A Cytosol-Localized Geranyl Diphosphate Synthase from Lithospermum erythrorhizon and Its Molecular Evolution

Geranyl diphosphate (GPP) is the direct precursor of all monoterpenoids and is the prenyl source of many meroterpenoids, such as geranylated coumarins. GPP synthase (GPPS) localized in plastids is responsible for providing the substrate for monoterpene synthases and prenyltransferases for synthesis of aromatic substances that are also present in plastids, but GPPS activity in Lithospermum erythrorhizon localizes to the cytosol, in which GPP is utilized for the biosynthesis of naphthoquinone pigments, which are shikonin derivatives. This study describes the identification of the cytosol-localized GPPS gene, LeGPPS, through EST- and homology-based approaches followed by functional analyses. The deduced amino acid sequence of the unique LeGPPS showed greater similarity to that of farnesyl diphosphate synthase (FPPS), which generally localizes to the cytosol, than to plastid-localized conventional GPPS. Biochemical characterization revealed that recombinant LeGPPS predominantly produces GPP along with a trace amount of FPP. LeGPPS expression was mainly detected in root bark, in which shikonin derivatives are produced, and in shikonin-producing cultured cells. The GFP fusion protein in onion (Allium cepa) cells localized to the cytosol. Site-directed mutagenesis of LeGPPS and another FPPS homolog identified in this study, LeFPPS1, showed that the His residue at position 100 of LeGPPS, adjacent to the first Asp-rich motif, contributes to substrate preference and product specificity, leading to GPP formation. These results suggest that LeGPPS, which is involved in shikonin biosynthesis, is recruited from cytosolic FPPS and that point mutation(s) result in the acquisition of GPPS activity.

Association of immunoglobulin G4 and free light chain with idiopathic pleural effusion

The cause of pleural effusion remains uncertain in approximately 15% of patients despite exhaustive evaluation. As recently described immunoglobulin (Ig)G4-related disease is a fibroinflammatory disorder that can affect various organs, including the lungs, we investigate whether idiopathic pleural effusion includes IgG4-associated etiology. Between 2000 and 2012, we collected 830 pleural fluid samples and reviewed 35 patients with pleural effusions undiagnosed after pleural biopsy at Yamaguchi-Ube Medical Center. Importantly, IgG4 immunostaining revealed infiltration of IgG4-positive plasma cells in the pleura of 12 patients (34%, IgG4⁺ group). The median effusion IgG4 level was 41 mg/dl in the IgG4⁺ group and 27 mg/dl in the IgG4^- group (P < 0·01). The light and heavy chains of effusion IgG4 antibodies of patients in the IgG4⁺ group were heterogeneous by two-dimensional electrophoresis, indicating the absence of clonality of the IgG4 antibodies. Interestingly, the κ light chains were more heterogeneous than the λ light chains. The measurement of the κ and λ free light chain (FLC) levels in the pleural fluids showed significantly different κ FLC levels (median: 28·0 versus 9·1 mg/dl, P < 0·01) and κ/λ ratios (median: 2·0 versus 1·2, P < 0·001) between the IgG4⁺ and IgG4^- groups. Furthermore, the κ/λ ratios were correlated with the IgG4⁺ /IgG⁺ plasma cell ratios in the pleura of the IgG4⁺ group. Taken together, these results demonstrate the involvement of IgG4 in certain idiopathic pleural effusions and provide insights into the diagnosis, pathogenesis and therapeutic opportunities of IgG4-associated pleural effusion.

A phase II trial of combination chemotherapy with irinotecan and amrubicin in pretreated patients with non-small cell lung cancer

18111

Background: Amrubicin, a totally synthetic anthracycline, is a topoisomerase II inhibitor and highly effective for non-small cell lung cancer (NSCLC) as a single agent with response rates of 25% to 28%. We previously conducted a phase I trial of combination chemotherapy with irinotecan and amrubicin for NSCLC and found acceptable toxicity profiles with a favorable efficacy in patients with pretreated NSCLC. The aim of this phase II trial was to further evaluate its efficacy and toxicity in this population. Methods: Primary endpoint was objective response. Patients with NSCLC previously treated with one or two chemotherapy regimens were enrolled in this trial. Irinotecan and amrubicin were both administered on days 1 and 8, every 3 weeks at doses of 100 and 40 mg/m2, respectively. Response and toxicity were assessed according to the RECIST guideline and NCI Common Terminology Criteria for Adverse Events v3.0. Results: Thirty-one pretreated NSCLC patients were enrolled between 2004 and 2006. A median number of courses administered was 3 (range: 1 to 6). All patients and courses were assessable for efficacy and safety. Demographics of the patients were as follows: M/F: 21/10, Ad/others: 21/10, ECOG-PS 0/1: 12/19, and smoker/non-smoker: 21/10. Platinum-based regimens were commonly used as the prior chemotherapy. Objective response was obtained in 9 of the 31 patients with a response rate of 29.0% (95%CI: 12.1–46.0%). Grade 4 leukopenia and neutropenia were observed in 6 (19%) and 14 (45%) patients, respectively, whereas thrombocytopenia were generally mild. Grade 3 febrile neutropenia was observed in 7 patients (23%), of whom two patients further developed Grade 4 and 5 septic shock each. Other grade 3 or greater non-hematological toxicities included diarrhea, vomiting, pneumonitis, liver dysfunction in 4, 1, 1 and 2 patients, respectively. At the time of this analysis with a median follow-up time in the surviving patients of 7.5 months, median survival time and median progression-free survival time were 11.9 and 4.0 months, respectively. Conclusion: This combination seemed highly effective for pretreated NSCLC despite the moderate toxicity profiles. Development of efficient patient selection is needed to avoid the serious toxicities.

No significant financial relationships to disclose.

Second primary cancer in survivors following concurrent chemoradiation for locally advanced non-small-cell lung cancer

Long-term cancer survivors risk development of second primary cancers (SPC). Vigilant follow-up may be required. We report outcomes of 92 patients who underwent chemoradiation for unresectable stage III non-small-cell lung cancer, with a median follow-up of 8.9 years. The incidence of SPC was 2.4 per 100 patient-years (95% confidence interval: 1.0–4.9).

Role of early serial change in serum carcinoembryonic antigen levels as a predictive marker for gefitinib sensitivity in Japanese patients with non-small cell lung cancer

17029

Background: The aim was to evaluate the utility of an early change in CEA levels for predicting subsequent gefitinib sensitivity in NSCLC patients. Methods: CEA level was measured before and after the beginning of gefitinib treatment (day1) in 110 (91%) of consecutive 121 patients. Daily decline rate of CEA was simply defined for each patient as follows: (M0−Mx)/Dx/M0*100(%), with the baseline level (M0), the level on days × (Mx), and days from day 1 to day X (Dx). Results: Patient characteristics were as follows; median age: 62, M/F: 61/39%, Ad/others: 84/16% and smoker: 66%. Objective response rate and disease control rate were 28.2% and 74.5%, respectively. Median baseline CEA level was 12.6 ng/mL. Daily decline rate of CEA level from day 1 to the date on which confirmation of objective response was performed significantly differed among the response categories; median decreases in percentages were 0.86, 0.06, and −1.52%/day in CR/PR, SD, and PD patients, respectively (p < 0.0001). This association was more evident in the 70 patients with abnormal baseline CEA level (≥5.0 ng/mL). A cutoff level of −0.58% decrease per day most accurately reflected tumor shrinkage in the 70 patients, with sensitivity, specificity, and positive and negative predictive values for disease control (CR/PR/SD) of 89.1, 73.3, 92.5 and 64.7%, respectively. Among 49 (41%) patients reassessed CEA levels within the first 2 weeks since day 1, 41 could continue the treatment without any disease progression during this period. The daily decline rate in this early phase tended to differ between the responses (median; 1.57 and −0.50% in CR/PR/SD and PD, respectively; p = 0.0975), and less exactly reflected disease control with sensitivity, specificity, and positive and negative predictive values of 82.1, 40.0, 88.5, and 28.6%, respectively when a cutoff of −0.58% was applied. Conclusion: Degree of change in CEA level from the start of gefitinib treatment to confirmation of objective response significantly correlated with tumor shrinkage. As a predictor for obtaining disease control, monitoring early change in CEA level might be useful due to high sensitivity and positive predictive value, in spite of low specificity for detection of PD patients.

No significant financial relationships to disclose.

Randomized phase III trial of docetaxel and cisplatin combination chemotherapy versus mitomycin, vindesine and cisplatin combination chemotherapy with concurrent thoracic radiation therapy for locally advanced non-small cell lung cancer: Preliminary report

7101

Background: Standard treatment of locally advanced non-small cell lung cancer (NSCLC) is cisplatin-based chemotherapy with concurrent thoracic radiation therapy (TRT). Furuse et al. demonstrated a superiority of mitomycin, vindesine and cisplatin (MVP) chemotherapy with concurrent TRT over that with sequential TRT (JCO 17, 1999). We demonstrated that docetaxel plus cisplatin (DP) chemotherapy with concurrent TRT shows better response rate and survival (Kiura K et al. BJC 89, 2003). We conducted a randomized phase III trial that compared DP with MVP in locally advanced NSCLC patients when concurrently administered with TRT. Methods: We randomly assigned patients with good performance status (PS)-stage IIIA/IIIB NSCLC to receive DP or MVP chemotherapy. Chemotherapy consisted of docetaxel 40 mg/m2 and cisplatin 40 mg/m2 on days 1, 8, 29, & 36 in the DP arm and mitomycin 8 mg/m2 on days 1 & 29, vindesine 3 mg/m2 on days 1, 8, 29, & 36, and cisplatin 80 mg/m2 on days 1 & 29 in the MVP arm. In the both groups, TRT began on day 1 at a dose of 60 Gy (2 Gy per fraction and 5 fractions per week for a total of 30 fractions). Results: Two hundred patients entered the trial between July 2000 and July 2005. Pretreatment characteristics were well balanced between the two treatment arms as follows: male/female 92/7, 88/13; median age (range) 65 (40–75), 64 (34–75); stage IIIA/IIIB 33/66, 33/68; and PS of 0/1 46/53, 50/51, for the DP arm and for the MVP arm, respectively. The response rates for the DP arm and the MVP arm were 78.8% and 70.3%, respectively. The 1- and 2-year survival rates were 81.8% and 59.9% for the DP arm, and were 68.8% and 49.1% for the MVP arm, respectively. Median follow up time is 1.4 years in January 2006. Complete analysis will be fixed in July 2007. Conclusions: The DP arm is exactly reproducing the response rate and survival of the phase II trial we have previously reported. The MVP arm seems to reveal better results than that we expected. Radiation dose and schedule might explain the difference because Furuse et al. splitted 56 Gy of TRT in the MVP arm whereas we did not split 60 Gy of TRT.

No significant financial relationships to disclose.

Secondary primary cancer in the long-term survivors with concurrent chemoradiotherapy for locally advanced non-small cell lung cancer

7147

Background: Although concurrent chemoradiotherapy (CT/RT) is associated with increased survival for patients (pts) with locally advanced non-small cell lung cancer (NSCLC), long-outcomes beyond 5 years have not been fully analyzed. Methods: Between 1994 and 1999, we conducted two phase II studies examining concurrent CT/RT for treatment of surgically unresectable stage IIIA or IIIB NSCLC. One regimen consisted of three cycles of 5-fluorouracil 500mg/m2 and cisplatin 20mg/m2, days 1–5, every 4 weeks and concurrent hyperfractionated thoracic RT (1.25Gy twice daily, total 62.5–70Gy) [FP-TRT] (Segawa et al. BJC 82, 2000). The other consisted of docetaxel 40mg/m2 and cisplatin 40mg/m2, days 1, 8, 29 and 36 and concurrent thoracic RT (2Gy daily, total 60Gy) [DP-TRT] (Kiura et al. BJC 89, 2003). Long-term data is presented. Results: In 50 pts treated with FP-TRT, the median survival time (MST) was 1.6 years (yr; 95% confidential interval [CI]: 0.91 - 2.25 yr) by a median follow-up time of 10.4 yr and the actual 5 yr-survival rate was 30%. In 15 long-term survivors, 3 and 2 pts died due to primary NSCLC and secondary primary cancer (SPC), respectively, 1 was lost to follow-up, and 9 are still alive. In 42 pts treated with DP-TRT, the MST was 2.1 yr (95% CI: 0.82 - 2.48 yr) by a median follow-up time of 6.3 yr and the actual 5 yr-survival rate was 31%. In 13 long-term survivors, 1 pt died due to primary NSCLC, 1 died due to SPC, 1 was lost to follow-up, and 10 are still alive. Overall, 7 of 92 pts enrolled in these studies developed SPCs (2 NSCLC, 1 small cell lung cancer, 2 esophageal cancers, 2 gall bladder cancers) although no pts developed leukemia or myelodysplastic syndrome. An observed incidence rate of SPCs was 2356.1/100,000 (95% CI: 947.6 - 4856.0). Cumulative incidence was 5.8% (standard error [SE] 4.0%) at 5 yr, 10.0% (SE 5.6%) at 8 yr and 60.8% (SE 18.9%) at 10 yr. The median time from the beginning of CT/RT to the diagnosis of SPC was 9.6 yr (95% CI: 8.1 - 11.1 yr). Conclusions: Approximately 30% of pts survived more than 5 years after concurrent CT/RT, however, they were still at risk of dying from primary NSCLC. Occurrence of SPC in long-term survivors should be concerned in follow-up.

No significant financial relationships to disclose.

Use of epigenetic aberrant promoter methylation in serum DNA for detection of pneumoconiosis-associated lung cancer

20059

Background: Pneumoconiosis is known to be associated with an independent increased risk of lung cancer. However, it is difficult to detect lung cancer radiographically in patient with pneumoconiosis because of pre-existing diffuse pulmonary shadows. The purpose of this study is to evaluate the usefulness of serum DNA methylation for detection of pneumoconiosis-associated lung cancer. Methods: We investigated to identify promoter methylation status of RAR-beta, p16INK4a, MGMT, DAPK, and RASSFIA gene in serum DNA using methylation-specific PCR. Sera were obtained from 31 control patients with non-malignant-non-pneumoconiotic pulmonary disease (Group I), 36 with pneumoconiosis (Group II), and 5 with pneumoconiosis-associated lung cancer (Group III). DNA was extracted using QIAamp DNA Blood Midi Kit (Qiagen, CA). Following DNA bisulfite modification using CpGenome DNA Modification Kit (Intergen, NY), PCR was performed with primers for methylated or unmethylated promoter sequences. Results: Median (range) age of patients were 61 (26–78), 71 (49–86), and 69 (56–78) for Group I, II, and III respectively. Median (range) duration of silica and asbestos exposure were 33 (3–47) years and 33(32–40) years for Group II and III respectively. All of 5 pneumoconiosis-associated lung cancer were adenocarcinoma. Eleven patients (35.5%) in Group I, 19 patients (52.8%) in Group II, and 5 patients (100%) in Group III were shown to have methylation of at least one gene. The total number of methylated genes per patient were, 0.35, 0.69, and 1.20 for groups I, II, and III respectively (p = 0.013, Kruskal-Wallis analysis). In Group II, methylation status did not correlate with duration of occupational exposure, smoking history, radiographic findings, and age. Conclusions: In patients with pneumoconiosis, monitoring of aberrant promoter methylation of serum DNA might be useful for assessing the risk of lung cancer and early detection of lung cancer.

No significant financial relationships to disclose.

Evidence against a role for simian virus 40 in malignant mesothelioma in Japan

10040

Background: Malignant mesothelioma is a highly aggressive tumor arising from serosal membranes, most commonly the pleura. Worldwide incidence is increasing because of widespread exposure to asbestos, the major causal agent. Incidence of this disease also is increasing dramatically in Japan. Association of simian virus 40 (SV40) with malignant mesothelioma has been reported, suggesting that SV40 plays an important role in the origin of a subset of these tumors. Most recently, evidence against any role for SV40 in this disease has been also reported. The role of SV40 in malignant mesothelioma remains still controversial. In addition, it has been argued that differences in the reported frequency of SV40 detection in malignant mesothelioma may be related to geographic variation in populations exposed to the virus. Whether SV40 is associated with malignant mesothelioma in Japan therefore is an important issue. However, no study concerning SV40 in malignant mesothelioma has been reported from Japan. Methods: To address this, we studied 35 malignant mesotheliomas including 32 men and 3 women with a median age of 61 years (ranges 34 to 85) and examined the presence of SV40 large T antigen DNA with real time PCR based on TaqMan technology using primers that PCR amplified a specific 156-bp region of the large Tag of SV40 as well as its expression with immnohistological methods using anti-SV40 large T antigen antibody (pAb101, Santa Cruz Biotechnology, Inc., CA). Results: Two of 35 mesotheliomas were considered positive for the presence of SV40 large T antigen DNA, showing ratios of 36.0 and 4.9. The ratio in the positive control was 199.0. The two positive cases consisted of one epithelioid tumor and one biphasic tumor. In addition, none of 35 malignant mesothelioma specimens were positve for staining with SV40 large T antigen antibody; in contrast, diffuse staining for SV40 large T antigen was observed in the cytoplasm and on the cell membranes in the positive control. Conclusions: Taken together, these findings strongly argue against any role of SV40 in the etiology of the majority of malignant mesothelioma in Japan.

No significant financial relationships to disclose.

Clinical factors affecting the late resistance to gefitinib in patients with non-small cell lung cancer (NSCLC)

7191

Background: The mechanism of late resistance of NSCLC to gefitinib is unclear. In this study, we assessed clinical factors affecting the late resistance in patients with NSCLC. Methods: Between 2000 and 2004, 197 consecutive patients with NSCLC underwent treatment with gefitinib in our institutions. Of those, 56 patients who had received a prior chemotherapy and continued treatment with gefitinib during at least 6 months were included in this study. The characteristics of these patients were as follows: median age, 62.5 years (range, 28 to 77 years); male/female, 22/34 patients; PS 0/1/2/3/4, 15/31/8/0/2 patients; and adeno/nonadenocarcinoma, 52/4 patients. Thirty-two patients never smoked and 24 were former or current smokers. Nineteen patients underwent surgical resection of NSCLC. Numbers of chemotherapy regimens were one in 31 patients, two in 18, three in 6, four in 1, respectively. Results: Of 56 patients, three achieved a CR and 39 attained a PR, with an overall response rate of 75% (95% CI, 69.2 to 80.8%). The remaining 14 patients had a long SD. At a median follow-up time of 21.6 months (range, 7.7 to 59.7 months), median time to progression was 19.5 months, with progression-free survival rates of 68.5% at 1-year, 33.6% at 2-year, and 21.2% at 3-year, respectively. In a univariate analysis regarding progression-free survival, presences of metastasis to brain (p = 0.008), bone (p = 0.025), liver (p = 0.046), and adrenal (p = 0.008), decreased levels of hemoglobin (p = 0.021) and albumin (p = 0.017), and use of multiple chemotherapy regimens prior to treatment with gefitinib (p = 0.026) were significant factors. In a multivariate analysis using Cox proportional hazard model, presence of brain metastasis was a significant factor clinically affecting the late resistance to gefitinib (hazard ratio, 2.14; 95% CI, 1.10 to 4.17, p = 0.025). In addition, decreased hemoglobin level (p = 0.074) and prior multiple chemotherapy regimens (p = 0.069) were tended to be significant. Conclusions: In patients undergoing treatment with gefitinib, presence of brain metastasis was an important factor indicative of the emergence of late resistance in this study. It is needed to confirm this finding in a large cohort of patients with NSCLC.

No significant financial relationships to disclose.

Continued gefitinib treatment after disease stabilisation prolongs survival of Japanese patients with non-small-cell lung cancer: Okayama Lung Cancer Study Group experience

BACKGROUND

This study aimed to investigate the survival outcome of patients with non-small-cell lung cancer (NSCLC) who had obtained disease stabilisation with gefitinib treatment and to clarify the effect of continued treatment with gefitinib on prognosis.

PATIENTS AND METHODS

We reviewed the clinical records of 365 Japanese patients with NSCLC who received gefitinib (250 mg/day).

RESULTS

Of 324 (89%) patients assessable for response, 147 (45%) obtained disease stabilisation and 71 (22%) patients achieved an objective response. Overall survival in patients obtaining disease stabilisation was significantly longer than in patients with progressive disease (median survival time 12.1 versus 4.4 months; P <0.0001). In patients obtaining disease stabilisation, those who continued gefitinib treatment until disease progression tended to have longer overall and progression-free survival compared with those discontinuing gefitinib treatment (1-year survival rate 52.1% versus 36.6%, P = 0.08; 1-year progression-free survival rate 31.8% versus 5.2%, P = 0.001). Multivariate analysis showed discontinuing gefitinib was an independent risk factor for progression-free survival (hazard ratio 1.66; 95% confidence interval 1.07-2.56; P = 0.022) but not for overall survival.

CONCLUSIONS

Our findings indicate the importance of achieving disease stabilisation with gefitinib treatment and continued gefitinib treatment in Japanese patients with disease stabilisation, although further studies are required to confirm these findings.

Addition of platinum compounds to a new agent in patients with advanced non-small-cell lung cancer: a literature based meta-analysis of randomised trials

BACKGROUND

Single new agents reportedly produce promising response and survival effects, but platinum-based doublets remain the standard chemotherapy for advanced non-small-cell lung cancer (NSCLC). The aim of this study was to evaluate the effectiveness of platinum for advanced NSCLC by carrying out a meta-analysis of trials that compared platinum-based doublets with single new agent therapy alone.

METHODS

We carried out a literature search to identify trials, conducted between 1994 and 2003, comparing a doublet of platinum plus a new agent with a new agent alone in previously untreated patients with advanced NSCLC. Outcomes analysed were response, survival and toxicity.

RESULTS

Eight trials encompassing 2374 patients were identified. Platinum-based doublets produced an approximately two-fold higher overall (complete and partial) response rate than the new agent alone [odds ratio = 2.32; 95% confidence interval (CI)=1.68-3.20]. Platinum-based doublet therapy was also associated with a 13% prolongation of survival (hazard ratio = 0.87; 95% CI = 0.80-0.94, P <0.001). Despite significant increases in the frequencies of various toxic effects in patients receiving platinum-based doublets, no significant difference in treatment-related mortality was observed.

CONCLUSION

This is the first published meta-analysis demonstrating the importance of combining platinum with single new agents in the treatment of advanced NSCLC.

Preoperative concurrent chemoradiotherapy with cisplatin and docetaxel in patients with locally advanced non-small-cell lung cancer

The objective of this study was to assess the feasibility and effectiveness of an induction chemoradiotherapy regimen followed by surgery in patients with locally advanced non-small-cell lung cancer (LA-NSCLC). A total of 22 patients with LA-NSCLC were treated with induction chemoradiotherapy consisting of cisplatin (40 mg m⁻²) and docetaxel (40 mg m⁻²) given on days 1, 8, 29 and 36 plus concurrent thoracic irradiation at a dose of 40–60 Gy (2 Gy fraction⁻¹ day⁻¹). Surgical resection was performed within 6 weeks after completion of induction therapy. Objective response to the induction therapy was obtained in 16 patients (73%). In all, 20 patients (91%) underwent surgery and complete resection was achieved in 19 patients (86%). Pathological downstaging and pathological complete response were obtained in 14 (64%) and five (23%) patients, respectively. With a median follow-up period of 32 months, the calculated 3-year overall and progression-free survival rates were 66 and 61%, respectively. It is noteworthy that the 3-year overall survival rate in 14 patients achieving pathological downstaging was extremely high (93%). Toxicity was manageable with standard approaches. No treatment-related deaths occurred. This combined modality treatment is feasible and highly effective in patients with LA-NSCLC. The results warrant further large-scale study to confirm the effectiveness of this regimen.

Evaluation of various cytological examinations by bronchoscopy in the diagnosis of peripheral lung cancer

To improve the efficacy of fibreoptic bronchoscopy in the diagnosis of peripheral lung cancer, we evaluated the effectiveness of various techniques for obtaining samples for cytological examination. Between January 1984 and December 2000, flexible fibreoptic bronchoscopy under fluoroscopic guidance was performed in 1372 patients with lung cancer having no visible endoscopic findings. Histological examination of specimens obtained by forceps biopsy and cytological examinations on imprints of biopsy specimens, brushing, selective bronchial lavage, curettage, transbronchial needle aspiration, rinse fluids of the forceps, brush, curette, and aspiration needle, and all fluids aspirated during the bronchoscopic examinations were evaluated for diagnostic power. Using these techniques, the overall diagnostic rate with bronchoscopy was 93.4%. The sensitivity of the histological examination was 76.9%; additional imprint cytology increased the sensitivity to 84.8% (P<0.0001), while additional cytology on the rinse fluid of the forceps increased the sensitivity to 83.7% (P<0.0001). The addition of both imprint cytology and cytology on the rinse fluid of the forceps increased the diagnostic rate to 86.2% (P<0.0001). Our results indicate that cytological examinations of the imprints of biopsy samples and the rinse fluids of the forceps and the brush improve the efficacy of fibreoptic bronchoscopy in the diagnosis of peripheral lung cancer.

Phase I/II study of docetaxel and cisplatin with concurrent thoracic radiation therapy for locally advanced non-small-cell lung cancer

Recent studies have suggested the superiority of concomitant over sequential administration of chemotherapy and radiotherapy. Docetaxel and cisplatin have demonstrated efficacy in advanced non-small-cell lung cancer (NSCLC). This study evaluated the safety, toxicity, and antitumour activity of docetaxel/cisplatin with concurrent thoracic radiotherapy for patients with locally advanced NSCLC. Patients with locally advanced NSCLC (stage IIIA or IIIB), good performance status, age <or=75 years, and adequate organ function were eligible. Both docetaxel and cisplatin were given on days 1, 8, 29, and 36. Doses of docetaxel/cisplatin (mg m(-2)) in the phase I study portion were escalated as follows: 20/30, 25/30, 30/30, 30/35, 30/40, 35/40, 40/40, and 45/40. Beginning on day 1 of chemotherapy, thoracic radiotherapy was given at a total dose of 60 Gy with 2 Gy per fraction over 6 weeks. In the phase I portion, the maximum tolerated doses (MTD) among 33 patients were docetaxel 45 mg m(-2) and cisplatin 40 mg m(-2). The major dose-limiting toxicity (DLT) was radiation oesophagitis. The recommended doses (RDs) for the phase II study were docetaxel 40 mg m(-2) and cisplatin 40 mg m(-2). A total of 42 patients were entered in the phase II portion. Common toxicities were leukopenia, granulocytopenia, anaemia, and radiation oesophagitis, with frequencies of grade >or=3 toxicities of 71, 60, 24, and 19%, respectively. Toxicity was significant, but manageable according to the dose and schedule modifications. Dose intensities of docetaxel and cisplatin were 86 and 87%, respectively. Radiotherapy was completed without a delay in 67% of 42 patients. The overall response rate was 79% (95% confidence interval (CI), 66-91%). The median survival time was 23.4+ months with an overall survival rate of 76% at 1 year and 54% at 2 years. In conclusion, chemotherapy with cisplatin plus docetaxel given on days 1, 8, 29, and 36 and concurrent thoracic radiotherapy is efficacious and tolerated in patients with locally advanced NSCLC and should be evaluated in a phase III study.

Preoperative induction chemotherapy with cisplatin and irinotecan for pathological N(2) non-small cell lung cancer

We conducted a phase I/II study to investigate whether the surgical resection after induction chemotherapy with cisplatin and irinotecan was feasible and could improve the treatment outcome for patients with pathological N(2) non-small cell lung cancer. Fifteen patients with stage IIIA non-small cell lung cancer having mediastinal lymph node metastases proved by mediastinoscopy were eligible. Both cisplatin (60 mg m(-2)) and irinotecan (50 mg m(-2)) were given on days 1 and 8. Patients received two cycles of chemotherapy after 3-4 weeks interval. Induction was followed by surgical resection in 4-6 weeks. Patients who had documented tumour regression after preoperative chemotherapy received two additional cycles of chemotherapy and other patients received radiotherapy postoperatively. After the induction chemotherapy, the objective response rate was 73%. All the 15 patients received surgical resection and complete resection was achieved in 11 (73%) patients. There was no operation-related death and one death due to radiation pneumonitis during postoperative radiotherapy. The median time from entry to final analysis was 46.5 months, ranging from 22 to 68 months. The 5-year survival rate was 40% for all the 15 patients and it was 55% for the 11 patients who underwent complete resection. We conclude that the surgical resection after induction chemotherapy with cisplatin and irinotecan is feasible, and associated with low morbidity and high respectability.

A case-control study of lung cancer screening in Okayama Prefecture, Japan

The effectiveness of lung cancer screening in reducing mortality still remains uncertain. In order to evaluate the efficacy of lung cancer screening, a case-control study was conducted in Okayama Prefecture, Japan. The study area consisted of 34 municipalities where a population-based lung cancer screening had been conducted. Chest X-ray examinations for all participants and sputum cytology for high-risk participants were offered annually. The cases analyzed in this study consisted of 412 individuals aged between 40 and 79 who died of lung cancer. A total of 3490 controls, two to ten for each case matched by gender, year of birth, and living district were randomly collected. Screening histories of cases were compared with those of and matched controls for the identical calendar period prio to diagnosis of the case. Smoking adjusted odds ratio (OR) of death from lung cancer for screened individuals versus unscreened, within 12 months before diagnosis, was calculated as 0.59 (95% confidence interval: 0.46-0.74; P=0.0001). The OR for women (0.39, 95% confidence interval: 0.24-0.64) was lower than that for men (0.67, 95% confidence interval: 0.51-0.87), although both were statistically significant. These results suggest that lung cancer screening contributes to reducing lung cancer mortality by 41%.

Metastasis to the penis in a patient with squamous cell carcinoma of the lung with a review of reported cases

Metastasis to the penis is very rare in lung cancer. We describe a patient with squamous cell carcinoma of the lung who developed a metastatic lesion in the penis. A 75-year-old Japanese male visited a local hospital complaining cough and bloody sputum. A chest plain radiograph and computed tomographic (CT) scans of the chest demonstrated a right hilar mass. He was diagnosed with squamous cell carcinoma of the lung at stage IIIB (T4N2M0). Then he was treated with concurrent chemoradiotherapy consisting of cisplatin, docetaxel, and thoracic irradiation, and after the chemoradiotherapy, he achieved a partial response. However, 6 months later, he visited an urologist complaining of firm mass in the penis with slight pain. A biopsy of the corpus cavernosum penis was performed, which provided a histological diagnosis of squamous cell carcinoma. The histology of the specimen was consistent with that of previous lung cancer, so he was considered to have penile metastasis from squamous cell carcinoma of the lung. Radiotherapy was given to the metastatic tumor in the penis. The penile tumor was diminished and the pain was completely relieved. In addition, we review reported cases to investigate the clinical characteristics and appropriate management of this rare involvement.

Successful treatment with concurrent chemoradiotherapy followed by surgery for a patient with thymic adenocarcinoma

Most neoplasms arising from the thymic epithelium are considered to be 'thymomas', which are composed of cytologically benign, neoplastic epithelial cells and nonneoplastic lymphocytes. In contrast, thymic epithelial neoplasms displaying cytologically malignant features have recently been classified as thymic carcinomas of various types of histology. However, primary thymic adenocarcinoma is extremely rare and only four cases of it have been reported in the literature. We report a rare case of primary thymic adenocarcinoma of 4-year complete remission with concurrent chemoradiotherapy followed by surgery. A 61-year-old Japanese man was referred to us complaining of facial edema and general fatigue. Computed tomography scans revealed a huge mass in the anterior mediastinum obstructing the superior vena cava. He was diagnosed with thymic adenocarcinoma on needle biopsy. He was treated with induction chemoradiotherapy consisting of cisplatin, 5-FU and concurrent thoracic radiation, which yielded a partial response. He then underwent surgical resection of the remaining mass. However, pathologic examination of the resected mass revealed no malignant cells. The patient is doing well without symptoms or signs of relapse 53 months after diagnosis.

Fractionated administration of irinotecan and cisplatin for treatment of non-small-cell lung cancer: a phase II study of Okayama Lung Cancer Study Group

A phase II study of fractionated administration of irinotecan (CPT-11) and cisplatin (CDDP) in patients with non-small-cell lung cancer (NSCLC) was conducted. Between January 1996 and January 1998, 44 previously untreated patients with stage IIIB or IV NSCLC were enrolled. CDDP at a dose of 60 mg x m(-2) was given first and followed by CPT-11 at a dose of 50 mg x m(-2). Both drugs were given by 1-hour infusion on days 1 and 8, and repeated every 4 weeks up to 4 cycles. 42 patients were evaluated for response and 44 for survival and toxicity. 20 patients (48%: 95% confidence interval 32-63%) achieved an objective response. The median duration of responses was 8 months, and the median survival time and the 1-year survival rate were 12.5 months and 56.8%, respectively. Major toxicities were neutropenia and diarrhoea. Grade 3 or 4 neutropenia occurred in 70.5% of the patients and one patient died of sepsis. Grade 3 or 4 diarrhoea was experienced in 25.0%, but manageable by conventional therapy. In conclusion, fractionated administration of CPT-11 and CDDP was highly effective for advanced NSCLC with manageable toxicities.

Generation of cytotoxic T lymphocytes against autologous lung cancer cells resistant to apoptosis

BACKGROUND

[corrected] Non-small cell lung cancer (NSCLC) is resistant to conventional treatment; so the development of a new therapy is urgent.

MATERIALS AND METHODS

50 patients with NSCLC and malignant effusion were enrolled in this study. Seventeen autologous lung cancer cell lines were established. Peripheral lymphocytes and irradiated autologous tumor cell lines were co-cultured to generate cytotoxic T lymphocytes (CTL). Expression of apoptosis-related molecules were analysed by RT-PCR or FACS.

RESULTS

CTL lines were established in 2 patients. Both CTL lines were CD3+, CD8+ and MHC class I-restricted T cells and showed cytotoxic activities not only against autologous tumor cell lines but against allogenic cancer cell lines. Two lung cancer cell lines were established from one patient before and after cisplatin-based chemotherapy. The tumor cell line established after chemotherapy was apoptosis-resistant, but was sensitive to cytotoxicity of CTL.

CONCLUSION

CTL-based immunotherapy may be one of the candidates for future therapies against NSCLC.

Complementary roles of pro-gastrin-releasing peptide (ProGRP) and neuron specific enolase (NSE) in diagnosis and prognosis of small-cell lung cancer (SCLC)

In this study, we evaluated the clinical usefulness of ProGRP and NSE for diagnosis and prognosis of small-cell lung cancer (SCLC). Serum levels of ProGRP and NSE were determined in 108 healthy subjects, 103 patients with benign pulmonary diseases, 142 with non-small cell lung cancer (NSCLC), and 114 with SCLC. Sensitivity of ProGRP in diagnosis of SCLC was significantly higher than that of NSE (64.9 vs. 43.0%, P < 0.001). The difference was substantial in patients with limited disease (56.5 vs. 20.3%, P < 0.001). However, 11 of 40 SCLC patients with normal levels of serum ProGRP (27.5%) showed elevated levels of serum NSE. In the SCLC patients receiving chemotherapy, the CR rate in patients with elevated NSE levels was significantly lower than in patients with normal levels of NSE (18.5 vs. 61.7%, P < 0.001). Elevation of both ProGRP and NSE was a poor prognostic factor, and patients with elevated levels of either ProGRP or NSE showed shorter survival than those without. From multivariate analysis, NSE was found to have a greater effect on survival of SCLC patients than ProGRP. These findings indicate that ProGRP is more sensitive than NSE for diagnosis of SCLC, while NSE is superior to ProGRP as a prognostic factor. In conclusion, both ProGRP and NSE are useful tumor markers and they have a complementary role for each other in diagnosis and prognosis of SCLC.

[Successful treatment of an elderly patient with idiopathic thrombocytopenic purpura accompanied with chronic subdural hematoma, using a Chinese herbal medicine, EK-49, and ascorbic acid]

An 88 year-old woman was admitted complaining of headache. CT scan of the head revealed a right subdural hematoma. She had been followed by a local physician because of chronic thrombocytopenia. Her peripheral platelet count on admission was 0.5 x 10(4)/microliter, with a high serum level of PAIgG. Bone marrow examination revealed marked increase of megakaryocyte. Idiopathic thrombocytopenic purpura(ITP) accompanied with chronic subdural hematoma was diagnosed. Transient increase of platelet count and improvement of subdural hematoma was obtained by administration of prednisolone. However, platelet count decreased with tapering of prednisolone. Then combined administration of a Chinese herbal medicine, EK-49, and ascorbic acid was started. Platelet count gradually increased and no adverse effects were experienced. These results indicated that elderly patients with chronic subdural hematoma can be treated non-invasively, and that a combination of EK-49 and ascorbic acid may be effective in the treatment of refractory ITP.

Combination of nedaplatin and vindesine for treatment of relapsed or refractory non-small-cell lung cancer

PURPOSE

A phase II study of nedaplatin and vindesine was conducted to evaluate their efficacy and safety for treatment of relapsed or refractory non-small-cell lung cancer (NSCLC).

METHODS

Between August 1996 and September 1998, 48 patients who had previously received chemotherapy, thoracic radiotherapy, and/or surgery were enrolled in the study. Patients were required to have an Eastern Cooperative Oncology Group performance status of 0 to 2 and an age between 20 and 79 years. Treatment consisted of nedaplatin (80 mg/m2, day 1) and vindesine (3 mg/m2, days 1 and 8) every 3 to 4 weeks.

RESULTS

Of 48 patients, 7 (14.6%) exhibited an objective response. Four (50%) of eight chemotherapy-naive patients had a partial response. However, of the 40 patients who had received prior chemotherapy, a partial response was observed in only 3 (7.5%). At a median follow-up time of 85.1 weeks, the median survival time was 43.6 weeks (95% confidence interval 34.4-52.7) for patients who had received chemotherapy, with a survival rate of 40% at 1 year. Grade 3 or 4 neutropenia occurred in 43 of 48 patients (90%), and neutropenic fever was observed in 3 of the 43 patients, one of whom died of sepsis. Pharmacokinetic and pharmacodynamic analyses of platinum were performed in 43 patients during the first cycle of chemotherapy. Percent reduction in absolute neutrophil count was correlated not only with the area under the plasma ultrafilterable platinum concentration versus time curve (r = 0.41, P = 0.007) but also with the duration of ultrafilterable platinum concentration above 1 microg/ml (r = 0.41, P = 0.007). Patients with progressive disease exhibited a shorter duration of ultrafilterable platinum concentration over 1 microg/ml (P = 0.046) than those with other responses.

CONCLUSION

A combination of nedaplatin and vindesine was unsatisfactory as second-line chemotherapy for NSCLC, although the combination was well tolerated. The duration of ultrafilterable platinum concentration above 1 microg/ml was an important pharmacokinetic parameter for predicting both chemotherapy-induced neutropenia and treatment outcome.

Polymorphisms of UDP-glucuronosyltransferase gene and irinotecan toxicity: a pharmacogenetic analysis

Irinotecan unexpectedly causes severe toxicity of leukopenia or diarrhea. Irinotecan is metabolized to form active SN-38, which is further conjugated and detoxified by UDP-glucuronosyltransferase (UGT) 1A1 enzyme. Genetic polymorphisms of the UGT1A1 would affect an interindividual variation of the toxicity by irinotecan via the alternation of bioavailability of SN-38. In this case-control study, retrospective review of clinical records and determination of UGT1A1 polymorphisms were performed to investigate whether a patient with the variant UGT1A1 genotypes would be at higher risk for severe toxicity by irinotecan. All patients previously received irinotecan against cancer in university hospitals, cancer centers, or large urban hospitals in Japan. We identified 26 patients who experienced severe toxicity and 92 patients who did not. The relationship was studied between the multiple variant genotypes (UGT1A1*28 in the promoter and UGT1A1*6, UGT1A1*27, UGT1A1*29, and UGT1A1*7 in the coding region) and the severe toxicity of grade 4 leukopenia (< or =0.9 x 10(9)/liter) and/or grade 3 (watery for 5 days or more) or grade 4 (hemorrhagic or dehydration) diarrhea. Of the 26 patients with the severe toxicity, the genotypes of UGT1A1*28 were homozygous in 4 (15%) and heterozygous in 8 (31%), whereas 3 (3%) homozygous and 10 (11%) heterozygous were found among the 92 patients without the severe toxicity. Multivariate analysis suggested that the genotype either heterozygous or homozygous for UGT1A1*28 would be a significant risk factor for severe toxicity by irinotecan (P < 0.001; odds ratio, 7.23; 95% confidence interval, 2.52-22.3). All 3 patients heterozygous for UGT1A1*27 encountered severe toxicity. No statistical association of UGT1A1*6 with the occurrence of severe toxicity was observed. None had UGT1A1*29 or UGT1A1*7. We suggest that determination of the UGT1A1 genotypes might be clinically useful for predicting severe toxicity by irinotecan in cancer patients. This research warrants a prospective trial to corroborate the usefulness of gene diagnosis of UGT1A1 polymorphisms prior tb irinotecan chemotherapy.

Prognostic factors in advanced non-small cell lung cancer: elevated serum levels of neuron specific enolase indicate poor prognosis

BACKGROUND

Non-small cell lung cancer (NSCLC) is resistant to chemotherapy and prognosis of advanced NSCLC patients is considered to be dependent on various prognostic factors.

METHODS

We analyzed prognostic factors in patients with advanced NSCLC who had been enrolled in clinical trials conducted by the Okayama Lung Cancer Study Group between 1978 and 1992 using two kinds of multivariate analysis, Cox's multivariate analysis and recursive partitioning and amalgamation (RPA) analysis.

RESULTS

The first analysis was performed on 261 patients using 28 variables. Performance status (PS), clinical stage, liver metastasis or serum albumin level was an independent prognostic factor by Cox's analysis. In the second analysis performed on 128 patients having data on neuron specific enolase (NSE), NSE was the most important prognostic factor. Using the RPA method, three subgroups with significantly different survival potentials were defined. Among them, patients with normal serum NSE levels and good PS were found to obtain a markedly favorable prognosis [median survival time (MST) 22.1 months, 3-year survival rate 42.9%], whereas the survival of patients with elevated serum NSE levels and bone metastasis was extremely short (MST 4.7 months, 3-year survival rate 0%).

CONCLUSIONS

These results indicate that analysis of prognostic factors including serum levels of NSE is useful for predicting the survival of patients with advanced NSCLC.

Intramedullary spinal cord recurrence after high-dose chemotherapy and autologous peripheral blood progenitor cell transplantation for limited-disease small cell lung cancer

Intramedullary spinal cord metastasis is very rare in small-cell lung cancer (SCLC), and develops in only 2% of neurological disorders associated with SCLC according to previous reports. We describe here a patient with SCLC who developed intramedullary spinal cord recurrence after high-dose chemotherapy (HDCT) followed by autologous blood progenitor cell transplantation (ABPCT). A 59-year-old Japanese male was referred to us for diagnosis and treatment of an abnormal shadow on a chest radiograph. Based on transbronchial biopsy and staging procedures, he was diagnosed with limited-disease (LD)-SCLC. He received concurrent chemoradiotherapy followed by late intensification with HDCT supported by ABPCT. He achieved complete response and was discharged after receiving prophylactic cranial irradiation (PCI). However 6 months later, he noticed rapidly progressive weakness of the left lower extremity and bowel/bladder dysfunction. Magnetic resonance imaging (MRI) of the spinal cord disclosed an intramedullary tumor exhibiting an enhancement effect with Gd-DTPA at the 11-12th level of the thoracic vertebra. Immediately, radiotherapy to the spinal cord metastasis was given at a dose of 30 Gy, and his neurological disorders were completely resolved. At this time of reporting, he is doing well without recurrence. This case indicates that intramedullary spinal cord is one of the recurrence sites implicated after HDCT and PCI in LD-SCLC.