Utility of restaging endoscopic ultrasound after neoadjuvant therapy for esophageal cancer

BACKGROUND

Currently, the most accurate staging test for patients with esophageal cancer is endoscopic ultrasound (EUS). At many institutions, patients who have completed neoadjuvant chemotherapy and radiotherapy for esophageal cancer undergo restaging EUS before proceeding to surgical resection. The benefit of this restaging procedure remains controversial.

METHODS

We retrospectively studied consecutive patients who had pre-resection restaging EUS after receiving neoadjuvant treatment to assess accuracy of EUS restaging and determine whether it predicted survival.

RESULTS

Final pathologic data were available for 73 patients who underwent restaging EUS (3 patients had missing T or N stage at one time point). Median time from restaging EUS to resection was 20 days. Restaging EUS accurately predicted pathologic T status in 26 of 72 patients (36%), N status in 44 of 71 (62%), and detected a complete pathologic response in 2 of 19 (10.5%). EUS inappropriately classified 10 patients as T0 N0. Agreement between EUS and pathologic staging was poor for T (κ=0.14) and N status (κ=0.24). Median time from resection to death or last follow-up was 20 months. Pathologic T and N status were each significant predictors of survival (p=0.049 and p=0.0004, respectively). There were nonsignificant trends toward better survival for lower EUS T (p=0.32) and N status (p=0.0946).

CONCLUSIONS

Restaging by EUS before resection did not accurately predict pathologic stage in patients with esophageal cancer who received neoadjuvant treatment. As a result of this investigation, our institution no longer routinely performs restaging EUS.

A decade of advances in treatment of early-stage lung cancer

Emerging from the past decade, there has been a diversification of options for the treatment of early-stage lung cancer. Video-assisted thoracoscopic surgery is now more widely performed, with oncologic outcomes equivalent to those with open thoracotomy. Although lobectomy remains the standard approach to surgical resection, lesser resections, such as segmentectomy and wedge resection, are considerations for some patients. Advances in surgical, radiation, and medical therapies continue to evolve. Future research questions will focus on comparing long-term outcomes with these modalities, including survival, as well as patient-centered endpoints, such as quality of life.

Sternoclavicular joint infection necessitating through skin and lung parenchyma

Infections of the sternoclavicular joint associated with extensive local soft tissue involvement or abscess formation often require surgical debridement and drainage. This condition typically presents with joint pain, local erythema, and swelling. This case demonstrates the simultaneous extension of a sternoclavicular joint infection into the left upper pulmonary lobe and through the overlying skin.

Stereotactic body radiation therapy versus surgical resection for stage I non-small cell lung cancer

OBJECTIVES

Stereotactic body radiation therapy has been proposed as an alternative local treatment option for high-risk patients with early-stage lung cancer. A direct comparison of outcomes between stereotactic body radiation therapy and surgical resection has not been reported. This study compares short-term outcomes between stereotactic body radiation therapy and surgical treatment of non-small cell lung cancer.

METHODS

We compared all patients treated with surgery (January 2000-December 2006) or stereotactic body radiation therapy (February 2004-May 2007) with clinical stage IA/B non-small cell lung cancer staged by computed tomography and positron emission tomography. Comorbidity scores were recorded prospectively using the Adult Co-Morbidity Evaluation scoring system. Charts were reviewed to determine local tumor recurrence, disease-specific survival, and overall survival. A propensity score matching analysis was used to adjust estimated treatment hazard ratios for confounding effects of patient age, comorbidity index, and clinical stage.

RESULTS

A total of 462 patients underwent surgery and 76 received stereotactic body radiation therapy. Overall, surgical patients were younger (P < .001), had lower comorbidity scores (P < .001), and better pulmonary function (forced expiratory volume in 1 second and carbon monoxide diffusion in the lung) (P < .001). Among the surgical and stereotactic body radiation therapy groups, 62.6% (291/462) and 78.9% (60/76) were in clinical stage IA, respectively. Final pathology upstaged 35% (161/462) of the surgery patients. In an unmatched comparison, overall 5-year survival was 55% with surgery, and the 3-year survival was 32% with radiation therapy. Among patients with clinical stage IA disease, 3-year local tumor control was 89% with radiation therapy and 96% with surgery (P = .04). There was no difference in local tumor control in stage IB disease (P = .89). No disease-specific survival differences were found in patients with 1A (P = .33) or IB disease (P = .69). Propensity analysis matched 57 high-risk surgical patients to 57 patients undergoing stereotactic body radiation therapy. In the matched comparison of this subgroup, there was no difference in freedom from local recurrence (88% vs 90%), disease-free survival (77% vs 86%), and overall survival (54% vs 38%) at 3 years.

CONCLUSIONS

In an unmatched comparison of clinical stage IA disease, surgical patients were healthier and had better local tumor control compared with those receiving stereotactic body radiation therapy. Propensity analysis in clinical stage IA/B non-small cell lung cancer revealed similar rates of local recurrence and disease-specific survival in patients treated with surgery compared with stereotactic body radiation therapy.

The use of gamma-irradiation and ultraviolet-irradiation in the preparation of human melanoma cells for use in autologous whole-cell vaccines

Background

Human cancer vaccines incorporating autologous tumor cells carry a risk of implantation and subsequent metastasis of viable tumor cells into the patient who is being treated. Despite the fact that the melanoma cell preparations used in a recent vaccine trial (Mel37) were gamma-irradiated (200 Gy), approximately 25% of the preparations failed quality control release criteria which required that the irradiated cells incorporate ³H-thymidine at no more than 5% the level seen in the non-irradiated cells. We have, therefore, investigated ultraviolet (UV)-irradiation as a possible adjunct to, or replacement for gamma-irradiation.

Methods

Melanoma cells were gamma- and/or UV-irradiated. ³H-thymidine uptake was used to assess proliferation of the treated and untreated cells. Caspase-3 activity and DNA fragmentation were measured as indicators of apoptosis. Immunohistochemistry and Western blot analysis was used to assess antigen expression.

Results

UV-irradiation, either alone or in combination with gamma-irradiation, proved to be extremely effective in controlling the proliferation of melanoma cells. In contrast to gamma-irradiation, UV-irradiation was also capable of inducing significant levels of apoptosis. UV-irradiation, but not gamma-irradiation, was associated with the loss of tyrosinase expression. Neither form of radiation affected the expression of gp100, MART-1/MelanA, or S100.

Conclusion

These results indicate that UV-irradiation may increase the safety of autologous melanoma vaccines, although it may do so at the expense of altering the antigenic profile of the irradiated tumor cells.

Stage IB nonsmall cell lung cancers: are they all the same?

BACKGROUND

There is renewed interest in adjuvant chemotherapy after complete resection of nonsmall cell lung cancer, including stage IB (T2N0) cancers. Given the heterogeneity of the T2 classification, we hypothesize that there are survival differences in patients with stage IB NSCLC based on specific histopathologic tumor characteristics.

METHODS

A retrospective evaluation of 119 consecutive patients from 1999 to 2004 with a pathologic diagnosis of T2N0 nonsmall cell lung cancer was performed. Patient follow-up was 97%. Overall survival and disease-free survival rates were calculated by the Kaplan-Meier method. Univariate analysis was performed using the log rank test and multivariate analysis by Cox's proportional hazard model. Data were significant if p < 0.05.

RESULTS

The 4-year overall survival and disease-free survival rates were 62% and 60%, respectively. The local and distant recurrence rates were 5% and 18%, respectively. Tumor size (p = 0.001), histologic grade (p = 0.002), the Eastern Cooperative Oncology Group performance status (p = 0.002), angioinvasion (p = 0.03), and visceral pleural involvement (p = 0.02) were predictors of overall survival by univariate analysis. Multivariate analysis demonstrated increasing tumor size (1.26 [95% confidence intervals 1.12, 1.64]) and histologic grade (4.05 [95% confidence intervals 1.38, 11.90]) to be significant independent predictors of a worse overall survival. The 4-year survival of patients without any of these variables was 89% compared with 56% if one or more of these factors were present (p = 0.03).

CONCLUSIONS

There is significant heterogeneity in the T2N0 class of nonsmall cell lung cancer. Risk stratification using specific histopathologic variables may help determine which patients will benefit most from adjuvant therapy.

Extensive neurocristic hamartoma with skeletal muscle involvement

Neurocristic hamartomas (NCH) are rare pigmented skin lesions based in the deep subcutaneous tissues that may be either congenital or acquired. The clinical importance of these lesions is the potential for misdiagnosis and the development of malignant melanomas over a poorly described time course. Histological pleomorphism precludes meaningful random biopsies as a means of cancer surveillance. We present the case of an extensive NCH in a 67-year-old man, with a reported duration of greater than 50 years and no current clinical or histological indication of malignancy. Incisional biopsies of nodular areas showed bland-appearing pigmented cells that extended into subcutaneous adipose tissue and skeletal muscle. The specimens contained numerous clusters of differing configurations and cell types. Positron emission tomography (PET) scanning was used as an adjunct to physical examination in follow up. A PET-avid mass was detected but proved to be a banal nodular melanocytic proliferation within the NCH. In conclusion, NCH may be characterized by extensive deep tissue involvement in the absence of overt malignancy. The possible development of malignant melanoma in such lesions warrants close surveillance.

Novel targeted therapies for non-small cell lung cancer

Targeted therapies will advance the treatment of NSCLC as we improve our understanding of the underlying biology of NSCLC and enhance our ability to clinically target the optimal therapy to an individual's cancer. Ongoing translational research including tissue arrays, genomic, and proteomic studies will help to identify clinically useful biomarkers that will allow further classification of NSCLC and may allow accurate prediction of response to specific chemotherapeutic regimens. Advances in targeted therapy in NSCLC are already yielding exciting results, and promises to become an increasingly important adjunct to surgical management of NSCLC.

Proactive versus reactive: the effect of experience on performance in a critical care simulator

BACKGROUND

We sought to study the cognitive performance of residents in a critical care patient simulator.

METHODS

Residents in general surgery and emergency medicine were recruited to participate in the study. Subjects were read a morning report and presented with written data for 4 critical care patients. The subjects were evaluated on completing essential clinical tasks, cognitive errors, and directionality of reasoning.

RESULTS

Nine residents completed the study. Months of clinical residency training did not significantly affect performance. Residents with more than 10 weeks of intensive care unit (ICU) experience (EXP) made significantly fewer cognitive errors than those with less than 10 weeks of ICU experience (N-I) (EXP: .75 +/- .96 vs N-I: 7 +/- 5.6 errors per subject, P < .05). An unexpected finding was that EXP performed far more proactive actions than N-I (EXP: 21.8 +/- 9.9/subject vs N-I: 5.7 +/- .6/subjects, P < .01).

CONCLUSIONS

A unique finding was that residents with more than 10 weeks of ICU experience initiated a large number of proactive actions immediately following presentation of patient information, while N-I rarely performed these actions. In addition, residents with this degree of experience committed significantly fewer cognitive errors. These differences might play a role in efficiency, cost, and overall outcome in the care of ICU patients.

Suberoylanilide Hydroxamic Acid Induces Akt-mediated Phosphorylation of p300, Which Promotes Acetylation and Transcriptional Activation of RelA/p65

We have previously demonstrated that the transcription factor NF-kappaB is activated by histone deacetylase inhibitors in a PI3K/Akt-dependent manner. The molecular mechanisms governing this process have not been well described. By virtue of their inhibitory action, it is unclear whether the addition of histone deacetylase inhibitors simply preserves the acetylation status of RelA/p65 or whether they actively stimulate signaling cascades that result in increased acetylation and transcription of NF-kappaB. Here we provide evidence that suberoylanilide hydroxamic acid stimulates NF-kappaB transcription through a signaling cascade that involves activation of both the serine/threonine kinase Akt and the p300 acetyltransferase. Using newly developed phosphospecific antibodies to p300 (pSer(1834)), and site-directed mutant proteins, we find that suberoylanilide hydroxamic acid stimulates Akt activity, which is required to phosphorylate p300 at Ser(1834). Akt-mediated phosphorylation of p300 dramatically increases its acetyltransferase activity as measured by an increased acetylation of RelA/p65 at Lys(310), a modification that is required for full NF-kappaB transcription. Importantly, coordinate activation of Akt/p300 pathway by suberoylanilide hydroxamic acid occurs at the chromatin level, resulting in recruitment of activated Akt (pSer(473)), p300 (pSer(1834)), acetylated RelA/p65 (Lys(310)), and RNA polymerase II to the NF-kappaB-dependent cIAP-2 and Bfl-1/A1 promoters. These studies provide evidence that histone deacetylase inhibitors, such as suberoylanilide hydroxamic acid, not only inhibit deacetylase activity but also stimulate active NF-kappaB transcription and cell survival through signaling pathways involving Akt and increased p300 acetyltransferase activity.

Suberoylanilide hydroxamic acid combined with gemcitabine enhances apoptosis in non-small cell lung cancer

BACKGROUND

We have shown that non-small cell lung cancer (NSCLC) is resistant to the histone deacetylase inhibitor (HDI) suberoylanilide hydroxamic acid (SAHA) through upregulation of the antiapoptotic transcription factor nuclear factor-kappaB (NF-kappaB). HDIs also promote chromatin remodeling, potentially making the DNA more accessible to chemotherapy. We hypothesize that combined SAHA and gemcitabine sensitizes NSCLC to apoptosis.

METHODS

Three NSCLC cell lines (A549, H358, H460) were untreated, or treated with SAHA, gemcitabine, or both agents. NF-kappaB-dependent transcription was determined by reporter gene assays, reverse transcriptase-polymerase chain reaction RT-PCR, and Western blot analysis for the NF-kappaB-regulated antiapoptotic gene MnSOD. Survival of NSCLC cells overexpressing Bfl/A1, Bcl-X(L), or MnSOD and treated with SAHA and gemcitabine was determined in the presence or absence of NF-kappaB. Survival of treated cells overexpressing HDAC-1, 2, 3 or p/CAF was determined. Apoptosis was determined by fluorescence-activated cell sorter analysis, DNA fragmentation, and caspase-3 activity. Colony formation assays were performed on cells treated concurrently and sequentially with SAHA and gemcitabine. Assays were performed in triplicate, and the Student t test was applied as appropriate.

RESULTS

SAHA-activated NF-kappaB (P <or= .05) and gemcitabine inhibited these effects (P <or= .01). Increased cell survival was observed after overexpression of antiapoptotic genes, as well as in cells overexpressing HDAC-1, -2, and -3. Fluorescence-activated cell sorter analysis, DNA fragmentation, and caspase-3 assays all showed enhanced apoptosis with combined therapy, compared with single-agent therapy (P <or= .01). Sequential treatment offered no improvement over concurrent treatment.

CONCLUSIONS

Combined SAHA and gemcitabine sensitized NSCLC cells to apoptosis. Potential "proapoptotic" mechanisms for this finding include gemcitabine inhibition of SAHA-induced NF-kappaB activation and chromatin remodeling mediated by the inhibition of histone deacetylases.

Inhibition of phosphatidylinositol 3-kinase/Akt and histone deacetylase activity induces apoptosis in non-small cell lung cancer in vitro and in vivo

OBJECTIVE

Resistance to histone deacetylase inhibitors in non-small cell lung cancer is mediated in part through activation of nuclear factor-kappaB through a phosphatidylinositol 3-kinase/Akt-dependent pathway. We hypothesize that inhibition of phosphatidylinositol 3-kinase/Akt will sensitize non-small cell lung cancer cells to histone deacetylase inhibitor-induced apoptosis.

METHODS

Tumorigenic non-small cell lung cancer cell lines H157, H358, H460, and A549 were treated with nothing, the histone deacetylase inhibitor butyrate, the phosphatidylinositol 3-kinase/Akt inhibitor LY294002, or both compounds. Nuclear factor-kappaB activity was assessed by reporter gene assays and reverse transcriptase-polymerase chain reaction of the nuclear factor-kappaB dependent genes cIAP-2, Bfl/A1, and MnSOD. Whole cell extracts were immunoblotted for phospho-Akt, Akt, and phospho-ser/thr-Akt substrate. Cell death and apoptosis were measured by crystal violet staining, caspase-3 activity, and DNA fragmentation. A549 non-small cell lung cancer xenografts were created in athymic nude mice, and tumor growth was assessed after treatments as noted above. Explanted tumors underwent terminal deoxynucleotide transferase-mediated dUTP nick-end labeling and Western blot analyses for apoptosis assessment and drug target validation, respectively.

RESULTS

Butyrate activated nuclear factor-kappaB-dependent transcription, and LY294002 abrogated this effect. Combined treatment induced more apoptosis and cell death in vitro compared with either drug alone as measured by caspase-3, DNA fragmentation, and clonogenic survival. Combined butyrate and LY294002 was tumoristatic in vivo, but all other xenografts grew. This decreased tumor growth correlated with more apoptosis in the xenografts treated with combined therapy. Tumor levels of phospho-Akt and acetylated histone H3 were decreased and increased, respectively, in xenografts treated with combined therapy.

CONCLUSIONS

Combined histone deacetylase inhibitor and phosphatidylinositol 3-kinase/Akt pathway inhibition sensitized non-small cell lung cancer xenografts to apoptosis. Further investigations of this combined therapy are warranted as new pharmacologic phosphatidylinositol 3-kinase/Akt pathway inhibitors are developed.

Laparoscopic gastric bypass complicated by gastric pouch necrosis: considerations in gastroesophageal reconstruction

Gastric pouch necrosis and intraabdominal sepsis is an uncommon complication following laparoscopic gastric bypass. The intraoperative management of this complication centers on resection of the necrotic pouch, esophageal diversion, drainage, and enteral access for nutrition. Reestablishing gastrointestinal continuity at a later surgery following this complication can be challenging. We present a case in which the colon was found to be unacceptable for use in reconstruction; the remaining stomach was used as the conduit for a transhiatal reconstruction of gastrointestinal continuity instead.

Proteasome inhibition sensitizes non-small cell lung cancer to histone deacetylase inhibitor-induced apoptosis through the generation of reactive oxygen species

OBJECTIVES

The histone deacetylase inhibitor suberoylanilide hydroxamic acid induces apoptosis in some malignancies through mitochondrial injury and generation of reactive oxygen species. Histone deacetylase inhibitors also activate the antiapoptotic transcription factor nuclear factor kappaB. We hypothesize that proteasome inhibition with bortezomib (Velcade; Millennium Pharmaceuticals, Inc, Cambridge, Mass)will inhibit nuclear factor kappaB activation, enhance suberoylanilide hydroxamic acid-induced mitochondrial injury, and sensitize non-small cell lung cancer cells to apoptosis.

METHODS

Four tumorigenic non-small cell lung cancer cell lines were treated with nothing, suberoylanilide hydroxamic acid, bortezomib, or both drugs. Nuclear factor kappaB-dependent transcription was determined by reporter gene assays and endogenous interleukin 8 transcription. Reactive oxygen species were quantified by using the fluorophore H 2 DCFDA. Cell viability was determined on the basis of clonogenic survival, and apoptosis was measured by quantifying caspase-3 activity and DNA fragmentation. Apoptosis and cell-survival assays were repeated in similarly treated cells incubated in the presence or absence of N-acetyl cysteine. Statistical significance was determined by means of analysis of variance.

RESULTS

Suberoylanilide hydroxamic acid significantly enhanced interleukin 8 and nuclear factor kappaB-dependent reporter gene transcription, and these effects were inhibited by bortezomib ( P < or = .01). Combined treatment with suberoylanilide hydroxamic acid and bortezomib induced greater reactive oxygen species generation, more apoptosis ( P < or = .02), and more cell death ( P < or = .001) than either drug alone. N-acetyl cysteine diminished the induction of apoptosis and enhanced cell survival ( P < or = .04).

CONCLUSIONS

Suberoylanilide hydroxamic acid and bortezomib synergistically induce reactive oxygen species generation in non-small cell lung cancer, and this plays a critical role in the induction of apoptosis after treatment. Combined treatment with suberoylanilide hydroxamic acid and bortezomib might be an effective treatment strategy for non-small cell lung cancer.

Proteasome Inhibition Sensitizes Non–Small-Cell Lung Cancer to Gemcitabine-Induced Apoptosis

BACKGROUND

My colleagues and I have previously shown that chemotherapy activates the antiapoptotic transcription factor nuclear factor (NF)-kappaB in non-small-cell lung cancer (NSCLC). We hypothesized that inhibition of NF-kappaB by using the proteasome inhibitor bortezomib (Velcade) would sensitize NSCLC to gemcitabine-induced apoptosis.

METHODS

Tumorigenic NSCLC cell lines (H157 and A549) were treated with nothing, gemcitabine, bortezomib, or both compounds. NF-kappaB activity was determined by nuclear p65 protein levels, electrophoretic mobility shift assays, and reverse transcription-polymerase chain reaction of the NF-kappaB-regulated genes interleukin-8, c-IAP2, and Bcl-xL. The p21 and p53 protein levels were determined in similarly treated cells. Cell-cycle dysregulation was assessed by fluorescence-activated cell sorting analysis. Cell death and apoptosis were quantified by clonogenic assays, caspase-3 activation, and DNA fragmentation. NSCLC A549 xenografts were generated and treated as noted previously. Tumor growth was assessed over a 4-week treatment period. Statistical analysis was performed with analysis of variance.

RESULTS

Gemcitabine enhanced nuclear p65 levels, NF-kappaB binding to DNA, and transcription of all NF-kappaB-regulated genes. Bortezomib inhibited each of these effects. Combined gemcitabine and bortezomib enhanced p21 and p53 expression and induced S-phase and G2/M cell-cycle arrests, respectively. Combined treatment killed 80% of the NSCLC cells and induced apoptosis, as determined by caspase-3 activation (p = 0.05) and DNA fragmentation (p = 0.02). NSCLC xenografts treated with combination therapy grew significantly slower than xenografts treated with gemcitabine alone (p = 0.02).

CONCLUSIONS

Bortezomib inhibits gemcitabine-induced activation of NF-kappaB and sensitizes NSCLC to death in vitro and in vivo. This combined treatment strategy warrants further investigation and may represent a reasonable treatment strategy for select patients with NSCLC given the current clinical availability of both drugs.

Combined histone deacetylase and NF-κB inhibition sensitizes non-small cell lung cancer to cell death

BACKGROUND

Non-small cell lung cancer (NSCLC) remains resistant to traditional and novel chemotherapeutic agents, relating, in part, to the activation of the antiapoptotic transcription factor NF-kappaB. We hypothesize that inhibition of NF-kappaB using BAY-11-7085 will sensitize NSCLC cells to death, induced by the histone deacetylase inhibitor suberoylanilide hydroxamic acid (SAHA).

METHODS

Five tumorigenic NSCLC cell lines (A549, H157, H358, H460, H1299) were treated with nothing, SAHA, BAY-11-7085, or both compounds. Cell death was determined by crystal violet staining. p65 nuclear translocation was determined by Western blot analysis. NF-kappaB activity was determined by reporter-gene assays and by reverse transcriptase-polymerase chain reaction of the endogenous NF-kappaB-dependent gene interleukin 8. Apoptosis was determined by DNA fragmentation. Clonogenic cell survival assays were also performed. Data was analyzed with the Student t test when appropriate.

RESULTS

SAHA alone resulted in no meaningful NSCLC cell death. SAHA induced nuclear translocation of p65, which was inhibited by BAY-11-7085. SAHA significantly induced NF-kappaB-dependent transcription which was ameliorated after treatment with BAY-11-7085 (P = .01). Combined SAHA and BAY-11-7085 induced significantly more apoptosis and cell death than either drug alone (P = .002).

CONCLUSIONS

Combined HDI and NF-kappaB inhibition using BAY-11-7085 sensitizes NSCLC cells to cell death and appears promising as a novel treatment strategy for this disease.

Combined proteasome and histone deacetylase inhibition in non-small cell lung cancer

OBJECTIVE

Inhibitors of histone deacetylases are potent inducers of cell-cycle arrest and apoptosis in certain malignancies. We have previously demonstrated that chemotherapy activates the antiapoptotic transcription factor nuclear factor kappa B in non-small cell lung cancer and fails to induce significant levels of apoptosis. We hypothesize that nuclear factor kappa B inhibition with the proteasome inhibitor bortezomib (formerly known as PS-341) will sensitize non-small cell lung cancer cells to histone deacetylase inhibitor-mediated apoptosis.

METHODS

Tumorigenic non-small cell lung cancer cells (A549, H358, and H460) were treated with bortezomib, followed by the histone deactylase inhibitor sodium butyrate. After treatment, nuclear factor kappa B transcriptional activity was measured by using a luciferase reporter assay and transcription of the nuclear factor kappa B-dependent gene IL8. Apoptosis was determined on the basis of caspase-3 activation and DNA fragmentation. Western blot analyses for the cell-cycle regulatory proteins p21 and p53 were performed, and cell-cycle alterations were determined by means of FACS analysis. Experiments were performed in triplicate, and statistical significance was determined by using unpaired t tests.

RESULTS

Butyrate increased nuclear factor kappa B transcriptional activity 4-fold relative to that seen in control cells (P =.05) in all non-small cell lung cancer cell lines. Treatment with bortezomib reduced butyrate-induced activation of nuclear factor kappa B to baseline levels. The proteins p21 and p53 were stabilized after treatment with bortezomib, correlating with a G(2)/M cell-cycle arrest. Treatment with butyrate alone resulted in minimal apoptosis, but combined histone deacetylase and proteasome inhibition increased apoptosis 3- to 4-fold (P =.02).

CONCLUSIONS

Combined molecular targeting of histone deacteylases and proteasomes synergistically induced apoptosis in non-small cell lung cancer. Pharmacologic nuclear factor kappa B suppression through proteasome inhibition, followed by treatment with histone deacetylase inhibitors, might represent a novel treatment strategy for patients with non-small cell lung cancer.

Modulation of antiapoptotic cell signaling pathways in non-small cell lung cancer: the role of NF-κB

Apoptosis, or programmed cell death, is a natural phenomenon that is critical for normal embryonic development and the maintenance of homeostasis in multicellular organisms. In adults, apoptosis represents a protective strategy that limits the spread of infection and helps prevent the development of malignancies. Cells acquiring nonrepairable DNA mutations are capable of "committing suicide" to prevent propagation of acquired genetic mutations and to eliminate their own malignant potential. Although malignant cells maintain the necessary intracellular apoptotic machinery, inappropriate inhibition of apoptosis allows for continued tumor growth and metastases. The majority of nonsmall cell lung cancer (NSCLC) exhibits dysregulated antiapoptotic pathways involving the transcription factor NF-kappaB. In addition, in NSCLC both chemotherapy and radiation upregulate antiapoptotic and cell-cycle regulatory proteins through NF-kappaB-dependent signaling mechanisms. Preclinical and phase I clinical trials suggest that inhibition of NF-kappaB markedly attenuates the resistance of NSCLC to undergo apoptosis and sensitizes these cells to chemotherapy. Modulation of the antiapoptotic cascade mediated by NF-kappaB, combined with either traditional or novel chemotherapeutic agents, represents a promising treatment strategy for patients with NSCLC.

Pulmonary segmentectomy: results and complications

BACKGROUND

Segmentectomy is an anatomic pulmonary parenchymal-sparing resection performed for certain benign lesions and on selected patients with lung cancer. We reviewed our experience with segmentectomy in this highly select group of patients.

METHODS

We retrospectively reviewed the records of 61 patients (5% of all anatomic resections) undergoing 62 segmentectomies from 1991 to 2001. Wedge resections were excluded. The operative indications were suspected or known lung cancer (43), benign disease (12), and metastatic cancer to the lung (7). Median follow-up for patients with malignancy was 28 months (range 1 to 89 months). Actuarial survival was calculated using the Kaplan-Meier method.

RESULTS

Segmentectomy was performed in 43 lung cancer patients with pathologic stages of Ia-22, Ib-14, IIa-2, IIb-1, IIIa/IIIb-2, and IV-2. All resection margins were negative for malignancy. Segmentectomy for benign diseases included granulomatous disease (5), pulmonary abscess (2), plasmacytoma (1), and others (4). Complications occurred in 39% (24/62) of patients, including atelectasis requiring bronchoscopy (10/62, 16%), pneumonia (9/62, 14%), air leak more than 7 days (5/62, 8%), and supraventricular dysrhythmias (6/62, 10%). In-hospital mortality was 3% (2 patients). Median length of hospital stay was 6 days (range 4 to 66 days). In the lung cancer patients the locoregional recurrence rate was 0% and the distant recurrence rate was 20%. The 4-year actuarial survival for patients with lung cancer was 72%.

CONCLUSIONS

Pulmonary segmentectomy has acceptable morbidity and mortality in selected patients with both benign and malignant lung disease and remains a useful procedure in a thoracic surgeon's armamentarium. Distant, not locoregional recurrence, was responsible for the cancer deaths.

Ineffectiveness of histone deacetylase inhibitors to induce apoptosis involves the transcriptional activation of NF-kappa B through the Akt pathway

Histone deacetylase (HDAC) inhibitors are emerging as a new class of anticancer agents for the treatment of solid and hematological malignancies. Although HDAC inhibitors induce cell death through an apoptotic process, little is known about the molecular events that control their effectiveness. In this study, we demonstrate that HDAC inhibitors are limited in their ability to induce apoptosis in non-small cell lung cancer (NSCLC) cell lines despite their ability to effectively inhibit deacetylase activity. Because the anti-apoptotic transcription factor NF-kappa B has been shown to be under the control of HDAC-mediated repression, we analyzed whether HDAC inhibitors activated NF-kappa B in NSCLC cells. HDAC inhibitors effectively stimulated endogenous NF-kappa B-dependent gene expression by up-regulating IL-8, Bcl-XL, and MMP-9 transcripts. The ability of HDAC inhibitors to increase NF-kappa B transcriptional activity was not associated with signaling events that stimulated nuclear translocation, but rather modulated the transactivation potential of the RelA/p65 subunit of NF-kappa B. The inhibition of HDAC activity was associated with the recruitment of the p300 transcriptional co-activator to chromatin in an Akt-dependent manner. Moreover, Akt directly phosphorylated p300 in vitro and was required for stimulating the transactivation potential of the co-activator following the addition of HDAC inhibitors. Selective inhibition of either the phosphoinositide 3-kinase/Akt pathway, or NF-kappa B itself blocked the ability of HDAC inhibitors to activate NF-kappa B and dramatically sensitized NSCLC cells to apoptosis following of the addition of HDAC inhibitors. Our study indicates that the ineffectiveness of HDAC inhibitors to induce apoptosis in NSCLC cancer cells is associated with the ability of these molecules to stimulate NF-kappa B-dependent transcription and cell survival.

Acquired systemic-to-pulmonary arteriovenous malformation secondary to Mycobacterium tuberculosis empyema

Pulmonary arteriovenous malformations (AVMs) with systemic arterial collateralization related to a prior tuberculosis empyema are extremely rare. We report the case of a 15-year-old boy who developed a pulmonary AVM with massive systemic arterial collateralization 5 years after being treated for a Mycobacterium tuberculosis empyema necessitans. The AVM was successfully managed with combined intraarterial embolization and surgical resection.