Endophenotype effect sizes support variant pathogenicity in monogenic disease susceptibility genes

Accurate and efficient classification of variant pathogenicity is critical for research and clinical care. Using data from three large studies, we demonstrate that population-based associations between rare variants and quantitative endophenotypes for three monogenic diseases (low-density-lipoprotein cholesterol for familial hypercholesterolemia, electrocardiographic QTc interval for long QT syndrome, and glycosylated hemoglobin for maturity-onset diabetes of the young) provide evidence for variant pathogenicity. Effect sizes are associated with pathogenic ClinVar assertions (P < 0.001 for each trait) and discriminate pathogenic from non-pathogenic variants (area under the curve 0.82-0.84 across endophenotypes). An effect size threshold of ≥ 0.5 times the endophenotype standard deviation nominates up to 35% of rare variants of uncertain significance or not in ClinVar in disease susceptibility genes with pathogenic potential. We propose that variant associations with quantitative endophenotypes for monogenic diseases can provide evidence supporting pathogenicity.

The genomics of heart failure: design and rationale of the HERMES consortium

Aims

The HERMES (HEart failure Molecular Epidemiology for Therapeutic targetS) consortium aims to identify the genomic and molecular basis of heart failure.

Methods and results

The consortium currently includes 51 studies from 11 countries, including 68 157 heart failure cases and 949 888 controls, with data on heart failure events and prognosis. All studies collected biological samples and performed genome‐wide genotyping of common genetic variants. The enrolment of subjects into participating studies ranged from 1948 to the present day, and the median follow‐up following heart failure diagnosis ranged from 2 to 116 months. Forty‐nine of 51 individual studies enrolled participants of both sexes; in these studies, participants with heart failure were predominantly male (34–90%). The mean age at diagnosis or ascertainment across all studies ranged from 54 to 84 years. Based on the aggregate sample, we estimated 80% power to genetic variant associations with risk of heart failure with an odds ratio of ≥1.10 for common variants (allele frequency ≥ 0.05) and ≥1.20 for low‐frequency variants (allele frequency 0.01–0.05) at P < 5 × 10⁻⁸ under an additive genetic model.

Conclusions

HERMES is a global collaboration aiming to (i) identify the genetic determinants of heart failure; (ii) generate insights into the causal pathways leading to heart failure and enable genetic approaches to target prioritization; and (iii) develop genomic tools for disease stratification and risk prediction.

p53 Loss in Breast Cancer Leads to Myc Activation, Increased Cell Plasticity, and Expression of a Mitotic Signature with Prognostic Value

Loss of p53 function is invariably associated with cancer. Its role in tumor growth was recently linked to its effects on cancer stem cells (CSCs), although the underlying molecular mechanisms remain unknown. Here, we show that c-myc is a transcriptional target of p53 in mammary stem cells (MaSCs) and is activated in breast tumors as a consequence of p53 loss. Constitutive Myc expression in normal mammary cells leads to increased frequency of MaSC symmetric divisions, extended MaSC replicative-potential, and MaSC-reprogramming of progenitors, whereas Myc activation in breast cancer is necessary and sufficient to maintain the expanding pool of CSCs. Concomitant p53 loss and Myc activation trigger the expression of 189 mitotic genes, which identify patients at high risk of mortality and relapse, independently of other risk factors. Altogether, deregulation of the p53:Myc axis in mammary tumors increases CSC content and plasticity and is a critical determinant of tumor growth and clinical aggressiveness.

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Myc is overexpressed and deregulated in breast tumors because of p53 signaling attenuation

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Myc activation favors SC symmetric divisions and SC reprogramming of progenitors

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Myc activation is necessary and sufficient to sustain the cancer SC phenotype

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Expression of 189 mitotic p53:Myc targets identifies high-risk breast cancer patients

Clinical and morphological effects of hyperbaric oxygen therapy in patients with interstitial cystitis associated with fibromyalgia

Background

Interstitial Cystitis (IC) is a debilitating disorder of the bladder, with a multifactorial and poorly understood origin dealing with microcirculation repeated damages. Also Fibromyalgia (FM) is a persistent disorder whose etiology is not completely explained, and its theorized alteration of pain processing can compromise the quality of life. Both these conditions have a high incidence of conventional therapeutic failure, but recent literature suggests a significant beneficial response to Hyperbaric Oxygen Therapy (HBOT). With this study, this study we evaluated the effects of HBOT on quality of life, symptoms, urodynamic parameters, and cystoscopic examination of patients suffering from both IC and FM.

Methods

We structured an observational clinical trial design with repeated measures (questionnaires, urodynamic test, and cystoscopy) conducted before and 6 months after a therapeutic protocol with hyperbaric oxygen for the treatment of patients suffering from both IC and FM. Patients were exposed to breathing 100% oxygen at 2 atm absolute (ATA) in a multiplace pressure chamber for 90 min using an oro-nasal mask. Patients undertook a cycle of 20 sessions for 5 days per week, and a second cycle of 20 sessions after 1 week of suspension.

Results

Twelve patients completed the protocol. Changes after HBOT were not significant, except for hydrodistension tolerance (mean pre-treatment: 409.2 ml; mean post-treatment: 489.2 ml; p < 0.05). A regression of petechiae and Hunner’s ulcers was also noted 6 months after the completion of HBOT.

Conclusions

Our study showed no improvement of symptoms, quality of life, and urodynamic parameters, except for hydrodistension, and a slight improvement in cystoscopic pattern. However, to date, we could not demonstrate the significance of overall results to justify the use of HBOT alone in patients with IC and FM. This observation suggests that additional studies are needed to better understand if HBOT could treat this subset of patients.

Trial registration

NCT03693001; October 2, 2018. Retrospectively registered.

Release of paused RNA polymerase II at specific loci favors DNA double-strand-break formation and promotes cancer translocations

It is not clear how spontaneous DNA double-strand breaks (DSBs) form and are processed in normal cells, and whether they predispose to cancer-associated translocations. We show that DSBs in normal mammary cells form upon release of paused RNA polymerase II (Pol II) at promoters, 5' splice sites and active enhancers, and are processed by end-joining in the absence of a canonical DNA-damage response. Logistic and causal-association models showed that Pol II pausing at long genes is the main predictor and determinant of DSBs. Damaged introns with paused Pol II-pS5, TOP2B and XRCC4 are enriched in translocation breakpoints, and map at topologically associating domain boundary-flanking regions showing high interaction frequencies with distal loci. Thus, in unperturbed growth conditions, release of paused Pol II at specific loci and chromatin territories favors DSB formation, leading to chromosomal translocations.

Cohort-wide deep whole genome sequencing and the allelic architecture of complex traits

The role of rare variants in complex traits remains uncharted. Here, we conduct deep whole genome sequencing of 1457 individuals from an isolated population, and test for rare variant burdens across six cardiometabolic traits. We identify a role for rare regulatory variation, which has hitherto been missed. We find evidence of rare variant burdens that are independent of established common variant signals (ADIPOQ and adiponectin, P = 4.2 × 10-8; APOC3 and triglyceride levels, P = 1.5 × 10-26), and identify replicating evidence for a burden associated with triglyceride levels in FAM189B (P = 2.2 × 10-8), indicating a role for this gene in lipid metabolism.

In Vivo Genetic Screens of Patient-Derived Tumors Revealed Unexpected Frailty of the Transformed Phenotype

The identification of genes maintaining cancer growth is critical to our understanding of tumorigenesis. We report the first in vivo genetic screen of patient-derived tumors, using metastatic melanomas and targeting 236 chromatin genes by expression of specific shRNA libraries. Our screens revealed unprecedented numerosity of genes indispensable for tumor growth (∼50% of tested genes) and unexpected functional heterogeneity among patients (<15% in common). Notably, these genes were not activated by somatic mutations in the same patients and are therefore distinguished from mutated cancer driver genes. We analyzed underlying molecular mechanisms of one of the identified genes, the Histone-lysine N-methyltransferase KMT2D, and showed that it promotes tumorigenesis by dysregulating a subset of transcriptional enhancers and target genes involved in cell migration. The assembly of enhancer genomic patterns by activated KMT2D was highly patient-specific, regardless of the identity of transcriptional targets, suggesting that KMT2D might be activated by distinct upstream signaling pathways.

SIGNIFICANCE

Drug targeting of biologically relevant cancer-associated mutations is considered a critical strategy to control cancer growth. Our functional in vivo genetic screens of patient-derived tumors showed unprecedented numerosity and interpatient heterogeneity of genes that are essential for tumor growth, but not mutated, suggesting that multiple, patient-specific signaling pathways are activated in tumors. Cancer Discov; 6(6); 650-63. ©2016 AACR.This article is highlighted in the In This Issue feature, p. 561.

Abstract A27: European Network NGS-PTL preliminary data: Whole exome sequencing identifies mutations of ALDH2, RETSAT, HSPG2, CHPF and other metabolic genes as a novel functional category in acute myeloid leukemia

Next Generation Sequencing (NGS) studies identified 9 functional categories of mutations in acute myeloid leukemia (AML), with &gt;99% of cases having at least one of those mutations (Ley et al. NEJM 2013). However, multiple genetic hits participate to AML pathogenesis, and metabolic dysregulations, as the one induced by IDH1/2 mutations, play oncogenic functions (Ward et al. Cancer Cell 2010).

Aim of the study was to define novel functional categories of AML mutations affecting relevant and druggable biological processes, with focus on genetic determinants of metabolic plasticity.

Out of 455 whole exome sequencing (WES) cases from onco-hematological patients collected in the NGS-PTL project, we analyzed 37 AML cases, belonging to our cohort of 239 FLT3-WT samples (886 AML total). We performed 100 bp paired-end WES (HiSeq2000, Illumina) and mapped the sequenced reads with Burrows-Wheeler Aligner. Variants where called with MuTect or GATK for single nucleotide variant (SNV) and indels detection, respectively (&gt;90% confidence). Gene expression profiling was performed using HTA2.0 microarray (Affymetrix) on 56 bone marrow samples, including AML (≥80% blasts) and healthy controls.

By WES analysis, we detected an average of 26 somatic variants per patient (range, 7 to 65). Gene ontology annotation identified 8 novel relevant functional categories of mutated genes: transcription, translation and post-translational modifications, protein degradation, cytoskeleton, cell cycle, DNA damage, cell survival and metabolism. Since metabolic pathways are promising targets for tailored therapies (e.g. IDH1/2 and glutaminase inhibitors), we focused our analysis on them. We identified 82 variants (74 SNVs, 2 frameshift and 4 nonframeshift deletions, 2 stopgains) targeting 70 genes involved in metabolism, with 78% of patients carrying at least one mutation in a metabolic gene and 35 variants rated as damaging by CONDEL algorithm. Among mutations in metabolic genes, the most represented pathways according to Recon X database were amino acids, lipids, CoA and nucleotides metabolism, transport and bioenergetics pathways. Notably, IMPDH2, a mediator of MYC-induced proliferation involved in nucleotide interconversion, was mutated and overexpressed in our AML cohort (p=0.01), suggesting a potential oncogenic function. Moreover, ALDH2, a regulator of hematopoietic stem cell functions which is involved in multiple metabolic pathways and associates with metabolic remodeling, was mutated and 2-fold downregulated in AML blasts. Seven genes were mutated in 5-8% of samples: RETSAT, HSPG2, CHPF, ABCA2, ND1, APOBR, NAAA. Among them, RETSAT, HSPG2, CHPF mutations were also predicted as “drivers” by DOTS-Finder tool. Bioenergetics pathways were affected by mutations in glycolysis and gluconeogenesis (GPI, ITPA), oxidative phosphorylation (ND1, ND4, ND5, CYTB), pentose phosphate pathway (H6PD, PGLS). Patients carrying mutations in the bioenergetics pathway showed a strong trend towards reduced overall survival, which did not associate with unfavorable molecular mutations.

In conclusion, metabolism is the most represented class of mutated genes (8.6% of variants) in our FLT3-WT AML cohort after signaling, leading us to propose a novel functional category. Our data suggest that, along with mutations in established oncogenes and tumor suppressors involved in metabolic control (KRAS, TP53, MYC pathway), a number of genetic determinants participate to leukemia metabolic plasticity and oncogenic mutations of metabolic enzymes may drive leukemogenesis, impact on patient's survival and become novel targets for personalized therapies.

Acknowledgements: ELN, AIL, AIRC, progetto Regione-Università 2010-12 (L. Bolondi), FP7 NGS-PTL project.

GS and AP equally contributed to this work.

Citation Format: Giorgia Simonetti, Antonella Padella, Ilaria Iacobucci, Italo Do Valle, Gabriele Fontanarosa, Elisa Zago, Francesca Griggio, Marianna Garonzi, Simona Bernardi, Cristina Papayannidis, Maria Chiara Abbenante, Giovanni Marconi, Giorgio Melloni, Laura Riva, Viviana Guadagnuolo, Mariachiara Fontana, Samantha Bruno, Elisa Zuffa, Eugenia Franchini, Annalisa Astolfi, Carmen Baldazzi, Elisa Dan, Barbara Sinigaglia, Michele Cavo, Nicoletta Testoni, Emanuela Ottaviani, Pier Giuseppe Pelicci, Marco Sazzini, Alberto Ferrarini, Massimo Delledonne, Daniel Remondini, Giovanni Martinelli. European Network NGS-PTL preliminary data: Whole exome sequencing identifies mutations of ALDH2, RETSAT, HSPG2, CHPF and other metabolic genes as a novel functional category in acute myeloid leukemia. [abstract]. In: Proceedings of the AACR Special Conference: Metabolism and Cancer; Jun 7-10, 2015; Bellevue, WA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(1_Suppl):Abstract nr A27.

New positron emission tomography derived parameters as predictive factors for recurrence in resected stage I non-small cell lung cancer

BACKGROUND

The recurrence rate for stage I non-small cell lung cancer is high, with 20-40% of patients that relapse after surgery. The aim of this study was to evaluate new F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) derived parameters, such as standardized uptake value index (SUVindex), metabolic tumor volume (MTV) and total lesion glycolysis (TLG), as predictive factors for recurrence in resected stage I non-small cell lung cancer.

METHODS

We retrospectively reviewed 99 resected stage I non-small cell lung cancer patients that were grouped by SUVindex, TLG and MTV above or below their median value. Disease free survival was evaluated as primary end point.

RESULTS

The 5-year overall survival and the 5-year disease free survival rates were 62% and 73%, respectively. The median SUVindex, MTL and TLG were 2.73, 2.95 and 9.61, respectively. Patients with low SUVindex, MTV and TLG were more likely to have smaller tumors (p ≤ 0.001). Univariate analysis demonstrated that SUVindex (p = 0.027), MTV (p = 0.014) and TLG (p = 0.006) were significantly related to recurrence showing a better predictive performance than SUVmax (p = 0.031). The 5-year disease free survival rates in patients with low and high SUVindex, MTV and TLG were 84% and 59%, 86% and 62% and 88% and 60%, respectively. The multivariate analysis showed that only TLG was an independent prognostic factor (p = 0.014) with a hazard ratio of 4.782.

CONCLUSION

Of the three PET-derived parameters evaluated, TLG seems to be the most accurate in stratifying surgically treated stage I non-small cell lung cancer patients according to their risk of recurrence.

The surgical treatment of lung cancer in patients with previous lymphoproliferative disorders: a historical cohort study

OBJECTIVES

We undertook a historical cohort study to compare, in terms of morbidity, mortality and long-term survival associated with lung cancer resection, a group of patients with previous lymphoproliferative disorders and a group without a hematological history.

METHODS

We identified 29 patients with a previous lymphoproliferative disorder who underwent lung cancer resection. These subjects (Group-A) were matched with 87 patients without a hematological history who underwent pulmonary resection during the same period (Group-B).

RESULTS

We found no significant difference between the two groups in length of hospitalization, comorbidities, spirometric parameters, type of surgery, histology, neoadjuvant chemotherapy, morbidity, mortality, median survival (Group-A = 37 months; Group-B = 52 months) and 5-year survival (Group-A = 37%; Group-B = 42%). The mean age of Group-A patients was significantly lower than that of Group-B patients (62 vs 66 years; p = 0.024). Group-A patients had a well differentiated lung cancer more frequently than Group-B patients (p = 0.001). Group-A patients had transitory bacteraemies more frequently than Group-B patients (p = 0.005). Multivariate Cox regression analysis showed that age (p = 0.01) and lung cancer stage (p = 0.04) were significantly associated with survival.

CONCLUSIONS

Patients with lymphoproliferative disorders had a lower age and more differentiated lung cancers than those without lymphoproliferative disorders. Patients with lymphoproliferative disorders and those without a hematological history had similar morbidity, mortality and long-term survival after pulmonary resection. Distinguishing patients with and without a lymphoproliferative disorder seems to be of limited value in the decision-making process of evaluating the indications for surgical treatment of lung cancer.

Combined treatment of non-small cell lung cancer with synchronous brain metastases: a single center experience

AIM

The aim of this study was to analyze our experience with combined treatment of non-small cell lung cancer with synchronous brain metastases.

METHODS

Between 1992 and 2008, 31 patients were treated by performing neurosurgery (or stereotactic radiosurgery) and lung surgery. Patients were divided into two groups according to their preoperative mediastinal work-up: group A (CT scan) and group B (FDG-PET scan).

RESULTS

Twenty-six patients had one brain metastasis and five had two. Neurosurgery was performed in 10 patients, stereotactic radiosurgery in 20 and both approaches in 1. Seven patients underwent chemotherapy after cerebral procedure. Pulmonary resection was complete in 27 cases and incomplete in 4. Histological findings showed: adenocarcinoma in 19 cases, squamous cell carcinoma in 8 and large cell carcinoma in 4. All patients underwent adjuvant chemotherapy. Overall 1, 2 and 5-year survival rates were 83%, 47% and 21%, respectively. The median survival was 22 months. Univariate analysis showed a better prognosis for complete resection (P=0.008), adenocarcinomas (P=0.015), N0 disease (P=0.038), and Group B (P=0.045). Multivariate analysis showed that only the radicality of the resection (P=0.027) and Group B (P=0.047) were independent prognostic factors.

CONCLUSION

Our experience confirms that selected patients with non-small cell lung cancer and synchronous brain metastases may be effectively treated by combined therapy. Complete resection, adenocarcinoma histology and N0 disease were prognostic factors. The incorporation of FDG-PET scan into the preoperative work-up may translate into a survival benefit.

Surgical treatment of multiple primary adenocarcinomas of the lung

INTRODUCTION

The incidence of lung adenocarcinomas has steadily increased over the last decades. The aim of this study was to assess the results of surgical treatment of multiple primary adenocarcinomas of the lung (MPAL) analyzing the radiological and histological features.

METHODS

From 1988 to 2005, 26 patients underwent surgical treatment for MPAL at our department, for a total of 52 tumors. Three patients had synchronous and 23 had metachronous tumors.

RESULTS

Thirty-seven tumors were classified as solid, two as ground-glass opacities (GGO) and 13 as mixed solid/GGO tumors on the basis of CT scan evaluation. Histology revealed 26 adenocarcinomas, five adenocarcinomas with a bronchioloalveolar (BAC) pattern and 21 BAC. There was no postoperative mortality. Five-year survival of patients with synchronous tumors was 66 %. Survival of patients with metachronous tumors was 95 % and 70 % from the first and second operation. Patients with stage II and III a tumors had significantly reduced survival rates ( P < 0.05). Survival was 60 % after lobectomy and 78 % after wedge resection.

CONCLUSIONS

Surgical treatment of MPAL is associated with favorable results. Sublobar resections, when technically feasible, provide adequate oncological management.

Preoperative assessment in patients with postintubation tracheal stenosis : Rigid and flexible bronchoscopy versus spiral CT scan with multiplanar reconstructions

BACKGROUND

Postintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible videobronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment.

METHODS

Twelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoperative findings.

RESULTS

The accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tracheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function.

CONCLUSIONS

Rigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up.

Neoadjuvant chemotherapy and pneumonectomy in a lung cancer patient on hemodialysis

Major pulmonary resections are rarely performed in non-small cell lung cancer patients on hemodialysis. To date only two cases of pneumonectomy performed in such patients are reported in the literature. Moreover, chemotherapy, as a treatment for advanced non-small cell lung cancer, is not routinely administered to patients with end-stage renal disease requiring hemodialysis. We present the case of a stage IIIB non-small cell lung cancer patient on hemodialysis who successfully underwent neoadjuvant chemotherapy followed by pneumonectomy. To our knowledge, this is the first case of non-small cell lung cancer patient on hemodialysis reported in the literature who successfully underwent this type of combined therapy.

Thoracoscopic treatment of a pericardial diverticulum

A 35-year-old female patient presented with a history of recurrent chest pain. On chest x-ray, a regularly shaped lesion at the right cardiophrenic angle was observed. The lesion appeared smaller on a subsequent x-ray. Magnetic resonance imaging showed a cystic lesion that could be differentiated from the pericardium only in its lower part. Thoracoscopy revealed a pericardial diverticulum. Resection of the lesion was performed thoracoscopically, with complete remission of the symptoms.

Surgical tracheostomy versus percutaneous dilatational tracheostomy. A prospective-randomized study with long-term follow-up

BACKGROUND

To compare surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) in terms of complication rates. In particular we specifically studied the late tracheal complications of both methods by means of endoscopic controls of patients up to 6 months after the procedures.

METHODS

DESIGN

prospective-randomized clinical study.

SETTING

University-affiliated tertiary care referral hospital.

PATIENTS

50 consecutive translaryngeally intubated patients with respiratory failure were randomized to undergo either ST (25 patients) or endoscopic guided PDT (25 patients).

RESULTS

ST was performed in 41+/-14 min versus 14+/-6 min for PDT (p<0.0001). There was no procedure-related death. In the ST group there were no intraoperative complications. In the PDT group 2 intraoperative complications (minor hemorrhages) were observed. In the ST group 9 early postoperative complications occurred: one minor bleeding, 7 stomal infections and one accidental decannulation. In the PDT group only one early postoperative complication (minor bleeding) occurred. Early postoperative complication rates were 36% for ST and 4% for PDT. In the ST group there were no late tracheal complications. In the PDT group 2 late tracheal complications (one segmental malacia and one stenosis at the level of the stoma) were observed.

CONCLUSIONS

This study confirms that PDT is a simpler and quicker procedure than ST and that it has a lower rate of early postoperative complications. Late tracheal complications were more frequent, although the difference was not statistically-significant, in the PDT group. Further investigations of long-term outcome following PDT are therefore necessary.

Therapeutic outcome according to histologic subtype in 121 patients with malignant pleural mesothelioma

One-hundred and twenty-one cases of malignant pleural mesothelioma (MPM) seen between 1986 and 1999 at the authors' Institution were reviewed. Histotype was epithelial in 88 patients (73%), sarcomatous in 21 (17%) and mixed in 12 (10%). Ninety-one patients received a treatment (38 palliative pleurectomy and no further therapy, 16 palliative pleurectomy followed by chemotherapy, 37 chemotherapy alone), while 30 were referred to supportive care only. Median survival of the whole population was 10.5 months. The 1-, 2- and 3-year survival were 40, 17 and 8%, respectively. Univariate analysis of subgroups showed that poor performance status (PS), non-epithelial histotype, Butchart stage>I and International Mesothelioma Interest Group (IMIG) stage>I were individually associated with lower survival. Patients receiving any therapy survived longer than patients treated with supportive care only (P=0.0004). Treatment modality had an independent prognostic value (P=0.00005), with a survival advantage for patients receiving surgery and adjuvant chemotherapy. Multivariate analysis confirmed the independent prognostic value of PS (P=0.001; HR=2.48) and treatment modality (P=0.003; HR=1.38). The prognostic role of PS (P=0.02) and treatment modality (P=0.01) was confirmed in the subset of patients with epithelial histology. On the contrary, therapy had no impact on survival in patients with sarcomatoid MPM (P=0.74). Despite the predicted bias of a retrospective non-randomized evaluation of treatment-related factors, patients with good PS and epithelial histology seemed to have a survival benefit from surgery or multimodality therapy, as opposite to patients with poor PS or non-epithelial histotype. However, these results must be confirmed in a larger prospective trial with uniform treatment.

Sporadic failure of botulinum toxin treatment in usually responsive patients with adductor spasmodic dysphonia

Botulinum toxin (BT) injections into vocalis (thyroarytenoid) muscle is currently considered the first-choice treatment for adductor spasmodic dysphonia, producing improvement for an average period of 3 months. In our experience, sporadic failure of BT efficacy can occur even in patients usually responsive to this therapy. The reasons for these episodes have not been clarified. In a retrospective, open trial, we investigated the effect toxin preparation (Botox or Dysport) and injection monitoring (electromyography or laryngoscopy) on the success rate of BT treatment. We studied 15 patients with adductor dysphonia usually responsive to BT therapy. BT was administered into the vocalis muscle in 112 and 36 injections under electromyographic or laryngoscopic guidance, respectively. Botox and Dysport were used in 106 and 42 sessions, respectively. In 29% of all injections, no subjective or objective changes, nor side effects were observed. Failure rate did not differ using electromyographic (28.6%) or laryngoscopic (30.5%) guidance. Failure rates with Botox and Dysport were 30.2% and 26.2%, respectively, but this difference was not statistically significant. These data suggest that treatment failure may occur regardless of the method of injection and of the drug preparation used, possibly due to mislocalisation of vocal folds.

[Treatment of malignant pleural mesothelioma]

BACKGROUND

In this study all patients observed between January 1993 and October 1997 with malignant pleural mesothelioma (MPM) have been analyzed in order to describe the impact of treatment modality on survival.

METHODS

Medical records of 56 patients with MPM (44 male, 12 female, median age = 59 yrs) were reviewed. In 34 cases the histotype was epithelial, in 4 sarcomatoid, in 4 mixed, in 3 desmoplastic, and in 11 not specified. Four treatment modalities were identified: 1) Surgery (subtotal pleurectomy) = 20 patients; 2) Chemotherapy = 19 patients; 3) Surgery+Chemo-therapy = 8 patients; 4) Supportive care = 9 patients.

RESULTS

The median survival was: 1) Surgery = 12.4 months; 2) Chemotherapy = 7.5 months; 3) Surgery+Chemotherapy = 12 months; 4) Supportive care = 11.4 months. Using univariate analysis, 8 prognostic factors were studied (age, sex, asbestos exposure, side, histotype, performance status, stage, treatment). Among these, only the stage and the performance status had shown a prognostic value on survival (p<0.05), while the treatment modality had not significantly influenced the prognosis. Using multivariate analysis only performance status showed to be significatively associated with survival (p=0.01 and odds ratio = 1.9, I.C. 1.2-3.2).

CONCLUSIONS

Despite the limits of a retrospective study, personal experience confirms the ineffectiveness of current therapeutical approaches to MPM. A better understanding of MPM is required to develop new therapeutical approaches and alter the dismal prognosis of this disease.

18-FDG positron emission tomography in the evaluation of malignant pleural diseases - a pilot study

OBJECTIVE

The diagnostic approach to pleural diseases may be difficult. The CT scan, which is the current diagnostic technique, has limited accuracy both in the differentiation between benign and malignant pleural diseases and in the diagnosis of primary and metastatic pleural neoplasms. Invasive procedures, such as thoracoscopy, are therefore frequently required to complete the diagnostic approach. The increasing incidence of malignant pleural mesothelioma has led to the development of new treatment strategies, which still need to be fully validated. There is, therefore, a need for new diagnostic techniques that can lead to a definite diagnosis and a satisfactory evaluation of the response to treatment. Encouraging results have been reported with the F-18-labeled analogue of 2-deoxyglucose (18-FDG) positron emission tomography (PET) in the evaluation of chest tumors such as lung cancer. The aim of this study was to evaluate the role of 18-FDG PET in the diagnostic assessment of pleural diseases.

METHODS

Patients with CT scan evidence of pleural thickening, or fluid, entered a study to evaluate the accuracy of 18-FDG PET in diagnosing pleural diseases. Image analysis was performed both with visual interpretation and using a semiquantitative method, standardized uptake values (SUV), on coronal, sagittal and axial reconstructions. The results of PET imaging were compared to histological data. PET was also performed before and after treatment in patients who underwent chemotherapy to evaluate the accuracy of this technique in the assessment of the response.

RESULTS

Fourteen patients entered the study. Histology demonstrated a malignant pleural disease in 13 patients; malignant pleural mesothelioma in ten patients, adenocarcinoma in two and liposarcoma in one. Benign pleural disease was diagnosed in the remaining patient. PET assessment demonstrated significant 18-FDG uptake in 12 of the 13 patients with a malignant disease, also revealing distant metastases in two of them. A false-negative result was observed in a patient with an epithelial mesothelioma. The overall accuracy was 92%. A benign pleural disease without significant uptake was correctly diagnosed in another patient. An aspecific uptake was observed in two patients who had undergone pleurectomy and intrapleural chemotherapy. A decreased tracer uptake was observed after chemotherapy in four patients.

CONCLUSIONS

These preliminary results demonstrate that 18-FDG PET may have a great potential, both in the differential diagnosis of pleural diseases and in the evaluation of the response to treatment. At present, however, histological thoracoscopic diagnosis remains mandatory before planning treatment. Further studies in larger groups of patients are needed to draw definite conclusions on the role of PET in the assessment of pleural diseases.

[Pleomorphic adenoma: a case treated by laryngotracheal resection and reconstruction]

Benign Pleomorphic Adenoma (PA) is a tumor rarely found in tracheal and laryngotracheal sites. A review of the literature published since 1922 has revealed only 30 certain cases of which 3 presented simultaneous involvement of both larynx and trachea. The present work describes the thirty-first case (the fourth with a laryngotracheal localization), diagnosed in a white, 40-year-old male who had been complaining of acute dyspnea for the last three years. Initially these symptoms had been interpreted as asthmatic crises. During one of these episodes, the patient underwent emergency tracheotomy and a laryngotracheoscopy revealed a rounded cricotracheal lesion with smooth surface and approximately 4 cm in cranio-caudal diameter. The mass occupied 90% of the air space and originated from the posterolateral right portion of the cricoid, and from the first 3 tracheal rings. CT and esophagoscopy ruled out its transmural invasion into the esophagus. Under rigid bronchoscopy, assisted NdYAG laser debulking was performed for biopsy purposes. The histological diagnosis was benign AP. For this reason a Grillo cricotracheal resection was performed with exeresis of the cricoid arch, mucosa of the cricoid plate and the first 4 tracheal rings. Reconstruction of the respiratory tract was achieved through termino-terminal cricothyrotracheal anastomosis. The initial diagnosis was confirmed and the resection edges were without evidence of neoplasm. Post-operative recovery proceeded without complications and the patient was discharged 7 days after surgery. Endoscopic and radiological follow-up after 30 months is still negative for any neoplastic recurrences. The laryngo-tracheal lumen is within the norm and cord motility has been preserved. The authors then describe the clinical, anatomopathological and radiological elements which prove useful in evaluating tracheal neoplasms and they underline the problems of differential diagnosis between benign AP and adenoid-cystic carcinoma. In addition, the various therapeutic options are discussed with special attention being focused on surgery through external approaches. Given the location of the AP described, the Grillo procedure-most commonly used in cases of inflammatory cricotracheal stenoses-proved well suited to the loco-regional control of the neoplasm. Stringent respect for some parts of this surgical technique make it possible to reduce post-operative complications to a minimum.

[Percutaneous or surgical trachetomy. Prospective, randomized comparison of the incidence of early and late complications]

BACKGROUND

To compare early and late complications after either conventional surgical or percutaneous dilatational tracheostomy.

DESIGN

Prospective, randomized study.

SETTING

General intensive care unit and neuro-surgical intensive care unit in a university hospital.

PATIENTS

50 consecutive patients, requiring tracheostomy for prolonged mechanical ventilation.

INTERVENTIONS AND MEASUREMENTS

Patients were randomly allocated to receive either surgical (surgical group, n = 25) or percutaneous dilatational tracheostomy (percutaneous group, n = 25). Occurrence of perioperative complication were carefully evaluated during ICU stay. Late complications were evaluated with both physical and endoscopic examination at 1, 3 to 6 months after tracheostomy.

RESULTS

All surgical and percutaneous tracheostomies were successfully completed and no deaths directly related to the tracheostomy procedures were reported. Completion of the procedure required 41 +/- 14 min in the surgical group and 14 +/- 6 min in the percutaneous one (p < 0.0001). The incidence of early perioperative complications was higher in the surgical group (36%) than in percutaneous one (12%), (p < 0.05). The endoscopic follow-up demonstrated one segmental malacia and one stenosis of the trachea in the percutaneous group only (p = n.s.). Skin repair was better after percutaneous tracheostomy than in the surgical group (p < 0.01).

CONCLUSIONS

In experienced hands, percutaneous dilatational tracheostomy is as safe and effective as the conventional surgical tracheostomy. The percutaneous technique is less time-consuming and has a lower rate of early infectious complications with better cosmetic results than the surgical technique.

[Laryngotracheal resection and reconstruction by Grillo's technic for postintubation stenosis]

BACKGROUND

Tracheal resection and reconstruction is the standard treatment for postintubation stenosis. However, when the stenosis extends proximally to the subglottic larynx surgical treatment is particularly difficult. Specific surgical techniques have to be used in order to preserve the recurrent laryngeal nerves. The aim of this study is to evaluate the results obtained at our Department with laryngotracheal resection and reconstruction with the Grillo technique for postintubation stenosis.

METHODS

From January 1984 to December 1997, 83 patients with tracheal and laryngotracheal lesions underwent surgical treatment. Eighteen patients had postintubation stenosis of the upper trachea and subglottic larynx and underwent single-stage laryngotracheal resection and reconstruction. Mean stenosis length was 3.5 cm (range 3-5 cm). Twelve patients underwent anterolateral laryngotracheal reconstruction, and 6 patients had a circumferential laryngotracheal reconstruction. A Montgomery suprahyoid laryngeal release was required in 4 cases.

RESULTS

There was no surgical mortality. Surgical results were excellent or good in 17 cases and satisfactory in one case. No recurrence of stenosis has been observed.

CONCLUSIONS

Cricoid cartilage involvement in postintubation stenosis should not be considered a contraindication to surgical treatment. However, laryngotracheal resection and reconstruction is technically difficult and should be performed only in selected cases.

Surgical treatment of non-small cell lung cancer in patients 70 years of age or older

BACKGROUND

Indications to surgical treatment of lung cancer in the elderly are still being discussed. The aim of this study was to evaluate postoperative complications and survival after surgery for non-small cell lung cancer (NSCLC) in patients 70 years of age or older.

METHODS

During a 4 year and 6 month period, 76 patients (67 men and 9 women) entered the study.

RESULTS

Postoperative complications occurred in 15 cases (19.7%) and the 30-day operative mortality was 1.3%. The overall 54 month actuarial survival was 53%. Mortality at 12 months wasn't related to stage of disease, histology or lobectomy versus wedge resection but was higher in those patients who had had postoperative cardiopulmonary complications. Results of preoperative spirometry, blood gas and cardiac status were predictive of mortality at twelve months (p < 0.05).

CONCLUSIONS

Surgery for NSCLC in the elderly should not be denied on the basis of age alone. Postoperative outcome is mainly related to concomitant cardiopulmonary disease.

Imaging of bronchial carcinoid tumors associated to Cushing syndrome with 111In-Octreoscan scintigraphy and immunoscintigraphy with anti-chromogranin monoclonal antibodies. Report of two cases

Bronchial carcinoid tumors are neuroendocrine neoplasms capable of expressing somatostatin receptors and of secreting neuromediators such as ACTH and chromogranins. Radiologic appearance is usually non-specific and has to be distinguished from benign pulmonary nodules and other malignant diseases. Standard radiological techniques have limited accuracy in the evaluation of such lesions. Radioisotopic imaging techniques may increase the specificity of diagnostic assessment. The role of immunoscintigraphy with anti-chromogranin A and B monoclonal antibodies (MoAbs) and of 111In-Octreoscan scintigraphy is evaluated in two cases of bronchial carcinoid tumors associated to Cushing syndrome.

Temporary main bronchial occlusion under bronchoscopic control in the evaluation of candidates for pneumonectomy

BACKGROUND

In this study we report our experience with temporary main bronchial occlusion in the preoperative evaluation of candidates for pneumonectomy.

METHODS

Between January 1991 and January 1994, 57 candidates for pneumonectomy underwent a 15-minute temporary main bronchial occlusion with an inflatable balloon during fiberoptic bronchoscopy. The following parameters were monitored during bronchial occlusion: general status, ECG, arterial pressure, heart rate and respiratory rate. Arterial blood gases were measured after 7 and 14 minutes. Values at 7 and at 14 minutes were compared with those obtained before the procedure. Patients were considered suitable surgical candidates for pneumonectomy if PaCO2 < 42 mmHg and pH > 7.35.

RESULTS

Fifty-three patients were considered functionally operable. Three patients were considered functionally inoperable (PaCO2 > 42 mmHg, pH < 7.35 and appearance of dyspnea). One patient was excluded from the analysis because of balloon mispositioning due to a coughing fit. Sixteen of the operable patients underwent pneumonectomy and all did well without clinical evidence of respiratory insufficiency. At present 11 patients are alive, all without chronic respiratory insufficiency (mean follow-up 14 months). No postoperative mortality related to cardiorespiratory problems was observed.

CONCLUSIONS

Temporary main bronchial occlusion is a simple and inexpensive test that can correctly predict functional resectability in candidates for pneumonectomy.

Surgical management of thyroid cancer invading the trachea

Airway invasion by thyroid carcinoma is a life-threatening disease and its severity is emphasized by the high incidence of death by suffocation because of bleeding or airway obstruction. A favorable prognosis may be obtained, however, with proper treatment of tracheal invasion. The standardization of reliable techniques for tracheal resection and reconstruction has made radical surgery a reasonable therapeutic approach to thyroid carcinomas invading the trachea. When the cricoid is invaded by the tumor, partial laryngeal resection becomes necessary but subsequent airway reconstruction is still possible with preservation of laryngeal function. Laryngectomy with placement of an end tracheostomy should be performed only in patients with extensive laryngeal infiltration. Our personal experience at the University of Milan Medical School supports the indications, techniques, and results reported in the literature and shows the effectiveness of tracheal resection and reconstruction in the treatment of infiltrating thyroid carcinoma. Tracheal resection and reconstruction for invasive thyroid carcinoma prevents death by asphyxiation, provides long-lasting palliation with good quality of life, and may even be curative.

Efficacy of ketorolac tromethamine and extrapleural intercostal nerve block on post-thoracotomy pain. A prospective, randomized study

BACKGROUND

Post-thoracotomy pain causes severe impairment of the respiratory function. Epidural analgesia is effective in the treatment of post-thoracotomy pain but may give rise to significant side-effects. Other low-risk and cost-effective analgesic treatments are therefore required.

METHODS

Thirty male patients who had undergone pulmonary lobectomy entered a prospective, randomized trial to evaluate the efficacy of ketorolac tromethamine (Group 2) and extrapleural intercostal nerve block (Group 3) with intermittent low-dose bupivacaine. Objective and subjective assessment was carried out at 8, 16, 24 and 48 hours postoperatively.

RESULTS

There were no significant differences between Groups 1 (control group) and 2. Vital capacity was significantly lower in Group 3 (p<0.05) than in Group 1 after 16 hours. Forced Vital Capacity was significantly higher in Group 2 than in Group 3 after 16 and 24 hours (p<0.05). Peak expiratory flow was also significantly better in Group 2 than in Group 3 after 16 hours (p<0.05). On-demand opioid consumption was significantly lower in Group 2 (p<0.001) and Group 3 (p<0.05). No side-effects were observed.

CONCLUSIONS

Ketorolac tromethamine was effective in the treatment of post-thoracotomy pain. Extrapleural intercostal nerve block allowed a significant reduction in the consumption of opioids. These analgesic techniques could be useful as low-risk, cost-effective and reproducible treatments when more effective techniques, such as epidural analgesia, are contraindicated.

[Blood preservation in thoracic surgery: feasibility and limitations]

The transfusion of homologous blood carries risks associated with reactions to transfusion and the transmission of diseases. Minimizing surgery-related blood use is therefore of utmost importance. However, the application of blood-saving methods in surgery is restricted by a number of factors. Thoracic surgery poses particular problems in this regard due to the type of diseases treated, patients' general status and the use of neoadjuvant chemotherapy protocols. The aim of this study was to analyse the feasibility of a blood conservation program for thoracic surgery. A detailed analysis of blood-sparing techniques was carried out and the factors influencing blood consumption were evaluated in the preoperative, intraoperative and postoperative periods. Although pre-operative autologus blood donation is an extremely important factor, its effect is limited in thoracic surgery since only a few patients are suitable candidates for such a procedure. Our personal experience confirms the difficulty of applying a blood sparing program to thoracic surgery. Nevertheless the risks associated to transfusions, especially those related to the use of homologous blood, can be reduced by optimizing existing blood sparing techniques or developing new hemostatic agents.

[The use of high resolution computerized tomography (HRCT) for the diagnosis of rejection and for monitoring air-way anastomosis in patients who have undergone lung transplantation. Preliminary study]

March, 1991, to June, 1992, five lung transplantations for end-stage lung disease were successfully performed at the Ospedale Maggiore Policlinico in Milan. All patients underwent high-resolution CT (HRCT) of the lung in a complex follow-up program to identify specific abnormalities of acute and chronic rejection (bronchiolitis obliterans) and to monitor the resolution of the bronchial anastomosis. Twenty-two HRCT exams were performed. In patients with acute rejection HRCT failed to identify specific abnormalities of lung parenchyma. In contrast, in one patient with pathological evidence of early bronchiolitis obliterans HRCT showed decreased peripheral vascularization. In the study of the bronchial anastomosis, HRCT showed optimal anastomosis resolution in 4 patients, whereas in one patient with a granuloma demonstrated by fibrobronchoscopy it confirmed the lesion showing also a small pneumomediastinum. Even though the HRCT finding of decreased peripheral vascularization does not appear to be specific for bronchiolitis obliterans, it may be of value in suggesting the diagnosis of early bronchiolitis obliterans in lung transplant. HRCT should be used in all patients with bronchoscopic diagnosis of bronchial complication to study the lesion and its mediastinal spread.

Self-expanding stents in the treatment of tracheobronchial obstruction

The self-expandable stainless steel stents (Gianturco, William Cook, Bjaeverskov, Denmark) used extensively in biliary ducts and the vascular system have recently been modified for use in the tracheobronchial tree. Between March 1991 and September 1992, six patients with unresectable tracheobronchial and mediastinal diseases were treated with the placement of one or more self-expanding stents under direct vision with a fiberoptic bronchoscope. All patients had been intubated for severe respiratory insufficiency. In all cases, immediate relief of respiratory symptoms was achieved and all patients were extubated 1 or 2 days after stent placement. Tolerance of the stents was excellent. No patient complained of pain, discomfort, or foreign body sensation. No infection or obstruction of the stents was observed. The chest roentgenogram and the bronchoscopies performed during follow-up have shown no change in the position of the stents. Our results seem promising since these devices provide effective palliation of airway obstructions and are well tolerated.

Surgery following neoadjuvant MPV chemotherapy (mitomycin, cisplatin, vinblastine) in locally advanced (IIIa and IIIb) non-small cell lung cancer

From November 1990 to August 1993, 32 patients with non-small cell lung cancer (NSCLC) entered a multimodality treatment study with neoadjuvant Mitomycin, Cisplatin and Vinblastine (MPV), surgery and radiotherapy at the San Raffaele Hospital in Milan, Italy. Neoadjuvant chemotherapy was performed on an outpatient basis. To date 23 patients (11 stage IIIa and 12 stage IIIb) have completed the chemotherapy treatment and are available for evaluation of response, toxicity, surgical eligibility and resection rate. The overall major response to MPV chemotherapy was 87%. The overall resection rate after major response to treatment was 60% (90% in stage IIIa and 17% in stage IIIb). After a median follow-up of 21 months (8-31) 17 patients are still alive (74%). Ten patients (83%) who had a complete resection are alive after a median follow-up of 23 months (21-30) and eight of them (66%) are in complete pathological remission. No treatment-related mortality was observed. The authors conclude that MPV is a highly effective neoadjuvant regimen for NSCLC and is feasible on an outpatient basis. Favorable resection rates can be obtained in stage IIIa patients. Stage IIIb patients can be downstaged and undergo complete resection. A longer follow-up is needed to assess the impact of this multimodality approach on long-term survival and to evaluate the role of adjuvant radiotherapy.

[Endoscopic monitoring in lung transplantation. Transplantation Group of the Maggiore Policlinico Hospital of Milan]

During the period March 1991-June 1992 5 single lung transplantations were successfully performed at the Ospedale Maggiore Policlinico in Milan. All patients underwent regular fibrobronchoscopies within the context of a complex follow-up programme in order to monitor the resolution of the bronchial anastomosis and identify the onset of intercurrent lung infections and rejections using bronchioalveolar lavage (BAL) and transbronchial biopsies (TBB). Forty-four fibrobronchoscopies were performed of which 24 for anastomotic follow-up, BAL and TBB, and 20 for the simple monitoring of the anastomosis. Fibrobronchoscopies confirmed the optimal resolution of bronchial anastomosis in 4 patients, whereas one patient showed a granulomatous anastomotic reaction which was successfully treated using local steroid injections. Although recovery was normal in one patient, kinking appeared in the bronchus of the receiving lung which was successfully treated by the insertion of Gianturco prosthesis. BAL enabled the identification of 2 CMV infections, one Pseudomonas aeruginosa, one Haemophilus influenzae and one Pneumocystis carinii infection. TBB allowed 3 cases of CMW lung infection and 7 episodes of rejection to be diagnosed. The authors' personal experience confirms the decisive role played by bronchoscopy in the follow-up of lung transplant patients. This procedure allowed bronchial anastomosis to be closely monitored and was of vital importance in the diagnosis of lung infections and rejection.

[Cardiorespiratory changes induced in man by the acute occlusion of the main bronchus]

Following the exclusion of the ventilation of a lung, perfusion is arrested as a consequence of the Von Euler and Liljestrand vasoconstrictive reflex. However it is as yet unknown how long this phenomenon takes to manifest itself in human beings. In order to verify whether hypoxic pulmonary vasoconstriction follows immediately on the arrest of ventilation or whether there is one some delay, in 21 candidates for pneumonectomy a bronchial block was provoked during fibrobronchoscopy and the hemogasanalytic modifications induced by the acute occlusion of the main bronchus have been studied. The analysis of the resulting data allows for the hypothesis that the exclusion of lung ventilation for 14 minutes is not sufficient to cause the complete manifestation of the hypoxic vasoconstrictive reflex.