SGSR: style-subnets-assisted generative latent bank for large-factor super-resolution with registered medical image dataset

PURPOSE

We propose a large-factor super-resolution (SR) method for performing SR on registered medical image datasets. Conventional SR approaches use low-resolution (LR) and high-resolution (HR) image pairs to train a deep convolutional neural network (DCN). However, LR-HR images in medical imaging are commonly acquired from different imaging devices, and acquiring LR-HR image pairs needs registration. Registered LR-HR images have registration errors inevitably. Using LR-HR images with registration error for training an SR DCN causes collapsed SR results. To address these challenges, we introduce a novel SR approach designed specifically for registered LR-HR medical images.

METHODS

We propose style-subnets-assisted generative latent bank for large-factor super-resolution (SGSR) trained with registered medical image datasets. Pre-trained generative models named generative latent bank (GLB), which stores rich image priors, can be applied in SR to generate realistic and faithful images. We improve GLB by newly introducing style-subnets-assisted GLB (S-GLB). We also propose a novel inter-uncertainty loss to boost our method's performance. Introducing more spatial information by inputting adjacent slices further improved the results.

RESULTS

SGSR outperforms state-of-the-art (SOTA) supervised SR methods qualitatively and quantitatively on multiple datasets. SGSR achieved higher reconstruction accuracy than recently supervised baselines by increasing peak signal-to-noise ratio from 32.628 to 34.206 dB.

CONCLUSION

SGSR performs large-factor SR while given a registered LR-HR medical image dataset with registration error for training. SGSR's results have both realistic textures and accurate anatomical structures due to favorable quantitative and qualitative results. Experiments on multiple datasets demonstrated SGSR's superiority over other SOTA methods. SR medical images generated by SGSR are expected to improve the accuracy of pre-surgery diagnosis and reduce patient burden.

Anti-CTLA-4 Antibody Might Be Effective Against Non-small Cell Lung Cancer With Large Size Tumor

BACKGROUND/AIM

Immunotherapy using immune checkpoint inhibitors (ICIs) has revolutionized the treatment of advanced non-small cell lung cancer (NSCLC). Although several ICI options are available, the treatment regimen for NSCLC with large size tumors (large NSCLC) is controversial and the efficacy of anti-CTLA-4 antibody is unclear. This study thus investigated potential biomarkers for CTLA-4 blockade.

PATIENTS AND METHODS

The correlation between tumor diameter and treatment duration was examined in patients with advanced NSCLC treated with anti-PD-1 antibody monotherapy in our institution. In addition, the ratio of tumor-infiltrating CD8+ T cells and regulatory T (Treg) cells in small and large size NSCLC was also evaluated using immunohistochemical staining. Finally, the efficacy of treatment with anti-CTLA-4 antibody against large NSCLC was investigated.

RESULTS

A negative correlation was found between tumor diameter and treatment duration in patients treated with anti-PD-1 antibody monotherapy. Immuno-histochemical staining revealed that Treg cell infiltration was significantly higher in large NSCLC tumors than in small tumors. Among the patients with large NSCLC, the ICI regimen including anti-CTLA-4 antibody showed significant efficacies.

CONCLUSION

Anti-PD-1 antibody monotherapy might be less effective against large NSCLC due to the infiltration of Treg cells. Therefore, it might be appropriate for large NSCLC to select a treatment including an anti-CTLA-4 antibody, which can target Treg cells.

SR-CycleGAN: super-resolution of clinical CT to micro-CT level with multi-modality super-resolution loss

Purpose: We propose a super-resolution (SR) method, named SR-CycleGAN, for SR of clinical computed tomography (CT) images to the micro-focus x-ray CT CT ( μ CT ) level. Due to the resolution limitations of clinical CT (about 500 × 500 × 500    μ m 3 / voxel ), it is challenging to obtain enough pathological information. On the other hand, μ CT scanning allows the imaging of lung specimens with significantly higher resolution (about 50 × 50 × 50    μ m 3 / voxel or higher), which allows us to obtain and analyze detailed anatomical information. As a way to obtain detailed information such as cancer invasion and bronchioles from preoperative clinical CT images of lung cancer patients, the SR of clinical CT images to the μ CT level is desired. Approach: Typical SR methods require aligned pairs of low-resolution (LR) and high-resolution images for training, but it is infeasible to obtain precisely aligned paired clinical CT and μ CT images. To solve this problem, we propose an unpaired SR approach that can perform SR on clinical CT to the μ CT level. We modify a conventional image-to-image translation network named CycleGAN to an inter-modality translation network named SR-CycleGAN. The modifications consist of three parts: (1) an innovative loss function named multi-modality super-resolution loss, (2) optimized SR network structures for enlarging the input LR image to 2 k -times by width and height to obtain the SR output, and (3) sub-pixel shuffling layers for reducing computing time. Results: Experimental results demonstrated that our method successfully performed SR of lung clinical CT images. SSIM and PSNR scores of our method were 0.54 and 17.71, higher than the conventional CycleGAN's scores of 0.05 and 13.64, respectively. Conclusions: The proposed SR-CycleGAN is usable for the SR of a lung clinical CT into μ CT scale, while conventional CycleGAN output images with low qualitative and quantitative values. More lung micro-anatomy information could be observed to aid diagnosis, such as the shape of bronchioles walls.

Realistic endoscopic image generation method using virtual-to-real image-domain translation

A realistic image generation method for visualisation in endoscopic simulation systems is proposed in this study. Endoscopic diagnosis and treatment are performed in many hospitals. To reduce complications related to endoscope insertions, endoscopic simulation systems are used for training or rehearsal of endoscope insertions. However, current simulation systems generate non-realistic virtual endoscopic images. To improve the value of the simulation systems, improvement of the reality of their generated images is necessary. The authors propose a realistic image generation method for endoscopic simulation systems. Virtual endoscopic images are generated by using a volume rendering method from a CT volume of a patient. They improve the reality of the virtual endoscopic images using a virtual-to-real image-domain translation technique. The image-domain translator is implemented as a fully convolutional network (FCN). They train the FCN by minimising a cycle consistency loss function. The FCN is trained using unpaired virtual and real endoscopic images. To obtain high-quality image-domain translation results, they perform an image cleansing to the real endoscopic image set. They tested to use the shallow U-Net, U-Net, deep U-Net, and U-Net having residual units as the image-domain translator. The deep U-Net and U-Net having residual units generated quite realistic images.

Automated mediastinal lymph node detection from CT volumes based on intensity targeted radial structure tensor analysis

This paper presents a local intensity structure analysis based on an intensity targeted radial structure tensor (ITRST) and the blob-like structure enhancement filter based on it (ITRST filter) for the mediastinal lymph node detection algorithm from chest computed tomography (CT) volumes. Although the filter based on radial structure tensor analysis (RST filter) based on conventional RST analysis can be utilized to detect lymph nodes, some lymph nodes adjacent to regions with extremely high or low intensities cannot be detected. Therefore, we propose the ITRST filter, which integrates the prior knowledge on detection target intensity range into the RST filter. Our lymph node detection algorithm consists of two steps: (1) obtaining candidate regions using the ITRST filter and (2) removing false positives (FPs) using the support vector machine classifier. We evaluated lymph node detection performance of the ITRST filter on 47 contrast-enhanced chest CT volumes and compared it with the RST and Hessian filters. The detection rate of the ITRST filter was 84.2% with 9.1 FPs/volume for lymph nodes whose short axis was at least 10 mm, which outperformed the RST and Hessian filters.

Pro-angiogenic cytokines for prediction of outcomes in patients with advanced hepatocellular carcinoma

Background:

We previously reported that expressions of the pro-angiogenic cytokines angiopoietin-2 (Ang-2), follistatin, granulocyte colony-stimulating factor, hepatocyte growth factor, leptin, platelet-derived growth factor-BB, platelet endothelial cell adhesion molecule-1, and vascular endothelial growth factor were associated with the response to sorafenib in patients with advanced hepatocellular carcinoma (HCC). The aim of the present study is to examine the same relationship in a larger cohort.

Methods:

In the current retrospective cohort study, we measured serum levels of the eightcytokines in 120 consecutive HCC patients who were treated with sorafenib. We evaluated the effects of increased expression of serum cytokines on progression-free survival (PFS) and overall survival (OS).

Results:

Elevated expression of Ang-2 correlated both with significantly shorter PFS (hazard ratio (HR), 1.84; 95% confidence interval (CI), 1.21–2.81), and OS (HR, 1.95; 95% CI, 1.21–3.17). Patients with more than three cytokines expressed above the median similarly had significantly shorter PFS (HR, 1.98; 95% CI, 1.30–3.06) and OS (HR, 1.94; 95% CI, 1.19–3.22). Differences in OS were evident in cases with the evidence of macroscopic vascular invasion or extrahepatic metastasis.

Conclusion:

High expression of Ang-2 or more than cytokines in serum is associated with poor PFS and OS in HCC patients treated with sorafenib.

Digital bowel cleansing free colonic polyp detection method for fecal tagging CT colonography

RATIONALE AND OBJECTIVES

Fecal tagging computed tomographic colonography (ftCTC) reduces the discomfort and the inconvenience of patients associated with bowel cleansing procedures before CT scanning. In conventional colonic polyp detection techniques for ftCTC, a digital bowel cleansing (DBC) technique is applied to detect polyps in tagged fecal materials (TFM). However, DBC removes the surface of soft tissues and hampers polyp detection. We developed a colonic polyp detection method for CT colonographic examination that enables the detection of polyps surrounded by air and polyps surrounded by TFM without DBC.

MATERIALS AND METHODS

CT values inside the polyps surrounded by air and polyps surrounded by TFM tend to gradually increase (blob structure) and decrease (inverse-blob structure) from outward to inward, respectively. We developed blob and inverse-blob structure enhancement filters based on the eigenvalues of a Hessian matrix to detect polyps using their intensity characteristic. False-positive elimination is performed using three feature values: volume, maximum value of filter outputs, and standard deviation of CT values inside the polyp candidates.

RESULTS

The proposed method is applied to 104 cases of ftCTC images that include 57 polyps larger than 6 mm in diameter. The sensitivity of the method was 91.2% (52/57) with 11.4 false positives per case.

CONCLUSIONS

The proposed method detects polyps with high sensitivity and 11.4 false positives per case without adverse effects on the DBC.

Bronchoscope tracking without fiducial markers using ultra-tiny electromagnetic tracking system and its evaluation in different environments

This paper presents a method for bronchoscope tracking without any fiducial markers using an ultra-tiny electromagnetic tracker (UEMT) for a bronchoscopy guidance system. The proposed method calculates the transformation matrix, which shows the relationship between the coordinates systems of the pre-operative CT images and the UEMT, by registering bronchial branches segmented from CT images and points measured by the UEMT attached at the tip of a bronchoscope. We dynamically compute the transformation matrix for every pre-defined number of measurements. We applied the proposed method to a bronchial phantom in several experimental environments. The experimental results showed the proposed method can track a bronchoscope camera with about 3.3mm of target registration error (TRE) for wood table environment and 4.0mm of TRE for examination table environment.

A method for bronchoscope tracking by combining a position sensor and image registration

This paper describes a method for tracking a bronchoscope by combining a position sensor and image registration. A bronchoscopy guidance system is a tool for providing real-time navigation information acquired from pre-operative CT images to a physician during a bronchoscopic examination. In this system, one of the fundamental functions is tracking a bronchoscope's camera motion. Recently, a very small electromagnetic position sensor has become available. It is possible to insert this sensor into a bronchoscope's working channel to obtain the bronchoscope's camera motion. However, the accuracy of its output is inadequate for bronchoscope tracking. The proposed combination of the sensor and image registration between real and virtual bronchoscopic images derived from CT images is quite useful for improving tracking accuracy. Furthermore, this combination has enabled us to achieve a real-time bronchoscope guidance system. We performed evaluation experiments for the proposed method using a rubber phantom model. The experimental results showed that the proposed system allowed the bronchoscope's camera motion to be tracked at 2.5 frames per second.

Solitary Capillary Hemangioma of the Lung

We report 2 cases of capillary hemangioma, each presenting as a solitary nodule in the peripheral lung. Both of the patients were asymptomatic with a small solitary nodule that had revealed by computed tomography. In both cases, the nodule was resected surgically under a clinical diagnosis of early lung cancer. Macroscopically, each lesion was ill defined and irregular in shape with a dark brown cut surface. Microscopically, the alveolar septa in both nodules were thickened by accumulations of numerous thin-walled capillary vessels, which characteristically extended along, or infiltrated, each septum. We diagnosed these lesions as "solitary capillary hemangioma" of the peripheral lung. Tumors or tumorlike lesions of capillary vessels in the lung are rare. Among them, pulmonary capillary hemangiomatosis (PCH) has been described as multiple nodules in the lung parenchyma or bronchovascular walls, comprised of infiltrating thin-walled capillary blood vessels. Moreover, PCH-like foci have been found in a retrospective study of autopsy cases. However, the presented cases should be differentiated from PCH in terms of their clinical setting such as history of hypertension or veno-occlusive disease and multiplicity of the lesion. This is a rare case series of solitary capillary hemangioma discovered incidentally during life, and the lesions were difficult to differentiate radiologically from early lung cancer. After the recent advances in imaging diagnosis for early detection of peripheral lung cancer, these lesions are important to bear in mind for differential diagnosis of bronchioloalveolar carcinoma.

Bronchoscope Tracking Based on Image Registration Using Multiple Initial Starting Points Estimated by Motion Prediction

This paper presents a method for tracking a bronchoscope based on motion prediction and image registration from multiple initial starting points as a function of a bronchoscope navigation system. We try to improve performance of bronchoscope tracking based on image registration using multiple initial guesses estimated using motion prediction. This method basically tracks a bronchoscopic camera by image registration between real bronchoscopic images and virtual ones derived from CT images taken prior to the bronchoscopic examinations. As an initial guess for image registration, we use multiple starting points to avoid falling into local minima. These initial guesses are computed using the motion prediction results obtained from the Kalman filter's output. We applied the proposed method to nine pairs of X-ray CT images and real bronchoscopic video images. The experimental results showed significant performance in continuous tracking without using any positional sensors.

Hybrid bronchoscope tracking using a magnetic tracking sensor and image registration

In this paper, we propose a hybrid method for tracking a bronchoscope that uses a combination of magnetic sensor tracking and image registration. The position of a magnetic sensor placed in the working channel of the bronchoscope is provided by a magnetic tracking system. Because of respiratory motion, the magnetic sensor provides only the approximate position and orientation of the bronchoscope in the coordinate system of a CT image acquired before the examination. The sensor position and orientation is used as the starting point for an intensity-based registration between real bronchoscopic video images and virtual bronchoscopic images generated from the CT image. The output transformation of the image registration process is the position and orientation of the bronchoscope in the CT image. We tested the proposed method using a bronchial phantom model. Virtual breathing motion was generated to simulate respiratory motion. The proposed hybrid method successfully tracked the bronchoscope at a rate of approximately 1 Hz.

Automated Nomenclature of Bronchial Branches Extracted from CT Images and Its Application to Biopsy Path Planning in Virtual Bronchoscopy

We propose a novel anatomical labeling algorithm for bronchial branches extracted from CT images. This method utilizes multiple branching models for anatomical labeling. In the actual labeling process, the method selects the best candidate models at each branching point. Also a special labeling procedure is proposed for the right upper lobe. As an application of the automated nomenclature of bronchial branches, we utilized anatomical labeling results for assisting biopsy planning. When a user inputs a target point around suspicious regions on the display of a virtual bronchoscopy (VB) system, the path to the desired position is displayed as a sequence of anatomical names of branches. We applied the proposed method to 25 cases of CT images. The labeling accuracy was about 90%. Also the paths to desired positions were generated by using anatomical names in VB.

Phase II study of cisplatin, ifosfamide, and irinotecan with rhG-CSF support in patients with stage IIIb and IV non-small-cell lung cancer

A phase II study of cisplatin, ifosfamide, and irinotecan with recombinant human granulocyte colony stimulating factor (rhG-CSF) support was conducted in previously untreated patients with stage IIIB or IV non-small-cell lung cancer (NSCLC). Between June 1998 and August 2001, 50 patients were registered in this phase II study. Cisplatin (20 mg m(-2)) and ifosfamide (1.5 g m(-2)) were administered on days 1-4 and irinotecan (60 mg m(-2)) was given on days 1, 8, and 15, respectively. This regimen was repeated every 4 weeks. rhG-CSF was administered subcutaneously at a dose of 50 microg m(-2) on days 5-18 except on the days of irinotecan treatment. In total, 49 patients were assessable for toxicity and response and 50 for survival. In all, 33, patients (67.3%; 95% confidence interval 57.4-77.2%) achieved an objective response. The median response duration was 192 days and the median time to progression for 49 patients was 170 days. The median survival time was 540 days with 1- and 2-year survival rates of 63.5 and 30.7%, respectively. Grade 3 or 4 neutropenia and thrombocytopenia developed in 63.3 and 38.8% of the patients, respectively. In conclusion, the combination of cisplatin, ifosfamide, and irinotecan with rhG-CSF support was highly effective for the treatment of stage IIIB or IV NSCLC with acceptable toxicities.

Tracking of a bronchoscope using epipolar geometry analysis and intensity-based image registration of real and virtual endoscopic images††A preliminary version of this paper was presented at the Medical Image Computing and Computer-Assisted Intervention (MICCAI) Conference, Utrecht, The Netherlands (Mori et al., 2001)

This paper describes a method for tracking the camera motion of a flexible endoscope, in particular a bronchoscope, using epipolar geometry analysis and intensity-based image registration. The method proposed here does not use a positional sensor attached to the endoscope. Instead, it tracks camera motion using real endoscopic (RE) video images obtained at the time of the procedure and X-ray CT images acquired before the endoscopic examination. A virtual endoscope system (VES) is used for generating virtual endoscopic (VE) images. The basic idea of this tracking method is to find the viewpoint and view direction of the VES that maximizes a similarity measure between the VE and RE images. To assist the parameter search process, camera motion is also computed directly from epipolar geometry analysis of the RE video images. The complete method consists of two steps: (a) rough estimation using epipolar geometry analysis and (b) precise estimation using intensity-based image registration. In the rough registration process, the method computes camera motion from optical flow patterns between two consecutive RE video image frames using epipolar geometry analysis. In the image registration stage, we search for the VES viewing parameters that generate the VE image that is most similar to the current RE image. The correlation coefficient and the mean square intensity difference are used for measuring image similarity. The result obtained in the rough estimation process is used for restricting the parameter search area. We applied the method to bronchoscopic video image data from three patients who had chest CT images. The method successfully tracked camera motion for about 600 consecutive frames in the best case. Visual inspection suggests that the tracking is sufficiently accurate for clinical use. Tracking results obtained by performing the method without the epipolar geometry analysis step were substantially worse. Although the method required about 20 s to process one frame, the results demonstrate the potential of image-based tracking for use in an endoscope navigation system.

Phase I study of carboplatin, irinotecan and docetaxel on a divided schedule with recombinant human granulocyte colony stimulating factor support in patients with stage IIIB or IV non-small cell lung cancer

A phase I study was conducted to determine dose-limiting toxicity (DLT) and maximum tolerated dose (MTD) of carboplatin combined with irinotecan and docetaxel on a divided schedule with recombinant human granulocyte colony stimulating factor (rhG-CSF) support in patients with stage IIIB or IV non-small cell lung cancer. Carboplatin was given at the dose of AUC5 on day 1. Irinotecan and docetaxel on days 1 and 8 were administered at a starting dose of 40 and 30 mg/m2 as level 1. Subsequent levels were: irinotecan/docetaxel (in mg/m2), 50/30 (level 2), 60/30 (level 3) and 60/35 (level 4). rhG-CSF was given at 50 mg/m2 on days 5-15. Cycles were repeated every 3 weeks. Between May 1999 and April 2001, 31 patients were registered in this phase I study. Level 4 was judged as the MTD. The DLTs were considered diarrhea and febrile neutropenia. The overall response rate was 32.3% and median survival was 490 days with 1-year survival of 65.1%. We conclude that both irinotecan 60 mg/m2 and docetaxel 30 mg/m2 on days 1 and 8 in combination with an AUC5 of carboplatin on day 1 with rhG-CSF support is recommended for phase II study. The response rate and survival data in this phase I study are encouraging. We considered that the pathogenesis of diarrhea involved not only direct cytotoxic damage to the mucosa, but also bacterial overgrowth.

PHA (polyhydroxyalkanoate) production potential of activated sludge treating wastewater

The main purposes of wastewater treatment systems are to remove organic pollutants, but it would be very attractive if there were a way to recover the organic pollutants as valuable organic materials. One of the possible ways to recover organic pollutants in wastewater is to convert them into polyhydroxyalkanoates (PHAs), which are biodegradable plastics. In this study, 18 activated sludge samples in 4 wastewater treatment plants (WWTPs) in Tokyo, Japan, were evaluated for their potential to produce PHAs by aerobic batch experiments with excess supply of acetate as the sole carbon source. The activated sludge samples tested had the capability to accumulate PHA up to 18.8% of dry cell weight on average, with the range of 6.0% to 29.5%. The results showed that the maximum PHA content was dependent on the influent more than on the operational conditions of the activated sludge, and that conventional activated sludge produced PHA as much as anaerobic-aerobic activated sludge did. The PHA content achieved in this study is still low, and further improvement is needed to put into practice the recovery process of organic pollutants as biodegradable plastics by activated sludge.

[Virtual bronchoscope system]

In this article, we describe the features of Virtual Bronchoscope System(VBS) and its practical use. VBS is constructed based on 3-D chest CT images. The bronchus region is automatically extracted from 3-D chest CT images by a three-dimensional region growing method. The surface rendering is employed for construction of virtualized tracheo-bronchial tree. It gives us an environment where we can observe inside the bronchi from an arbitrary viewpoint and a view direction. By mouse operation, the user can control the viewpoint and the view direction to fly through inside the airway in real time. VBS is applicable for a variety of purposes such as diagnosis, surgical planning, informed consent, education and training. One of extension of this system is a teaching tool for medical students. In the module for educational use, we have developed four functions for using the system as a teaching tool as follows: (a) automated display of bronchial anatomical names, (b) presenting questions about the currently observed branch in the endoscopic view, (c) display of the path which the user should follow, and (d) display of a question about the location of the artificially created tumor in the bronchus. These functions use the processed results of automated anatomical labeling. The method proposed here combines the knowledge based processing technique 'automated labeling of bronchial branch' and the novel visualization technique 'virtual bronchoscope'. This is one of new teaching tools of medical images. We conclude that this virtual bronchoscope system might have an important role in the medial students' education.

[A case of primary malignant hemangiopericytoma of the lung with marked response to combination chemotherapy with cisplatin, ifosfamide and gemcitabine]

A 51-year-old man was admitted because of complaints of cough and bloody sputa. A chest CT scan revealed a giant mass lesion in the right middle and lower lobes of the lung and mediastinal lymphadenopathy. Bronchoscopic findings showed a tumor which almost completely obstructed the intermediate bronchus. Histopathological examination of a biopsy specimen demonstrated malignant hemangiopericytoma. Two courses of chemotherapy that combined cisplatin, ifosfamide and gemcitabine were performed every 3 weeks. Both primary lesion and mediastinal lymph node metastases showed marked reduction and toxicity was manageable.

Phase I/II study of cisplatin, ifosfamide and irinotecan with rhG-CSF support in patients with stage IIIB and IV non-small-cell lung cancer

PURPOSE

We conducted a phase I/II study in previously untreated patients with stage IIIB or IV non-small-cell lung cancer (NSCLC) to: (1) determine the maximum tolerated dose (MTD) of cisplatin combined with a fixed schedule of ifosfamide and irinotecan with rhG-CSF support; and (2) to determine the overall response rate and median survival of patients entered on this study.

METHODS

Ifosfamide (1.5 g/m2) and irinotecan (60 mg/m2) were administered at fixed doses on days 1-4 and on days 1, 8 and 15, respectively. Cisplatin was given on day 1 at 60 mg/m2 and was increased in 10-mg/m2 increments. This regimen was repeated every 4 weeks. rhG-CSF (nartograstim) was administered subcutaneously at a dose of 1 microg/kg on days 5-18 except on the day of irinotecan treatment.

RESULTS

Between June 1995 and April 1998, 46 patients were registered onto this phase I/II study. The MTD of cisplatin was defined according to toxicity and the dose during three courses was increased. Since at the 80 mg/m2 dose level more than one-third of the patients were treated with dose modification, the dose of 70 mg/m2 was recommended for phase II study. The dose-limiting toxicity was leukopenia. The overall response rate was 62.2% (95% CI 48.0-76.4%, the median response duration was 144 days, and the median survival time was 393 days.

CONCLUSION

For phase II study, we recommend doses of cisplatin 70 mg/m2 on day 1 combined with ifosfamide and irinotecan with rhG-CSF support. Both the response rate and preliminary survival data in this study suggest a high degree of activity of this combination in previously untreated NSCLC.

Combination chemotherapy in patients with malignant pleural effusions from non-small cell lung cancer : cisplatin, ifosfamide, and irinotecan with recombinant human granulocyte colony-stimulating factor support

OBJECTIVES

Malignant pleural effusions develop frequently in patients with non-small cell lung cancer (NSCLC), and the prognosis for these patients is very poor. We evaluated the role of systemic chemotherapy for patients with malignant pleural effusions from NSCLC.

METHODS

We analyzed 34 patients who were found to have malignant pleural effusions in the course of diagnosis of 118 patients enrolled in three consecutive clinical trials on advanced NSCLC assessing combination chemotherapy of cisplatin, ifosfamide, and irinotecan with recombinant human granulocyte colony-stimulating factor support. The objective response in the malignant pleural effusion was evaluated by CT scans every course with the response criteria of the Japan Lung Cancer Society.

RESULTS

All patients had adenocarcinoma. The pleural effusion showed a complete response in 13 patients, a partial response in 7 patients, and no response in 14 patients. In the assessment of the efficacy of the treatment for the measurable primary or metastatic lesions, there was a partial response in 25 patients, no change in 8 patients, and progressive disease in 1 patient. The response rate in pleural effusions was 58.8%, and overall response in mensurable lesions was 73.5%. The median time to response and duration of response for pleural effusions were 54 days and 151 days, respectively. The median survival time and 1-year survival rates were 362 days and 48.5%, respectively.

CONCLUSIONS

Both the response rate and survival data in this retrospective study suggest a high degree of activity of this combination chemotherapy in patients with malignant pleural effusions from NSCLC.

Phase I study of carboplatin, docetaxel and irinotecan with recombinant human granulocyte colony stimulating factor support in patients with advanced non-small cell lung cancer

A phase I study was conducted in patients with stage IIIB or IV non-small cell lung cancer to determine the maximum tolerated dose (MTD) of irinotecan combined with a fixed schedule of docetaxel and carboplatin with recombinant human granulocyte colony stimulating factor (rhG-CSF) (nartograstim) support. Docetaxel was given at 60 mg/m2 on day 1 with carboplatin. The dose of carboplatin was calculated using the Calvert formula to achieve an estimated AUC of 5.0 mg/ml x min. Irinotecan was administered at a starting dose of 40 mg/m2 on day 1 and increased in increments of 10 mg/m2. rhG-CSF was given at 1 microg/kg on days 5-15. Cycles were repeated every 3 weeks. Between February 1998 and March 1999, 22 patients were enrolled in this phase I study. Five patients were chemotherapy naive. The MTD of irinotecan was 60 mg/m2. Diarrhea was considered to be the dose-limiting toxicity. The irinotecan dose intensity of 16.7 mg/m2/week was low compared with other irinotecan-containing regimens. The overall response rate was 38.1% and median survival was 278 days. Irinotecan 50 mg/m2 in combination with 60 mg/m2 docetaxel and carboplatin on day 1 with rhG-CSF support is recommended for phase II study. The response rate and survival data in this phase I study are encouraging.

Combination chemotherapy of cisplatin, ifosfamide, and irinotecan with rhG-CSF support in patients with brain metastases from non-small cell lung cancer

BACKGROUND

Brain metastases develop frequently in patients with non-small cell lung cancer (NSCLC), and the prognosis for these patients is very poor. We evaluated the role of chemotherapy for patients with brain metastases from NSCLC.

METHODS

We analyzed 30 patients who were discovered to have brain metastases during the diagnosis of 121 patients enrolled in three consecutive clinical trials on advanced NSCLC assessing combination chemotherapy of cisplatin, ifosfamide and irinotecan with rhG-CSF support. Response in the brain lesions was evaluated by contrast-enhanced MRI scans after at least two courses.

RESULTS

Fourteen patients achieved a partial response (PR) but there was no change (NC) in 13 patients and progressive disease (PD) in 1. Among patients with extracranial lesions, 18 had a PR and 11 had NC. The response rate in brain metastases was 50.0%, and that in extracranial primary and metastatic lesions was 62.1%. The median duration of response for intra- and extracranial lesions was 140 and 147 days, respectively. After completing chemotherapy, Gamma Knife radiosurgery was performed on 2 patients in remission and 8 patients at disease progression. The median survival time and 1-year survival rate were 382 days and 56.1%, respectively.

CONCLUSIONS

Both the response rate and survival data in this retrospective study suggest a high degree of activity of this combination chemotherapy in patients with brain metastases from NSCLC.

Combination of cisplatin, ifosfamide, and irinotecan with rhG-CSF support for the treatment of refractory or relapsed small-cell lung cancer

OBJECTIVE

This study was conducted in refractory or relapsed small-cell lung cancer to determine activity and toxicity of the combination of cisplatin, ifosfamide, and irinotecan with rhG-CSF support.

METHODS

Eighteen patients entered the trial. The median chemotherapy-free interval was 3.1 (range 1.0-14.5) months. Cisplatin (20 mg/m(2)) and ifosfamide (1.5 g/m(2)) were administered on days 1-4, and irinotecan (60 mg/m(2)) was administered on days 1, 8, and 15. In patients who experienced grade 4 hematological toxicity during the prior chemotherapy, the doses of cisplatin and irinotecan were reduced to 15 and 50 mg/m(2), respectively. After 10 patients were entered, cisplatin and irinotecan were administered at doses of 15 and 50 mg/m(2), respectively. This regimen was repeated every 4 weeks. rhG-CSF was administered subcutaneously at a dose of 50 microgram/m(2) from days 50 to 18, except on the day of irinotecan treatment.

RESULTS

All patients could be assessed for response and toxicity. There were 1 complete and 16 partial responses, and an overall response rate of 94.4%. The median survival time of all patients was 339 days, and the 1-year survival rate was 47.5%. Hematological toxicities were significant. Grade 4 neutropenia and thrombocytopenia were observed in 61 and 33% of the patients, respectively. Diarrhea was mild and transient. There was no treatment-related death.

CONCLUSION

The combination of cisplatin, ifosfamide, and irinotecan with rhG-CSF support was highly active for the treatment of refractory or relapsed small-cell lung cancer.

[Intrathoracic neurofibroma originating in the left vagus nerve]

A 20-year-old man was admitted because of an abnormal mass shadow on chest X-ray film. Computed tomography (CT) and magnetic resonance imaging (MRI) disclosed a mass lesion in the superior portion of the left mediastinum. CT scans showed a well-defined mass with low density. Axial MRI rendered the mass lesion with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The preoperative diagnosis was bronchogenic cyst. Video-assisted thoracic surgery revealed that the tumor originated in the truncus of the left vagus nerve. The resected tumor was 90 x 24 x 18 mm in size. The postoperative course was uneventful and hoarseness did not develop. The pathologic diagnosis was benign mediastinal neurofibroma without von Recklinghausen's disease. Such cases are extremely rare in the Japanese literature.

Allergic bronchopulmonary aspergillosis due to Aspergillus niger without bronchial asthma

A 65-year-old woman was admitted to our hospital with a dry cough and pulmonary infiltrates. Chest radiograph and CT revealed mucoid impaction and consolidations. Peripheral blood eosinophilia and elevated serum IgE were observed. Aspergillus niger was cultured repeatedly from her sputum, but A. fumigatus was not detected. Immediate skin test and specific IgE (RAST) to Aspergillus antigen were positive. Precipitating antibodies were confirmed against A. niger antigen, but not against A. fumigatus antigen. She had no asthmatic symptoms, and showed no bronchial hyperreactivity to methacholine. Thus, this case was diagnosed as allergic bronchopulmonary aspergillosis (ABPA) without bronchial asthma due to A. niger, an organism rarely found in ABPA. The administration of prednisone improved the symptoms and corrected the abnormal laboratory findings.

Phase I study of cisplatin, ifosfamide and irinotecan with rhG-CSF support in advanced non-small cell lung cancer

A phase I study was conducted in advanced non-small cell lung cancer to determine the maximum tolerated dose (MTD) of irinotecan combined with a fixed schedule of cisplatin and ifosfamide with rhG-CSF support. In addition, efficacy including survival time was evaluated at 2 years after the completion of patient registration. Cisplatin (20 mg/m2) and ifosfamide (1.5 g/m2) were administered at fixed doses on days 1-4, and irinotecan was given on days 1, 8 and 15 starting at 40 mg/m2, which was increased in 10 mg/m2 increments. This regimen was repeated every 4 weeks. rhG-CSF was administered subcutaneously at a dose of 50 microg/m2 on days 5-18 except on the day of irinotecan treatment. Forty-five patients were registered and 35 had received no prior chemotherapy. MTD or irinotecan was defined according to toxicity and the dose during three courses was increased up to 70 mg/m2. The dose 60 mg/m2 was recommended for phase II study. The dose-limiting factor was thrombocytopenia. The overall response rate was 57.8% and the median survival time was 492 days. In chemotherapy-naive patients, the response rate was 65.7% (95% CI; 50-81.4%), median response duration 161 days, median survival time 513 days, 1-year survival rate 62.4%, and 2-year survival rate 27.3%.

[Period of time patients with advanced non-small cell lung cancer could remain at home during CIC--therapy (cisplatin + ifosfamide + CPT-11)]

Two phase I studies (CIC-therapy) were conducted in advanced non-small cell lung cancer (NSCLC) to determine the maximum tolerable dose (MTD) of CPT-11 combined with cisplatin and ifosfamide, and MTD of cisplatin combined with CPT-11 and ifosfamide with G-CSF support, respectively. Both regimens were repeated every 4 weeks. G-CSF was administered on days 5 to 18. Eighty-eight patients were registered in both studies. The overall response rate was 59.1%, and the median survival time was 393 days. In all patients enrolled, we examined retrospectively the period of time they could remain at home during chemotherapy. We examined this period divided into day 1-18 and day 18-28 until the third course. Although myelotoxicity occurring during the third course was the most severe, the mean time was 7.1 days (day 1-18 2.2, day 18-28 4.9) for the first course, 10.1 days (day 1-18 4.0, day 18-28 6.0) for the second course, and 11.0 days (day 1-18 4.7, day 18-28 6.3) for the third course. Only two patients came to the hospital because of acute upper respiratory tract infection. Although CIC-therapy was an aggressive chemotherapy with G-CSF support, most of the patients were able to stay at home during chemotherapy.

[Efficacy of systemic chemotherapy in adenocarcinoma of the lung with pleuritis carcinomatosa]

The efficacy of systemic chemotherapy (CDDP + IFO + 5-FU or CDDP + IFO + CPT-11) was evaluated in 41 patients with malignant pleural effusion secondary to adenocarcinoma of the lung. The overall response rate for measurable disease was 56.1%. The response for pleural effusion was evaluated according to the criteria of the Japan Lung Cancer Society. The overall response for pleural effusion was 53.7% (34.1% CR and 19.5% PR). The median survival time was 361 days. These results suggested that systemic chemotherapy is an effective treatment for pleuritis carcinomatosa.

[Three cases of resected primary mediastinal yolk sac tumor following six courses of bleomycin, etoposide and cisplatin (BEP) combination chemotherapy]

We experienced three cases of primary mediastinal yolk sac tumor which were resected after 6 courses of BEP chemotherapy with G-CSF support. All cases had high levels of AFP. CT scan revealed an anterior mediastinal tumor infiltrating the surrounding tissue in all cases, and multiple pulmonary nodules in one case. The serum AFP level decreased markedly, but did not return to normal after the chemotherapy was completed. The markedly decreased mediastinal tumor masses were removed with en-bloc resection of the lung and pericardium. Viable tumor cells were not present in the resected tumors. These three cases remain free of disease at present, 3 years, 9 months and 5 months after operation.

[Phase I study of cisplatin, ifosfamide and CPT11 with granulocyte colony-stimulating factor support in advanced non-small cell lung cancer]

A phase I study was conducted to define the maximal tolerated dose of cisplatin, ifosfamide and CPT-11 with granulocyte colony stimulating factor support in advanced non-small cell lung cancer. CPT-11 was given on days 1, 8 and 15 in combination with a fixed dose of cisplatin (20 mg/m2 i.v. on days 1-4) and ifosfamide (1.5 g/m2 i.v. on days 1-4) every 4 weeks. G-CSF (50 micrograms/m2/day s.c.) was administered on days 5 to 18, except on the days of CPT-11 treatment. The starting dose of CPT-11 was 40 mg/m2, and the dose was escalated in increments of 10 mg/m2. Forty-five patients with stage III or IV, and 35 with no prior chemotherapy, were entered in the study. The dose limiting toxicity of the combination was thrombocytopenia. The maximal tolerated dose of CPT-11 was 70 mg/m2, and the recommended phase II dose is 60 mg/m2. There were 26 partial responses among 45 entered patients for an overall response rate of 57.8%. In 35 chemotherapy-naive patients, the objective response rate was 65.7%, the median response duration was 155 days, and 1 year survival was 62.3%.