Whole genome gene expression changes and hematological effects of rikkunshito in patients with advanced non-small cell lung cancer receiving first line chemotherapy

It has been demonstrated that the traditional Chinese medicine rikkunshito, ameliorates anorexia in several types of human cancer and attenuates lung injury by inhibiting neutrophil infiltration. The current study investigated the clinical and hematological effects of rikkunshito and its underlying mechanisms of action in the treatment of advanced non-small cell lung cancer (NSCLC). The Illumina microarray BeadChip was used to analyze the whole-genome expression profiles of peripheral blood mononuclear cells in 17 patients with advanced NSCLC. These patients were randomized to receive combination chemotherapy (cisplatin and gemcitabine) with (n=9, CTH+R group) or without (n=8, CTH group) rikkunshito. The primary endpoint was the treatment response and the categories of the scales of anorexia, nausea, vomiting and fatigue; secondary endpoints included the hematological effect and whole genome gene expression changes. The results of the current study indicated that there were no significant differences in clinical outcomes, including treatment response and toxicity events, between the two groups. Median one-year overall survival (OS) was 12 months in the CTH group and 11 months in the CTH+R group (P=0.058 by log-rank test), while old age (>60 years old) was the only independent factor associated with one-year OS (hazard ratio 1.095, 95% confidence interval, 1.09–1.189, P=0.030). Patients in the CTH+R group experienced significantly greater maximum decreases in both white cell count (P=0.034) and absolute neutrophil count (P=0.030) from the baseline. A total of 111 genes associated with neutrophil apoptosis, the cell-killing ability of neutrophils, natural killer cell activation and B cell proliferation were up-regulated following rikkunshito treatment. A total of 48 genes associated with neutrophil migration, coagulation, thrombosis and type I interferon signaling were down-regulated following rikkunshito treatment. Rikkunshito may therefore affect the blood neutrophil count when used with combination chemotherapy in patients with NSCLC, potentially by down-regulating prostaglandin-endoperoxidase synthase 1, MPL, AMICA1 and junctional adhesion molecule 3, while up-regulating elastase, neutrophil expressed, proteinase 3, cathepsin G and cluster of differentiation 24.

Peripheral immune cell gene expression changes in advanced non-small cell lung cancer patients treated with first line combination chemotherapy

Introduction

Increasing evidence has shown that immune surveillance is compromised in a tumor-promoting microenvironment for patients with non-small cell lung cancer (NSCLC), and can be restored by appropriate chemotherapy.

Methods

To test this hypothesis, we analyzed microarray gene expression profiles of peripheral blood mononuclear cells from 30 patients with newly-diagnosed advanced stage NSCLC, and 20 age-, sex-, and co-morbidity-matched healthy controls. All the patients received a median of four courses of chemotherapy with cisplatin and gemcitabine for a 28-day cycle as first line treatment.

Results

Sixty-nine differentially expressed genes between the patients and controls, and 59 differentially expressed genes before and after chemotherapy were identified. The IL4 pathway was significantly enriched in both tumor progression and chemotherapy signatures. CXCR4 and IL2RG were down-regulated, while DOK2 and S100A15 were up-regulated in the patients, and expressions of all four genes were partially or totally reversed after chemotherapy. Real-time quantitative RT-PCR for the four up-regulated (S100A15, DOK2) and down-regulated (TLR7, TOP1MT) genes in the patients, and the six up-regulated (TLR7, CRISP3, TOP1MT) and down-regulated (S100A15, DOK2, IL2RG) genes after chemotherapy confirmed the validity of the microarray results. Further immunohistochemical analysis of the paraffin-embedded lung cancer tissues identified strong S100A15 nuclear staining not only in stage IV NSCLC as compared to stage IIIB NSCLC (p = 0.005), but also in patients with stable or progressive disease as compared to those with a partial response (p = 0.032). A high percentage of S100A15 nuclear stained cells (HR 1.028, p = 0.01) was the only independent factor associated with three-year overall mortality.

Conclusions

Our results suggest a potential role of the IL4 pathway in immune surveillance of advanced stage NSCLC, and immune potentiation of combination chemotherapy. S100A15 may serve as a potential biomarker for tumor staging, and a predictor of poor prognosis in NSCLC.

Prognostic values of serum IP-10 and IL-17 in patients with pulmonary tuberculosis

Objective: To identify patients at high risk of relapse after anti-tuberculosis (TB) therapy or with poor long-term outcomes.

Methods: Fifty-one patients with pulmonary TB: 7 were classified as high association with both cavitations on initial chest radiography and positive sputum smear/cultures after two months of anti-TB treatment (HA group); 19 medium association (MA, one risk alone); and 25 low association (LA, neither risk). Serum interferon (IFN)-γ-inducible protein 10 (IP-10), interleukin-17 (IL-17), and C-reactive protein levels were investigated.

Results: There was a trend towards higher serum IP-10 levels (p = 0.042) for HA patients throughout the 6-month treatment period. Month-2 IP-10 levels were higher in the HA than in the MA/LA group (656.2 ± 234.4 vs. 307.6 ± 258.5 pg/ml, adjusted p = 0.005). Receiver operating characteristic curves showed that the risk of relapse was well-captured by month-2 IP-10 levels at a cut-off value of 431 pg/ml (AUC=0.857, 95% CI 0.75–0.97, p = 0.003). Month-2 serum IL-17 levels were lower in non-survivors than survivors (15.7 ± 2.9 pg/ml vs. 24.6 ± 8.2 pg/ml, p = 0.001). Multivariate analysis demonstrated that a month-2 serum IL-17 level of ≤ 17 pg/ml (p = 0.026) was independently associated with all-cause mortality.

Conclusions: Serum IP-10 and IL-17 levels after 2 months of anti-TB treatment may be biomarkers for estimating risk of both cavitation and delayed sputum conversion, and for predicting long-term mortality, respectively.

First- or second-line gefitinib therapy in unknown epidermal growth factor receptor mutants of non-small-cell lung cancer patients treated in Taiwan

Gefitinib is effective in treating patients with non-small-cell lung cancer (NSCLC). The response rate and improvement in survival are related to several aspects, including race, gender, smoking status, and histology; however, little is known about the relationship between survival and length of gefitinib treatment. We conducted this retrospective study to examine this relationship and identify the predictive factors influencing survival and tumor response in chemonaive and chemotherapy patients who had stage IIIb or IV NSCLC with unknown epidermal growth factor receptor mutants. This analysis was aimed to clarify the difference between first- and second-line gefitinib therapy. Among the 918 newly diagnosed, inoperable NSCLC patients from March 2003 to December 2006, 437 (47.6%) had ever received gefitinib therapy. One hundred forty-nine patients (34.0%) who selected gefitinib as first- or second-line therapy were included in the analysis. The overall survival rates of first- and second-line gefitinib therapy were 12.8 months and 20.7 months, respectively (P = .110). The shorter overall survival may be caused by the omission of platinum-based doublet chemotherapy in 37 patients from the first-line group (39.4%). There was also no significant difference in progression-free survival (6.8 months versus 4.9 months; P = .415), and the objective tumor response and disease control rates were similar. Better prognosis and tumor response was associated with female gender, adenocarcinoma, nonsmokers, and good performance status. The difference in overall survival between patients undergoing second-line treatment compared with those undergoing first-line treatment preceding chemotherapy was significant (P = .041). The overall survival, progression-free survival, and tumor response rates were similar in the patients who received gefitinib as initial therapy or after conventional chemotherapy.

Blood absolute T cell counts may predict 2-month treatment response in patients with pulmonary tuberculosis

Background and objective: Little is known about the usefulness of lymphocyte subsets as early predictors of anti-tuberculosis (TB) treatment response in immuno-competent patients.

Methods:Among a total of 64 patients with culture positive pulmonary TB, 29 remained sputum smear/culture positive or had delayed resolution on CXR (slow responders (SR)), and 35 had sputum culture conversion to negative and rapid resolution on CXR (fast responders (FR)) after two months of anti-tuberculosis treatment. Clinical parameters and lymphocyte subsets were investigated.

Results: A larger proportion of patients in the SR group had cavities on CXR, bilateral lung involvement, positive acid-fast bacilli stains, and complaint of cough at diagnosis than those in the FR group. Absolute counts of CD3⁺ T cells (p = 0.016) and CD8⁺ T cells (p = 0.012) at diagnosis were both significantly higher in the SR group. This trend was present throughout the 6-month treatment course. Absolute T cell counts (odds ratio (OR) 1.002, 95% confidence interval (CI) 1.0–1.004), positive sputum acid fast bacilli stain (OR 6.69, 95% CI 1.37–32.77) and bilateral lung involvemment on CXR (OR 13.114, 95% CI 1.87–92.14) at diagnosis were independent predictors for a slow response. Combining these three predictors, a prediction score (PS) could be calculated to display an optimal discrimination for slow response (area under the curve (AUC) = 0.855, p < 0.001) whereas absolute T cell counts yielded the highest discriminative value on an individual level (AUC = 0.676, p = 0.015).

Conclusions: A higher T cell count at diagnosis in patients with TB may predict a slow response to two months of treatment. The calculation of a PS further increased predictive accuracy and performance.

[Detection of aneurysm by 3 Tesla MRA in third cranial nerve palsy]

The diagnostic work-up of patients with third cranial nerve palsy includes neuroimaging because the lesion of the oculomotor nerve may result from compression due to an aneurysm. The advantages and disadvantages of different neuroimaging techniques, i. e. magnetic resonance angiography (MRA), computed tomography angiography (CTA) and intra-arterial digital subtraction angiography (DSA), are still under debate. In this context, the present case report demonstrates that the application of 3 Tesla-MRA may help to detect an aneurysm of the internal carotid artery which had remained undetected by non-invasive standard methods applied before. Therefore 3 Tesla-MRA may help to fill a gap in diagnostic approaches between non-invasive (MRA, CTA) and invasive (DSA) neuroimaging techniques.

New image characteristics in endobronchial ultrasonography for differentiating peripheral pulmonary lesions

Endobronchial ultrasonography (EBUS) rapidly and accurately localizes peripheral pulmonary lesions. It can aid differential diagnosis by characterizing lesions and discriminating between neoplastic and non-neoplastic disease. From July 2005 through December 2006, patients with peripheral lesions underwent EBUS examination in a tertiary-referral teaching hospital. Image characteristics were subsequently correlated with definite histopathologic diagnosis. Three current-issued image patterns of EBUS were assayed from 40 initial patients, including (a) hypoechoic areas, (b) anechoic areas and (c) luminant areas around the probe. Excluding 22 cases because of inconsistent typing, 193 patients possessing definite diagnoses were enrolled in the investigation, of which 107 cases (55.4%) were neoplastic diseases. Hypoechoic areas appeared to be unrelated to the nature of the lesions (p = 0.288). Most lesions with anechoic areas were neoplasms (18 of 21 cases, 85.7%) and lesions without luminant areas suggested non-neoplastic disease (19 of 24 cases, 79.2%). Anechoic and luminant areas were significantly different between neoplasm and non-neoplasm groups (p = 0.003 and p < 0.001, respectively). The average additional time for EBUS required was 3.85 +/- 2.36 min (range 1 to 13 min). In conclusion, this uncomplicated and time-saving method of using EBUS image patterns could provide additional information to facilitate differential diagnoses.

Bronchial epithelial-myoepithelial carcinoma

An epithelial-myoepithelial tumor is an extremely rare pulmonary neoplasm. Only 21 cases have been reported to date. This report presents a case of left main bronchial epithelial-myoepithelial carcinoma in a 43-year-old woman. No mediastinal lymph nodes were enlarged in computed tomographic scan, and no tumor growth was noted beyond the bronchial cartilage layer by endobronchial ultrasound imaging. This report highlights the usefulness of endobronchial ultrasound imaging for determining the depth of tumor invasion and choosing an alternative approach to surgical resection.

Differentiating peripheral pulmonary lesions based on images of endobronchial ultrasonography

PURPOSE

To attempt to develop a simple method to discriminate between neoplasm and nonneoplasm peripheral pulmonary lesions based on images of endobronchial ultrasonography (EBUS).

METHODS

Between June 2004 and June 2005, 151 patients with bronchoscopic peripheral lesions that could not be detected via a conventional bronchoscope underwent EBUS for advanced localization with a 20-MHz miniature radial probe in a tertiary-referral teaching hospital. The image characteristics were applied subsequently to correlate definite histopathologic results in studied patients.

RESULTS

Based on an initial 20 consecutive patients with a definite diagnosis, four image characteristics were issued: (1) continuous hyperechoic margin outside the lesion, (2) homogeneous, or heterogeneous internal echoes, (3) hyperechoic dots in the lesion, and (4) concentric circles along the echo probe. In the following 131 patients, excluding five cases due to inconsistent typing, 93 patients (73.8%) established a diagnosis later. Most cases involving the image characteristics of homogenous internal echoes and concentric circles had nonneoplasm lesions (18 of 19 cases, 94.7%, and 14 of 16 cases, 87.5%, respectively). The difference shown in these two respects with neoplasm lesions was significant by univariate analysis (p < 0.001), although only concentric circles had a significant p value after multivariate analysis. Another two image patterns (continuous hyperechoic margins and hyperechoic dots) did not yield a significant difference (p = 0.090 and p = 0.079, respectively). The average additional time for EBUS was 3.94 min (1.5 to 10 min).

CONCLUSION

EBUS can provide characteristic information to differentiate the nature of a peripheral pulmonary lesion from the image characteristics of concentric circles.

Endobronchial ultrasonography with distance for peripheral pulmonary lesions

BACKGROUND

We assessed the effectiveness of applying the distance from the orifice of the bronchus to visualized peripheral pulmonary lesion (PPL) under endobronchial ultrasonography (EBUS) to transbronchial biopsy (TBB), as an alternative to EBUS with a guide sheath (GS) and fluoroscopy.

PATIENTS AND METHODS

From October 2004 to July 2005, a total of 158 consecutive patients with solitary PPLs, which were not visualized under flexible video bronchoscopy, were received EBUS for advanced localization subsequently. One hundred and thirteen of 158 patients with solitary PPLs which were visualized on EBUS image were included in this prospective study and randomly divided into two groups for TBB using different methods. In group EBUS-D (57 patients) the distance from the bronchial orifice to pulmonary lesion was measured, then the biopsy forceps were advanced to this measured distance and biopsy followed. In group EBUS (56 patients) the biopsy forceps were advanced regardless of distance. The diagnostic yields were then compared.

RESULTS

TBBs in group EBUS-D patients had a significantly higher diagnostic yield (45/57, 78.9%) than group EBUS patients (32/56, 57.1%) [P=0.013]. Size and location of lesion, duration of EBUS, diagnosis of malignancy, and whether the probe was located within the lesion on EBUS image did not differ between these two groups. Mild bleeding occurred in three patients in group EBUS-D and two in group EBUS. One group EBUS patient had a self-limited pneumothorax.

CONCLUSIONS

Measuring and applying the distance between the orifice of bronchus and the lesion could increase the diagnostic yield of EBUS-guided TBBs for PPLs.

Primary pulmonary malignant melanoma presenting with haemoptysis

Primary pulmonary melanoma is a rare disease, and only 20 cases have been published previously in the English literature. A 44-year-old woman presented initially with haemoptysis, and a chest roentgenogram showed a single lung mass. The diagnosis of primary pulmonary melanoma necessitates reliance on both clinical and histological criteria. The image of endobronchial ultrasonography (EBUS) in our case was not distinct from the image of lung cancer.