Correlation of different markers (p53, EGF-R, c-erbB-2, Ki-67) expression in the diagnostic biopsies and the corresponding resected tumors in non-small cell lung cancer

Substaging using molecular markers has been proposed to try to identify prognostic factors allowing to define groups of patients with lung cancer for whom specific therapy might be of benefit. The pre-operative assessment of these markers seems to be important specially in case of neoadjuvant chemotherapy. The aim of our study was to compare the expression of two potential prognostic factors (p53 and Ki-67) and two potential therapeutic targets (EGF-R and c-erbB-2) assessed on biopsy samples (B) of non-small cell lung cancer (NSCLC) with that of the corresponding resected tumor (RT). The expression of these biological markers was evaluated by immunohistochemistry on B and on the paired RT in 28 patients. The mean percentage of p53 positive cells was 28% in RT and 38% in B with 81% CR between B and RT and 19% FP on B. Considering RT results as standard, the positive (PPV) and negative predictive value (NPV) of the B were, respectively, 74 and 100%. The mean percentage of EGF-R positive cells was 11% in RT and 28% in B. With a cut-off of 1%, we found 85% concordant results (CR) between B and RT, 4% false negative (FN) and 11% false positive (FP) on B. The PPV and NPV values of the B were, respectively, 80 and 92%. The 8% B and 19% RT were considered as positive for c-erbB-2. We found 15% FN and 4% FP on B with 81% CR between B and RT for c-erbB-2. The NPV of the B was 83%. The mean percentage of Ki-67 positive cells was 32% in RT and 14% in B. We found 82% CR between B and RT, 14% FN and 4% FP on B. The PPV of the B was 96%. In conclusion, biopsies may provide reliable information about p53, EGF-R, c-erbB-2 and Ki-67 in lung carcinoma and could help to elaborate a therapeutic strategy.

Is a specific oncological scoring system better at predicting the prognosis of cancer patients admitted for an acute medical complication in an intensive care unit than general gravity scores?

OBJECTIVE

To evaluate the effectiveness of a specific oncologic scoring system-the ICU Cancer Mortality model (ICM)-in predicting hospital mortality in comparison to two general severity scores-the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Simplified Acute Physiology Score (SAPS II).

PATIENTS AND METHODS

All 247 patients admitted for a medical acute complication over an 18-month period in an oncological medical intensive care unit were prospectively registered. Their data, including type of complication, vital status at discharge and cancer characteristics as well as other variables necessary to calculate the three scoring systems were retrospectively assessed.

RESULTS

Observed in-hospital mortality was 34%. The predicted in-hospital mortality rate for APACHE II was 32%; SAPS II, 24%; and ICM, 28%. The goodness of fit was inadequate except for the ICM score. Comparison of the area under the ROC curves revealed a better fit for ICM (area 0.79). The maximum correct classification rate was 72% for APACHE II, 74% for SAPS II and 77% for ICM. APACHE II and SAPS II were better at predicting outcome for survivors to hospital discharge, although ICM was better for non-survivors. Two variables were independently predicting the risk of death during hospitalisation: ICM (OR=2.31) and SAPS II (OR=1.05).

CONCLUSIONS

Gravity scores were the single independent predictors for hospital mortality, and ICM was equivalent to APACHE II and SAPS II.

[Good and bad uses of the Impact Factor, a bibliometric tool]

The Impact Factor (IF) is a bibliometric tool that has become very popular among the academic people. It has been developed by the publishers of scientific reviews to determine the impact of their journal among the scientific and medical community. It is based on the following principle: more often are cited the articles of a journal, more often is that journal read and thus sold. Various secondary applications have been performed with the IF, including the evaluation of the academic curriculum of a scientist or of a research group. That approach is however not validated, a recent methodological study having demonstrated a lack of good correlation between the IF of a given review and the quality scores of its published articles.

Continuous venovenous haemofiltration in cancer patients with renal failure: a single-centre experience

OBJECTIVE

To assess the effect of continuous venovenous hemodiafiltration (CVVHDF) in cancer patients with acute renal failure.

PATIENTS AND METHODS

Retrospective study of all patients with acute renal failure requiring dialysis and treated with CVVHDF in a medical intensive care unit (ICU) from a cancer hospital.

RESULTS

From January 1997 until December 2002, 32 cancer patients were treated with CVVHDF for acute renal failure. Their characteristics were: male/female 23/9, median age 61 years, haematological/solid tumours 16/16, and median APACHE II and IGS II scores 31/67. The number of organ failures was 1/2/3/4 in respectively 10/6/13/2 patients. Complete, partial or absence of resolution of acute renal failure was noted in 13, 8 and 11 patients. Sixteen patients (50%) died in the ICU and 15 (47%) were discharged alive from the hospital. In univariate analysis, variables statistically significantly adversely associated with hospital mortality were renal failure of renal origin, bone marrow transplant, increasing number of organ failures, reduced lymphocyte count, elevated bilirubin and lower creatinine levels, increased thromboplastin time, younger age, increased APACHE II and IGS II, ARDS and mechanical ventilation. In multivariate analysis, two models were used including either APACHE II or IGS II. The number of organ failures was found as the only significant prognostic factor in both models ( p=0.01). Elevated phosphate level was a poor prognostic factor for hospital mortality ( p=0.04) in the model including APACHE II.

CONCLUSIONS

In the experience of a single centre, CVVHDF is effective in the treatment of acute renal failure in cancer patients. The increasing number of organ failures was the single independent poor predictive factor for hospital mortality. Cancer characteristics and general gravity scores were not predictive factors.

Critical factors for patient management

The main critical factors for lung cancer patient management, apart from TNM staging, include expertise required to offer optimal management and conditions related to the patient, including performance status and weight loss and the presence of lung, cardiac or other comorbidities. Performance status and weight loss must be assessed for all patients. The minimal pulmonary functional evaluation should include spirometry. The minimal cardiac evaluation should consist of a clinical history and evaluation for cardiac risk factors and disease and at least preoperatively, and ECG. Age per se is not a contraindication for curative treatment.

Consensus: the follow-up of the treated patient

This is the first consensus document on the follow-up of the treated patient with non-small cell lung cancer that has been written by this group. The document has been drawn up by doctors coming from many different cultures and philosophical backgrounds. It acknowledges that there are published guidelines on the follow-up particularly those in trials, and does not wish to contradict these. There is lack of evidence-based medicine to recommend a strong general policy in this area. For those patients who were treated with curative intent the initial follow-up will depend upon the toxicity that is evident from the treatment given. Thereafter the interval between follow-up visits should be every 3 months for the first two years, then every 6 months for up to five years. Rapid and easy access to the multidisciplinary team should be available. Full examination and chest X-ray should be carried out on each visit but other investigations should be determined by clinical need. For those patients treated with palliative intent the interval between follow-up visits once the acute reactions have settled will depend upon the adequacy of the control of the symptom and the availability of separate palliative care teams. At all times the patient should have rapid access to the multidisciplinary team and in general frequent follow-up, that is at intervals of one to two months, may be appropriate during the first six months. Follow-up constitutes an important part of lung cancer management. Efforts should be made to gain clinical material to give us evidence-based guidelines.

[Detection of early stage bronchopulmonary cancer: contribution of bronchoscopy]

Efficient methods for lung cancer screening is today an important challenge in research. Into this article, we review the available techniques for the detection of hilar located lung cancers, mainly squamous cell carcinoma. Fluorescence bronchoscopy is the latest major advance for lung cancer diagnosis.

A prospective study of infections in lung cancer patients admitted to the hospital

STUDY OBJECTIVES

To determine the type of infections occurring in hospitalized patients with lung cancer.

DESIGN

Prospective cohort study.

SETTING

Department of internal medicine in a cancer hospital.

PATIENTS

All patients with lung cancer who were hospitalized for any cause and who acquired infections at the time of admission or during the hospital stay between January 1997 and February 2001.

INTERVENTIONS

None.

RESULTS

Two hundred seventy-five patients with lung cancer had 435 episodes of fever and/or microbiologically or otherwise documented infection. Two hundred eighteen patients (79.3%) presented with non-small cell lung carcinoma, while 49 patients (17.8%) had small cell lung cancer. The majority of the infections occurred in the tracheobronchial tree (56%). There were 38 episodes of bacteremia or fungemia, and the primary site of infection was identified in 18 cases (47%). Microbiologically documented infections accounted for 61% of the infectious episodes, and included a total of 312 microorganisms. The most frequent pathogens were Gram-negative bacteria (64%), followed by Gram-positive bacteria (25%) and fungi (8%). The predominant Gram-negative bacteria were Haemophilus influenzae and Moraxella catarrhalis. Staphylococcus aureus, Streptococcus pneumoniae, coagulase-negative staphylococci, and Enterococcus faecalis essentially represented the Gram-positive bacteria. No multiresistant bacteria were observed. Bacteria were susceptible to most of the antibiotics classically administered for their treatment.

CONCLUSIONS

The predominant site of infection in patients with lung cancer is the tracheobronchial tree, with S pneumoniae, S aureus, H influenzae, Escherichia coli, Pseudomonas aeruginosa, and M catarrhalis as the principal pathogens.

Fragile histidine triad protein expression in nonsmall cell lung cancer and correlation with Ki-67 and with p53

Fragile histidine triad (FHIT) is a tumour suppressor gene, which is altered in a variety of epithelial tumours, including lung cancer. Biochemical and functional pathways of its tumourigenicity are not yet understood. Its role in tumour proliferation is particularly controversial. The purpose of this study was to correlate the expression of FHIT protein in nonsmall cell lung cancer (NSCLC) with tumour proliferation as estimated by Ki-67 antigen and with p53, a suppressor gene. FHIT, Ki-67 and p53 expression were evaluated by immunohistochemistry in 119 resected NSCLC. Altogether, 58 tumours were negative (expression <10%) for FHIT. The median expression in tumours was 15% positive cells, in comparison with 100% in normal matched lung tissue. The expression was as strong as in normal tissue in only 19 cases. FHIT expression was significantly lower in squamous cell carcinoma (SCC) (5%) than in adenocarcinoma (ADC) (64%). The median expression of Ki-67 was 20% and 69% of tumours were positives (expression >10%). Ki-67 expression was significantly higher in SCC (33.3%) than in ADC (10%). The loss of FHIT protein was not correlated with the expression of p53 (median: 7.5%, 58% of positive tumours for a cut-off of 10% of positive cells) or Ki-67. But percentage of labelled cells for p53 and Ki-67 were significantly correlated. The results suggest that for fragile histidine triad, the pathway of tumourigenesis is independent of p53 and of tumoural proliferation, as reported previously in vitro.

Citation indexes do not reflect methodological quality in lung cancer randomised trials

BACKGROUND

Citation factors are applied to assess scientific work despite the fact that they were developed commercially in order to compare competing journals. The aim of the present study was to determine whether there is a relationship between citation factors and a trial's methodological quality using published randomised trials in lung cancer clinical research. Material and methods All of the randomised trials included in nine systematic reviews performed by the European Lung Cancer Working Party (ELCWP) were assessed using two quality scales (Chalmers and ELCWP).

RESULTS

One hundred and eighty-one articles were eligible. The median overall ELCWP and Chalmers quality scores were 61.8% and 49.0%, respectively, with a correlation coefficient (r(s)) of 0.74 (P <0.001). A weak association was observed between citation factors and quality scores with the respective correlation coefficients ranging from 0.18 to 0.40 (ELCWP scale) and from 0.21 to 0.38 (Chalmers scale). American authors published trials significantly more often in journals with high citation factors than European or non-American authors (P <0.0001), despite no better methodological quality. Positive trials, which were significantly more likely to be published in journals with higher citation factors, were of no better quality than negative ones.

CONCLUSION

Journals with higher citation factors do not appear to publish clinical trials with higher levels of methodological quality, at least for trials in the field of lung cancer research.

Splenic spontaneous rupture (SSR) and hemoperitoneum associated with low molecular weight heparin: a case report

We describe the first case of spontaneous splenic rupture associated with tinzaparin in a cancer patient. This low-molecular-weight heparin was administrated for deep venous thrombosis and pulmonary embolism. No underlying splenic pathology predisposing to this condition was found.

Epidermal growth factor receptor expression in pre-invasive and early invasive bronchial lesions

The 1999 World Health Organization/International Association for the Study of Lung Cancer histological classification of preneoplastic bronchial lesions has been shown to be reproducible but little is known about its biological significance. The current study evaluated the correspondence between the morphological changes of the bronchial epithelium and epidermal growth factor receptor (EGF-R) expression. Thirteen normal bronchial epithelia, 19 hyperplasia, 16 metaplasia, 10 mild dysplasia, one moderate dysplasia, 10 severe dysplasia (SD), 14 carcinoma in situ (CIS) and 11 microinvasive tumours were assessed. A global EGF-R score obtained by the sum of the positivity score plus the EGF-R staining intensity score was calculated for each lesion. A global EGF-R score of >5 was reached only in one metaplasia, in six SD, in six CIS and in six microinvasive tumours. There was no difference in EGF-R expression between normal, hyperplastic and metaplastic epithelia versus mild dysplasia or between severe dysplasia versus CIS and microinvasive tumours but there was a statistically significant difference between mild versus severe dysplasia. This study demonstrates that epidermal growth factor receptor expression rate changes with the stage of the bronchial lesion, increasing from normal epithelium to carcinoma in situ and microinvasive tumours with a statistically significant difference between mild versus severe dysplasia.

[Acute complications in lung cancer]

Lung cancer may be responsible for various complications due to locoregional invasion or distant metastases or paraneoplastic syndromes. These complications may reveal the lung cancer and may disappear with efficient anticancerous therapy. Sometimes the severity of the complication necessitates a symptomatic treatment before any anticancer therapy may be administered.

Leucopenia is an independent predictor in cancer patients requiring invasive mechanical ventilation: a prognostic factor analysis in a series of 168 patients

OBJECTIVE

To determine prognostic factors predicting success of invasive mechanical ventilation in medical cancer patients admitted to ICU for a complication, in terms of extubation and ICU and hospital discharges.

DESIGN

Retrospective study

SETTING

Medical ICU of an European cancer hospital.

SUBJECTS

A total of 168 consecutive cancer patients who were admitted to ICU for an acute medical complication requiring immediate mechanical ventilation or who later needed mechanical ventilation.

MEASUREMENTS

Variables related to the demographic, cancer, scores and complication characteristics. Extubation rates, ICU and hospital mortalities and duration of survival were measured.

RESULTS

Respectively, 26%, 22% and 17% of the patients were extubated, discharged from the ICU and discharged from hospital. For weaning from mechanical ventilation, a higher APACHE II score and leucopenia were poor prognostic factors in univariate analysis, but leucopenia remained the only significant one in multivariate analysis. For ICU mortality, no significant prognostic feature was identified. For hospital mortality, leucopenia was the only significant factor in univariate as well as in multivariate analyses.

CONCLUSION

Leucopenia appeared to be the only independent poor prognostic factor for both extubation and hospital discharge. None of the variables related to the cancer disease process was shown to be a predictor of success.

Noninvasive ventilation: application to the cancer patient admitted in the intensive care unit

The objective of this retrospective study of prospectively registered patients was to determine the usefulness and efficacy of noninvasive ventilation (NIV) in cancer patients admitted to the medical intensive care unit of an European cancer hospital for a medical complication, as reflected in discharges from the intensive care unit (ICU) and from hospital. The subjects were a total of 40 consecutive cancer patients (28 with solid tumours and 12 with haematological malignancies) who required immediate or delayed NIV. Variables relating to demographic parameters, severity scores, cancer characteristics, intensive care data and hospital discharge were recorded. The complications making NIV necessary were hypoxaemic pneumonia in 32.5%, hypercapnic ventilatory failure in 30%, multifactorial respiratory failure in 17.5%, acute haemodynamic oedema in 10%, acute respiratory distress syndrome in 2.5%, alveolar haemorrhage in 2.5%, pulmonary embolism in 2.5% and lysis pneumopathy in 2.5%. Most of the patients, 57.5% and 42.5%, respectively, were discharged from the ICU and from the hospital. Among the 10 patients (25%) who required salvage invasive mechanical ventilation, only 1 was discharged from hospital. Sixty-four per cent of the solid tumour patients and 42% of those with haematological malignancies were discharged from the ICU and 50% and 25%, respectively, from the hospital. NIV thus appears to be an effective form of ventilatory support for cancer patients, including those with solid tumours.

[Pleural effusion]

A Spanish man is diagnosed with a non-small cell lung cancer with pleural extension. A chemotherapy combining cisplatin and gemcitabine allows obtaining an excellent partial remission. A contralateral pleural effusion is noted in a context of weight loss and fever. The differential diagnosis of pleural effusion is discussed.

Age and treatment of non-small-cell lung cancer: a database analysis in elderly patients

The present study was conducted to determine whether it is justifiable to adapt treatment to age in patients with non-small-cell lung cancer (NSCLC). All NSCLC patients treated at the Institut Jules Bordet who were 75 years old or over were prospectively entered in our database. Patients were divided into those who were "eligible" and those who were "ineligible" for clinical trials according to the standard criteria used by the ELCWP. The 604 consecutive patients treated for NSCLC between March 1995 and August 2001 included 60 (9.9%) aged 75 years or over. Their principal characteristics were as follows: median age 78 years (75-93); male-to-female ratio 45/15; stages I/II/III/IV in 16/1/23/18 cases (in 2 cases complete work-up was refused by the patient); squamous/glandular/other histology in 23/24/13 cases; the median performance status was 70 (30-100). Except for their age, 37 patients met the eligibility criteria for the ELCWP standard treatment study protocol in progress during the study period. Twenty-five (67.6%) of these patients received an adequate treatment according to the stage of the disease, and 5 (13.5%) refused conventional therapy and received less aggressive treatment or none at all. For 7 (18.9%) patients, an adapted treatment was chosen solely on the basis of their age. For patients with disease in stages I-III who underwent adequate treatment survival rates were equivalent to the results found in the literature, with median survival times of 770 days and 262 days for those with stage I-II and those with stage III disease, respectively. Survival rates for patients with stage IV disease ranged from 10 days to 17 months. NSCLC patients 75 years of age or more without significant co-morbidities can probably be treated in the same way as younger people with similar survival rates if their disease is in stages I-III. Because the number of patients was too small, our data do not allow us to provide meaningful conclusions for stage IV disease.

Activity of chemotherapy and immunotherapy on malignant mesothelioma: a systematic review of the literature with meta-analysis

The role of chemotherapy for unresectable malignant mesothelioma is unclear. The aims of the present study were to evaluate the methodological quality of published papers relative to chemotherapy or immunotherapy in malignant mesothelioma and to aggregate, for trials having a similar methodology, the response rates in order to identify the most active chemotherapeutic drugs and regimens. The literature relative to this topic, published between 1965 and June 2001 was reviewed. A methodological qualitative evaluation was performed according to the European Lung Cancer Working Party scale, specifically designed for phase II trials. A study was considered as potentially positive if the upper limit of the 95% confidence interval (CI) of the response rate was greater than 20% and positive if the lower limit of the 95% CI was > 20%. Eighty-three studies (88 treatment arms) were eligible for the systematic review. Fifty-three arms were considered as positive or potentially positive. No statistically significant difference in the methodological quality was observed between negative and positive studies. Studies were aggregated in four groups according to the presence of cisplatin and/or doxorubicin in the treatment regimen. The combination of cisplatin and doxorubicin had the highest response rate (28.5%; P < 0.001). Cisplatin was the most active single-agent regimen. Our systematic qualitative and quantitative overview of the literature suggests that the most active chemotherapeutic regimen, in term of objective response rate, is the combination of cisplatin and doxorubicin and the best single-agent is cisplatin. The combination of these two drugs can be recommended as control arm for future randomised phase III trials.

The role of EGF-R expression on patient survival in lung cancer: a systematic review with meta-analysis

The prognostic value of epidermal growth factor receptor (EGF-R) for survival of patients with lung cancer remains controversial. The authors performed a systematic review of the literature in order to clarify its impact. Published studies were identified using an electronic search in order to aggregate the available survival results, after a methodological assessment using a scale specifically designed by the European Lung Cancer Working Party (ELCWP). To be eligible, a study had to have dealt with EGF-R assessment in lung cancer patients on the primary site and to have analysed survival according to EGF-R expression. Among the 16 eligible studies, 14 assessed any nonsmall-cell lung cancer (NSCLC) subtype, one adenocarcinoma only and one squamous-cell carcinoma only. The overall median quality score was 56.3%, with no significant difference either between studies assessable or not assessable for meta-analysis or between studies with significant and nonsignificant results. One individual trial reported a survival benefit for patients with EGF-R expression, three a survival disadvantage and 12 no statistically significant difference. Eleven studies (2,185 patients) provided sufficient data to allow a meta-analysis of the survival results. EGF-R expression positivity was determined according to the cut-off as determined by the authors. The meta-analysis showed that EGF-R expression was not a statistically significant prognostic factor for survival in NSCLC. In the subgroup of studies using immunohistochemistry, statistical tests reached a significant level against EGF-R. Epidermal growth factor receptor might be a poor prognostic factor for survival in nonsmall-cell lung cancer. The amplitude of the impact is small, however, and may be subject to publication bias.

[Meta-analysis: a guide to interpretation]

The article has as purpose to propose a systematic approach for the reading of meta-analysis. Using a particular example, a literature search is proposed to identify the two types of meta-analyses: those based on individual data of the patients and those performed in systematic reviews of the literature. The proposed approach for the literature reading is evidence-based.