lymphoma. There is a nonsignificant trend to higher and longer clinical benefit for MF and SS patients receiving conventional dose. Low-dose TSEB regimens are well tolerated and achieve short-term palliation.

Paclitaxel Delivered to Adventitia Attenuates Neointima Formation without Compromising Re-Endothelialization after Angioplasty in a Porcine Restenosis Model

Purpose: To investigate the effect of paclitaxel delivered into the adventitia of pig femoral arteries on neointima formation and hyperplasia as well as re-endothelialization. Methods: Paclitaxel or vehicle was delivered into the adventitia of pig femoral arteries using a needle injection catheter following balloon overstretch. Arteries were then serially examined by angiography, Evans blue staining, morphometry, and immunohistochemistry for up to 12 weeks. Results: Local adventitial delivery of paclitaxel significantly attenuated neointima formation. The area of neointima (0.41±0.17 versus 2.75±0.81 mm2, p<0.01), the ratio of intima to media (0.12±0.05 versus 0.86±0.35, p<0.05), and the degree of stenosis (12.80%±3.13% versus 47.06%±7.25%, p<0.01) were significantly lower in the paclitaxel-treated group compared to controls. Furthermore, cell proliferation was significantly diminished following adventitial delivery of paclitaxel from day 3 to 21 compared to controls. Complete reendothelialization was observed 3 weeks after intervention in both groups of arteries treated with paclitaxel or vehicle alone. Conclusion: Paclitaxel delivered into the adventitia of pig femoral arteries effectively attenuates neointima formation after angioplasty without compromising re-endothelialization. Adventitial drug delivery may therefore be an alternative to drug-eluting stents for the prevention of restenosis.

A treatment planning study comparing tomotherapy, volumetric modulated arc therapy, Sliding Window and proton therapy for low-risk prostate carcinoma

BackgroundComparing radiation treatment plans to ascertain the optimal intensity-modulated radiation technique for low-risk prostate cancer.MethodsTreatment plans for 20 randomly selected patients were generated using the same dose objectives. A dosimetric comparison was performed between various intensity-modulated techniques, including protons. All treatment plans provided conventional treatment with 79.2Gy. Dosimetric indices for the target volume and organs at risk (OAR), including homogeneity index and four conformity indices were analyzed.ResultsNo statistically significant differences between techniques were observed for homogeneity values. Dose distributions showed significant differences at low-to-medium doses. At doses above 50Gy all techniques revealed a steep dose gradient outside the planning target volume (PTV). Protons demonstrated superior rectum sparing at low-to-higher doses (V10-V70, P < .05) and bladder sparing at low-to-medium doses (V10–V30, P < .05). Helical tomotherapy (HT) provided superior rectum sparing compared to Sliding Window (SW) and Rapid Arc (RA) (V10–V70, P < .05). SW displayed superior bladder sparing compared to HT and RA (V10–V50, P < .05). Protons generated significantly higher femoral heads exposure and HT had superior sparing of those.ConclusionAll techniques are able to provide a homogeneous and highly conformal dose distribution. Protons demonstrated superior sparing of the rectum and bladder at a wide dose spectrum. The radiation technique itself as well as treatment planning algorithms result in different OAR sparing between HT, SW and RA, with superior rectum sparing by HT and superior bladder sparing by SW. Radiation plans can be further optimized by individual modification of dose objectives dependent on treatment plan strategy.

Advances in Image-Guided Radiation Therapy for Primary Cardiac Angiosarcoma: The Role of PET-CT and MRI

Background: With advances in modern diagnostic and therapeutic modalities, the main goal of intrathoracic radiation treatment is to reduce treatment-related toxicities. Here, we describe a series of cases that involved positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI)-based radiation therapy (RT) for the treatment of primary cardiac angiosarcoma (PCA). Patients and Methods: The medical records of 3 patients who underwent image-guided RT at our department between 2012 and 2015 were analyzed. Results: 3 patients with PCA underwent pre-therapeutic imaging with fluorodeoxyglucose (FDG)-PET/CT (n = 3), as well as PET/MRI (n = 2) or MRI alone (n = 1). 2 patients underwent primary tumor resection (cases 1 and 2). The tumor in case 3 was unresectable and the patient underwent definitive chemoradiation. Intensity-modulated RT was applied with a median RT dose of 50.4 Gy. At the end of the study, 2 of the patients had survived for 35 and 16 months post-treatment (cases 1 and 3, respectively), and no evidence of tumor progression has since been detected. Conclusion: For the cases examined, RT was a feasible and tolerable treatment for PCA, and FDG-PET-MRI successfully characterized each PCA for therapy planning.

A case of radiotherapy for an advanced bronchial carcinoma patient with implanted cardiac rhythm machines as well as heart assist device

We present a case of radiotherapy for a 66-year-old patient with squamous cell carcinoma on the left main bronchus undergoing implantation of pacemaker, implantable cardioverter defibrillator (ICD) as well as cardiopulmonary support (CPS) device. The radiation area was determined according to 4D List Mode positron emission tomography–computed tomography (PET-CT) data. Planning Target Volume (PTV) included a part of the active ICD. For the optimal tumor coverage and sparing of both the implantable cardiac devices and organs at risk, we combined the conformal radiotherapy with stereotactic body radiotherapy (SBRT) using helical tomotherapy. The prescription dose of 25.2Gy was applied by conventional radiotherapy. SBRT was performed hypofractionated with a prescription dose of 35Gy in 5 fractions. A dynamic electrocardiogram was performed during every radiation fraction. The implanted aggregates were checked three times a week. Despite partial localization of the active ICD in the radiation field, the tumor was treated without inappropriate shock delivery during radiation treatment and over twelve months afterwards. The reduced tumor size as well as tumor metabolic activity were observed by PET-CT three months after radiation treatment. The patient exhibited no signs of pneumonitis on the last radiological follow-up examination six months after radiotherapy. The reduced dyspnea and cough over the first four months after treatment were observed.In conclusion, tumor shrinkage and temporary clinical improvement of the patient as well as no technical complications of implanted cardiac devices were achieved by the radiation treatment.

A treatment planning study of prone vs. supine positions for locally advanced rectal carcinoma

PurposeTo ascertain the optimal radiation technique and radiation position for the neoadjuvant radiotherapy of patients with rectal cancer.Materials and methodsTreatment plans with similar dose objectives were generated for 20 selected patients. Dosimetric comparison was performed between prone and supine positions and between different radiation techniques. Dosimetric indices for the target volume and organs at risk (OAR) as well as normal tissue complication probability (NTCP) of late small bowel toxicity were analyzed.ResultsThe helical tomotherapy (HT) in the prone position provided the optimal dose homogeneity in the target volume with the value of 0. Superior conformity values were obtained for Sliding Window (SW), Rapid Arc (RA) and HT compared to three-dimensional conformal radiotherapy (3D-CRT) techniques. All of the techniques showed dose reduction to OAR in the high-dose area in prone position versus supine position. Pairwise comparison revealed significantly higher small bowel protection by RA in the prone position in the high-dose area (V75, V45Gy). Similarly, superior bladder sparing was found for 3D-CRT in the prone position at higher doses (V50, V75). More healthy tissue in the radiation volume was involved by application of 3D-CRT with no relevant difference between positions. The mean values of NTCP for the small bowel did not show clinically meaningful variation between the techniques.ConclusionAll techniques provided superior sparing of OAR in the prone position. At higher radiation doses, treatment in prone position resulted in significant OAR protection, especially concerning small bowel sparing by RA and bladder sparing by 3D CRT.ZusammenfassungZielErmittlung der optimalen Bestrahlungstechnik und -position für die neoadjuvante Radiotherapie bei Patienten mit Rektumkarzinom.Material und MethodenBestrahlungspläne, mit gleichen Dosisvorgaben wurden für 20 ausgewählte Patienten erstellt. Ein Dosisvergleich wurde für verschiedene Bestrahlungstechniken, sowie für eine Lagerungsvariation in Bauch-oder Rückenlage durchgeführt. Verschiedene Indizes für das Zielvolumen und die Risikoorgane wurden analysiert, inklusive „normal tissue complication probability“ (NTCP) für Spättoxizitäten des Dünndarms.ErgebnisseDie helikale Tomotherapie (HT) erzielt in der Bauchlagerung die optimale Dosishomogenität für das Zielvolumen mit einem Wert von 0. Die „Sliding Window“ (SW), „Rapid Arc“ (RA) und die HT sind bezüglich ihrer Konformität den dreidimensionalen konformalen Radiotherapie (3D-CRT) –Techniken überlegen. Alle Bestrahlungstechniken zeigen eine Dosisreduktion im Hochdosisbereich der Risikoorgane sowohl in Bauch- als auch Rückenlagerung auf. Ein paarweiser Vergleich zwischen Bestrahlungstechniken in zwei Lagerungspositionen (Bauch-versus Rückenlage) zeigt eine signifikant höhere Dünndarmschonung durch die RA in der Bauchlagerung, vor allem im Hochdosisbereich (V75, V45Gy). Die 3D-CRT führt zu einer Dosisreduktion im Bereich der Blase für den Hochdosisbereich (V50, V75). Eine höhere Dosisbeteiligung des Normalgewebes wurde bei der 3D-CRT beobachtet unabhängig von der Bestrahlungsposition. Die gemittelten NTCP-Werte für den Dünndarm zeigen keine großen Unterschiede zwischen den Techniken.SchlussfolgerungAlle Techniken führen zur einen besseren Risikoorganschonung in der Bauchlagerung. In Bauchlage zeigt die RA signifikante Dosisvorteile im Dünndarm und die 3D-CRT im Bereich der Blase.

Proteomics: State of the Art and Its Relevance for Gene Therapy

The molecular mechanisms underlying most diseases, including those of the cardiovascular system, are widely unknown. Basically, pathological changes in the organism arise from protein alterations. Proteomics comprises a set of tools allowing the identification of protein alterations, i.e. changes of protein abundance and posttranslational modifications, associated with diseases. The linkage of information about such protein changes with functional alterations as revealed by physiological studies constitutes functional proteomics that enables the disclosure of disease mechanisms. Disease-linked protein alterations include those of suitable candidates for drug targets and disease biomarkers as well as therapeutic proteins/peptides. Since gene therapy depends on the function of a therapeutic protein encoded by a “therapeutic” gene, proteomic analyses provide the basis for the design and application of gene therapies. The storage and administration of experimental data obtained by the application of proteomic analyses is supported by speciesand tissue-specific protein databases and specific software. Publications in this field are reviewed in this chapter.