Randomized phase II study of first-line carboplatin-paclitaxel with or without bevacizumab in Japanese patients with advanced non-squamous non-small-cell lung cancer

PURPOSE

This multicenter, randomized, open-label, phase II study (JO19907) compared the efficacy and safety of first-line carboplatin-paclitaxel (CP) alone with bevacizumab-CP in Japanese patients with advanced non-squamous non-small-cell lung cancer (NSCLC).

METHODS

Chemonaïve patients with stage IIIB, IV or recurrent non-squamous NSCLC were eligible for participation. Patients were randomly assigned in a 2:1 ratio to receive bevacizumab-CP or CP alone. Chemotherapy was repeated for up to 6 cycles or until disease progression or unacceptable toxicity. Bevacizumab recipients who completed ≥3 cycles of chemotherapy could continue bevacizumab as monotherapy until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS).

RESULTS

After confirming the tolerability of bevacizumab-CP in a small number of patients, 180 patients were recruited, of whom 121 were assigned to bevacizumab-CP and 59 to CP alone. Hazard ratio (HR) for PFS was 0.61 with bevacizumab-CP versus CP alone (p=0.0090; median 6.9 versus 5.9 months). Objective response rate was significantly higher with bevacizumab-CP than with CP alone (60.7% versus 31.0%; p=0.0013). Median overall survival was >22 months in both treatment groups (HR 0.99; p=0.9526). No new safety signals were detected.

CONCLUSION

Study JO19907 met its primary endpoint, demonstrating that the addition of bevacizumab to first-line CP significantly improves PFS in Japanese patients with advanced non-squamous NSCLC. This prolonged PFS by bevacizumab did not translate into OS benefit with the extremely longer underlying survival compared to historical data. No new safety signals were identified in this population. (Japan Pharmaceutical Information Center [JAPIC] registration number: CTI-060338).

Peptidoglycan from Staphylococcus aureus induces T(H)2 immune response in mice

BACKGROUND AND OBJECTIVE

Atopic dermatitis patients have an increased number of type 2 helper (T(H)2) cells in their peripheral blood and superficial Staphylococcus aureus colonization. The purpose of this study was to clarify the effects of peptidoglycan (PEG) from S aureus on the induction of the TH2 immune response in mice.

METHODS

Mice were primed with PEG- and ovalbumin (OVA)-pulsed Langerhans cells (LCs) and given a booster OVA injection 2 days later via the hind footpad. Five days later, the cytokine response in the draining popliteal lymph nodes was investigated by reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA). IL-12 production from cultured LCs was detected by ELISA and Western blot analysis.

RESULTS

Administration of PEG- and OVA-pulsed LCs into the hind footpads of the mice induced a T(H)2-prone immune response as represented by the enhanced interleukin (IL) 4 expression in the lymph nodes. We further showed that higher levels of IL-12 p40 production by PEG-stimulated LCs relative to IL-12 p70 (p35/p40) production were associated with the induction of the T(H)2 immune response.The LC-derived IL-12 p40 protein induced by PEG stimulation was detected mainly as monomeric and homodimeric IL-12 p40 subunits; other heterodimers including the L-12 p40 subunit, such as IL-23, were undetected.

CONCLUSION

These results suggest that PEG may have the ability to induce the development of T(H)2 cells through insufficient production of IL-12 p70 and excessive production by LCs of homodimeric IL-12 p40, a known antagonist of bioactive IL-12 p70, offering a possible explanation for the role of S aureus colonization in patients with atopic dermatitis.

Active hexose correlated compound inhibits the expression of proinflammatory biomarker iNOS in hepatocytes

BACKGROUND/AIMS

Excess production of nitric oxide (NO) by inducible nitric oxide synthase (iNOS) has been implicated as proinflammatory biomarker in liver injury. The application of active hexose correlated compound (AHCC) as a functional food in complementary and alternative medicine has increased. The possibility that AHCC might inhibit iNOS induction was investigated as a potential liver-protective effect.

METHODS

Hepatocytes were isolated from rats by collagenase perfusion and cultured. Primary cultured hepatocytes were treated with interleukin-1β in the presence or absence of AHCC-sugar fraction (AHCC-SF).

RESULTS AND CONCLUSION

AHCC-SF inhibited the production of NO and reduced expressions of iNOS mRNA and its protein. AHCC-SF had no effects on either IκB degradation or nuclear factor-κB (NF-κB) activation. In contrast, AHCC-SF inhibited the upregulation of type I interleukin-1 receptor (IL-1RI) through the inhibition of Akt phosphorylation. Transfection experiments with iNOS promoter-luciferase constructs revealed that AHCC-SF reduced the levels of iNOS mRNA at both promoter transactivation and mRNA stabilization steps. AHCC-SF inhibited the expression of iNOS gene antisense transcript, which is involved in iNOS mRNA stabilization. These findings demonstrate that AHCC-SF suppresses iNOS gene expression through a IκB/NF-κB-independent but Akt/IL-1RI-dependent pathway, resulting in the reduction of NO production. AHCC-SF may have therapeutic potential for various liver injuries.

Phase II study of topotecan with cisplatin in Japanese patients with small cell lung cancer

BACKGROUND

We conducted a phase II study of topotecan (Tp) with cisplatin (CDDP) in previously untreated Japanese patients with extensive-disease small cell lung cancer (ED-SCLC).

PATIENTS AND METHODS

In stage 1, a total of 30 patients were allocated to Tp 0.65 mg/m(2) with CDDP 60 mg/m(2) day 1 or Tp 1.00 mg/m(2) with CDDP day 5 following prophylactic granulocyte colony stimulating factor (G-CSF) from day 6. In stage 2, the selective combination in 29 patients was evaluated for response rate, toxicity and overall survival.

RESULTS

In stage 1, Tp 1.00 mg/m(2) with CDDP day 5 was selected this schedule had a better hematological profile. In stage 2, the response rate was 83%, and grade 3/4 adverse events were hematological-toxicities. The median survival time was 17.5 months and the 1 year survival rate was 79%.

CONCLUSION

Combination of Tp and CDDP on day 5 with G-CSF support is safe and effective for previously untreated ED-SCLC Japanese patients.

Phase II study of gefitinib as a first-line therapy in elderly patients with pulmonary adenocarcinoma: West Japan Thoracic Oncology Group Study 0402

OBJECTIVE

Elderly patients prefer to receive less-toxic therapy. Monotherapy using drugs such as vinorelbine, gemcitabine or docetaxel is a preferable chemotherapy in elderly patients with advanced non-small-cell lung cancer. Gefitinib shows remarkable efficacy in patients with advanced non-small-cell lung cancer, who have activating epidermal growth factor receptor mutations. Adenocarcinoma histology is related to these mutations. Therefore, we conducted a phase II study of gefitinib as a first-line therapy in elderly patients with pulmonary adenocarcinoma.

METHODS

Eligible patients were 70 years or older, had pulmonary adenocarcinoma, stage IIIB or IV disease, an Eastern Cooperative Oncology Group performance status of 0-2 and adequate organ functions. Patients were treated with oral gefitinib 250 mg daily until disease progression or unacceptable toxicity.

RESULTS

Thirty-one patients were enrolled, of whom 30 were eligible. The median age was 78.5 years. The response rate was 20%, the disease control rate was 47%, the median progression-free survival was 2.7 months and the median overall survival was 11.9 months. Narrowing it down to those who had never smoked, the response rate increased to 43%, the disease control rate increased to 57%, the median progression-free survival prolonged to 7.1 months and the median overall survival prolonged to 13.0 months. The most frequent toxicity was rash. Other major toxicities were diarrhea, anorexia, liver dysfunction and anemia. These toxicities were mild and easily managed.

CONCLUSIONS

Gefitinib as a first-line therapy is active and well tolerated in elderly patients with pulmonary adenocarcinoma, especially in those who have never smoked.

A phase I study of oral panobinostat (LBH589) in Japanese patients with advanced solid tumors

OBJECTIVE

The objective was to determine the maximum tolerated dose and the dose-limiting toxicity of panobinostat (LBH589) when administered as a single agent to adult patients with advanced solid tumors or cutaneous T-cell lymphoma whose disease had progressed despite standard therapy or for whom no standard therapy existed.

METHODS

Panobinostat was administered orally once daily on Monday, Wednesday, and Friday of each week. A total of 13 patients were treated with one of three initial doses: 10 mg (n = 3), 15 mg (n = 4), or 20 mg (n = 6).

RESULTS

No dose-limiting toxicity was observed in 12 evaluable patients. The most frequently reported adverse events, regardless of whether they were related to the study drug, were diarrhea and nausea in 10 patients (76.9%). Thrombocytopenia was reported in 12 of 13 patients (92.3%). Five of 11 patients (45.4%) had stable disease.

CONCLUSION

Panobinostat administered orally once daily on Monday, Wednesday, and Friday of each week was well tolerated at doses up to 20 mg in Japanese patients. Dose escalation did not proceed after exploration of the 20 mg dose due to emerging global clinical data at that time.

Percutaneous application of peptidoglycan from Staphylococcus aureus induces infiltration of CCR4+ cells into mouse skin

BACKGROUND

The lesional skin of patients with atopic dermatitis has an increased number of type 2 helper T (TH2) cells in the dermis and is superficially colonized by Staphylococcus aureus. The purpose of this study was to determine the effects of peptidoglycan (PEG) from S aureus on TH2 cell induction in murine skin.

METHODS

Mice were sensitized with house dust mite antigen (MA) by topical application to barrier-disrupted abdominal skin. Seven days after sensitization, PEG was applied to the barrier-disrupted dorsal skin. After a further 3 days, C-C chemokine receptor type 4-positive (CCR4+) cells were counted in the PEG-treated skin.The production of chemokine (C-C) motif ligand 17 (CCL17) (thymus- and activation-regulated chemokine) and CCL22 (macrophage-derived chemokine) in the skin was investigated using reverse transcriptase polymerase chain reaction and immunohistological analysis.

RESULTS

Application of PEG to the dorsal skin of MA-sensitized mice led to a significant increase in the number of cells expressing CCR4 in the dermis. The skin of PEG-treated mice showed an increased level of CCL17 mRNA expression, which coincided with TH2 cytokine mRNA expression. Immunohistological analysis demonstrated that levels of CCL17 transcripts corresponded to those of protein synthesis in the epidermis. CCL17 production was induced mainly by Langerhans cells stimulated with PEG. Furthermore, intraperitoneal injection of anti-CCL17 antibody abrogated the induction of CCR4+ cells in the skin.

CONCLUSION

These results suggest that PEG may induce TH2 cells in the skin through the production of CCL17 by Langerhans cells and would explain the role of colonization by S aureus in patients with atopic dermatitis.

Attitudes of medical professionals and transplantation facilities toward living-donor liver transplantation in Japan

The Japan Society for Transplantation (JST) revised their guidelines in 2003 to specify that a living donor must be "a relative by blood within the sixth degree or an in-law within the third degree." Although several criticisms have been raised on this issue, these criteria have persisted without any empirical data showing the opinions and attitudes of people who are affected by the revision. Therefore, we performed a questionnaire survey to determine what Japanese medical professionals involved with living-donor liver transplantation (LDLT) regarded as eligible relationships for donation, as well as the kind of relationship for which they would be willing to donate their liver, and what donor eligibility criteria was currently used by their institutions. Among the 71 representatives of the Japanese Liver Transplantation Society, >90% answered that liver donations to emotionally close parents, siblings, children, or spouses were acceptable. However, the numbers were considerably lower for donation to emotionally close blood relatives, in-laws, friends, and strangers (78.2%, 52.1%, 18.6%, and 5.9%, respectively). This gap was more prominent when participants were questioned about their own willingness to donate. More than two-thirds of facilities that perform LDLTs have independent regulations for donor eligibility that are more conservative than the JST guidelines. No facility accepted friends or strangers as donors. When introducing policies or guidelines, it is important to carefully investigate the views of the people who are affected. The data obtained in this study should serve as a resource for ongoing discussions about the JST revised guidelines.

Phase I and pharmacologic study of weekly bolus topotecan for advanced non-small-cell lung cancer

PURPOSE

We conducted a phase I trial of the topoisomerase I inhibitor topotecan for the purpose of determining the maximum tolerated dose (MTD) and the dose-limiting toxicities (DLTs) of topotecan when administered weekly to patients with advanced non-small-cell lung cancer.

PATIENTS AND METHODS

Twelve patients with stage IIIB or IV disease were treated with topotecan by 30-minute intravenous infusion on days 1, 8, and 15 every 4 weeks. The dose was escalated in 2-mg/m2 increments from the starting dose of 4 mg/m2 until the MTD was reached. After the MTD had been reached in previously treated patients, chemotherapy-naive patients were enrolled for treatment at that dose, and the dose was escalated to estimate the MTD in the treatment-naive group.

RESULTS

The MTD of topotecan was determined to be 6 mg/m2 in the previously treated group and 8 mg/m2 in the chemotherapy-naive group. All 3 previously treated patients experienced DLT at the 6-mg/m2 dose level. Although only 1 of the 3 previously treated patients experienced DLT (grade 4 neutropenia for > or = 3 days) at the 8-mg/m2 dose level, skipping the topotecan dose on day 15 because of neutropenia was reported in 2 patients. Anorexia and general fatigue were the common nonhematologic toxicities.

CONCLUSION

The recommended dose of topotecan for phase II studies in previously untreated patients is 6 mg/m2 on days 1, 8, and 15, every 28 days, and 4 mg/m2 appears to be a suitable dose for use in previously treated patients with this schedule.

Bone regeneration by octacalcium phosphate collagen composites in a dog alveolar cleft model

Octacalcium phosphate (OCP) and porcine atelocollagen sponge composites (OCP/Col) markedly enhanced bone regeneration in a rat cranial defect model. To assess clinical application, the authors examined whether OCP/Col would enhance bone regeneration in an alveolar cleft model in an adult dog, which was assumed to reflect patients with alveolar cleft. Disks of OCP/Col or collagen were implanted into the defect and bone regeneration by OCP/Col or collagen was investigated 4 months after implantation. Macroscopically, the OCP/Col-treated alveolus was obviously augmented and occupied by radio-opacity, and the border between the original bone and the defect was indistinguishable. Histological analysis revealed it was filled and bridged with newly formed bone; a small quantity of the remaining implanted OCP was observed. X-ray diffraction patterns of the area of implanted OCP/Col indicated no difference from those of dog bone. In the collagen-treated alveolus, the hollowed alveolus was mainly filled with fibrous connective tissue, and a small amount of new bone was observed at the defect margin. These results suggest that bone was obviously repaired when OCP/Col was implanted into the alveolar cleft model in a dog, and OCP/Col would be a significant bone regenerative material to substitute for autogeneous bone.

Phase I and pharmacologic study of BNP7787, a novel chemoprotector in patients with advanced non-small cell lung cancer

Purpose

We conducted a phase I trial of BNP7787 (disodium 2,2′-dithio-bis-ethane sulfonate, Tavocept™), a novel chemoprotective and antitumor enhancing agent administered in combination with paclitaxel and cisplatin. The primary aim was to determine a safe and potentially efficacious BNP7787 dose for preventing and mitigating paclitaxel- and cisplatin-induced toxicities and to evaluate for preliminary evidence of efficacy of treatment.

Patients and methods

Twenty-two patients with stage IIIB/IV non-small cell lung cancer (NSCLC) received BNP7787 alone 1 week before co-administration of BNP7787 with paclitaxel followed by cisplatin. Twenty-one patients were treated with BNP7787 in escalating doses of 4.1–41.0 g/m² concurrently with paclitaxel 175 mg/m² and cisplatin 75 mg/m² every 3 weeks.

Results

The appropriate dose was determined to be 18.4 g/m² of BNP7787 although no dose-limiting toxicity was observed up to 41.0 g/m². Mild intravenous site discomfort, thirst, and nausea were the most common toxicities. One patient developed grade 2 skin rash, which was severe enough to preclude further study treatment. The AUC_0-inf of the metabolite mesna was approximately 6.3% of the AUC_0-inf of BNP7787. Co-administration of paclitaxel and cisplatin did not appear to influence the pharmacokinetics of BNP7787 and mesna. The overall response rate was encouraging; 43% including 11 patients with prior chemotherapy.

Conclusions

The recommended dose for phase II/III studies is 18.4 mg/m² of BNP7787 in combination with paclitaxel and cisplatin. Further studies are warranted to assess whether BNP7787 prevents and mitigates common and serious paclitaxel- and cisplatin-related side effects and enhances the efficacy of paclitaxel and cisplatin in advanced NSCLC patients.

[Renal salt-wasting syndrome progressing to severe hyponatremia after chemotherapy--a case report]

A 66-year-old woman with small-cell lung cancer was administered chemo-radiotherapy consisting of cisplatin (CDDP) and etoposide (ETP). From day 3, she developed vomiting and hyponatremia that persisted despite fluid infusion and cortico-steroid administration. On day 7, the hyponatremia worsened (serum sodium level, 109 mEq/L), leading to disturbed consciousness and convulsions. The serum sodium level gradually increased after intravenous administration of hypertonic saline; on day 22, the serum sodium level was almost normal without any neurological implication. We diagnosed this clinical condition as renal salt-wasting syndrome (RSWS) on the basis of dehydration and high urinary sodium excretion at the onset. In the second course of chemotherapy, CDDP was replaced with carboplatin (CBDCA); consequently, hyponatremia was not observed. Hyponatremia that develops after the administration of CDDP may be due to not only the syndrome of inappropriate secretion of anti diuretic hormone (SIADH) but also RSWS. When RSWS is suspected, hypertonic saline should be administered.

A phase II study directed by a clinical pathway for carboplatin and weekly paclitaxel in previously untreated patients with unresectable non-small cell lung cancer

The objective of this phase II study was to evaluate the efficacy and safety of carboplatin and weekly paclitaxel in previously untreated patients with unresectable non-small cell lung cancer. In addition, the clinical pathway intensified the management of chemotherapy including the assessment of efficacy, safety and implementation of treatment and patient education. Patients received paclitaxel at a dose of 70 mg/m(2) on days 1, 8 and 15 and carboplatin (area under the curve of 6) on day 1 and every 28th day thereafter. Fifty-eight patients were enrolled. A median of 3 cycles (range 1-6) were administered. Twenty-eight cases showed objective responses (48.2%), including 2 complete (3.4%) and 26 partial responses (44.8%; 95% confidence interval 35.4-61.1). The median survival time was 663 days, and the 1-year survival rate was 59.9%. Nineteen patients (32.8%) had grade 3, and 4 patients (6.9%) had grade 4 neutropenia. Nine patients (15.5%) experienced > or =3 grade nonhematological toxicities. There were no treatment-related deaths due to this study. Carboplatin and weekly paclitaxel combination chemotherapy might be an alternative treatment selection in patients with unresectable non-small cell lung cancer.

Inhibitory effects of Schefflera leucantha extract on production of allergic mediators by Langerhans cells and mast cells

BACKGROUND

Schefflera leucantha Viguier is used as a traditional medicine in Thailand and China to relieve chronic cough and asthma. However, little is known about its anti-allergic effects.

OBJECTIVE

This study was designed to investigate the effects of S leucantha ethanol extract (SLEE) on chemokine production by epidermal Langerhans cells (LCs) stimulated with peptidoglycan (PEG) from Staphylococcus aureus and histamine release from mast cells.

METHODS

LCs were purified from murine epidermal cells using the panning method with anti-IA(d) monoclonal antibody. Chemokine production by LCs was investigated by reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA). Mast cells for histamine release assay were induced by long-term culture of mouse spleen cells. Histamine release from these mast cells was measured by a competitive ELISA.

RESULTS

Production of the eosinophil chemoattractant CCL5 and the type 2 T helper (TH2)-associated chemokine CCL17 from PEG-stimulated LCs was significantly inhibited by SLEE. Furthermore, SLEE significantly decreased the release of histamine from mast cells by IgE-mediated degranulation.

CONCLUSION

These results suggest that S leucantha may offer a new therapeutic approach for the control of atopic dermatitis associated with S aureus colonization through inhibition of the production of allergic mediators.

Randomized phase III trial of platinum-doublet chemotherapy followed by gefitinib compared with continued platinum-doublet chemotherapy in Japanese patients with advanced non-small-cell lung cancer: results of a west Japan thoracic oncology group trial (WJTOG0203)

PURPOSE Gefitinib is a small molecule inhibitor of the epidermal growth factor receptor tyrosine kinase. We conducted a phase III trial to evaluate whether gefitinib improves survival as sequential therapy after platinum-doublet chemotherapy in patients with advanced non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS Chemotherapy-naïve patients with advanced stage (IIIB/IV) NSCLC, Eastern Cooperative Oncology Group performance status of 0 to 1, and adequate organ function were randomly assigned to either platinum-doublet chemotherapy up to six cycles (arm A) or platinum-doublet chemotherapy for three cycles followed by gefitinib 250 mg orally once daily, until disease progression (arm B). Patients were stratified by disease stage, sex, histology, and chemotherapy regimens. The primary end point was overall survival; secondary end points included progression-free survival, tumor response, safety, and quality of life. Results Between March 2003 and May 2005, 604 patients were randomly assigned. There was a statistically significant improvement in progression-free survival in arm B (hazard ratio [HR], 0.68; 95% CI, 0.57 to 0.80; P < .001); however, overall survival results did not reach statistical significance (HR, 0.86; 95% CI, 0.72 to 1.03; P = .11). In an exploratory subset analysis of overall survival by histologic group, patients in arm B with adenocarcinoma did significantly better than patients in arm A with adenocarcinoma (n = 467; HR, 0.79; 95% CI, 0.65 to 0.98; P = .03). CONCLUSION This trial failed to meet the primary end point of OS in patients with NSCLC. The exploratory subset analyses demonstrate a possible survival prolongation for sequential therapy of gefitinib, especially for patients with adenocarcinoma.

Distribution of the introduced cyprinid herpesvirus 3 in a wild population of common carp, Cyprinus carpio L

Cyprinid herpesvirus 3 (CyHV-3), which causes a lethal disease in common carp, Cyprinus carpio L., and koi, C. carpio koi, first occurred in Lake Biwa, Japan in 2004. To elucidate distribution of CyHV-3 in a wild common carp population, we conducted a PCR survey of CyHV-3 among such fish in Lake Biwa in 2006. Only 6% (1/18) of the common carp smaller than 300 mm were positive with PCR, whereas 31% (18/58) of fish larger than 300 mm were positive. To evaluate their past exposure to CyHV-3 infection based on the presence of antibodies, we also measured the levels of serum anti-CyHV-3 antibodies in the carp, using an enzyme-linked immunosorbent assay. None (0/26) of the fish smaller than 300 mm was positive for the antibodies, whereas 54% (33/61) of fish larger than 300 mm were positive. Of the antibody-positive individuals, 44% (14/32) were also positive by PCR strongly suggesting that wild common carp that survived infection become CyHV-3 carriers. Five individuals were positive by PCR but negative for antibodies indicating that their infection with CyHV-3 had occurred recently. These results suggest that transmission of CyHV-3 from carriers to naïve common carp is still occurring in Lake Biwa.

[The contribution of widely used devices in the diagnosis of peripheral pulmonary lesions in patients presenting with respiratory distress]

PURPOSE

We retrospectively reviewed the contribution of widely used devices such as the standard fiberoptic bronchoscope in the diagnosis of peripheral pulmonary lesions (PPLs) in patients who presented with respiratory distress.

SUBJECT

We performed bronchoscopy for 106 PPLs in January-December 2007, and diagnosed access to the lesions to be difficult.

METHOD

For these lesions, we applied Sasada transbronchial angled forceps (STAF), transbronchial needle aspiration cytology (TBAC), thin bronchoscopy, and ultra-thin bronchoscopy, which are widely used devices, after routinely performing biopsy with standard forceps and saved each specimen separately, and finally compared the pathological diagnosis.

RESULTS

The diagnostic yield obtained with specimens using standard forceps was 36.8%; however, the overall diagnosis was improved to 70.8% after we used these other devices and methods. We achieved diagnosis with STAF (10 lesions), followed by thin bronchoscopy (5 lesions), and ultra-thin bronchoscopy (14 lesions). No diagnosis was made by TBAC.

CONCLUSION

We conclude that these widely employed devices can contribute to improvements in the diagnosis of cases of respiratory distress in which arrival to the lesions is difficult.

[Tracheostenosis caused by blunt thoracic trauma]

Blunt thoracic trauma rarely implicate retropharyngeal hematoma obstructing trachea. 85-year-old woman being struck on her cheek and anterior chest, visited our emergency room. She was nearly suffocated following stridor and dyspnea. Tracheal intubation relieved her dyspnea Chest computed tomography (CT) showed retropharyngeal hematoma obstructing trachea. 5 days conservative management reduced the hematoma and tracheal tube was extubated through an uneventful course.

[A case of malignant lymphoma successfully diagnosed using Sasada transbronchial angled biopsy forceps]

A 68-year-old man was referred to our hospital due to general fatigue, fever and weight loss. His chest radiograph showed a nodule (2.8 cm) in the right middle lobe. Computed tomography and positron emission tomography showed multiple metastases to the bone, liver and lymph nodes. The lung nodule was not accessible by standard transbronchial forceps. However, biopsy specimens obtained using Sasada Transbronchial Angled Biopsy Forceps (STAF) pathologically confirmed the diagnosis of malignant lymphoma. We report the case, and discuss the utility of STAF for lung lesions that are difficult to access with standard forceps.

Disruption of the EGFR E884-R958 ion pair conserved in the human kinome differentially alters signaling and inhibitor sensitivity

Targeted therapy against epidermal growth factor receptor (EGFR) represents a major therapeutic advance in lung cancer treatment. Somatic mutations of the EGFR gene, most commonly L858R (exon 21) and short in-frame exon 19 deletions, have been found to confer enhanced sensitivity towards the inhibitors gefitinib and erlotinib. We have recently identified an EGFR mutation E884K, in combination with L858R, in a patient with advanced lung cancer who progressed on erlotinib maintenance therapy, and subsequently had leptomeningeal metastases that responded to gefitinib. The somatic E884K substitution appears to be relatively infrequent, and resulted in a mutant lysine residue that disrupts an ion pair with residue R958 in the EGFR kinase domain C-lobe, an interaction that is highly conserved within the human kinome as demonstrated by our sequence analysis and structure analysis. Our studies here, using COS-7 transfection model system, show that E884K works in concert with L858R in-cis, in a dominant fashion, to change downstream signaling, differentially induce MAPK-ERK1/2 signaling and associated cell proliferation, and differentially alter sensitivity of EGFR phosphorylation inhibition by ERBB family inhibitors in an inhibitor-specific fashion. Mutations of the conserved ion pair E884-R958 may result in conformational changes that alter kinase substrate recognition. The analogous E1271K-MET mutation conferred differential sensitivity towards preclinical MET inhibitors SU11274 (unchanged), and PHA665752 (more sensitive). Systematic bioinformatics analysis of the mutation catalog in the human kinome (COSMIC) revealed the presence of cancer-associated mutations involving the conserved E884 homologous residue, and adjacent residues at the ion pair, in known proto-oncogenes (KIT, RET, MET, FAK) and tumor suppressor gene (LKB1). Targeted therapy using small molecule inhibitors should take into account potential cooperative effects of multiple kinase mutations, and their specific effects on downstream signaling and inhibitor sensitivity. Improved efficacy of targeted kinase inhibitors may be achieved by targeting the dominant activating mutations present.

[Involvement of zinc in taste disturbance occurring during treatment for malignant tumor in the chest and the effects of polaprezinc oral disintegrating tablets (a retrospective study)]

We analyzed the correlation between serum zinc levels and taste disturbance, and between patient backgrounds and serum zinc levels or taste disturbance, and evaluated the effects of polaprezinc oral disintegrating tablets on taste disturbance in 29 patients with lung cancer and one patient with malignant pleural mesothelioma who were receiving chemotherapy. Taste disturbance developed in 11 (36.7%) out of 30 patients. Serum zinc levels significantly correlated with taste disturbance (p=0.0227). Serum zinc levels were significantly lower (p=0.0235) and taste disturbance tended to be more frequent (p=0.0625) in males. Polaprezinc improved taste disturbance in 5 of 8 patients.

Megakaryocyte potentiating factor as a tumor marker of malignant pleural mesothelioma: evaluation in comparison with mesothelin

PURPOSE

An early and reliable blood test is one deficiency in diagnosis of malignant pleural mesothelioma (MPM). Megakaryocyte potentiating factor (MPF) and mesothelin variants (MSLN), members of the mesothelin gene family, have been studied as candidate serum markers for MPM. We developed a novel enzyme-linked immunosorbent assay (ELISA) system to compare the diagnostic efficacy of MPF and MSLN in MPM and control groups.

EXPERIMENTAL DESIGN

MPF and MSLN were assayed with ELISA in 27 consecutive MPM patients and 129 controls including patients with lung cancer and asymptomatic asbestos-exposed subjects.

RESULTS

Statistically significant elevation of serum MPF and MSLN levels was noted in MPM patients in comparison with every control group. The area under the receiver operating characteristic curve (AUC) was calculated for differentiation of MPM and lung cancer, healthy asbestos-exposed subjects, and healthy adults. While the AUC for serum MPF was 0.879, cut-off=19.1ng/ml (sensitivity=74.1%, specificity=90.4%), the AUC for serum MSLN was 0.713, cut-off=93.5ng/ml (sensitivity=59.3%, specificity=86.2%). Comparison between AUC for MPF and MSLN values shows that MPF is significantly superior to MSLN (p=0.025). Finally, there was a significant correlation between MPF and MSLN values for MPM (Pearson's correlation coefficient=0.77; p<0.001).

CONCLUSIONS

These findings suggest that diagnostic value of MPF for MPM was better than that of MSLN although both markers showed almost equal specificity for MPM.

[Two cases of severe myelosuppression from amrubicin in previously-treated small cell lung cancer]

The patients were a 59-year-old man and 68-year-old man with previously-treated small cell lung cancer (extensive disease). Amrubicin (40 mg/m(2) and 45 mg/m(2)) was administered for 3 days after brain irradiation. Severe neutropenia continued for nine days from day 8 following administration. Although both patients had an infection, it improved by granulocyte-colony stimulating factor (G-CSF), and antibiotics, plus a blood transfusion. Particular attention for severe myelosuppression should be given to amrubicin therapy with previously-treated small cell lung cancer. However, a detailed blood test in course 1 and early administration of drugs such as G-CSF make this therapy feasible. In addition, to control the condition of patients, repeated administration of amrubicin with dose reduction is recommended.

Randomised phase II trial of irinotecan plus cisplatin vs irinotecan, cisplatin plus etoposide repeated every 3 weeks in patients with extensive-disease small-cell lung cancer

Patients with previously untreated extensive-disease small-cell lung cancer were treated with irinotecan 60 mg m(-2) on days 1 and 8 and cisplatin 60 mg m(-2) on day 1 with (n=55) or without (n=54) etoposide 50 mg m(-2) on days 1-3 with granulocyte colony-stimulating factor support repeated every 3 weeks for four cycles. The triplet regimen was too toxic to be considered for further studies.

Randomized phase II trial of three intrapleural therapy regimens for the management of malignant pleural effusion in previously untreated non-small cell lung cancer: JCOG 9515

To evaluate the efficacy and toxicity of three intrapleural therapy regimens consisting of bleomycin (BLM), OK-432 (a pulverized product of heat-killed Streptococcus pyogenes) or cisplatin plus etoposide (PE) for the management of malignant pleural effusion (MPE) in previously untreated non-small cell lung cancer. Eligible patients were randomized to the BLM arm: BLM 1mg/kg (maximum 60mg/body), the OK-432 arm: OK-432 0.2 Klinische Einheit units (KE)/kg (maximum 10KE/body), or the PE arm: cisplatin (80mg/m(2)) and etoposide (80mg/m(2)). Pleural response was evaluated every 4 weeks according to the study-specific criteria. All responders received systemic chemotherapy consisting of PE every 3-4 weeks for two or more courses. Pleural progression-free survival (PPFS) was defined as the time from randomization to the first observation of pleural progression or death due to any cause. The primary endpoint was the 4-week PPFS rate. Of 105 patients enrolled, 102 were assessed for response. The 4-week PPFS rate for the BLM arm was 68.6%, 75.8% for the OK-432 arm, and 70.6% for PE arm. Median survival time (MST) for the BLM arm was 32.1 weeks, 48.1 weeks for the OK-432 arm, and 45.7 weeks for the PE arm. However, the outcomes did not differ significantly between groups. Toxicity was tolerable in all arms except for one treatment-related death due to interstitial pneumonia induced by BLM. We will select intrapleural treatment using OK-432 in the management of MPE in NSCLC for further investigation because it had the highest 4-week PPFS rate.

Preliminary experience with a modified premedication protocol that included intravenous diphenhydramine and calcium bromide for the prophylaxis of paclitaxel-related hypersensitivity reactions

BACKGROUND

Paclitaxel often causes severe hypersensitivity reactions (HSRs) rapidly after infusion, even in patients given prophylactic therapy. The purpose of this study was to analyze the incidence of paclitaxel-related HSRs in patients with non-small cell lung cancer (NSCLC) retrospectively, and to assess the feasibility of a modified premedication protocol.

METHODS

One hundred and seven patients who were pretreated with either a conventional premedication regimen (two doses of dexamethasone) or a short premedication regimen (single dose of dexamethasone with oral diphenhydramine and intravenous ranitidine), prior to paclitaxel infusion were retrospectively analyzed. A modified premedication regimen, consisting of 12.5 ml of Rescalmin (intravenous diphenhydramine 50 mg and calcium bromide 437.5 mg), intravenous ranitidine 100 mg, and intravenous dexamethasone 20 mg, was given 30 min prior to paclitaxel, with oral dexamethasone 8 mg given on the night before the paclitaxel. Patients received paclitaxel intravenously at 175 mg/m(2) over 3 h, followed by carboplatin, AUC 5, over 1 h on day 1 every 3 weeks.

RESULTS

In the conventional premedication group, 21 patients had HSRs (32.3%); in 1 of these patients the HSR was considered to be severe (1.5%). In the short premedication group, 19 patients had HSRs (45.2%); in 6 of these patients the HSRs were considered to be severe (14.3%). The incidence of severe HSRs was significantly higher in the short premedication group than in the conventional premedication group (P = 0.027). In the modified premedication protocol study, HSR events were recorded in 14 patients (63.6%); 14 showed flushing, 2 had skin rash, and 1 had tachycardia. No severe HSRs were seen.

CONCLUSIONS

The incidence of HSRs in the short premedication group tended to be higher than that in the conventional premedication group. The modified premedication protocol was found to be feasible for preventing paclitaxel-related HSR, but case accumulation is needed.

Proteomics-based identification of ?-enolase as a tumor antigen in non-small lung cancer

Autoantibodies against tumor antigens represent one type of biomarker that may be assayed in serum for detection of cancer and monitoring of disease progression. In the present study, we used a proteomics-based approach to identify novel tumor antigens in non-small cell lung cancer (NSCLC). By combining two-dimensional electrophoresis, western blotting, mass spectrometry and enzyme-linked immunosorbent assay technology, we detected autoantibodies against alpha-enolase in a subset of NSCLC patients' sera. When 'Mean OD(healthy control sera) + 3 SD(healthy control sera)' was used as the cut-off point, the prevalence of this autoantibody was 27.7% in patients with NSCLC (26 of 94), 1.7% in healthy control subjects (1 of 60), and not detectable in sera from 15 patients with small cell lung cancer, 18 patients with gastrointestinal cancer and nine patients with Mycobacterium avium complex infection of lung. Immunohistochemical staining showed that expression of alpha-enolase was increased in cancer tissues of NSCLC patients, and flow cytometric analysis confirmed the expression of alpha-enolase at the surface of cancer cells. The combined detection of autoantibodies against alpha-enolase, carcinoembryonic antigen and cytokeratin 19 fragment (CYFRA21-1) enhanced sensitivity for the diagnosis of NSCLC. Therefore, autoantibodies against alpha-enolase may constitute a promising biomarker for NSCLC.

[A case of prostatic adenocarcinoma clinically presenting as supraclavicular and mediastinal lymphadenopathy]

We report a 70-year-old man with prostatic carcinoma presenting as supraclaviculer and mediastinal lymphadenopathy. He had no urinary tract symptoms, and computed tomography and FDG-PET showed no abnormality in the prostate or pelvic lymph nodes. Metastatic prostatic adenocarcinoma was finally diagnosed from the results of immunohistochemical staining for PSA of a biopsy specimen of the mediastinal lymph node, and he was treated by hormonal therapy. There are fears that some other similar cases might be treated with chemotherapy as lung cancer without immunohistochemical staining. Prostatic carcinoma should always be considered in the differential diagnosis of elderly men with supraclaviculer or mediastinal lymph node metastases, since appropriate treatment will lead to a prolonged survival.

Attitudes about chemotherapy for Japanese patients with or without cancer: Doctors, nurses, and the general public

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Background: A prospective survey in England demonstrated that patients with cancer were much more likely to accept radical treatment with minimal chance of benefit than people who did not have cancer (Slevin et al. Br Med J 1990; 300: 1458–60). We compared responses of Japanese patients with cancer with those of a control group of physicians, nurses, and patients without cancer in assessing personal cost-benefit of chemotherapy using the same questionnaire with Slevin's study. Methods: Subjects were asked with questionnaires whether of not to accept intensive and mild chemotherapy with a supposed minimum chance of effectiveness. 153 patients with cancer, 265 controls, 213 doctors, 397 nurses, and 51 patients without cancer were subjects of the study. Results: Percentage of subjects who accepted intensive chemotherapy with a supposed minimum chance of effectiveness (1% chance of cure, 3-month prolonging life, 1% relief of symptoms) by subject group were as follows: cancer patients; 62/55/52, doctors; 27/32/4, nurses; 11/12/5, non-cancer patients; 35/40/36, controls; 23/24/15, respectively. Conclusions: More patients with cancer than people without cancer accepted treatments giving the minimal benefit for cure, prolonging life or palliation of symptoms. Interestingly, the results in Japanese survey were similar to the previous study in England.

No significant financial relationships to disclose.

Percutaneous application of peptidoglycan from Staphylococcus aureus induces eosinophil infiltration in mouse skin

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease with immunopathologic features that vary depending on the duration of the lesion. The lesioned skin of AD patients shows an increased number of inflammatory cells such as eosinophils, mast cells and mononuclear cells in the dermis and superficial Staphylococcus aureus colonization.

OBJECTIVE

The purpose of this study was to determine the effects of peptidoglycan (PEG) from S. aureus on eosinophil induction in murine skin.

METHODS

PEG was applied to the barrier-disrupted abdominal skin of mice every 5 days. Twenty days later, the number of eosinophils in the abdominal skin was counted. The cytokine response in the skin was investigated by RT-PCR and immunohistological analysis. The regulated-upon activation in normal T cells expressed and secreted (RANTES) production from cultured epidermal cells was measured by ELISA.

RESULTS

The skin of mice treated with PEG showed a significantly increased number of eosinophils compared with that of mice treated with vehicle alone. In addition, application of PEG to the abdominal skin of mice increased the expression of mRNA for RANTES, but not that of mRNA for eotaxin, eotaxin-2 and monocyte chemotactic protein-3 in the skin. Immunohistologic analysis demonstrated that the levels of RANTES transcripts corresponded with those of protein synthesis in the epidermis. In vitro experiments using epidermal Langerhans cells (LCs) and keratinocytes (KCs) showed that RANTES production was induced by LCs but not by KCs stimulated with PEG. Furthermore, an intraperitoneal injection of anti-RANTES antibody neutralized the induction of eosinophils in the skin.

CONCLUSION

These results suggest that PEG may have an ability to induce eosinophil infiltration in the skin through RANTES production by LCs, and would explain the role of S. aureus colonization in AD patients.