Women have more body fat than men, but in contrast to the deleterious metabolic consequences of the central obesity typical of men, the pear-shaped body fat distribution of many women is associated with lower cardiometabolic risk. To understand the mechanisms regulating adiposity and adipose tissue distribution in men and women, significant research attention has focused on comparing adipocyte morphological and metabolic properties, as well as the capacity of preadipocytes derived from different depots for proliferation and differentiation. Available evidence points to possible intrinsic, cell autonomous differences in preadipocytes and adipocytes, as well as modulatory roles for sex steroids, the microenvironment within each adipose tissue, and developmental factors. Gluteal-femoral adipose tissues of women may simply provide a safe lipid reservoir for excess energy, or they may directly regulate systemic metabolism via release of metabolic products or adipokines. We provide a brief overview of the relationship of fat distribution to metabolic health in men and women, and then focus on mechanisms underlying sex differences in adipose tissue biology. Women, compared to men, have higher percent body fat and deposit it in a different pattern, with relatively more adipose tissue in the hips and thighs. This ‘female’ fat distribution, independent of total body fat, confers protection against metabolic diseases, such as type 2 diabetes and atherosclerosis . AlthougCinti convincingly argues that body fat is stored in the adipose organ which consists of definable fat depots . SubcutaIt has been recently recognized that humans, even in adulthood, possess islands of brown adipose tissue, mainly in the supraclavicular/dorsal cervical area ,15. WherFor the same body mass index (BMI), women typically present with ~10% higher body fat compared to men ,20. AginAt comparable levels of total adiposity (estimated either from BMI or by imaging techniques), women have more SAT both in the abdominal -25 and iStriking sex differences arise during puberty: the increase in body weight in boys is primarily due to increases in lean mass whereas in girls due to increases in fat mass; typical android and gynoid fat distributions also appear for the first time during this time period -33. MenoTwin studies demonstrate that genetic factors account for up to 70% of the BMI variance , and thaRSPO3, TBX15, ITPR2, WARS2 and STAB1), differential mRNA expression is also noted between abdominal and gluteal tissue [GWAS and meta-analyses of GWAS have also identified novel loci associated with central or peripheral fat distribution, some of which are sex-specific  in men . UndoubtSince the seminal work of Jean Vague, it has become clear that sex differences in adiposity and fat distribution are closely associated with whole body metabolism and long-term health ,75. ThusThe clinical significance of body fat distribution is supported by multiple epidemiological studies that confirm the detrimental effect of central body and the protective effect of gluteal-femoral fat on diabetes ,82, cardAs recently reviewed , premenoThe storage capacity of gluteal-femoral adipose tissues may play a role in determining the level of central adiposity. A recent randomized-controlled trial in nonobese women showed that removal of thigh fat by liposuction is followed by re-accumulation preferentially in the abdominal area, suggesting that effective peripheral fat storage may protect from the expansion of central fat depots . This ‘rThe major function of adipose tissue is the appropriate and highly regulated storage and release of energy Figure . Free fain vitro studies suggested that subcutaneous adipocytes/adipose tissue from women show higher LPL activity [In vivo studies however show that the answer is more complex.It would be reasonable to expect that women are more effective in storing fat subcutaneously and men intra-abdominally, as that could explain preferential fat deposition. Indeed early activity , lipid sactivity  and insuactivity ,108 compWomen store a higher percentage of meal-derived FA in SAT compared to men (38% vs 24%) ,110, butper gram of adipose tissue lipid is increased preferentially in the gluteo-femoral SAT of women compared to men [Under certain conditions though, the female tendency to store fat in the peripheral subcutaneous depots becomes more apparent. In response to a hypercaloric, high-fat meal, storage of meal-derived triglyceride-fatty acids d to men , despited to men . These fd to men , which id to men -116 in min vitro in isolated adipocytes of pre- [Net fat storage in the adipose tissue after a meal requires inhibition of lipolysis, achieved by increased circulating insulin levels. This mechanism is less effective both in men and in upper body obese women ,118 comp of pre- , but not of pre-  and can Although it was once believed that LPL-mediated uptake of fatty acids from circulating TG-rich lipoproteins at the fed state is the major or sole mechanism for FA provision to the adipose tissue, the importance of direct uptake of circulating FFA at the postabsorptive state is now realized . This paTo summarize, differences in fat deposition between sexes are likely to arise partly due to: a) the preferential postabsorptive direct FFA uptake by SAT in women and b) the enhanced postprandial meal-derived FFA uptake by VAT in men Figure .To achieve normal fatty acid homeostasis, the FFA flux to or from adipose tissue needs to match whole body energy requirements. FA release in excess of the needs of other tissues leads to elevated circulating FFA levels or flux, which in turn contribute to insulin resistance, ectopic lipid accumulation and lipotoxicity. Thus, it comes as no surprise that total FFA flux correlates closely with whole body energy requirements (resting energy expenditure ). Given not with any detrimental effects on whole body metabolism [On the other hand, lipolytic rates in women are higher than in men even under resting conditions when FA oxidation is comparable between sexes . This istabolism ,128. It tabolism . Indeed,tabolism  and aftetabolism . FFA canin vivo and ex vivo[ex vivo and in vivo stimulation of lipolysis is higher in men [x vivo lipolysis is higher in intra-peritoneal  than retro-peritoneal depots, while the opposite occurs in women, but the in vivo physiological significance of these observations is unclear [Sex differences in systemic lipolysis appear to arise at the level of the upper-body SAT which is, in both sexes, the main source of circulating FFA ,131,132.d ex vivo,134. Simd ex vivo,135, as d ex vivo. Prolongd ex vivo,138. Ther in men ,140, but unclear .To summarize: women, compared to men, show higher rates of mobilization of adipose tissue TG stores, possibly because they are more dependent on FFA as an energy source under conditions of high energy demands like exercise. At the same time they are more efficient in handling FFA and thus retain their insulin sensitivity. Depot differences in lipolysis however cannot explain the peripheral deposition of fat in women compared to men Figure .ex vivo adipose tissue cultures [Apart from regulating fuel homeostasis, adipose tissue releases a multitude of secretory products, collectively called adipokines. The regulation of adipokine release and their individual roles have been reviewed extensively  of male and female mice clearly shows that gene networks identified in each sex affect different pathways and have different associations with metabolic and obesity traits (4). Recent studies in humans indicate the existence of sex biased mRNA and miRNA expression in abdominal and gluteal adipose tissues that will undoubtedly yield new mechanistic insights ,171.in vivo studies of depot- and sex-specific differences in adipose tissue metabolism showed that the primary suspects (lipid uptake and mobilization) are not the main mediators and at the same time pointed to new pathways (direct FFA uptake) for further investigation. We still do not know if sex differences in the function of female adipocytes are mainly derived from genetic, cell autonomous properties related to sex chromosomes or from critical early imprinting events by sex steroids. The direct effects of sex hormones on adipocyte function and the importance of the microenvironment of specific adipose depots on growth remain poorly understood. Much more work will be required to integrate all the data arising from studies of global gene and miRNA expression, as well as of epigenetic changes, and to understand why females can accumulate more adipose tissue than men without deleterious metabolic consequences, and how gluteal-femoral adipose tissue in particular lessens metabolic risk.Sex differences in the fat phenotypes are probably determined by a complex interplay of genetic, epigenetic, and hormonal factors. Elegant The authors have no competing interests to disclose.KK drafted and SKF edited the manuscript. SRS and ASG reviewed the manuscript and made suggestions. All authors read and approved the final manuscript.


As sessile organisms, plants are inevitably exposed to one or a combination of stress factors every now and then throughout their growth and development. Stress responses vary considerably even in the same plant species; stress-susceptible genotypes are at one extreme, and stress-tolerant ones are at the other. Elucidation of the stress responses of crop plants is of extreme relevance, considering the central role of crops in food and biofuel production. Crop improvement has been a traditional issue to increase yields and enhance stress tolerance; however, crop improvement against abiotic stresses has been particularly compelling, given the complex nature of these stresses. As traditional strategies for crop improvement approach their limits, the era of genomics research has arisen with new and promising perspectives in breeding improved varieties against abiotic stresses. Abiotic stresses are the most significant causes of yield losses in plants, implicated to reduce yields by as much as 50% . Among aRecent technological advances and the aforementioned agricultural challenges have led to the emergence of high-throughput tools to explore and exploit plant genomes for crop improvement. These genomics-based approaches aim to decipher the entire genome, including genic and intergenic regions, to gain insights into plant molecular responses which will in turn provide specific strategies for crop improvement. In this paper, genomics approaches for crop improvement against abiotic stresses will be discussed under three generalized classes, functional, structural, and comparative genomics. However, it should be noted that genomics approaches are highly intermingled, in terms of both the methodologies and the outcome .Genomics research is frequently realized by functional studies, which produce perhaps the most readily applicable information for crop improvement. Functional genomics techniques have long been adopted to unravel gene functions and the interactions between genes in regulatory networks, which can be exploited to generate improved varieties. Functional genomics approaches predominantly employ sequence or hybridization based methodologies which are discussed below. One way to explore the expressed gene catalogue of a species is to analyze Expressed Sequence Tags (ESTs). ESTs are partial genic sequences that are generated by single-pass sequencing of cDNA clones . Despitehttp://www.ncbi.nlm.nih.gov/dbEST/). cDNA libraries from various tissues, developmental stages, or treatments generally serve as the sources for EST sequencing to reveal differentially expressed genes [Large-scale EST sequencing has been one of the earliest strategies for gene discovery and genome annotation , 6. Curred genes . These aed genes . EST seqed genes . http://mpss.udel.edu/) contain publicly available MPSS expression data for a number of plant species, including important crops such as rice, maize, and soybean [An alternative approach, Serial Analysis of Gene Expression (SAGE), has been developed to quantitate the abundance of thousands of transcripts simultaneously. In this approach, short sequence tags from transcripts are concatenated and sequenced, giving an absolute measure of gene expression , 10. The soybean . These M soybean .Arabidopsis thaliana and rice [In contrast to sequence-based approaches, array-based techniques utilize hybridization of the target DNA with cDNA or oligonucleotide probes attached to a surface to assess expression , 26. Theand rice –31, modeand rice , barley and rice , and maiand rice , as welland rice , cassavaand rice , and tomand rice  to unravBesides inherent limitations such as cross-hybridization and background noise, microarray studies investigating stress-responsive genes suffer from technical considerations that may limit their usefulness. Isolation of total RNA from complex tissues that are composed of different types of cells may obscure transcript changes occurring in cell types that are particularly relevant to the stress response. Subtle transcriptional changes may be diluted in the overall stress response of the whole tissue and, thus, remain unnoticed. Similarly, the choice of tissue or genotype that is sampled in a microarray study is closely related to the relevance of results. Reproductive tissues and stress-tolerant genotypes are most relevant in terms of agricultural gain and stress adaptation mechanisms, respectively . In addiFor species with an available whole genome sequence, a successful expansion of array-based transcript profiling is whole genome tiling arrays . Tiling Genome wide expression profiles are most useful in the detection of candidate genes for desired traits, such as stress tolerance. A fraction of functional studies then adopt inactivation or overexpression of such candidate genes for further characterization and utilization. Of these, Targeting Induced Local Lesions IN Genomes (TILLING) enables high-throughput analysis of large number of mutants . TILLINGImportantly, a modified strategy, called EcoTILLING, has been developed to identify natural polymorphisms, analogous to TILLING-assisted identification of induced mutations. Polymorphisms demonstrating natural variation in germplasms are valuable tools in genetic mapping. Furthermore, via the discovery of polymorphisms among individuals, EcoTILLING is able to implicate favorable haplotypes for further analyses, such as sequencing. Similar to TILLING, EcoTILLING is applicable to polyploid species, where it can be utilized to differentiate between alleles of homologous and paralogous genes . In a reThe availability of comprehensive EST databases is central to the success of the above-mentioned approaches to identify genes accurately and unambiguously. Besides their utility in genome annotation and expression profiling, ESTs also provide a source of sequences for designing “functional markers.” Functional markers refer to polymorphic sites on genes that are attributed to phenotypic variation of traits among individuals of a species. Functional marker design requires the knowledge of the allelic sequences of functionally characterized genes . In contWhile functional genomics focus on the functions of genes and gene networks, structural genomics focus on the physical structure of the genome, aiming to identify, locate, and order genomic features along chromosomes. Together, structural genomics and functional genomics can characterize a genome to its full extent. http://www.454.com/) or Illumina Solexa Genome Analyzer (http://www.illumina.com/) can carry out high capacity sequencing at reduced costs and increased rates compared to conventional Sanger sequencing [Arabidopsis thaliana and Brachypodium distachyon, along with important crop species such as rice, sorghum, soybean, and maize, have been published [In the last decade, advances in DNA sequencing technologies have enabled the generation of a wealth of sequence information including whole genome sequences. Next-generation sequencing (NGS) platforms such as Roche 454 GS FLX Titanium  [Drosophila is equivalent to approximately 1x coverage of wheat genome in terms of sequence read counts, demonstrating the challenging genome size of wheat. The high content of repetitive elements is another major challenge, causing ambiguities in sequence assembly. In polyploid species such as wheat, the sequence assembly problem is further exacerbated due to the presence of homoeologous genomes and paralogous loci [r wheat) . As poinr wheat) , 25x covous loci . For sucOver the last few years, advances in chromosome sorting technologies have enabled construction of chromosome-specific Bacterial Artificial Chromosome (BAC) libraries to tackle the challenges of complex genomes. Physical mapping of the 1 Gb chromosome 3B of hexaploid wheat has proven the feasibility of a chromosome-by-chromosome approach to explore and exploit complex genomes . PhysicaIn the absence of reference genome sequences, whole genome or BAC-end shotgun sequences provide valuable insights into genome structure and evolution –69. IntrVrn-D4 has recently been mapped to the centromeric region of chromosome 5D of hexaploid wheat [Genomics applications involving molecular markers are largely dominated by Single Nucleotide Polymorphisms (SNPs)  as refleid wheat , 74.A recently developed molecular marker type, Insertion Site-Based Polymorphisms (ISBPs), utilizes the insertional polymorphisms observed in the repeat junctions of complex genomes . ISBP maA major impact of NGS-mediated shotgun sequences has been their substantial contribution to the development of molecular markers. These markers indicate diagnostic polymorphisms at the DNA sequence level, and in contrast to morphological markers which once had been the focus of traditional breeding studies, they are not affected by the environment . In geneAdditionally, for efficient MAS, markers should be highly polymorphic in the germplasm used for breeding. MAS can make use of molecular markers at multiple levels. Plant breeding depends on genetic diversity to improve crops . MoleculThe major drawbacks of MAS in breeding are high costs of implementation, typically requiring specialized equipment, and the risk of recombination between the marker and the trait that reduces the reliability of MAS to predict phenotype via genotype. The high cost of MAS is particularly relevant in cases where an effective phenotyping method is already established through conventional breeding. Additionally, MAS usually requires the validation of QTLs when applied in different genetic backgrounds. Functional markers, however, may overcome the issue of QTL validation . DespiteAnother use of molecular markers is Map-Based Cloning (MBC) where the gene or a QTL linked to a desired trait is isolated via a “mini” physical map. Such a local physical map flanking the gene must be saturated with molecular markers for efficient MBC . Prior tFor species with largely unexplored genomes, comparative genomics is a promising tool to gain information by utilizing the conservation between closely related plant species. In fact, plant genomes share extensive similarities even between distantly related species (Brachypodium, sorghum, and rice with various sources of data from less well-studied species, such as genomic survey sequences and genetically mapped markers, to predict the gene order and organization in these species [Triticeae provide the closest approximation to a reference genome sequence currently available [Comparative genomics has contributed significantly to the emergence of the “genome zipper” concept, which enables the determination of a virtual gene order in a partially sequenced genome. Genome zippers compare the fully sequenced and annotated genomes of  species , 89. Thevailable . HoweverIn addition to syntenic genes that are found in colinear blocks of conserved genes, nonsyntenic genes that are found outside their syntenic location in other genomes also provide valuable insight into genome evolution and speciation. Intriguingly, a recent study focused on the nonconserved portion of wheat and barley genome that suggested novel mechanisms, besides transposable element-driven expansion, have driven the evolution and size of these genomes. Many of these non-syntenic genes exhibited pseudogene characteristics, which may have implications for gene content estimate of these large genomes based on survey sequences .Despite the utility of comparative genomics and genome zippers, it is evident that species-specific genomic features can only be accessed through a fully annotated reference genome sequences. Homoeologous genes with different orthologous relationships are examples of such species-specific features . Species


Demographic distribution of the population is progressively changing with the proportion of elderly persons increasing in most societies. This entails that there is a need to evaluate the impact of common diseases, such as asthma and other allergic conditions, in this age segment. Frailty, comorbidities and polymedication are some of the factors that condition management in geriatric patients. The objective of this review is to highlight the characteristics of allergic diseases in older age groups, from the influence of immunosenescence, to particular clinical implications and management issues, such as drug interactions or age-related side effects. People 65 years old or more are the fastest growing segment of the population in the developed countries. By 2030, it is estimated that this group will comprise about 20% of the total population, and among elderly persons, the percentage of patients aged above 80 years will increase disproportionately. The prevalence of allergic diseases, in the elderly is estimated around 5-10% [Specific issues that arise when investigating allergies in the elderly patients are several. First of all, the definition of older persons needs to be clarified in order to homogenize nomenclature when addressing this entity. Usually, the term older adults is applied to persons 65 years or older, since it takes into account not only the chronologic aspect of aging, but also the fact that around this is retirement age in many countries. Subclassification into several ranges after this age may take into account increasing frailty, comorbidities and dependence.A number of factors in older subjects contribute to their risk for developing allergic related conditions. These include frailty, coexisting medical problems, memory issues and use of multiple prescribed and non prescribed medications . HoweverThe complex process of immunosenescence, the aging of the immune system, affects both the innate and the adaptive immune system. The clinical consequences include not only increased susceptibility to infection, malignancy and autoimmunity, but also decreased response to vaccination, and impaired wound healing. The most severe clinical impact is probably a result of the loss of diversity in the T-cell-receptor and B-cell-receptor repertoire, owing to the accumulation of dysfunctional cells, and decreased thymic and bone-marrow output. Immunosenescence in the innate immune system appears to reflect dysregulation, rather than exclusively impaired function. Changes of inmunosenescence features on immune cells are summarized in Table Some molecules such as zinc, vitamin D or iron, seem to play a relevant role in maintaining the immune response. Data reported clearly suggest that the essential trace element, zinc (Zn) plays a pivotal role for the immune efficiency. It is required to reach healthy aging and longevity. The intracellular zinc homeostasis is regulated by buffering metallothioneins (MT) and zinc transporters (ZnT and ZIP families) that mediate the intracellular zinc signalling assigning to zinc a role of "second messenger". In aging, the intracellular zinc homeostasis is altered, because high MT are unable to release zinc and some zinc transporters deputed to zinc influx (ZIP family) are defective leading to low intracellular zinc content for the immune efficiency. Physiological zinc supplementation in the elderly improves these functions in some cases, although it remains unclear which old subjects who effectively need zinc supplementation .Serum concentrations of vitamin D are generally lowered in older compared with younger subjects . CalcitrClinical observations supported by epidemiological data, have demonstrated age-related declines in serum total immunoglobulin E (IgE) and in allergen sensitization in the elderly. Serum total IgE comparisons between younger and older subjects without any allergic disease have demonstrated significantly lower levels in the older subjects . NeverthTypical symptoms of allergic rhinitis like nasal obstruction, postnasal drip or cough may be worsened by the anatomic and physiological changes of the nose that occur with age . StructuAlthough asthma is nowadays considered a heterogeneous disease with many phenotypes and endotypes accounting for differential clinical expression, several biologic processes related to aging seem to be involved in the physiopathology of asthma in the elderly. Genetic, epigenetic and environmental factors are known to account for these changes. Processes such as cell aging, progressive loss of lung function during life, together with anomalies in the inflammation associated with asthma, may be some of the hallmarks of asthma in this age group. Current knowledge and further needs in research have recently been reviewed in a workshop of the National Institute on Aging (NIA) of the United States .Skin aging is characterized by atrophy of the epidermis and dermis due to loss of hydration, as a result of chronologic and environmental factors . CharactElderly patients may develop allergic contact dermatitis (ACD) despite the fact that cell-mediated immunity is decreased as a result of unknown mechanisms. Absolute T and B cell counts are not reduced with age. Age does not seem to affect the number of Langherhans cells in the elderly skin compared with the nonelderly skin . It has de novo sensitization. One of the first-line gastrointestinal defence mechanisms against ingested antigens is secretory IgA. It has been reported that orally induced antigen-specific IgA responses are weakened in aged animals [Murine as well as human studies indicate that physiological changes affecting also the local immune responses might contribute to the development of food allergy. The induction of mucosal tolerance has been shown to be impaired in aged animals, while the effector phase is maintained , so oral animals . Iron de animals , known t animals  and huma animals  have sho animals ,31, or w animals  or antia animals  have alsAlthough the peak incidence is during adulthood, allergic rhinitis (AR) is prevalent among older people affecting around 5.4 to 10.7% of patients above 65 years ,34,35. PAsthma affects older patients just as in any other age group. The prevalence of asthma in the elderly in developed societies is estimated around 6-10%. Fatalities are higher in older asthmatics compared to other age groups in which mortality is steadily decreasing .Diagnosis of asthma is hampered by certain limitations in elderly asthmatics, rendering an estimate that only half of asthmatics patients being diagnosed . SymptomClinically, aged skin is characterized by atrophy, wrinkling, fragility, alterations in pigmentation, a higher frequency of benign and malignant tumours, and a greater tendency to xerosis. Altogether, these factors contribute to greater susceptibility to dermatologic diseases and pruritus, the most common skin complaint in patients over the age of 65 years, frequently associated with dry skin -47.Systemic pruritus is defined as pruritus arising from disease of organs other than the skin, such as liver, kidney, or blood. This type of pruritus should be differentiated from neurologic pruritus, which can arise from neuronal damage (neuropathic itch) or can have neurogenic origin without neuronal damage, such as itching after administration of opioids (neurogenic itch). Systemic diseases, including also some neurologic disorders that may be responsible for pruritus, are mentioned in Table ACD in the elderly is not uncommon ,51,52. TAtopic dermatitis is much less common in the elderly compared with children and young adults. It is associated with seasonal mucosal allergies, asthma and positive prick tests to various allergens. Late onset atopic dermatitis, without the usual history of atopy, may explain eczema of unknown origin and negative patch tests . ScabiesUrticaria (with or without angioedema), especially chronic spontaneous urticaria, is quite common in elderly patients. Systemic diseases that may induce urticaria should be ruled out table . AngioedRosaceae fruits and fish, which are more frequent in young patients. Regarding clinical manifestations, anaphylaxis is less common in older patients [Although epidemiological studies reveal an increase in food allergies (FA) in industrialized countries these are mainly focused on children and young adults. Nevertheless, a proportion of patients will face a persistence of their problem. Also, previously unaffected individuals may develop symptoms of food allergy during adulthood for the first time. In the Allergy Section at Hospital Vall d'Hebron, we have observed a prevalence of 5% of FA in our outpatients older than 65 years, compared to 26% in patients aged 40 to 65 and 69% in younger patients (16-39 years old) (data not published). The profile of sensitization to different foodstuffs does not differ among groups except for patients .Adverse drug reactions (ADR) are very common in frail elderly, cause clinically significant morbidity and mortality and are associated with large economic costs -66. ADR Drugs most commonly implicated in type I, II and III hypersensitivity reactions in older patients include beta-lactam drugs, nonsteroidal anti-inflammatory drugs (NSAIDS), quinolones, trimethoprim-sulfamethozaxole, nitrofurantoin, heparin, neuromuscular blocking agents, antiepileptics, chemotherapeutic agents, monoclonal antibodies and immunosuppressive drugs -74. On tThe evaluation of a potential drug allergy in the elderly may include a thorough history, skin tests  and in selected cases oral, intramuscular or intravenous challenge tests. However, it is important to evaluate the extent of comorbidity and functional impairment that is present in elderly patients prior to the initiation of a drug allergy study. For this reason, a comprehensive geriatric assessment (CGA) can be particularly useful . Most ouPolymedication is a limitation in drug allergy assessment. Older ambulatory patients use approximately three times as many medications as younger patients. Hence, the use of large numbers of medications by older patients increases the likelihood of harmful drug interactions, adverse drug reactions and drug allergies and, in occasions, makes it difficult for the allergist to identify the suspected medication responsible for the ADR .The potential for drug interaction increases with age and with the number of drugs prescribed . The mosWhen prescribing a treatment for AR in the elderly, the possibility of drug-drug interactions, and the impact of drug treatment on concomitant diseases should be taken into account. Nasal steroids, topical antihistamines and non-sedating antihistamines are particularly suited for management of AR in the elderly both for safety and efficacy. Clearance of leukotriene receptor antagonists is decreased in the elderly, and has the potential to interact with a wide range of drugs that inhibit or induce the CYP 3A4 or 2C9 systems . As a geManagement of asthma in older patients seems suboptimal, and the use of inhaled corticosteroids is low, although they are probably the best maintenance therapy in most patients ,84. NeveThe use of long-acting β-adrenergic agonists (LABAs) has a synergic effect with inhaled corticosteroids. Although older patients with coronary disease may be more prone to adverse side effects, they are generally considered safe, but discontinuation should be considered when control of asthma is achieved ,86. AlsoOptions for treatment of skin allergic disorders include topical and systemic drugs. Topical treatments may prevent major adverse effects. Cooling agents such as menthol, may decrease the intensity of itching by activation of low temperature receptors in the skin. Anaesthetics with formulations based on benzocaine or lidocaine are widely used, especially in neuropathic pruritus, but they can induce ACD and may induce side effects in the circulatory system . AntihisSystemic treatment options for pruritus include sedating antihistamines, antidepressants, μ- or κ-opioid receptor agonists and neuroleptics. Most of these drugs are not devoid of relevant side effects, such as drowsiness. Therefore it is usually recommended to start at low doses in the elderly and to taper up . UVB phoAtopic dermatitis, and all of the others forms of dermatitis that are recalcitrant to other therapies, can be treated with topical or systemic corticosteroids. If they are ineffective or adverse effects preclude the use of corticosteroids, treatment with calcineurin inhibitors, phototherapy, or systemic immunosuppressives such as cyclosporine could be used .First-generation H1 receptor antagonists are lypophilic and therefore may cross the blood-brain barrier. Elderly persons may be at greater risk of adverse effects involving the CNS, such as confusion, sedation, dizziness, sleepiness or impaired cognitive function . It has Second-generation antihistamines have a lower capacity to cause CNS-related adverse effects as they have a low potential to cross the blood-brain barrier, and provide selective H1 blockade without anticholinergic or alpha-adrenoreceptor antagonist activity. Some second-generation antihistamines are metabolized by the cytochrome 450 enzyme system in their first pass through the liver, which may lead to drug-drug interactions or elevated plasma drug interactions in patients with liver dysfunction and others are excreted through the kidneys and dosage has to be adjusted according renal function . Second-Topical and oral corticosteroids are particularly useful in the treatment of acute and delayed hypersensitivity diseases. However, they have adverse effects on many organ system, and these range from those that are not necessarily serious (e.g. cushingoid appearance), to those that are life-threatening (e.g. serious infections).Some of these adverse effects may be aggravated in the elderly. Patients receiving prednisolone 5-40 mg/day for at least 1 year have a partial loss of explicit memory, and elderly patients may be more susceptible to memory impairment with less protracted treatment .The risk of developing diabetes mellitus is increased by more than two-fold in elderly patients who are newly initiated on oral corticosteroid therapy . An incrOther frequent conditions of old age such as cataracts  or osteoAltered function of aged immune system is primarily associated with exposure to "new" antigenic challenges, as is the case for decreased efficient therapeutic value of vaccinations among the elderly population. While influenza vaccination has shown to reduce influenza-related mortality, current influenza vaccines have limited efficacy in elderly (17-53%) compared to vaccine efficacy in young adults (70-90%). To provide better protective measures for the increasingly aging population new and improved vaccines are needed. Currently, a variety of approaches are being explored to enhance the efficacy of influenza vaccines in the elderly, including the use of adjuvants, altering antigen dose and identifying the best routes of vaccine administration . There iSpecific immunotherapy (SIT) is deemed the only treatment that can at least partly modify the natural course of the disease during its initial stages. Its use in elderly patients is still debated.Injection SIT can be considered an effective therapeutic option in otherwise healthy elderly patients with a short disease duration whose symptoms cannot be adequately controlled by drug therapies alone ,108. OneAllergic diseases do affect elderly patients and special considerations regarding diagnosis and treatment should be taken into account when assessing these patients. Clinical manifestations may be less straightforward than in younger age groups, hampering the recognition of the disease, and rendering a more complicated differential diagnosis. Treatment options may be limited by comorbidities and ongoing medication use, which may give rise to deleterious effects on the allergic disease or to drug interactions with anti-allergic medications. Therefore, further research is warranted in this area.AAE-C1-INH: acquired C1 inhibitor deficiency; ACD: allergic contact dermatitis; ADR: adverse drug reactions; AE: angioedema; AE-ACEi: angiotensin-converting enzyme inhibitor angioedema; AR: allergic rhinitis; CGA: comprehensive geriatric assessment; COPD: chronic obstructive pulmonary disease; FA: food allergies; HAE-C1-INH: hereditary deficiency in the C1 inhibitor; IgE: Immunoglobulin E; LABAs: long-acting β-adrenergic agonists; MT: metallothioneins; NK cells: natural killer cells, NKT cells: natural killer T cells; NKT cells: natural killer T cells; NSAIDS: nonsteroidal anti-inflammatory drugs; SIT: specific immunotherapy; TCR: T cell receptor; TLR: toll like receptors; Zn: zinc.The authors declare that they have no competing interests.Each author was responsible to draft a part of the manuscript. All authors read and approved the final manuscript.


Over the past decades, scientific understanding of unexplained chronic pain disorders has increased substantially. Several chronic musculoskeletal pain disorders may be explained by alterations in central nervous system processing. More specifically, the responsiveness of central neurons to input from unimodal and polymodal receptors is augmented, resulting in a pathophysiological state corresponding to central sensitization, characterized by generalized or widespread hypersensitivity. Central sensitization encompasses altered sensory processing in the brain, impaired functioning of top-down anti-nociceptive mechanisms, and (over)activation of top-down and bottom-up pain facilitatory pathways which augment nociceptive transmission. Importantly, a different ‘pain signature’ arises in the brain of those with chronic musculoskeletal pain and central sensitization.Given the increasing evidence supporting the clinical significance of central sensitization in those in a wide variety of disorders, including chronic whiplash associated disorders, chronic tension-type headache and migraine among others, the awareness is growing that desensitising the central nervous system should be a treatment target in these patients. Besides pharmacological options, rehabilitation  and neurotechnology options  offer interesting perspectives.


Matricaria chamomilla L., Calendula officinalis L., and Solanum distichum Schumach. and Thonn.) cultivated on organically managed Egyptian desert farm and to develop biological control strategies. The soil microbiome of the desert ecosystem was comprised of a high abundance of Gram-positive bacteria of prime importance for pathogen suppression under arid soil conditions. For all three plants, we observed a clearly plant-specific selection of the microbes as well as highly specific diazotrophic communities that overall identify plant species as important drivers in structural and functional diversity. Lastly, native Bacillus spec. div. strains were able to promote plant growth and elevate the plants’ flavonoid production. These results underline the numerous links between the plant-associated microbiome and the plant metabolome.Past medicinal plant research primarily focused on bioactive phytochemicals, however, the focus is currently shifting due to the recognition that a significant number of phytotherapeutic compounds are actually produced by associated microbes or through interaction with their host. Medicinal plants provide an enormous bioresource of potential use in modern medicine and agriculture, yet their microbiome is largely unknown. The objective of this review is (i) to introduce novel insights into the plant microbiome with a focus on medicinal plants, (ii) to provide details about plant- and microbe-derived ingredients of medicinal plants, and (iii) to discuss possibilities for plant growth promotion and plant protection for commercial cultivation of medicinal plants. In addition, we also present a case study performed both to analyse the microbiome of three medicinal plants ( Currently, research continues to show that a significant number of natural products are actually produced by microbes and/or microbial interactions with the host from whence they were isolated , phytotherapeutic knowledge from the Mayans, the aboriginal medicine of Australia, and several other cultures comprise a huge spectrum of natural remedies that can be exploited as sources for new and effective therapeutic agents. Still widely practiced in the modern era, TCM supplies ethnopharmaceutical knowledge on over 5,000 plant species used for the treatment of numerous diseases and has already provided the basis for the discovery of many modern drugs, such as anticancer agents ,2012b. Iisolated , and forisolated ,b, and tIn regards to the alarming incidence of antibiotic resistance in bacteria with medical relevancy, medicinal plants with antibacterial properties are of central importance as bioresources for novel active metabolites . LikewisBurkholderia cepacia, Staphylococcus epidermidis, and strains of the Bacillus subtilis group, stimulate plant growth by the emission of volatile organic compounds  cultivated in a sub-Himalayan region  Airy-Shaw., Garcinia morella Desr., Evodia daneillii (Benn) Hemsl., Meliosma squamulata Hance., Skimmia arborescens Anders., and Brandisia hancei Hook. f. were determined as highly active against the clinical pathogens Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Candida albicans which corresponds to their traditional applications in skin and other infections . Due to the long-term agricultural use of the desert and the associated increasing occurrence of plant pathogens, the indigenous antagonistic potential in soil was almost twice as high as in the uncultivated desert soil. However, the diversity of antagonistic bacteria was lower and highly dominated by isolates of the Bacillus subtilis group. The most efficient antagonists from the native desert soil belonged to Streptomyces, and Bacillus and Paenibacillus species were the most frequently isolated antagonists from all investigated arid habitats including both desert and agriculturally used soil, as well as from the rhizosphere and endorhiza of three different species of medicinal plants cultivated on the desert farm . None of the plants are native to Egypt, and therefore were exposed to a previously unencountered microbiome. Interestingly, despite a clearly plant-specific selection of the associated bacterial microbiome, indigenous Bacillus and Paenibacillus strains of native desert soil with promising antagonistic properties against a wide range of soil-borne phytopathogens were enriched in all investigated plant roots. Conversely, several extremophilic bacterial groups, such as Acidimicrobium, Rubellimicrobium, and Deinococcus–Thermus decreased or completely disappeared from soil after agricultural use  and III (molybdenum nitrogenases from anaerobes), while no sequences of alternative nitrogenases (cluster II) and nifH paralogs (clusters IV and V) were found. In general, the diazotrophic soil microbiota was highly dominated by NifH sequences related to Alphaproteobacteria. Each investigated medicinal plant cultivated on the desert farm harbored a specific root-associated diazotrophic microbiome. The rhizosphere inhabitants of Matricaria chamomilla  and Calendula officinalis were similar and both dominated by potential root-nodulating rhizobia acquired mainly from soil. Conversely, the rhizosphere of Solanum distichum was colonized in higher abundances by free-living nitrogen fixers most likely transmitted between plants as they were undetectable in soils. Although well-known for taxonomic community structure , Stenotrophomonas rhizophila P69 from oilseed rape (Brassica napus) rhizosphere, and Serratia plymuthica 3Re4-18 from the endorhiza of potato (Bacillus subtilis Co1-6 and Paenibacillus polymyxa Mc5Re-14 were also able to further elevate the plants’ flavonoid production. Higher contents of the bioactive compounds apigenin-7-O-glucoside and apigenin, which belong to the major flavonoids of chamomile florets (These three autochthonous Gram-positive strains were selected for f potato . The fir florets , were me florets . These fConceived and designed the experiments: Gabriele Berg, Rudolf Bauer, Elshahat M. Ramadan and Martina Köberl. Performed the experiments: Martina Köberl and Ruth Schmidt. Analyzed the data: Martina Köberl, Ruth Schmidt and Gabriele Berg. Contributed reagents/materials/analysis tools: Gabriele Berg. Wrote the paper: Martina Köberl and Gabriele Berg.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The peritoneal metastatic route of cancer dissemination is shared by cancers of the ovary and gastrointestinal tract. Once initiated, peritoneal metastasis typically proceeds rapidly in a feed-forward manner. Several factors contribute to this efficient progression. In peritoneal metastasis, cancer cells exfoliate into the peritoneal fluid and spread locally, transported by peritoneal fluid. Inflammatory cytokines released by tumor and immune cells compromise the protective, anti-adhesive mesothelial cell layer that lines the peritoneal cavity, exposing the underlying extracellular matrix to which cancer cells readily attach. The peritoneum is further rendered receptive to metastatic implantation and growth by myofibroblastic cell behaviors also stimulated by inflammatory cytokines. Individual cancer cells suspended in peritoneal fluid can aggregate to form multicellular spheroids. This cellular arrangement imparts resistance to anoikis, apoptosis, and chemotherapeutics. Emerging evidence indicates that compact spheroid formation is preferentially accomplished by cancer cells with high invasive capacity and contractile behaviors. This review focuses on the pathological alterations to the peritoneum and the properties of cancer cells that in combination drive peritoneal metastasis. Intraperitoneal dissemination is the primary metastatic route of ovarian cancers. It is also a common progression for gastrointestinal malignancies including colorectal, gastric, and pancreatic cancers, for which it signifies a grim prognosis , 2. The While all cells within the ovary can give rise to malignancies, epithelial ovarian cancers (EOC) are the most common and lethal. EOCs are a heterogeneous group of cancers that may be categorized into two major groups . Type I EOCs generally have an insidious onset. Due to the asymptomatic nature of early-stage disease, most patients are not diagnosed until after their tumors have metastasized intraperitoneally. At this point, their chance of surviving beyond 5 years is only about 25 % , which iIntraperitoneal metastases can cause peritoneal organ adhesion and malfunction, massive ascites, and/or pleural effusions –11, leadA key factor contributing to the poor prognosis of intraperitoneally metastasizing cancers is the rapid, self-perpetuating, feed-forward cycle of seeding and growth that is fuelled by inflammation. Since the prognosis of patients with peritoneal metastases is tightly correlated with the completeness of surgical cytoreduction , 16, andThe mechanisms involved in peritoneal metastasis are distinct from those of the hematological route. Relative to hematological metastasis, peritoneal metastasis is a passive, efficient process that occurs locally in a self-perpetuating, feed-forward cycle. This presents unique challenges to intervention.The peritoneal cavity is particularly receptive to metastasis, as evidenced by several key observations. First, although EOC cells are detected in the circulation at relatively early stages of disease , metastaAdditional evidence that the peritoneal environment provides a privileged site for cancer metastasis is reflected in prognostic data. Colorectal carcinoma prognosis is dramatically worsened by accidental bowel perforation during surgery , 19, a mCancer cells can freely disseminate in the peritoneal cavity after exfoliating from exposed primary intraperitoneal tumors: ovarian epithelia for type I EOC, fallopian tube epithelia for type II EOC, and the serosal membrane for colorectal or gastric cancers. They also gain access when introduced through accidental surgical perforation of the bowel wall . In eith2, comparable to the surface area of the skin). Mesothelial cells apically secrete glycosaminoglycans , surfactant (mainly phosphatidylcholine) and proteoglycans to provide an anti-adhesive peritoneal surface that ensures the appropriate gliding of the abdominal viscera and prevents intra-abdominal organ fusion [The peritoneum is comprised of a single layer of mesothelial cells and its associated underlying ECM, which cover the vast surface of the abdominal and pelvic cavities, as well as visceral organs  and myofibroblast transformation in response to normal tissue repair and pathological stimuli . The ECMin vitro model system selected have greatly influenced study conclusions.Metastasizing cancer cells have two main options for attachment to the peritoneum: the surface mesothelial cells or the exposed ECM. Many investigations have focused on the mechanisms mediating cancer cell attachment to a cultured mesothelial monolayer. Some studies suggest that the mechanisms normally used for leukocyte attachment to mesothelial cells may be exploited by cancer cells. Ovarian, colorectal, and pancreatic cancer cells bind to mesothelial cell surface receptors ICAM-1 and/or VCAM-1 –30, whicin vitro models are an accurate representation of the in vivo events is crucial for identifying meaningful targets for intervention. Many studies have been designed with the assumption that peritoneal metastasis relies on cancer cell attachment to mesothelial cells. However, other studies indicate that cancer cells have a much greater affinity for the peritoneal ECM, which is consistent with the clinical pattern of metastatic spread.Ensuring that the Several lines of evidence indicate that mesothelial cells protect against, rather than mediate, cancer cell attachment. Collagen I, a major constituent of the sub-mesothelial ECM , is the ex vivo omental tissue was markedly elevated when the mesothelial layer was removed.Surgical trauma and stress damage the mesothelium and expose the underlying ECM, creating privileged sites for cancer cell attachment , 46. TheThe clinical pattern of disease progression underscores the concept that cancer cells preferentially attach to areas where the mesothelium is disrupted. During the initial stages of peritoneal metastasis, cancer cells attach to milky spots where the collagen-rich connective tissue matrix is exposed –53 Fig.. The resSecretions from cancer, stromal, mesothelial, and immune cells, particularly macrophages, contribute to an inflammatory environment that drives peritoneal metastasis –58. ConsThe impact of inflammatory cytokines on peritoneal metastasis is profound and transforms the initial pattern of dissemination, which is limited to milky spots, into a widespread peritoneal metastasis , 61. ThiTNFα is highly expressed by cancer and inflammatory cells , 62, 63,In light of the preference of cancer cells for the sub-mesothelial matrix, it is unclear why blocking interactions between cancer cells and mesothelial cells impedes metastasis in experimental models. Antibody-mediated inhibition of CD44 , 66 for Collectively, the evidence supports an inhibitory role of the mesothelium in peritoneal cancer cell attachment Fig. . While aAscites, an accumulation of protein-rich exudate within the abdominal cavity, is a complication that often accompanies cancers metastasizing within the peritoneum. In EOC, ascites is frequently a presenting feature of advanced-stage disease, and although it often resolves following chemotherapy, it generally re-accumulates in chemo-resistant and recurrent disease. In other cancers, ascites is a late event when the goal of treatment is palliation . AscitesClinically, ascites is a distressing and debilitating complication that significantly impacts quality of life . The volThe pathophysiology of ascites accumulation involves increased net filtration and/or decreased drainage of peritoneal fluid; that is, fluid production is more rapid than its clearance . AscitesA positive feedback cycle of cytokine release that involves cancer, mesothelial, and inflammatory cells contributes to ascites . In EOC,A cellular mechanism by which VEGF increases vascular permeability has recently been revealed . VEGF biCancer-associated ascites is enriched in other growth factors and pro-inflammatory factors secreted from cancer, reactive stromal, and inflammatory cells that contribute to the aforementioned peritoneal inflammatory alterations that promote cancer cell attachment. These include IL-8 , 83, IL-Peritoneal metastasis, in contrast to hematologic metastasis, does not require cancer cells to degrade matrix barriers associated with intravasation and extravasation of the vasculature. Rather, peritoneal metastasis entails cell adhesion, highly variable degrees of invasive growth and/or carpet-like spreading on peritoneal surfaces. The degree of invasion into the stroma varies and may be related to EOC grade and histotype, although the determinants of invasive behavior are undoubtedly multifactorial. Irrespective of invasive depth, proteolysis is required for cancer cells to anchor and establish metastatic implants.Cancer cell interactions with basal lamina components are probably not a prime determinant of peritoneal metastasis since the cancer cells have direct access to their preferred substrate, the fibrillar collagen I-rich peritoneal stroma, at milky spots and in areas exposed by mesothelial cell retraction. The collagenolytic matrix metalloproteinase (MMP) subset, which includes MMP-1, MMP-8, MMP-13, and the MT-MMPs, is therefore implicated in invasion. While the importance of MMPs in EOC metastasis is recognized , 93, cliin vivo (reviewed by [A deterministic role for the transmembrane subgroup of MMPs (MT-MMPs) has been revealed for cancer cell transmigration through stromal and basement membrane matrices, which pose protease-dependent barriers to cell migration iewed by ). MT-MMPiewed by .in vivo in an intraperitoneal xenograph murine model [MT1-MMP (MMP-14) has been revealed as a critical determinant of EOC cell invasion through collagen I matrices  where cene model . MT1-MMPne model .ex vivo peritoneal membrane and mammary gland explants [Studies using collagen I , 90 and explants , 83 exclexplants . As MT1-explants , this imIn addition to degrading the ECM and activating soluble MMPs, MT1-MMP promotes peritoneal metastasis through its sheddase activity. One such target is the transmembrane epidermal growth factor HB-EGF. This growth factor has a prominent role in peritoneal metastasis, and its elevated expression is correlated with a poor clinical outcome . HB-EGF Cells maintain a reciprocal dialogue with their surrounding ECM through integrin receptors which indirectly link the ECM to the actin cytoskeleton. Integrin activation can be mediated by growth factor “inside-out” activation or ECM-mediated “outside-in” activation. The clustering of activated integrins triggers signaling cascades involving FAK, Src, PI3K, RhoA, Rho kinase (ROCK), and myosin regulatory light chain (MLCK) phosphorylation, culminating in actinomyosin-mediated cell contractility, which transmits forces that alter the ECM. Tissue homeostasis is dependent on a balance between ECM deposition and turnover. When this delicate balance is disrupted by growth factors and cytokines associated with wounding or cancer, a feed-forward cycle of increased ECM deposition, rigidity, and cell contractile behavior ensue, which perpetuates peritoneal metastasis in several ways, as discussed below.The dense, rigid matrices formed through excessive collagen deposition and actomyosin-mediated contraction strongly promote cell proliferation and tumorigenesis –117. RigContractile behavior by surrounding stromal cells can also facilitate metastasis. Force-mediated matrix remodeling by fibroblasts was required for squamous cell carcinoma cell invasion through a mixed collagen I-based matrix . MoreoveTumor-associated myofibroblasts originate from several precursor cell types, including fibroblasts, mesothelial cells, and cancer cells, and contribute to ECM alterations that promote metastasis. Fibroblast–myofibroblast transdifferentiation is a well-recognized phenomenon that contributes to numerous pathologies , 127. InThe transdifferentiation of mesothelial cells into myofibroblasts is also stimulated by TGF-β. This process is commonly observed in peritoneal dialysis patients and leads to loss of the mesothelium, fibrosis, and peritoneal membrane failure , 131. A Contractile behavior may be particularly beneficial for the survival of cancer cells during peritoneal metastasis. When suspended individually during transit in the peritoneal fluid, cancer cells are susceptible to anoikis and other apoptotic triggers. However, by combining with other suspended cells to form compact multicellular “spheroid” aggregates, these cells can resist anoikis and apoptosis, including that induced by chemotherapeutics. The abundance of integrin attachments available to cells within the 3D spheroid configuration is thought to be a major contributor to pro-survival signaling , 135.Spheroids, which range from 50 to 750 μm in size , are comCancer cells possess varying capacities for spheroid formation , 137. WhAs a first step in spheroid formation, cells must interact with one another either directly or through ECM bridges. An ECM network interconnects EOC cells within spheroids , and intThe compaction of aggregated cells into dense spheroids is dependent upon the contractile capacity of the cells . A similECM molecules, growth factors, and cytokines present in ascites, including fibronectin, TGF-β, HGF, EGF, and LPA, promote cell adhesion and motility , 146 andIn solid tumors, contractile behavior creates dense rigid matrices that confer drug resistance by (1) increasing the potential for integrin attachments and their associated pro-survival signaling  and (2) in vivo showed a striking ability to form compact spheroids as compared to their parental cells. Moreover, their enhanced resistance to chemotherapeutics was evident in vitro only when they were compared to the parental cells as a spheroid culture. When cultured as monolayers, differences in drug resistance were admonished [Strong support for a role of compact spheroid formation in conferring drug resistance is provided by a study that compared drug-resistant cells to their parental cell lines. Cells selected for drug resistance monished . This prmonished , and givmonished , these smonished , targetiCell contractile behavior potentially drives peritoneal cancer progression through several mechanisms. By inhibiting actomyosin contractility, the increases in matrix density and rigidity that promote malignant progression and interfere with the delivery of chemotherapeutics could be reduced. Moreover, cells in transit should be sensitized to anoikis and chemotherapeutics if compact spheroid formation could be prevented.ROCK plays a major role in cell contractile behavior. ROCK ensures myosin II remains active and capable of binding and contracting actin filaments by (1) phosphorylating and inactivating myosin regulatory light chain phosphatase and (2) promoting myosin regulatory light chain phosphorylation directly, as well as indirectly by phosphorylating MLCK. ROCK also activates LIM kinase, which phosphorylates and inactivates cofilins, thus preventing F-actin severing . Two isoThe conditional overexpression of ROCK2 in murine skin increased tissue stiffness and thickening and enhanced tumor incidence, growth, and progression. These effects were reversible when ROCK2 or its downstream effectors  or its upstream activator FAK was inhibited . The celROCK1/2 inhibition using Y-27632 interfered with a process similar to spheroid formation: the cell sorting and compaction involved in microtissue formation . Y-27632While it is tempting to speculate that ROCK inhibition could slow peritoneal metastatic progression by blocking spheroid compaction and motile behavior of cancer cells, the observation that ROCK inhibition enabled embryonic stem cells  and prosHigh-throughput genetic and proteomic approaches hold promise for the discovery of early-stage disease biomarkers that may improve survival rates. However, identifying disease-specific markers capable of heralding early events in carcinogenesis has been proven to be a formidable challenge. Effective therapies to combat metastatic disease are urgently required and will continue to be needed, independent of gains in our ability for early detection, as screening approaches cannot be expected to detect all cancers at early stages. While many ovarian cancers are initially responsive to current chemotherapeutic approaches, progression to a drug-resistant form is an almost universal occurrence. Novel strategies that target cancer cell interactions with the peritoneal ECM and inflammation-driven peritoneal modifications that expose the peritoneal ECM are likely to be broadly applicable to cancers that metastasize within the abdominal cavity.in vitro and in vivo invasion models that accurately mirror the clinical situation. Cancer cells preferentially attach to and invade regions of the peritoneum where the sub-mesothelial ECM is exposed rather than to an intact mesothelium. This is evident in the pattern of peritoneal metastasis. Initially, cancer cells disseminate to milky spots where the basement membrane is disrupted and where they have direct access to the collagen I-rich connective tissue matrix. Collagen I is arguably the most important ECM component with which cancer cells interact during peritoneal dissemination, both for adhesion and invasion.A cornerstone to devising strategies to block peritoneal metastasis is the selection and implementation of suitable in vivo situation [Mounting evidence indicates that cell behavior in 3D culture differs from monolayer culture and better reflects the ituation . Consideituation , 162–164ituation . Basemenituation , 162. Hein vivo are not reflected in vitro due to the limited solubility of collagen, which is an important consideration in light of compelling evidence that matrix density and rigidity have fundamental effects on cell behavior and differentiation [Ex vivo peritoneal matrices retain a requirement for MMP-driven invasion as well as a density and complexity that resembles the in vivo situation [Collagen I with intact telopeptide regions can be isolated by acid extraction and reconstituted as a 3D gel that forms a true (MMP-dependent) barrier to cell transmigration. A limitation is that the density and rigidity found ntiation , 167. Exituation . It woulStrategies that block tumor cell interaction with the sub-mesothelial ECM (rather than the mesothelium itself) should prove more effective in blocking intraperitoneal metastatic dissemination at clinically relevant disease stages since cancer cells preferentially adhere to exposed peritoneal ECM. In addition, minimizing the amount of exposed peritoneal ECM by preventing mesothelial retraction is an intriguing avenue to further reduce peritoneal metastasis , 169. IfCells that gain a survival advantage by forming compact spheroids likely represent an aggressive subpopulation of cells, at least for EOC. This underscores the importance of targeting spheroid formation. Whether invasive capacity and compact spheroid formation are linked in other intraperitoneal cancers should be determined. The likelihood that compact spheroid formation and cancer cell-induced ECM remodeling both involve cellular contractility presents the exciting possibility that chemoresistance and invasion can be simultaneously targeted.The peritoneal cavity is highly susceptible to tumor cell implantation and growth. Cells need only to exfoliate from primary tumors and secondary sites into the peritoneal fluid, which provides efficient transport to additional sites within the abdominal cavity. The presence of milky spots/lymphatic ducts, where a basement membrane is lacking and the adhesive collagen-I-rich connective tissue matrix is directly exposed, encourages the attachment of metastasizing cells.Cancer cells stimulate a pro-inflammatory response within the peritoneal cavity, which augments metastasis. Inflammatory mediators cause retraction and uplifting of the protective mesothelial cell lining, which promotes cancer cell attachment by exposing the underlying pro-adhesive ECM. Inflammatory mediators also cause myofibroblast transdifferentiation of mesothelial cells and fibroblasts and initiate a fibrotic response within the peritoneum. The dense, rigid, fibrotic matrices that result promote tumor cell survival, growth, invasion, and chemoresistance by enhancing integrin signaling.MT1-MMP has emerged as an important contributor to peritoneal metastasis. In addition to its established pericellular collagenolytic activity that is crucial for invasive growth, its conversion of HB-EGF into a more potent, heparin-independent form, as well as its activation of soluble pro-MMP-2, likely contribute to its ability to promote intraperitoneal metastasis.Invasive cancer cells likely attain resistance to anoikis and chemotherapeutics by virtue of their propensity for contractile behavior and compact spheroid formation. This link between cancer cell invasive ability and capacity for compact spheroid formation highlights the importance of targeting these multicellular aggregates.Several events conspire to promote peritoneal metastasis:


Numerous angiogenesis-vascular targeting agents have been admitted to the ranks of cancer therapeutics; most are used in polytherapy regimens. This review looks at recent progress and our own preclinical experience in combining angiogenesis inhibitors, mainly acting on VEGF/VEGFR pathways, and vascular targeting agents with conventional chemotherapy, discussing the factors that determine the outcome of these treatments. Molecular and morphological modifications of the tumor microenvironment associated with drug distribution and activity are reviewed. Modalities to improve drug delivery and strategies for optimizing combination therapy are examined. Recognition of the multi-compartment nature of the tumor microenvironment has challenged the conventions of anticancer therapy, giving rise to a radically different approach toward the discovery of new treatments. Historically aimed at killing tumor cells (cytotoxic agents), the search now seeks to identify novel “biologicals,” that selectively target not only the cancer cell, but also the tumor stroma.Angiogenesis – the development of new vasculature – is required for tumor growth, invasion, and metastatic dissemination, hence the rationale for anti-angiogenic therapy . Numerou®), or, among others, with the VEGF-trap (Aflibercept®), an engineered soluble VEGF receptor able to bind VEGF as well as platelet growth factor (PLGF) (®), sorafenib (Nexavar®), and pazopanib (Votrient®) have been approved for different tumor types  axis. VEGF can be blocked directly, with the antibody bevacizumab (Avastinr (PLGF) , or indior types . An alteor types –8. VDA cInhibition of a single target or pathway is of limited benefit for cancer patients . The priThe mechanism by which anti-angiogenic agents increase the efficacy of chemotherapy is not yet clear. An angiogenesis inhibitor combined with chemotherapy affects multiple compartments, depriving the tumors of nutrients and oxygen , and killing highly proliferative tumor cells  . In termThe tumor microenvironment has an abnormal vasculature, structurally and functionally , mainly because of an imbalance between pro- and anti-angiogenic factors , 20. As Anti-VEGF, and more in general anti-angiogenesis agents, modify the tumor microenvironment; abnormal microvessels are destroyed and the remaining vessels are remodeled . These cWhether these morphological changes are accompanied by functional modifications, such as improved drug delivery, is still debated –27. CurrThis review focuses on recent progress, and our own preclinical experience in combining angiogenesis inhibitors/vascular targeting agents with conventional chemotherapy. Molecular, morphological and functional modifications of the tumor microenvironment related to drug distribution and activity are reviewed and, we examine some modalities to improve drug delivery and strategies for the optimization of combination therapy.Bevacizumab is a humanized monoclonal antibody that targets VEGF . It has According to the hypothesis of vessel “normalization,” Jain and coworkers showed in a number of tumor models transplanted in the cranial window or in the dorsal skinfold chamber of mice, that vessels begun to function better when treated with a neutralizing antibody anti-VEGF, possibly enhancing delivery of chemotherapy . Next, tThe main concern about the “normalization window” is the limited time in which it occurs. As an example, orthotopic neuroblastoma xenografts treated with bevacizumab were evaluated at serial time points for treatment-associated changes in intratumoral vascular physiology, penetration of chemotherapy, and efficacy of combination therapy. After bevacizumab, there was a progressive decrease in tumor microvessel density, with a rapid, sustained fall in tumor vessel permeability and tumor IFP, while tumor perfusion (mirrored by drug delivery) improved. Unfortunately these changes were short-lasting; the improvement in drug delivery was observed only for a few days after bevacizumab, but not when both drugs were given concomitantly. Although the combination was always superior to single-agent treatment, sequential treatment within the “normalization window” gave no significant advantage over concomitant treatment .Our laboratory found that bevacizumab in combination with chemotherapy delayed tumor progression in mice bearing ovarian carcinoma xenografts, significantly prolonging survival . We obseSimilar considerations can be extended to the combination of bevacizumab with large molecules, such as antibodies. For example reduced uptake of trastuzumab  after bevacizumab was observed in HER-2 expressing breast cancer xenografts. This was presumably due to tumor blood flow and vascular permeability reduction which contribute to the changes of trastuzumab pharmacokinetics . HoweverFew clinical studies report the effects of anti-angiogenic therapy on drug uptake. One of the first pointers to the anti-vascular effect of bevacizumab in a clinical setting, came from a phase I study, in which patients with non-metastatic CRC were given a single infusion of bevacizumab, concomitantly with neo-adjuvant chemotherapy with 5-fluorouracil. Twelve days after its infusion, bevacizumab reduced tumor blood perfusion and vascular volume, accompanied by decreases in microvessel density, lower IFP, and increased pericyte coverage, confirming the drug’s anti-vascular and normalizing effects in human tumors . Vessel 11C)docetaxel in NSCLC patients. Bevacizumab reduced perfusion and the net influx rate of docetaxel, shortly after its administration, and for several days afterward, showing no substantial improvement in drug delivery into tumors. Interestingly, bevacizumab prolonged systemic drug exposure, reducing plasma clearance, and causing more homogeneous intratumoral distribution, as a result of some normalization of tumor vasculature  with chemotherapy  raises tSeveral preclinical studies have exploited RTKIs in combination with chemotherapy aimed to study drug interaction and modification of the tumor/stroma compartment which can ultimately affect drug distribution. RTKIs often give rise to increased hypoxia and decreased drug uptake [for review see Ref. ].For example, the small-molecule axitinib  affected tumor vasculature as the number of blood vessels decreased, and hypoxia increased , 45. In Some years ago we studied the combination of SU6668  with paclitaxel on ovarian cancer xenograft models , 48. TheThese initial findings prompted us to investigate morphological and functional changes of the tumor vasculature induced by the RTKI vandetanib , and its effect on intratumoral delivery and the antitumor activity of paclitaxel . In lineWe have observed reduced paclitaxel delivery into the tumor with no change in systemic pharmacokinetics, in combination experiments with different RTKIs , despite the improved antitumor activity. E-3810 reduced vessel number, and induced tumor microenvironment modifications which ultimately lead to remodeling of the extracellular matrix .At variance, inhibition of PDGFR signaling with an increase in taxol uptake into the tumor and greater therapeutic effect have been described . ImatiniOne possible explanation for these controversial findings could be the different inhibitors of angiogenesis used in those study. Also the dose of the anti-angiogenic drug, might play an important role, as a too high dose can cause too rapid vessel pruning and not favor drug delivery and anticancer effects . The effIn the light of these considerations, we suggest that the combination of RTKI with chemotherapy is feasible. A better use of pharmacodynamics and pharmacokinetics, might help to maximize the effect and avoid negative interactions of RTKI combined with chemotherapy. Recently we have shown that the addition of certain chemotherapeutics to sunitinib is able to counteract the unwonted negative effect on tumor metastasization .per se to account for the greater delay in tumor growth  is expressed in endothelial cells, where it serves as an endogenous inhibitor of angiogenesis, and is lost during tumor progression. Its long-term re-expression at a later stage of carcinogenesis stably normalized the tumor vasculature in transgenic mouse tumor models and impaired tumor growth . In an aSelective killing of tumor neovasculature with an antibody directed against tumor vascular endothelial VE-cadherin, conjugated with an α-particle-emitting isotope generator, caused vascular remodeling, increased tumor delivery of chemotherapy, and reduced tumor growth. Interestingly, the effect was seen when chemotherapy was scheduled several days after the anti-vascular therapy. The authors pointed out that after depletion of the majority of vessels, the remaining ones appear more mature, so small-molecule drugs more homogeneously distribute and accumulate better, as reflected in the improvement of antitumor activity .Therapeutic vascular targeting agents comprise small molecules, mainly tubulin-binding agents, flavonoids, antagonists of junctional proteins intended to selectively target the tumor vasculature (VDA), and compounds that target proteins expressed selectively on tumor vasculature used to deliver bioactive molecules , 58, 59.A number of VDA have reached the clinical stage . Their eWe administered the VDA ZD6126 followed by paclitaxel 24–72 h later; this combination had greater antineoplastic activity than each single agent, leading to complete tumor remissions . That stThe actual target in the tumor periphery might include endothelial cells, thus providing a rationale for combining a VDA with an anti-angiogenic agent . Rapid mPaclitaxel is one of the most widely used cytotoxic drugs, employed in the treatments of several neoplasms. This tubulin-binding agent promotes microtubule polymerization (at high concentrations) and impairs microtubule dynamics (at low concentrations), ultimately affecting mitosis, as well as other microtubule-dependent cell functions . The antin vivo optical, and dynamic contrast enhanced (DCE)-MRI imaging that paclitaxel can modify certain tumor vessel functions related to vascular perfusion and permeability  (We have shown by  kTrans) . This wa kTrans) . The use kTrans) , 69.Herein paclitaxel given before, but not after, F8-IL2 potentiated the latter’s antitumor activity on EDA-Fn expressing human melanoma xenografts. We attributed this to increased vascular permeability and perfusion at the tumor site, as the area perfused by Hoechst 33342 was larger in paclitaxel treated tumors than controls.Although the mechanism of this effect of paclitaxel is far from clear, our findings are in line with other reports. Jain and coworkers proposed that taxane-induced tumor cell apoptosis reduced the IFP generated by neoplastic cell proliferation (solid stress) and decompressed tumor blood vessels. The increase in vessel diameter suggests that taxanes might improve tumor response by increasing the vascular surface area for the delivery of therapeutics . Paclita2 in order to improve the delivery of subsequent therapy, particularly of large molecules such as antibodies. However, the theory of solid stress in tumors only partially explains the biologic mechanisms by which taxanes boost the activity of combination therapy.The translational potential of these findings is substantiated by clinical studies. In breast cancer patients treated with neo-adjuvant chemotherapy, paclitaxel lowered IFP, and increased oxygenation ; this su®, nab-paclitaxel) and gemcitabine in patients with pancreatic cancer (Two mechanisms have been proposed to explain the activity of co-administration of albumin-bound paclitaxel (Abraxanec cancer . In a fic cancer . In a sec cancer .The inhibition of tumor growth by drugs affecting the tumor vasculature has been achieved in preclinical and clinical studies. The combination of an angiogenesis inhibitor, namely bevacizumab, with chemotherapy, showed a benefit in patients with advanced disease, leading to increased interest in developing more effective ways to combine anti-angiogenic/vascular targeting agents with conventional chemotherapy. Morphological changes in the tumor microenvironment and vasculature are widely observed after angiogenesis inhibitors. However, the balance between lowering tumor microvessel density, impairing their function, and reducing/increasing drug uptake needs to be carefully considered in choosing the doses and schedule for combination settings.Some preclinical studies have reported functional improvement in tumor blood perfusion after angiogenesis inhibitors, with increased tumor exposure to cytotoxic drugs. However, in other studies tumor vascular patency decreased, and hypoxia increased, with impaired cytotoxic drug uptake. The causal relationships between the effect on the microvasculature, the IFP reduction, and the improved trans-vascular transport are still not completely clear.Nevertheless the combination of angiogenesis inhibitors with chemotherapy is almost always superior to single-drug treatment, indicating the beneficial effect of tumor cell starvation induced by angiogenesis inhibition. The order of administration of the two types of agents – anti-vascular and antitumor – is critical for a successful outcome and has far-reaching impact on the design of combination therapy. Careful optimization of drug scheduling and dosage is essential to maximize tumor response. Robust tumor pharmacodynamics and pharmacokinetics could help in fine-tuning drug timing and sequences so as ultimately to achieve a better outcome.Monitoring the activity of angiogenesis inhibitors/vascular targeting agents is a significant practical challenge in the clinical setting, where non-invasive procedures such as imaging analysis and the detection of soluble biomarkers can be used to optimize the administration and determine the efficacy of combination regimens in patients.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Continuous spike and wave during slow wave sleep (CSWS) is an epileptic encephalopathy that presents with neurocognitive regression and clinical seizures, and that demonstrates an electroencephalogram (EEG) pattern of electrical status epilepticus during sleep, as defined by the Commission on Classification and Terminology of the International League Against Epilepsy 1989. CSWS is an age-related condition, typically presenting in children around 5 years of age, with clinical seizures which progress within 2 years to a severe epileptic encephalopathy. The pathophysiology of CSWS is not completely understood, but the corticothalamic neuronal network involved in sleep patterns is thought to be involved. Genetic predisposition and injury in early development are thought to play etiological roles. Treatment strategies have involved traditional anticonvulsants, hormonal therapies, and other newer techniques. Outcomes are fair, and the thought is that earlier diagnosis and intervention preserve neurocognitive development, as in the case of other epileptic encephalopathies. Further understanding of the mechanisms of CSWS may lead to improved therapeutic options and thus outcomes of children with CSWS. Electrical status epilepticus during sleep was first described in 1971 as EEG abnormalities that became continuous with sleep onset and ceased to be continuous upon arousal, occupying at least 85% of slow sleep tracing . SubsequElectrical status epilepticus during sleep (ESES) is now the term typically used to describe solely the electrographic findings, while the CSWS syndrome remains a clinical diagnosis of the constellation of neurocognitive deterioration from baseline, affecting motor, language, cognitive, or behavioral development, and a significant proportion of non-REM sleep disrupted by spike-wave discharges .Continuous spike and waves during sleep (CSWS) is an age-related condition uniquely affecting children. While data are sparse, it is thought to represent 0.5% to 0.6% of all childhood epilepsy cases seen at tertiary referral epilepsy centers , 4. TherThe classical presentation is a child with around 5 years of age, typically between age 4 and 7 years, who presents with new-onset seizures accompanied by mild developmental regression. While rarely presenting in children beyond age 10–12 years , cases aIn up to 80% of children, seizures are the presenting symptom and typically occur out of sleep . ChildreNeurocognitive regression along with the development of ESES on EEG tends to appear within 2-3 years after seizure onset, typically by 7 years of age , 11. UncMost authors have agreed upon a few key criteria for defining ESES, including the activation of epileptiform discharges during sleep , 14, theThe spike-wave index (SWI) aims to quantify the frequency of spikes in the EEG record, thought of as the percentage of non-REM sleep occupied by spike waves . Some haLocalization of electrographic findings tends to be frontotemporal or centrotemporal during both wakefulness and sleep, though during sleep, discharges tend to become much more widespread and frequent and commonly generalize .The characteristic electrographic findings of stage 2 and 3 sleep are difficult to ascertain in the context of ESES, as spike-wave discharges disrupt the typical background findings. Electrographic REM sleep findings are more readily noticeable as the ESES activity is diminished, and rare spikes can be seen, similar to those seen during wakefulness , 14.Interictal findings during wakefulness include focal or multifocal spikes, or slow waves, sometimes occurring in bursts. As neurocognitive regression occurs, the interictal abnormalities during wakefulness also become more prominent .Some studies report abnormal neuroimaging findings in as many as 45–59% of cases of ESES , 17. WhiA-related inhibitory postsynaptic potentials to GABAB-mediated inhibitory postsynaptic potentials, which are associated with a longer latency and thus perhaps slowing frequencies seen [B-receptor antagonists can eliminate the epileptiform activity occurring at 3 hertz in vivo [B-receptor antagonists treat the associated learning impairment [The mechanisms underlying development of the ESES pattern are complicated, though several hypotheses exist. One such explanation is that the corticothalamic network modulating oscillatory rhythms becomes pathologically hyperactivated, which may produce the ESES pattern seen on scalp EEG . The thaies seen . It was  in vivo . In addipairment . Functiopairment . In CSWSpairment .There have been some conditions associated with the development of CSWS. Some reports have described CSWS associated with neurodegenerative disorders , 23. In The natural history of seizures suggests that clinical seizures cease spontaneously, typically around puberty. This is seen regardless of associated etiological lesion and is seen in cases of fixed structural abnormalities as well as progressive degenerative conditions .The natural history of the electrographic finding of ESES suggests that ESES ceases around age 11 years and thus has been described as a self-limited condition , 11.Typically, improvement of clinical seizures and ESES is associated with cognitive improvement, though most patients continue to demonstrate some degree of impairment . It has Given the effect that seizure frequency and duration of ESES have on neurocognitive outcome, treatments have focused on minimizing clinical seizure frequency as well as targeting the ESES pattern. It seems that no one anticonvulsant is better than any other anticonvulsant . Case seTreatments with medications other than traditional anticonvulsants, such as with steroids, adrenocorticotropic hormone (ACTH), or intravenous immunoglobulin (IVIg), have been used in patients who do not respond to traditional anticonvulsants , 17, 28.Another avenue for treatment is the ketogenic diet. The ketogenic diet is a high-fat, low-carbohydrate diet used in the treatment of intractable childhood epilepsy. It has been described as useful in children with a condition related to CSWS called the Landau-Kleffner syndrome . A studySurgical treatment is an option in those with focal lesions, even if the EEG pattern is generalized and includes therapies such as multiple subpial transections, focal resective surgery, and even hemispherectomy , 28. VarIt seems that over half of all treated patients improve, but it is still unclear what effect these treatment strategies have on long-term outcomes, when considering the natural history of age-related improvement . In addiThere have been some recent advances with experimental systems in potential treatments for those with ESES and CSWS, particularly those with drug-refractory conditions. One such system used transcranial DC stimulation (tDCS) in patients with drug-refractory CSWS. Electrical DC polarization of the brain has previously been demonstrated to change neuronal discharges in the cortices of animals , 34. ConFurther, our personal experience has demonstrated that pharmacologic coma with pentobarbital, titrated to a burst-suppression pattern on EEG, has shown some efficacy in clearing the scalp EEG findings of ESES. This method has been tried in those children whose ESES is refractory to all other traditional treatment approaches, including high-dose diazepam, intravenous pulse steroids, chronic daily steroids, and amantadine. While pentobarbital-induced suppression of EEG in the setting of ESES has demonstrated some efficacy in our experience, this is still at a case report level and ought to be studied further.CSWS is thought to lie on the more severe end of a clinical spectrum in which benign epilepsy of childhood with centrotemporal spikes (BECTS) and benign occipital epilepsy of childhood (BOEC) represent the milder end . BECTS aCSWS is also related to a condition known as acquired epileptic aphasia, or Landau-Kleffner syndrome (LKS). This is an acquired syndrome characterized by subacute and progressive language only dysfunction, that occurs in an age-related manner. Children with LKS present with an acquired auditory agnosia, or “word deafness” , 29, thoOther less commonly associated conditions include the Lennox-Gastaut syndrome (LGS) or its variants. Unlike CSWS, in the Lennox-Gastaut syndrome, hyperexcitability during non-REM sleep is not a prominent feature. The electrical status epilepticus of LGS is not related to sleep and is also unrelated to age .Continuous spike and wave during slow wave sleep (CSWS) is an epileptic encephalopathy that presents with neurocognitive regression and clinical seizures, and that demonstrates an electroencephalogram (EEG) pattern of electrical status epilepticus during sleep. While the pathophysiology is not completely understood, there are known genetic and developmental associations with this condition. Traditional anticonvulsants as well as hormonal therapies are used with mixed results. Only with improved understanding of the pathophysiology of this condition, will advances in treatment be achieved. The end goal remains to preserve neurocognitive development.


Treatment options for early-stage (T1-2 N0) non-small cell lung cancer are often limited by the patient's advanced age, poor performance status, and comorbidities. Despite these challenges, stereotactic ablative radiotherapy (SABR) provides a highly effective and safe therapy for intrathoracic tumors and has become the standard of care for delivering definitive treatment in medically inoperable patients. High-quality treatment, which includes reliable immobilization, accurate tumor targeting, and precise verification of dose delivery, is essential both to achieve successful cure and to avoid debilitating toxicities. Generally, SABR is well tolerated in patients with peripherally located tumors, but even centrally or superiorly located lesions can be treated if there is adequate conformal avoidance of normal structures and/or modified fractionation to meet dose constraints. While several preliminary studies suggest that SABR is as efficacious as surgery in operable patients, results of randomized data will illuminate whether the indications for SABR can be expanded to include patients who are candidates for surgical resection. Herein, we review the rationale for using SABR and its application in treating different patient populations with early-stage lung cancer. Within a span of approximately 15 years (1995–2010), a multiplicity of new technologies were not only invented but also rapidly implemented into broad clinical practice. Some of these technologies, such as three-dimensional computed tomography (CT) planning, positron-emission tomography (PET) scans, four-dimensional CT simulation, and intensity-modulated radiation therapy, have become indispensable for accurate and effective delivery of radiation therapy. Even in the company of these technologies, stereotactic ablative radiotherapy (SABR), also called stereotactic body radiation therapy (SBRT)  fluorodeoxyglucose avidity for up to a year following SABR [A different kind of challenge in the use of SABR is the delineation of proper follow-up after treatment has occurred. Parenchyma changes such as fibrosis and persistent radiation pneumonitis can occur following SABR, and the resultant radiographic appearance on surveillance CT imaging can run the gamut from diffuse consolidation and ground-glass opacities to focal consolidation and scarring. In some cases, focal consolidation during follow-upis hard to distinguish from tumor recurrence . This wiing SABR ,73. Moreing SABR . Despiteing SABR . Future 5.The early-stage lung cancer patient can present a therapeutic challenge due to advanced age, frail performance status, and comorbidities arising from tobacco use. For patients who are medically inoperable, SABR has become the standard of care for achieving a high rate of local control and overall survival. Toxicity is minimal with peripherally located tumors, but centrally or superiorly located lesions can also be treated with a modified dose and fractionation. Proper technique that includes reliable immobilization, accurate tumor targeting, and precise verification of dose delivery is critical for safe, effective, and ethical use of this technology. While several preliminary studies suggest that SABR could be as efficacious as surgery in the treatment of operable patients, the impetus to preserve or change practice patterns will likely depend on the publication of ongoing randomized trials. In the meantime, lobectomy remains the standard of care for patients with early-stage (T1-2 N0) NSCLC if they are in good health and have adequate pulmonary function. Whether future physicians unsheathe SABR instead of a scalpel for these patients remains to be seen.