Randomized Trials of Systemic Medically-treated Malignant Mesothelioma: A Systematic Review

Malignant pleural mesothelioma (MPM) is a rare but aggressive malignancy mainly localized to the pleura. Malignant mesothelioma grows highly invasive into surrounding tissue and has a low tendency to metastasize. The median overall survival (OS) of locally advanced or metastatic disease without treatment is 4-13 months but, during recent years, improvement in survival has been achieved since treatment for patients with mesothelioma has improved with better palliative care, systemic medical treatment, surgery and improved diagnostics methods. The present review aims at describing available data from randomized trials considering systemic medical treatment for this patient category.

FACT: an open-label randomized phase III study of fulvestrant and anastrozole in combination compared with anastrozole alone as first-line therapy for patients with receptor-positive postmenopausal breast cancer

PURPOSE

To compare the effect of therapy with anastrozole versus a combination of fulvestrant and anastrozole in women in first relapse of endocrine-responsive breast cancer.

PATIENTS AND METHODS

Postmenopausal women, or premenopausal women receiving a gonadotropin-releasing hormone agonist, with estrogen receptor- and/or progesterone receptor-positive disease at first relapse after primary treatment of localized disease were open-label randomly assigned to a fulvestrant loading dose (LD) regimen followed by monthly injection plus 1 mg of anastrozole daily or to 1 mg of anastrozole daily alone. The primary end point was time to progression (TTP).

RESULTS

In all, 514 women were randomly assigned to fulvestrant plus anastrozole (experimental arm; n = 258) or anastrozole (standard arm; n = 256). Approximately two thirds had received adjuvant antiestrogens, but only eight individuals had received an aromatase inhibitor. Median TTP was 10.8 and 10.2 months in the experimental versus standard arm, respectively (hazard ratio [HR] = 0.99; 95% CI, 0.81 to 1.20; P = .91); median overall survival was 37.8 and 38.2 months, respectively (HR = 1.0; 95% CI, 0.76 to 1.32; P = 1.00). Incidences of prespecified adverse events (AEs) were similar. Hot flashes were more common in the experimental arm: 63 patients (24.6%) versus 35 patients (13.8%) in the standard arm (P = .0023). Death owing to AEs was reported in 11 (4.3%) and five patients (2.0%) in the experimental versus standard arm, respectively.

CONCLUSION

Fulvestrant (250 mg + LD regimen) in combination with anastrozole offered no clinical efficacy advantage over anastrozole monotherapy in this population of individuals with a relatively high proportion of previous adjuvant antiestrogen exposure.

Fractionated irradiation of five human lung cancer cell lines and prediction of survival according to a radiobiology model

BACKGROUND

This study evaluates a predictive radiobiology model by measurements of surviving fraction (SF) by the clonogenic assay or the extrapolation method and the proliferation rate in vitro. It is hypothesized that incorporating proliferation to intrinsic radiosensitivity, measured by SF, to predict radiation responsiveness after fractionated irradiation adds to the model's accuracy. Materials and Methods. Five lung cancer cell lines with known SF after 1 Gy (SF1), and also SF2 and SF5, were irradiated with three different fractionation regimes; 10 × 1 Gy, 5 × 2 Gy or 2 × 5 Gy during the same total time to achieve empirical SF. In addition, the SF1, SF2 and SF5 after fractionated irradiation was calculated for each cell line based on the already known single fraction SF and with or without a proliferation factor. The results were compared to the empirical data.

RESULTS AND DISCUSSION

By using the clonogenic assay to measure radiosensitivity, prediction of radiosensitivity was improved after fractionated radiotherapy when proliferation was used in the radiobiology model. However, this was not the case in the cell lines where the extrapolation method was used to calculate SF. Thus, a radiobiology model including intrinsic radiosensitivity, measured by the clonogenic assay, as well as proliferation, is better at predicting survival after fractionated radiotherapy, compared to the use of intrinsic radiosensitivity alone.

Esophageal cancer: current and emerging therapy modalities

During the last few years, there has been a gradual increase in treatment options for patients with esophageal malignancies. Several clinical studies have been performed, covering not only radiation and chemotherapy, but also the introduction of novel biological agents into the treatment arsenal. Patients with esophageal carcinoma are now offered second-line and sometimes even third-line treatments, and the number of research protocols is increasing. Despite the newly awakened interest in this malignancy, the overall 5-year survival rate has remained at approximately 10% since the 1980s. This review contains a compilation of available studies of esophageal malignancies and discusses current treatment options as well as newly developed therapies targeted at growth factor receptors.

The role of circulating angiogenic factors in patients operated on for localized malignant melanoma

Malignant melanoma is a disease capable of rapid progression and rapidly developing metastases. Angiogenesis is a key event signalling tumour progression and elevated levels of angiogenic markers may indicate metastatic disease. No previously published work has, so far, examined plasma vascular endothelial growth factor (VEGF) and its receptor, VEGFR-1, in melanoma. This study investigated circulating levels of the angiogenic factors, VEGF-A and -D, their receptors 1-3 and hepatocyte growth factor (HGF)/scatter factor, in patients shortly after primary surgery for localized malignant melanoma. Elevated circulating levels of VEGF and its receptors, and of HGF, were found postoperatively, possibly derived from the reactive stroma adjacent to the tumours. Using univariate analysis, a correlation between levels of VEGFR-1 and relapse was found, but a correlation between the investigated angiogenic factors and survival could not be established. The results of the present study indicate that production of these angiogenic factors may be due to sources other than malignant melanoma cells.

HER-2 overexpression (3+) in patients with squamous cell esophageal carcinoma correlates with poorer survival

The incidence of esophageal carcinoma is increasing worldwide. In Sweden, approximately 400 patients are diagnosed each year. The present study retrospectively investigates survival in 97 patients with esophageal carcinoma in regard to their HER-2 status as examined by immunohistochemistry (IHC) and chromogen in situ hybridization (CISH). Sixty-eight patients had localised disease and 29 patients had advanced disease. Seventy patients had squamous cell carcinoma, and nine of these patients (13%) had HER-2 overexpression (3+). Eight (30%) of 27 adenocarcinoma patients overexpressed (3+) HER-2. In patients overexpressing (3+) HER-2 a statistical trend towards poorer survival was observed (P = 0.057). In squamous cell carcinoma patients, HER-2 overexpression (3+) correlated with poorer survival (P = 0.035), whereas in adenocarcinoma patients, HER-2 status (3+) did not. HER-2 amplification according to CISH was present in five (two squamous cell carcinomas and three adenocarcinomas) out of 17 HER-2 overexpressing (3+) tumours. In conclusion, HER-2 overexpression (3+) seems to be associated with poorer survival in esophageal carcinomas, especially in patients with squamous cell esophageal carcinoma.

Telomerase activity is not a key determinant of sensitivity to standard cytotoxic drugs in human esophageal carcinoma cell lines

The aim of the present study was to investigate if basal telomerase activity levels may predict sensitivity to cytotoxic drugs in a panel of human esophageal carcinoma cell lines. The TRAPeze telomerase detection assay was used to investigate telomerase activity in the cell lines. Cytotoxic drug sensitivity for 20 standard cytotoxic agents was assessed using the fluorometric microculture cytotoxicity assay (FMCA). Telomerase activity was detected in all cell lines with a broad range of activity levels. Drug sensitivity also varied considerably between the cell lines. Except for a P value towards a correlation between mitoxantrone and telomerase activity (P=0.054), no statistically significant correlation was found between telomerase activity levels and sensitivity to investigated drugs, including key drugs such as cisplatin (P=0.9), 5-fluorouracil (P=0.8) and doxorubicin (P=0.54). We therefore conclude that basal telomerase activity level is not a key determinant of sensitivity to standard cytotoxic drugs in esophageal carcinoma cell lines.

High-risk human papilloma virus (HPV) and survival in patients with esophageal carcinoma: a pilot study

BACKGROUND

Human papilloma virus (HPV) in patients with esophageal carcinoma has previously been studied with an average detection rate of 15%, but the role of HPV in relation to survival is less clear. In cervical cancer, lung cancer and tonsil cancer HPV viral load is a predictive factor for survival and outcome of treatment. The primary aim was to study the spectrum of high-risk HPV types in esophageal tumors. Secondary, as a pilot study we investigated the association between HPV status and the survival rates.

METHODS

We compared both the presence and the viral load of high-risk HPV types 16, 18, 31, 33, 39, 45, 52, 58, and 67 in relation to clinical data from patients with esophageal carcinoma. Survival data and tumor samples were retrieved from 100 patients receiving treatment at the Department of Oncology, Uppsala Hospital, Uppsala, Sweden. The tumor samples were investigated for HPV viral load using real-time PCR.

RESULTS

HPV 16 was detected in 16% of the patients; no other HPV type was detected. HPV 16 infection had no significant effect on survival (p = 0.72). Also, HPV 16 did not improve survival after treatment (radiotherapy or chemotherapy).

CONCLUSION

Only HPV 16 was detected among the patients. HPV 16 in esophageal carcinoma patients did not influence survival or improve therapy response. However, given the size of the study there is a need to examine a larger cohort in order to understand in more detail the effect of high risk HPV types in esophageal carcinoma.

Genes associated with telomerase activity levels in esophageal carcinoma cell lines

Telomerase activity levels have been shown to correlate with tumor progression in several malignancies. However, the genetic regulation of telomerase activity levels is not fully understood. The aim of the present study has been to identify a gene expression profile, predicting correlation with the telomerase-activity test. Ten human esophageal carcinoma cell lines were investigated using the telomerase activity assay (TRAPeze) Telomerase Detection Kit), followed by further characterization using the GeneChip Human Genome U133A 2.0 Array (Affymetrics Inc., USA), including 14 500 human genes. Telomerase activity levels were detected in all cell lines with a broad range of activity levels. Using a high correlation coefficient, r > 0.90, the following genes were found to be positively correlated with telomerase activity levels: N-myristoyltransferase 2; ribosomal protein L3; retinoblastoma-like 2 (pRb2/p130); and cyclin G2. Only one gene was negatively correlated with telomerase activity levels, zinc finger protein 207. In conclusion, the present microarray data provide primary validation data indicating possible candidates for prognostic and prediction factors in esophageal cancer in relation to telomerase activity.

Role of circulating cytokeratin fragments and angiogenic factors in NSCLC patients stage IIIa-IIIb receiving curatively intended treatment

Non-small cell lung cancer (NSCLC) is derived from epithelial cells and accounts for approximately 80% of all lung cancers. Cytokeratins are specific for epithelial cells and during malignant transformation the cytokeratin profile usually remains constant. Angiogenesis is the formation of new blood vessels out of the existing vascular bed. Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) are potent circulating angiogenic factors. The aim of the present study was to determine if increased levels of a new cytokeratin assay (MonoTotal, which in comparison with TPAcyk detects not only fragments of cytokeratins 8 and 18 but also of cytokeratin 19) is correlated with circulating angiogenic factors (VEGF and bFGF) and the secondary aim was to investigate if increased levels of these circulating markers are associated with survival. In the present study, a total of 45 NSCLC patients (26 patients stage IIIa and 19 patients stage IIIb) receiving only curatively intended treatment for advanced NSCLC were included. These patients donated a total of 291 serum samples during follow-up which was investigated for the presence of MonoTotal, VEGF and bFGF. MonoTotal was statistically significantly correlated with bFGF (R=0.26, p=0.00049) and VEGF (R=0.26, p=0.00007). From the time of histological diagnosis until time of death, MonoTotal increased by 603 U/l (p<0.0001). VEGF increased by 430 pg/ml (p=0.0004) whereas the corresponding value for bFGF was 5.93 pg/ml (p=0.018). MonoTotal, a newly developed commercial cytokeratin assay, seems to be a potentially very interesting serum marker that, in conjunction with other clinical data, might be used for monitoring of patients with NSCLC.

Newly developed assay measuring cytokeratins 8, 18 and 19 in serum is correlated to survival and tumor volume in patients with esophageal carcinoma

Esophageal carcinoma is the seventh most common cause of cancer-related death in the Western world. In Sweden, approximately 400 new esophageal carcinomas are diagnosed yearly. Cytokeratins (CK) are specific for epithelial cells and the expression profile usually remains unchanged even when the epithelium undergoes malignant transformation. In the present study, MonoTotal, a newly developed RIA-assay detecting circulating CK 8, 18 and 19 fragments, was investigated in sera from patients with esophageal carcinoma. Serum samples from 40 patients with esophageal carcinoma were collected. The median value of circulating CK 8, 18 and 19 measured with MonoTotal was 378 U/L (range 53-6843) and with regard to the defined cut-off (< 75 U/L), 39/40 (98%) patients were shown to have elevated levels of circulating CK 8, 18 and 19. Patients with localized disease had a median value of circulating CK 8, 18 and 19 of 305 U/L (mean: 500 U/L), whereas the corresponding value for metastatic disease was 771 U/L (mean: 1506 U/L). This difference was statistically significant (P = 0.016). Circulating CK 8, 18 and 19, according to cut-off, were not associated with survival in univariate analysis (P = 0.34). However, continuous values of circulating levels of CK 8, 18 and 19 were associated with survival (P = 0.000083) in univariate as well as in the multivariate analysis (P = 0.03). In conclusion, circulating CK 8, 18 and 19 correlates with increased tumor burden and might, in conjunction with other clinical parameters, aid the clinician in estimating the prognosis of the individual patient.

The role of cystatin C and the angiogenic cytokines VEGF and bFGF in patients with esophageal carcinoma

Angiogenesis is the formation of new blood vessels out of the existing vascular bed. Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) are potent circulating angiogenic factors, whereas cystatin C is one of the most important extracellular inhibitors of several cysteine proteinases. Because proteases degrade interstitial connective tissue and basement membranes during tumor growth and metastasis, an association between cystatin C and the angiogenic factors seems plausible. The primary aim of the present study was to investigate if such a correlation exists between these serum markers. The secondary aim was to determine the prognostic value of these circulating cytokines and cystatin C, collected prior to therapy, in patients with esophageal carcinoma.A total of 42 patients with esophageal carcinoma donated serum samples prior to therapy. VEGF and bFGF were correlated to platelet and leukocyte counts and VEGF was correlated to tumor volume (p = 0.04), whereas bFGF was not (p = 0.08). VEGF was significantly correlated with cystatin C (p = 0.027). Survival analysis showed that VEGF regarded as a continuous variable was associated with a significantly poorer survival in the univariate analysis (p = 0.023); however, this was not found for bFGF (p = 0.46). Neither of the angiogenic factors were associated with survival in the multivariate analysis. In the univariate analysis, cystatin c was correlated with survival (p = 0.01), but this was not found in the multivariate analysis (p = 0.28). In conclusion, VEGF was correlated with cystatin C, possible explanations being discussed in the present article. Results of the present study indicate that use of the angiogenic factors as prognostic factors, prior to therapy in patients with esophageal carcinoma, appears limited.

Novel agents in the treatment of non-small cell lung cancer: implications for neoadjuvant chemotherapy?

During recent years, we have seen an increasing awareness among physicians about the possibilities of helping patients stricken by non-small cell lung cancer using active intervention with chemotherapeutics. This has emerged mainly from the development of new chemotherapeutics and novel drug combinations with an improved therapeutic ratio better tolerated by the patients. However, these new combinations of chemotherapeutics have proved to be only marginally better in terms of survival than the earlier used cytotoxic agents. Thus, many clinicians consider the effects of systemic therapy on symptom control and improved quality of life to be at least as important as survival when evaluating new drugs or new combinations. It is also obvious that improvements using traditional cytotoxics are slow and that there is a need for novel approaches. The present review focuses on novel drugs that have recently been introduced, or soon await to be included, in the management of advanced lung cancer and which have a potential value for use in neoadjuvant treatment of patients with non-small cell lung cancer, i.e. pemetrexed, EGFR-inhibiting agents, anti-angiogenesis inhibitors and other small molecules.

The role of circulating anti-p53 antibodies in patients with advanced non-small cell lung cancer and their correlation to clinical parameters and survival

BACKGROUND

Lung cancer causes approximately one million deaths each year worldwide and protein p53 has been shown to be involved in the intricate processes regulating response to radiation and/or chemotherapeutic treatment. Consequently, since antibodies against p53 (anti-p53 antibodies) are associated with mutations within the p53 gene it seems likely that these antibodies could, hypothetically, be correlated with prognosis.

METHODS

Serum samples from patients with non-small cell lung cancer (NSCLC) admitted to the Department of Oncology, University Hospital, Uppsala, Sweden, during 1983-1996 were studied. Anti-p53 abs were measured using a sandwich ELISA (Dianova, Hamburg, Germany).

RESULTS

The present study included 84 patients with stage IIIA-IV (advanced NSCLC). At least three serum samples from each patient were collected and altogether 529 serum samples were analysed for the presence of anti-p53 antibodies. The median value of anti-p53 antibodies was 0.06 (range 0 - 139.8). Seventeen percent of investigated NSCLC first serum samples (n = 84) expressed elevated levels of anti-p53 antibodies. Anti-p53 antibodies were not correlated to tumour volume or platelets. Survival analysis showed that anti-p53 antibodies were not associated with survival as revealed by univariate analysis (p = 0.29). However, patients with adenocarcinoma had a significantly poorer survival if they expressed anti-p53 antibodies (p = 0.01), whereas this was not found for patients with squamous cell carcinoma (p = 0.13). In patients where the blood samples were collected during radiation therapy, a statistically significant correlation towards poorer survival was found (p = 0.05) when elevated anti-p53 antibodies levels were present. No correlations to survival were found for serum samples collected prior to radiation therapy, during chemotherapy, or during follow-up. When anti-p53 antibodies were measured continuously, no increase in median anti-p53 values was observed the closer the individual patient come to death.

CONCLUSION

The result of the present retrospective study indicates that anti-p53 antibodies are not suitable for predictions concerning selection of patients with a more favourable outcome. Further prospective studies are, though, needed to fully elucidate this issue.

Endothelial markers and circulating angiogenic factors and p53 may be potential markers for recurrence in surgically resected non-small cell lung cancer patients

BACKGROUND

Early stage lung cancer is potentially curable by resection, but 30-50% of patients will relapse within five years after surgery. Therefore, the search for a predictive method capable of estimating the risk of recurrence in this population of patients is important.

MATERIAL/METHODS

We analysed, on the one hand, the predictive powers for recurrent disease of the immunohistochemical expressions of p53 and the endothelial markers CD34 and CD105 in 53 NSCLC tumor samples, and, on the other hand, their correlations to serum VEGF and bFGF levels. Moreover, we sequenced the whole coding region of the p53 gene in 32 tumor samples for the presence of p53 mutations (exons 2-11) using a cDNA technique.

RESULTS

The two endothelial markers correlated with each other. CD105 expression correlated with p53 expression, which was overexpressed in 49%. No other significant correlations between markers could be demonstrated. A significant correlation between p53 overexpression and recurrent disease was demonstrated (p=0.029). The mutational status of p53 correlated to p53 protein overexpression, but did not correlate with either of the immunohistochemical markers. The mutational status could not confirm an immunohistochemical correlation between p53 and recurrences (p=0.068).

CONCLUSIONS

The present study demonstrates that p53 expression correlates with CD105 expression, and that p53 overexpression may indicate a lower recurrence risk in patients undergoing surgery for NSCLC stage I-IIIA, although future larger prospective studies are needed to fully elucidate this finding.

The presence of anti-p53 antibodies in sera from patients with oesophageal carcinoma: correlation to treatment, tumour volume and survival

BACKGROUND

A correlation between mutations in the p53 gene and the presence of anti-p53 antibodies in sera has been reported. The aim of the present study was to analyse anti-p53 antibodies in sera from patients with oesophageal carcinoma and their implications for clinical outcome and survival

PATIENTS AND METHODS

Between 1996 and 2002, patients treated for oesophageal carcinoma at the Department of Oncology, Uppsala University Hospital, Sweden, were asked to donate serum samples during treatment and follow-up. A total of 42 patients, with serum samples collected prior to therapy, were analysed for expressions of anti-p53 antibodies using a commercially available sandwich ELISA (Dianova, Hamburg, Germany).

RESULTS

Anti-p53 antibodies did not correlate with investigated laboratory parameters. No correlation between anti-p53 antibodies and tumour volume was found (n=31; r=0.08;p=0.66). Anti-p53 antibodies as a continuous variable was not associated with survival (p = 0.42). Neither was the presence of anti-p53 antibodies (according to defined cut-off of 1.1, provided by the manufacturer) associated with survival (p = 0.99).

CONCLUSION

The presence of anti-p53 antibodies correlated neither to tumour volume nor to clinical parameters.

A retrospective study focusing on clinical predictive factors in 126 patients with oesophageal carcinoma

In Sweden, approximately 400 patients are diagnosed each year with oesophageal carcinoma. Despite the introduction of different treatment schedules, only modest improvements in survival have been accomplished. To be able to select patients in whom a more favourable outcome of radiation/-chemotherapeutic treatment could be expected, the present study reviewed the charts from 126 consecutive patients with oesophageal carcinoma. All patients were treated at the Department of Oncology, Uppsala University Hospital, Sweden, between 1990 and 2000. The charts were reviewed with focus on known and potential prognostic factors. Performance status, smoking habits, swallowing function, localisation of the tumour, leucocytes and albumin levels at first admittance, and stage of the disease were prognostic factors. However, performance status and stage of the disease only remained as significant independent prognostic factors in the multivariate analysis (both with p-values < 0.001). The results imply that further characterisation of tumour biology in oesophageal carcinoma is needed to find additional predictive factors for survival and future treatment strategies.

HER-2, EGFR, COX-2 expression status correlated to microvessel density and survival in resected non-small cell lung cancer

The incidence of lung cancer is increasing throughout the world and is the most common cause of cancer-related death. Early detection followed by surgery has a reasonable, curative potential, but 30-50% of patients experience relapses. The immunohistochemical expressions of HER-2, EGFR and COX-2 were investigated in 53 resected non-small cell lung carcinomas and correlated to microvessel density and clinical data. HER-2, EGFR and COX-2 overexpressions were demonstrated in 15%, 30% and 40% of the tumours, respectively. In adenocarcinomas, HER-2 and COX-2 overexpression were more common, whereas in squamous cell carcinomas, EGFR overexpression was more common. COX-2 expression correlated with HER-2 expression (p = 0.002), and demonstrated a trend towards a correlation with microvessel density (p = 0.10). None of the markers alone had any impact on survival. However, HER-2+/EGFR- tumours proved to have a poor prognosis. In conclusion, adjuvant treatment with HER-2 antagonists might be a future treatment option in resected non-small cell lung cancer patients, especially when HER-2 is overexpressed without a concomitant overexpression of EGFR.

Serum Semicarbazide-Sensitive Amine Oxidase (SSAO) Activity Correlates with VEGF in Non-Small-Cell Lung Cancer Patients

Semicarbazide-sensitive amine oxidase (SSAO) is an enzyme associated with vascular systems in mammals. SSAO catalyzes the deamination of primary monoamines and has been suggested to be a risk factor in vascular disorders, e.g., diabetic vascular complications. The primary aim of the present study was to investigate if serum SSAO activity is associated with clinical parameters in non-small cell lung cancer (NSCLC) patients. Secondary aims were to investigate if there is a correlation between SSAO activity and the angiogenic factors vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF).Thirty-three patients donated 231 serum samples. Detectable levels of bFGF, VEGF, and SSAO were observed in all patients. Serum SSAO activity was not statistically associated with survival (p = 0.35). A highly significant statistical correlation was found between SSAO activity and VEGF (p < 0.0001). No significant correlation between SSAO and bFGF was observed. We conclude that SSAO was not associated with survival in patients with NSCLC. However, a strong correlation between serum SSAO activity and the angiogenic factor VEGF was found that might implicate new aspects of the mechanisms controlling angiogenesis.

Serum VEGF and bFGF adds prognostic information in patients with normal platelet counts when sampled before, during and after treatment for locally advanced non-small cell lung cancer

Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) have both been implicated to have roles in tumour angiogenesis. In the present retrospective study, serum VEGF and bFGF from patients with locally advanced non-small cell lung cancer (NSCLC) were analysed before, during and after treatment. Seventy-three patients and a total of 460 serum samples were analysed for VEGF and 443 serum samples were analysed for bFGF. Pre-treatment bFGF levels in patients with normal platelet counts, were correlated to poorer survival, P-value = 0.047. During chemotherapy, each rise of one unit bFGF corresponded to a hazard ratio of 4.06 (P=0.022). In patients with normal platelet counts, VEGF levels after radiotherapy significantly correlated to good prognosis (P=0.023), during radiotherapy VEGF levels indicated the same correlation (P=0.085). We conclude that serum VEGF and especially bFGF are of clinical interest as prognostic factors, especially in patients presenting with normal platelet counts.

The presence of anti-p53 antibodies in sera prior to thoracic surgery in non small cell lung cancer patients: its implications on tumor volume, nodal involvement, and survival

BACKGROUND

During recent years, a correlation between the presence of antibodies in sera against p53 and survival has been reported. The aim of the present study was to analyze anti-p53 antibodies in sera from patients with non small cell lung cancer (NSCLC) prior to thoracic surgery and their correlation to survival, nodal involvement, and tumor volume.

PATIENTS AND METHODS

Serum samples from 58 patients with NSCLC admitted to the Department of Pulmonary Medicine in Uppsala were collected between 1993 and 1995 and analyzed for the expression of anti-p53 antibodies.

RESULTS

Antibodies against p53 were detected in 12 patients (21%). No association was found between increased levels of anti-p53 antibodies and tumor volume (P =.84). There was a numerical trend towards higher levels of anti-p53 antibodies in patients without nodal disease, when compared with patients with nodal involvement, although not statistically significant (P =.136). However, when patients with metastatic disease were included, statistically significantly lower levels of anti-p53 antibodies were demonstrated, in comparison to patients without any sign of nodal engagement or metastatic disease (P =.038). Anti-p53 antibodies and survival showed no correlation between increasing index levels of anti-p53 antibodies and survival (P =.18). Neither was a correlation found between using the cutoff (>1.1) described by the manufacturer and survival.

CONCLUSION

The presence of anti-p53 antibodies was correlated neither to survival nor to tumor volume in the present study. However, patients with either nodal or metastatic disease had lower levels of anti-p53 antibodies in comparison to patients without signs of either nodal or metastatic disease. These issues are discussed.

p53 status and its in vitro relationship to radiosensitivity and chemosensitivity in lung cancer

The following study was designed to investigate if mutations within the p53 gene are associated with radiation responsiveness or response to different cytotoxic drugs. Nine human lung cancer cell lines were examined (four SCLC and five NSCLC cell lines). cDNA-based sequencing of the entire p53 gene was performed. All cell lines were characterised with respect to drug-sensitivity towards eight cytotoxic drugs using the FMCA method and data from the clonogenic assay were studied to obtain information concerning radioresponsiveness. All the cell lines expressed mutations; six were missense mutations and three were deletions. A statistically significant increase in radiosensitivity was found for mutations in exon 7 (p = 0.019), compared with the other mutations localised within different exons of p53. Further statistical analyses using Fisher's two-tailed exact test confirmed that mutations in exon 7 were significantly associated with radiosensitivity, p = 0.047. No correlation concerning mutations in separate exons and response towards different chemotherapeutic agents could be found. Our results indicate that p53 mutations in exon 7 might be associated with increased radiation sensitivity in these human lung cancer cell lines, but our data should be interpreted with caution since several other explanations might exist regarding what determines the response towards radiation.

Elevated preoperative serum levels of angiogenic cytokines correlate to larger primary tumours and poorer survival in non-small cell lung cancer patients

We have analysed the predictive and prognostic information in preoperatively collected serum levels of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in patients clinically evaluated as operable non-small cell lung cancer (NSCLC). Fifty-eight patients with operable NSCLC were included. VEGF and bFGF levels in serum were analysed using enzyme linked immunosorbent assays (Quantikine human VEGF and Quantikine HS human FGF basic, R&D Systems). Univariate analysis demonstrated that tumour volume, platelet counts, VEGF and bFGF were significant prognostic factors. However, only bFGF remained significant in the multivariate analysis (P=0.014). Significant correlation's were demonstrated between VEGF levels and tumour volume (r=0.33; P=0.012) and platelet count (r=0.43; P=0.001). bFGF levels correlated significant with recurrent disease (r=0.34; P=0.01), platelet count (r=0.53, P<0.001) and performance status (r=0.29; P=0.029). Furthermore, bFGF levels and VEGF levels correlated significantly (r=0.44; P<0.001). We conclude that elevated circulating angiogenic cytokines correlate with tumour volume, higher relapse risk and poorer survival in patients with operable non-small cell lung cancer.

The frequency of micronuclei in lung cancer cell lines and their correlation to intrinsic radiation sensitivity

BACKGROUND

Micronuclei arise from chromosomal, acentric, fragments or whole chromosomes that are not incorporated into the daughter nuclei at mitosis. The micronuclei assay is technically simple and requires only one mitosis in order to obtain information concerning the amount of micronuclei. This study was performed to investigate whether the formation of micronuclei could be used as a marker for intrinsic radiation sensitivity in lung cancer patients.

MATERIALS AND METHODS

Two human lung cancer cell lines, a non-small cell lung cancer (NSCLC) cell line (U-1810) and a small cell lung cancer (SCLC) cell line (U-1906L), were used. Radiosensitivity data on the survival fraction at 2 Gy were obtained from the clonogenic assay. Radiation was delivered as one-fraction doses: 0, 1, 2, 4, 10 and 20 Gy. After irradiation, the cells were incubated for 0, 24, 48, 60, 72 and 96 hours before fixation and staining.

RESULTS

The frequency of micronuclei in U-1906L was clearly elevated after 96 hours in the 20 Gy fraction. The frequency of micronuclei reached 5.5%. For U-1810 the micronuclei had a peak clearly different than the other settings after 48 hours in the 10 Gy fraction. The frequency of micronuclei was 1.2%.

CONCLUSION

Counting micronuclei is not sensitive enough for estimation of radiosensitivity in clinical doses. However, our results demonstrated a distinct difference between NSCLC and SCLC cell lines at higher doses. This difference might be due to different repair fidelity, so future studies with this assay should aim to investigate this hypothesis.

Different fraction schedules and combinations with chemotherapy in radiation treatment of non-small cell lung cancer

BACKGROUND

In locally advanced non-small cell lung cancer (NSCLC), studies demonstrating advantages with hyperfractionated accelerated radiotherapy versus conventional radiotherapy have been published, so have studies demonstrating the value of chemotherapy concomitantly with radiotherapy. However, the value of non-conventional fractionation together with concomitant chemotherapy has not been investigated.

MATERIALS AND METHODS

Consecutive patients from a single institution were studied in a retrospective non-randomised fashion. Inclusion criteria were stage III NSCLC, treatment with curative intent and a total dose above 50 Gy.

RESULTS

Eighty-two patients were included and further divided into four different treatment groups. Multivariate analysis indicated a survival advantage with non-conventional radiotherapy (NCRT), especially if combined with concomitant chemotherapy. Toxicity was feasible, however there was a trend towards higher toxicity, mainly esophagitis, in patients given concomitant chemotherapy with NCRT.

CONCLUSION

Our results suggest that accelerated hyperfractionated radiotherapy with concomitant chemotherapy could be an interesting test-arm in a future prospective study.

Cytokeratin 8 and 18 fragments measured in serum and their relation to survival in patients with non-small cell lung cancer

BACKGROUND

In this study we investigated if the newly developed monoclonal antibodies against Cytokeratin 8 and 18 fragments (Cyk 8/18) have prognostic information in patients with non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Serum from 69 patients with NSCLC was investigated using a sandwich ELISA, Cyk 8/18, provided by IDL Biotech, Sollentuna Sweden.

RESULTS

Cyk 8/18 levels varied between 0.34-14.2 ng/mL, compared with a cut-off value of 1.0 ng/mL for healthy individuals (95% specificity). Using that cut-off value, 80% of NSCLC patients had elevated levels. A statistically significant diminished survival was found for Cyk 8/18 values of 8.0 ng/mL or higher (p = 0.0001). When survival data and Cyk 8/18 levels were analysed according to continuous Cox regression analysis, increased levels of Cyk 8/18 were significantly related to decreased survival (p = 0.016).

CONCLUSIONS

The Cyk 8/18 monoclonal antibody had in this study prognostic information regarding survival in patients with NSCLC.

Complete sequence of p53 gene in 20 patients with lung cancer: comparison with chemosensitivity and immunohistochemistry

In this study the entire p53 complementary DNA has been sequenced in 20 non-small cell lung carcinomas (NSCLC) and the results correlated with chemosensitivity, immunohistochemistry and clinical data. Ten patients had mutations in p53, 8 missense mutations and 2 nonsense mutations. The method discovered two mutations never described previously and two other mutations that have never been described before in connection with NSCLC tumours. Chemosensitivity data, according to a short-term assay (FMCA), indicated that tumours with p53 mutation were more resistant to cisplatin and cyclophosphamide. Immunohistochemical studied demonstrated a 70% concordance between over-expression of p53 protein and mutation in p53. No conclusions or trends could be drawn from the immunohistochemical studies of Bcl-2 and Bax.

Evaluation of radiation-induced DNA damage and DNA repair in human lung cancer cell lines with different radiosensitivity using alkaline and neutral single cell gel electrophoresis

Using the comet assay, radiation-induced DNA strand breaks were evaluated in human lung cancer cell lines with different radiosensitivity (U-1285, U-1906E, U-1752 and U-1810). Single strand breaks were more sensitive indicators of the radiation-induced damage than double strand breaks. However, there was no consistent pattern in the way the various cell lines responded to 1-5 Gy of gamma-irradiation and all cell lines showed a remarkably efficient DNA repair after 1 h. In a separate study of the repair kinetics of DNA double strand breaks, the radioresistant cell line U-1810 showed a more efficient initial strand rejoining than the radiosensitive cell line U-1285 after irradiation at 2 Gy. The latter finding suggests that the detection of early DNA repair may be useful when monitoring the intrinsic radiosensitivity of human lung cancer cells.

P53 auto-antibodies in non-small cell lung cancer patients can predict increased life expectancy after radiotherapy

BACKGROUND

In this study we investigated whether the presence of p53 antibodies in sera before of during/after radiation therapy can predict increased survival in patients with non-small cell lung cancer.

PATIENTS AND MATERIALS

Sera from 67 patients with a histopathologically confirmed diagnosis of nonsmall cell lung cancer have been investigated using sandwich ELISA (Dianova, Hamburg, Germany). Sera was collected before or during/after radiation therapy.

RESULTS

Antibodies were detected in 18 (27%) patients. 46/67 (69%) of the sera had been taken before start of radiation therapy and the presence of p53 antibodies was a statistically significantly good prognostic factor in terms of increased survival (p = 0.025).

CONCLUSION

p53 antibodies in sera, before the start of radiation therapy, can predict increased survival after radiation treatment in patients with non-small cell lung cancer.

Irradiation of brain metastases from lung cancer: a retrospective study

A total of 94 patients with brain metastases from lung carcinomas were treated with irradiation of their brain metastases. Two fractionation schedules were applied, a non-conventional one (76 patients) mixing hypofractionation and accelerated hyperfractionation to a total dose of 47 Gy and a conventional one (18 patients), with 3 Gy once a day to a total dose of 30 or 36 Gy. No benefit was found for the non-conventional treatment schedule over the conventional one. A difference in survival was demonstrated between patients whose brain metastases originated from adenocarcinoma or squamous cell carcinoma of the lung with a median survival of 3.5 and 1.9 months, respectively (P = 0.006). Median survival of patients with brain metastases from small cell lung cancer (SCLC) was 2.8 months, and when compared with the squamous cell carcinoma group, there was no statistically improved survival (P = 0.12). There were indications of a better palliative effect in adenocarcinomas compared with squamous or large cell carcinomas. In a few patients (1/22 adenocarcinoma and 7/32 SCLC), the patients were free from malignant cells in the brain at autopsy, demonstrating that irradiation of brain metastases might be efficient in certain patients.

Basic fibroblast growth factor and vascular endothelial growth factor in sera from non-small cell lung cancer patients

BACKGROUND

The formation of new microvessels from the existing vascular bed is known as angiogenesis and is normally under the tight regulatory control of angiogenic factors. This control is lost in malignant tumours. Previous studies have correlated increased microvessel density with poor prognosis in patients with primary lung cancer.

MATERIALS AND METHODS

Our group measured levels of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in sera from 68 patients with non-small cell lung cancer (NSCLC) and compared elevated levels of VEGF and bFGF with clinical outcome. Serum basic FGF and VEGF were measured using commercially available enzyme- linked immunosorbent assays (R & D Systems Inc., Minneapolis, MN USA).

RESULTS

In 26/68 (38%) patients we found that elevated circulating levels of bFGF and in 27/68 (39%) serum samples levels of VEGF were elevated. Elevated bFGF values in sera was a statistically significant good prognostic factor, p- value = 0.048, when adjusted to stage and there was a trend in that patients with elevated levels of bFGF had a higher fraction of adenocarcinomas compared with squamous epithelial carcinomas (chi 2 = 2.0). No significant correlations could be demonstrated when elevated levels of VEGF in serum was present. Elevated levels of both VEGF and bFGF was present in 45% of the patients.

CONCLUSIONS

We found that elevated levels of bFGF is a good prognostic factor when measured in sera from NSCLC patients. As this result disagrees with earlier studies on other malignancies the results from our study needs to be further investigated in a prospective study.