Lung cancer with epidermal growth factor receptor exon 20 mutations is associated with poor gefitinib treatment response

PURPOSE

Clinical reports about responsiveness to gefitinib treatment in patients of non-small cell lung cancer (NSCLC) with mutations in exon 20 of epidermal growth factor receptor (EGFR) are limited. To increase understanding of the influence of exon 20 mutations on NSCLC treatment with gefitinib, we investigated the clinical features of lung cancer in patients with exon 20 mutations and analyzed the gefitinib treatment response.

EXPERIMENTAL DESIGN

We surveyed the clinical data and mutational studies of NSCLC patients with EGFR exon 20 mutations in the National Taiwan University Hospital and reviewed the literature reports about EGFR exon 20 mutations and the gefitinib treatment response.

RESULTS

Twenty-three patients with mutations in exon 20 were identified. Nine (39%) had coexisting mutations in EGFR exons other than exon 20. Sixteen patients received gefitinib treatment, and a response was noted in 4 patients. The gefitinib response rate of NSCLC with exon 20 mutations was 25%, far lower than those with deletions in exon 19 and L858R mutations. Interestingly, different exon 20 mutations and coexisting mutations seemed to have a different influence on gefitinib response.

CONCLUSIONS

EGFR exon 20 mutations of NSCLC patients result in poorer responsiveness to gefitinib treatment, but variability exists between different individuals.

Improved local control by surgery and paclitaxel-based chemoradiation for esophageal squamous cell carcinoma: results of a retrospective non-randomized study

BACKGROUND AND OBJECTIVES

To investigate the impact of using paclitaxel in chemoradiation on locally advanced esophageal squamous cell carcinoma (SCC) treated with or without surgery.

METHODS

Of 127 patients with AJCC stages II-III esophageal SCC undergoing definitive chemoradiation (DefCRT, n = 44) or neoadjuvant chemoradiation plus surgery (NeoCRT + S, n = 83), 57 received chemotherapy with paclitaxel and cisplatin (TP), and 70 received 5-fluorouracil and cisplatin (PF). Three-year local progression-free survival (LPFS), distant metastasis-free survival, overall survival, and prognostic factors were retrospectively analyzed.

RESULTS

The median survival was 30 months. Pathological complete response rate was 41% and 27% with TP and PF, respectively (P = 0.19). NeoCRT + S achieved significantly higher LPFS than DefCRT (71% vs. 39%, P < 0.001). Patients receiving TP had significantly higher LPFS than PF (74% vs. 48%, P = 0.04). Local control was similar between DefCRT with TP and NeoCRT + S. Distant metastasis-free survival and overall survival were not different between treatment modalities or chemotherapy regimens. In multivariate analysis, surgery (HR 0.30, P < 0.001), TP regimen (HR 0.38, P = 0.007), and mediastinal lymphadenopathy (HR 2.37, P = 0.008) were independent factors for LPFS.

CONCLUSIONS

Both surgery and the use of paclitaxel-based chemoradiation may improve local disease control. Future randomized trials should integrate paclitaxel into definitive chemoradiation.

YC-1 induces apoptosis of human renal carcinoma A498 cells in vitro and in vivo through activation of the JNK pathway

BACKGROUND AND PURPOSE

The aim of this study was to elucidate the mechanism of YC-1{3-(5'-hydroxy methyl-2'-furyl)-1-benzylindazole}-induced human renal carcinoma cells apoptosis and to evaluate the potency of YC-1 in models of tumour growth in mice.

EXPERIMENTAL APPROACH

YC-1-mediated apoptosis was assessed by analysis of MTT, SRB, DAPI staining and flow cytometry analysis. Knockdown of JNK protein was achieved by transient transfection using siRNA. The mechanisms of action of YC-1 on different signalling pathways involved were studied using western blot. Fas clustering was analysed by confocal microscopy and in vivo efficacy was examined in a A498 xenograft model.

KEY RESULTS

YC-1 displayed cytotoxicity in renal carcinoma cells at 10(-7)-10(-8) M. Increased condensation of chromatin was observed and an increase in the cell population in subG1 phase. Moreover, YC-1 triggered mitochondria-mediated and caspase-dependent pathways. YC-1 significantly induced Fas ligand expression, but did not modify either the protein levels of death receptors or ligands. In addition, Fas clustering in cells responsive to YC-1 was observed, suggesting involvement of a Fas-mediated pathway. Furthermore, YC-1 markedly induced phosphorylation of JNK and a JNK inhibitor, SP600125, and siRNA JNK1/2 significantly reversed YC-1-induced cytotoxicity and protein expression. We suggest that YC-1 induced JNK phosphorylation, the upregulation of FasL and Fas receptor clustering to promote the activation of caspases 8 and 3, resulting in apoptosis. Finally, we demonstrated the antitumour effect of YC-1 in vivo.

CONCLUSIONS AND IMPLICATIONS

These data suggest that YC-1 is a good candidate for development as an anticancer drug.

Viscoelastic thin polymer films under transient residual stresses: two-stage dewetting on soft substrates

A nonmonotonic, two-stage dewetting behavior was observed for spin coated thin viscoelastic polymer films on soft elastic substrates. At times shorter than the relaxation time of the polymer (t<tau_{rep}), dewetting generated deep trenches in the soft rubbery substrate which, in turn, almost stopped dewetting. At later stages (t>>tau_{rep}), dewetting accelerated, accompanied by an unstable rim. However, holes nucleated at t<tau_{rep} showed only this second-stage behavior. Our observations are attributed to large elastic deformations in the substrate caused by transient residual stresses within the film.

Outcome of antenatally diagnosed cardiac rhabdomyoma: case series and a meta-analysis

OBJECTIVES

Rhabdomyoma, the most common primary fetal cardiac tumor, is often associated with tuberous sclerosis (TS). We aimed to evaluate outcome in cases diagnosed with fetal cardiac rhabdomyoma.

METHODS

This study presents 11 cases with fetal cardiac rhabdomyoma. In addition, all relevant published cases of antenatally diagnosed cardiac rhabdomyoma since 1982 were identified from MEDLINE. We evaluated the following risk factors associated with clinical impact and perinatal outcome: family history of TS, gestational age at diagnosis, tumor size, site and number of tumors, tumor progression, and associated intracardiac and extracardiac anomalies.

RESULTS

In this meta-analysis, 138 cases, including nine newly added by us, were categorized into Group A (107 live babies) and Group B (16 neonatal deaths and 15 intrauterine fetal deaths). Univariate analysis showed that large cardiac tumors (P < 0.0001), fetal dysrhythmia (P < 0.0001) and hydrops (P < 0.0001) were strong predictors of neonatal outcome. Tumor size >or= 20 mm (relative risk (RR), 20.6; 95% CI, 2.2-195.9; P = 0.009) and fetal dysrhythmia (RR, 13.6; 95% CI, 2.9-62.3; P = 0.001) were significantly associated with neonatal morbidity. TS, present in 85/133 (63.9%) cases, was significantly associated with multiple cardiac tumors (P < 0.0001) and family history of TS (P = 0.02).

CONCLUSIONS

Large tumor size and hydrops are significantly associated with poor neonatal outcome, whereas family history of TS and multiple fetal cardiac tumors are associated with TS. Any sonographic detection of a fetal cardiac tumor should warrant further investigation for the possible presence of associated disorders.

Paraneoplastic Pemphigus and Bronchiolitis Obliterans in a Patient with Splenic B-cell Lymphoma

Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome, is a rare disorder associated with underlying neoplasia. The common underlying neoplasms include non-Hodgkins lymphoma, chronic lymphocytic leukemia, and Castlemans disease. Though B-cell lymphoma is the most common underlying malignancy, only one case associated with splenic B-cell lymphoma has been recognized. The prognosis of PNP is very poor, and PNP-associated bronchiolitis obliterans (BO) is not uncommon. Herein, we report a 44-year-old woman who initially presented with multiple oral ulcers, conjunctivitis, and numerous cutaneous blisters. Serial workup established the diagnosis of PNP and revealed an underlying splenic B-cell lymphoma. Although the mucocutaneous lesions gradually healed after splenectomy and chemotherapy, deteriorating respiratory function developed 7 months later with pathologically proven BO. She finally succumbed to respiratory failure 12 months after presentation despite intensive respiratory care.

The Tumor Suppressor DAPK Is Reciprocally Regulated by Tyrosine Kinase Src and Phosphatase LAR

Death-associated protein kinase (DAPK) is a calmodulin-regulated serine/threonine kinase and elicits tumor suppression function through inhibiting cell adhesion/migration and promoting apoptosis. Despite these biological functions, the signaling mechanisms through which DAPK is regulated remain largely elusive. Here, we show that the leukocyte common antigen-related (LAR) tyrosine phosphatase dephosphorylates DAPK at pY491/492 to stimulate the catalytic, proapoptotic, and antiadhesion/antimigration activities of DAPK. Conversely, Src phosphorylates DAPK at Y491/492, which induces DAPK intra-/intermolecular interaction and inactivation. Upon EGF stimulation, a rapid Src activation leads to subsequent LAR downregulation, and these two events act in synergism to inactivate DAPK, thereby facilitating tumor cell migration and invasion toward EGF. Finally, DAPK Y491/492 hyperphosphorylation is found in human cancers in which Src activity is aberrantly elevated. These results identify LAR and Src as a DAPK regulator through their reciprocal modification of DAPK Y491/492 residues and establish a functional link of this DAPK-regulatory circuit to tumor progression.

Surgical treatment of synchronous multiple primary lung cancers: Experience of 92 patients

OBJECTIVES

According to our previous study, the concurrent detection of p53 and epidermal growth factor receptor mutations significantly improves the clonality assessment and impact management of patients with multiple primary lung cancer. Nevertheless, the treatment, outcome, and safety of patients with this complex disease remain controversial. This series of cases detail our experiences with surgical resections in 92 patients during the past 16 years.

METHODS

A database of 1651 patients was evaluated for unilateral and bilateral synchronous multiple primary lung cancers. The relationships among the location of tumors, number of tumors, tumor size, tumor histology, vascular invasion, regional lymph node metastasis, extranodal extension, type of surgery, mortality, and survival were analyzed.

RESULTS

The 5-year survival for all synchronous multiple primary lung cancers was 35.3%. The overall surgical mortality was 1.1%. Notably, lymph node metastasis, extranodal extension, vascular invasion, tumors with adenosquamous carcinoma or different histology, and poor survival were observed. Multivariate analysis showed that only the occurrence of lymph node metastasis remained a statistically significant prognostic factor. The 5-year survivals were 15.5% [corrected] and 52.5% [corrected] for patients with and without lymph node metastasis, respectively (P < .001).

CONCLUSION

An aggressive surgical approach is safe and justified in patients with synchronous multiple primary lung cancers and node-negative diseases. The status of this particular form of non-small cell lung cancers might be considered in the conventional TNM staging system for more accurate prediction of patient prognosis.

Postpartum urinary retention after cesarean delivery

OBJECTIVE

To investigate the incidence of postpartum urinary retention (PUR) after cesarean delivery and determine which obstetric factors contribute to this problem.

METHOD

A prospective study recruited 605 pregnant women who had a cesarean delivery. Each patient's postvoid residual bladder volume (PVRBV) was estimated with an ultrasound scan after first micturition. The women were divided into 2 groups: PUR (PVRBV > or =150 mL) and normal. Patients' characteristics, obstetric parameters, and prevalence of lower urinary tract symptoms at 3 months postpartum were compared.

RESULT

The overall incidence of PUR was 24.1%. The incidence of overt and covert PUR was 7.4% and 16.7%, respectively. Morphine-related postoperative analgesia, multiple pregnancy, and low body mass index were significantly associated with PUR. At 3-month follow-up, 5.0% of patients had obstructive voiding symptoms and 9.1% had irritative voiding symptoms.

CONCLUSION

Our results revealed PUR was a common phenomenon in patients who had a cesarean delivery, and morphine-related postoperative analgesia was the main contributing factor.

Significance of extranodal extension of regional lymph nodes in surgically resected non-small cell lung cancer

STUDY OBJECTIVES

Regional lymph node (LN) involvement affects the prognosis of patients with surgically resected non-small cell lung cancer (NSCLC). The significance of extranodal extension in these groups of patients was prospectively studied to determine its clinicopathologic relationships and its influence on patient survival.

METHODS

A total of 199 NSCLC patients who were proved to have regional LN involvement after resection were included. Histologic examinations including tumor cell type, grade of differentiation, vascular invasion, regional LN metastasis emphasizing the number and station of LN involvement, the presence or absence of extranodal extension, and the immunohistochemistry of p53 expression were obtained. The relationships between extranodal extension and histologic type, grade of differentiation, vascular invasion, tumor size, pathologic stage, p53 expression, or patient survival were analyzed.

RESULTS

Extranodal extension was significantly higher in women, adenocarcinoma, advanced stage, tumors with vascular invasion, or p53 overexpression. The total number and positive rate of resected LNs with extranodal extension were significantly correlated with advanced stage, tumors with vascular invasion, or p53 overexpression. By multivariate analysis of survival, the presence or total number of LNs with extranodal extension, tumor stage, and p53 expression were significant prognostic factors. The 5-year survival rate of stage IIIA patients without extranodal extension (30.4%) was significantly better than that of stage II patients with extranodal extension (16.8%). No survival difference between extranodal positive stage II and IIIA patients was noted.

CONCLUSIONS

Extranodal extension of regional LNs is an important prognostic factor in patients with surgically resected NSCLC.

Clonality and prognostic implications of p53 and epidermal growth factor receptor somatic aberrations in multiple primary lung cancers

PURPOSE

For treatment decision and prognostic applications, we evaluated p53/epidermal growth factor receptor (EGFR) somatic aberrations in multiple primary lung cancers to differentiate multifocal tumors from intrapulmonary metastasis.

EXPERIMENTAL DESIGN

Fifty-eight multiple primary lung cancers of 1,037 patients in a 10-year period were identified to investigate somatic mutations and altered expression of p53 and EGFR for clonality assessment. Genomic DNA was extracted from microdissected cells of paraffin-embedded multiple primary lung cancer tissues. Overexpression and somatic mutations in exons of p53 (exons 5-8) and tyrosine kinase domain of EGFR (exons 18-22) were examined by immunohistochemical staining and DNA sequencing, respectively.

RESULTS

High frequency of somatic mutations in p53 (33 of 58, 56.9%) and/or EGFR (44 of 58, 75.9%) resulted in high discrimination rate of tumor clonality (50 of 58, 86.2%) of multiple primary lung cancers. Twenty-two cases (37.9%) were assessed as having the same clonality and 28 cases (48.3%) were determined as having different clonality, which further supported the carcinogenic theory of field cancerization. Notably, the occurrence of lymph node metastasis was more commonly observed in tumors with the same clonality (P = 0.045) and was associated with poor patient 5-year survival rate (P = 0.001). However, no correlation was found between tumor clonality and patient survival (P = 0.630). The EGFR somatic aberrations in 58 multiple primary lung cancers, including vascular invasion associated with EGFR overexpression (P = 0.012) and mutation (P = 0.025), further suggested the potential benefits of target therapy of inoperable multiple primary lung cancers.

CONCLUSIONS

Our results suggest that analysis of somatic alterations in p53 and EGFR can significantly improve the clonality assessment and impact management of multiple primary lung cancer patients.

Intrapulmonary bronchogenic cysts: computed tomography, clinical and histopathologic correlations

BACKGROUND/PURPOSE

Bronchogenic cysts (BCs) are usually located in the mediastinum and they occur less commonly in the lung parenchyma. This study investigated the findings from computed tomography (CT) images, clinical presentation and histopathologic findings of intrapulmonary BCs.

METHODS

From the last 7 years, the CT images of 20 patients (12 females, 8 males; mean age, 38.8 +/- 21.7 years; median age, 34 years) with intrapulmonary BC were available. Contrast-enhanced CT findings were characterized and correlated with clinical presentation and histopathologic findings (using Fisher's exact tests).

RESULTS

The majority of intrapulmonary BCs were subpleural in location (55%), in the lower lobes (60%), symptomatic (80%), and in adults (90%). Three CT patterns were identified: cyst with content of fluid attenuation (9 patients), cyst with air and fluid content (9 patients), cyst with content of soft tissue attenuation (2 patients). Preoperative diagnosis of intrapulmonary BC was correct in only 20% using the CT criteria of cysts with fluid attenuation and without anomalous blood supply. Cysts with air component were significantly larger than those without air component (p = 0.0452), but cyst size and air component were not correlated with clinical presentation. Surrounding infiltration or thick wall on CT were significantly correlated with the presence of any clinical symptom (p = 0.014) or fever (p = 0.042). CT findings of surrounding consolidation, ground glass opacity or thick wall were significantly correlated with chronic inflammation or pneumonic change on histopathology (p = 0.0008).

CONCLUSION

There is a wide spectrum of intrapulmonary BCs that have CT findings that are correlated with clinical presentations and histopathologic findings.

Excellent survival of pediatric dermatofibrosarcoma protuberans in Taiwanese

The purpose of this study was to explore the clinical outcome of pediatric dermatofibrosarcoma protuberans (DFSP) in Taiwan. Patients with DFSP diagnosed before 18 years and treated in our institute from 1977 to 2002 were identified through institutional cancer registry. After approved by institutional research ethic committee, active patient contact and linkage with National Residency Registry were done to explore their clinical outcome (Clinical Trials gov Identifier: NCT00173355). Twelve patients were identified. Pathological review confirmed DFSP for all of them. All of them underwent wide excision and none of them underwent neoadjuvant or adjuvant therapy. Nine patients underwent operation as initial therapy and three of them underwent salvage therapy. We recognized only one uncontrollable local recurrence and subsequent death. The 10-year and 15-year overall survival rates were 100 and 83%, respectively, without obvious complications. The prognosis of pediatric DFSP in Taiwanese was excellent.

Identification of trophinin as an enhancer for cell invasion and a prognostic factor for early stage lung cancer

The explosion of microarray studies has promised to shed light on the identification of disease markers. To find novel prognostic factors, we used the expression profile of a poor prognostic factor of lung cancer, survivin (BIRC5), as a template to search for and compare transcriptome expression profiles in a lung adenocarcinoma microarray dataset. Trophinin (TRO) was identified as one of the best-correlated genes. The trophinin expression in lung cancer specimens was examined by immunohistochemical staining. The role of trophinin in cancer metastasis was further investigated by approaches of overexpression and knock down with small interfering RNA (siRNA). For stage I lung adenocarcinoma, the patients without trophinin expression had a better overall and disease-free survival. Overexpression of trophinin increases cell invasion ability and knock down with siRNA inhibits cell invasion. Through a combination of data mining and biochemical assays, we identified trophinin, which could enhance cell invasion, as a novel prognostic factor for early stage lung cancer.

Prognostic factors for pulmonary metastasectomy in hepatocellular carcinoma

Purpose

To identify the prognostic factors for pulmonary metastasectomy (PM-ectomy) in hepatocellular carcinoma (HCC).

Patients and methods

We conducted a retrospective review of patients with pulmonary metastases (PM) from HCC who had undergone curative PM-ectomy at National Taiwan University Hospital between 1990 and 2004. Univariate (log-rank) and multivariate (Cox’s model) analyses of survival were used to identify the significant prognostic factors.

Results

In total, 34 patients were eligible for curative PM-ectomy. The overall survival rates (Kaplan-Meier) after PM-ectomy were 65.2% and 27.5% at 2 and 5 years, respectively. High alpha-fetoprotein level, positive hepatic resection margin, and short disease-free interval (DFI) were unfavorable factors for overall survival from univariate analysis, however, only DFI (P = 0.028) was identified as an independently prognostic factor by multivariate analysis. Bilateral distribution and more PMs were unfavorable factors for PM-free survival from univariate analysis, with only PM number identified as an independent prognostic factor by multivariate analysis (P = 0.017).

Conclusion

Patients with longer DFIs and fewer PMs can benefit from PM-ectomy in HCC.

Treatment of Mediastinal Immature Teratoma in a Child With Precocious Puberty and Klinefelter’s Syndrome

Teratoma is the most common germ cell tumor, which can be divided into the mature and the immature histologically. Concurrent Klinefelter's syndrome may be overlooked in a patient with a germ cell tumor. This is because the tumor that secrets alpha-fetoprotein and beta human chorionic gonadotropin can mimic puberty in a patient with Klinefelter's syndrome, masking the usual clinical signs. In reviewing the literature on the subject, the role of neoadjuvant and adjuvant chemotherapy remains ill-defined for the immature teratoma. Age-dependent prognosis seems to demonstrate that children with immature teratomas have a better outcome. We share the experience of treating a child with immature teratoma with surgical excision alone, and it ended in a local recurrence.

Secondary infection and ischemic necrosis after fine needle aspiration for a painful papillary thyroid carcinoma: a case report

BACKGROUND

Papillary thyroid carcinoma (PTC) is often asymptomatic and rarely presents as a painful goiter. Further, the thyroid gland is not easily infected. Therefore, acute suppurative thyroiditis (AST) is unusual. PTC is also seldom combined with AST. We report a case of painful PTC with secondary infection after fine needle aspiration (FNA).

CASE

A 19-year-old girl complained of a painful goiter without skin change after an episode of upper airway infection. PTC was diagnosed according to the FNA cytology (FNAC) at another hospital. The goiter became more painful after FNA. The patient's second FNAC at our hospital revealed only many polymorphonuclear leukocytes (PMNs). Antibiotic treatment ameliorated the pain, but the goiter persisted. The third FNAC revealed some PMNs and papillary carcinomatous cells. After total thyroidectomy, pathology revealed ischemic necrosis with a focal PMN aggregation around the needle track and papillary carcinomatous cells nearby. According to the time sequence, secondary infection after FNA was suspected.

CONCLUSION

A painful goiter is an unusual presentation of PTC. Although FNAC is feasible for studying a thyroid lesion, malignant cells might be missed when secoandary injection and ischemic necrosis occur after FNA. Therefore, aseptic procedures are necessary to prevent bacteria from seeding into the thyroid.

Molecular recoiling in polymer thin film dewetting

The molecular recoiling force stemming from nonequilibrium chain conformation was found to play a very important role in the dewetting stability of polymer thin films. Correct measurements and inclusion of this molecular force into thermodynamic consideration are crucial for analyzing dewetting phenomena and nanoscale polymer chain physics. This force was measured using a simple method based on contour relaxation at the incipient dewetting holes. The recoiling stress was found to increase dramatically with molecular weight and decreasing film thickness. The corresponding forces were calculated to be in the range from 9.0 to 28.2 mN/m, too large to be neglected when compared to the dispersive forces (approximately 10 mN/m) commonly operative in thin polymer films.

Transcription repressor slug promotes carcinoma invasion and predicts outcome of patients with lung adenocarcinoma

PURPOSE

In a previous genome-wide gene expression profiling analysis using an invasion cancer cell lines model, we have identified Slug as selectively overexpressed in the highly invasive cancer cells. Here, we investigated the clinical significance of Slug in lung adenocarcinoma and the role of Slug in the process of cancer cell invasion and metastasis.

EXPERIMENTAL DESIGN

Real-time quantitative reverse transcription-PCR was used to investigate Slug mRNA in surgically resected lung adenocarcinoma of 54 patients and its correlation with survival. We overexpressed Slug in a lung adenocarcinoma cell line with very low Slug levels and investigated the in vitro and in vivo effects of Slug expression.

RESULTS

High expression of Slug mRNA in lung cancer tissue was significantly associated with postoperative relapse (P = 0.03) and shorter patient survival (P < 0.001). The overexpression of Slug enhanced xenograft tumor growth and increased microvessel counts in angiogenesis assay. Both inducible and constitutive overexpression of Slug suppressed the expression of E-cadherin and increased the in vitro invasive ability. Zymography revealed increased matrix metalloproteinase-2 activity in Slug overexpressed cells. ELISA, reverse transcription-PCR, and immunohistochemistry confirmed the increase of matrix metalloproteinase-2 proteins and mRNA in Slug overexpressed cells and xenograft tumors.

CONCLUSIONS

Slug expression can predict the clinical outcome of lung adenocarcinoma patients. Slug is a novel invasion-promoting gene in lung adenocarcinoma.