Improved Accuracy and Sensitivity in Diagnosis and Staging of Lung Cancer with Systematic and Combined Endobronchial and Endoscopic Ultrasound (EBUS-EUS): Experience from a Tertiary Center

BACKGROUND

Combined endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided tissue acquisition (EUS-TA) are accurate procedures for the diagnosis and staging of mediastinal lymph nodes (MLNs) in lung cancer. However, the respective contribution of separate and combined procedures in diagnosis and staging has not been fully studied. The aim of this study was to assess their respective performances.

METHODS

Patients with suspected malignant MLNs in lung cancer or recurrence identified by PET-CT who underwent combined EBUS-TBNA and EUS-TA were retrospectively reviewed.

RESULTS

A total of 141 patients underwent both procedures. Correct diagnosis was obtained in 82% with EBUS-TBNA, 91% with EUS-TA, and 94% with the combined procedure. The overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of EBUS-TBNA, EUS-TA, and the combined procedure for diagnosing malignancy were [75%, 100%, 100%, 58%], [87%, 100%, 100%, 75%], and [93%, 100%, 100%, 80%], respectively, with a significantly better sensitivity of the combined procedure (p < 0.0001). Staging (82/141 patients) was correctly assessed in 74% with EBUS-TBNA, 68% with EUS-TA, and 85% with the combined procedure. The overall sensitivity, specificity, PPV, and NPV of EBUS-TBNA, EUS-TA, and the combined procedure for lung cancer staging were [62%, 100%, 100%, 55%], [54%, 100%, 100%, 50%], and [79%, 100%, 100%, 68%], respectively, significantly better in terms of sensitivity for the combined procedure (p < 0.001).

CONCLUSION

The combined EBUS-EUS approach in lung cancer patients showed better accuracy and sensitivity in diagnosis and staging when compared with EBUS-TBNA and EUS-TA alone.

Restin protein expression in non-small cell lung cancer

BACKGROUND

Restin is a member of the melanoma-associated antigen (MAGE) superfamily. Its expression has been reported to be up- or downregulated in cancer. Preclinical data suggest it is a tumor suppressor. In this study, we aimed to evaluate restin expression and prognostic value in non-small cell lung cancer (NSCLC).

METHODS

Restin expression was analyzed by immunohistochemistry in three tissue microarrays consisting of formalin-fixed/paraffin-embedded NSCLC specimens from 113 patients, represented in triplicate. Restin staining H-score was the result of the staining intensity (0-no, 1-weak, 2-moderate, and 3-strong) multiplied by the percentage of stained tumor cells; it was defined as low if 1-100, moderate if 101-200, and strong if 201-300. Haverage-score was the average H-score in the triplicate. Restin Haverage-scores were tested for correlations with clinical and pathological characteristics and patient outcome.

RESULTS

Restin expression was localized to the cytoplasm, with nuclear enhancement, of 112/113 (99.1%) NSCLCs. Restin Haverage-scores were 0 in 1/113 (0.88%), low in 15/113 (13.3%), moderate in 48/113 (42.5%), and strong in 49/113 (43.4%) NSCLCs. Restin Haverage-scores did not correlate with NSCLC histological subtype, disease stage, recurrence/progression-free, or overall survival.

CONCLUSION

Restin is moderately to strongly expressed in the majority of NSCLC tumors but its expression has no prognostic value in patients with NSCLC.

Treatment and Prognosis of Patients with Lung Cancer and Combined Interstitial Lung Disease

BACKGROUND

Interstitial lung disease (ILD) is associated with a higher lung cancer (LC) risk and may impact cancer's clinical characteristics, treatment strategies, and outcomes. This impact's extent is unclear, particularly in Caucasians.

METHODS

In this retrospective observational study, we reviewed the files of all LC patients diagnosed in a 38-month period. Expert radiologists reviewed the computed tomography scans performed at diagnosis. Patients with LC and ILD (n = 29, 7%) were compared to those without ILD (n = 363, 93%) for population and cancer characteristics, treatments, and clinical outcomes.

RESULTS

Patients with LC and ILD were older (73 ± 8 vs. 65 ± 11 years; p < 0.001). There was no significant difference in LC histology, localization, stage, or treatment modalities. The respiratory complication rate after cancer treatment was significantly higher in the ILD group (39% vs. 6%; p < 0.01). Overall survival rates were similar at 12 (52% vs. 59%; p = 0.48) and 24 months (41% vs. 45%; p = 0.64) but poorer in the ILD group at 36 months, although not statistically significant (9% vs. 39%; p = 0.06). The ILD group had a higher probability of death (hazard ratio (HR) = 1.49 [0.96;2.27]), but this was not statistically significant (p = 0.06). In a Cox regression model, patients with ILD treated surgically had a significantly higher mortality risk (HR = 2.37 [1.1;5.09]; p = 0.03).

CONCLUSIONS

Patients with combined LC and ILD have worse clinical outcomes even when similar treatment modalities are offered.

Long-term complete remission after severe pembrolizumab-induced immune-related encephalitis in metastatic lung adeno-squamous carcinoma: A case report

Immune checkpoint inhibitors became the treatment of choice, in monotherapy or in association with platinum-based doublet chemotherapy, in first-line therapy for advanced-stage non-small-cell lung cancer without oncogenic driver. Nevertheless, it can be associated with diverse immune-related adverse events; several immune-related adverse events can also follow each other involving multiple organ systems, leading to immune checkpoint inhibitors discontinuation and immunosuppressive therapy that could compromise the prognosis of patients, with the exception of rare situations such as this clinical case. This case report illustrates a succession of immune-related adverse events including a rare and severe pembrolizumab-induced immune-related encephalitis in a patient with metastatic lung adeno-squamous carcinoma in whom we could observe a long-term and complete remission despite discontinuation of treatment and high-dose corticosteroids. In metastatic non-small-cell lung cancer, a disease with a poor initial prognosis, some patients can benefit from immune checkpoint inhibitors and can even now present a long-term and complete remission and this despite severe and rare immune-related adverse events, high-dose corticosteroids and an early discontinuation of treatment.

[Potential therapeutic implication of focal adhesion kinase in small-cell lung cancer]

The molecular steps leading to small cell lung cancer (SCLC) development and progression are still poorly understood, resulting in the absence of targeted therapy and an extremely poor prognosis. Activation of Focal Adhesion Kinase (FAK) plays a key role in the invasive behavior of this cancer in vitro. Our hypothesis is that FAK could be a therapeutic target in SCLC. Our work aims to describe a mouse model to study the role of FAK and the antitumoral potential of its inhibition in SCLC in vivo.

Neurocognitive testing in predicting conversion to Alzheimer's disease

Introduction

Alzheimer’s disease (AD) is a neurodegenerative disorder that affects memory, thinking, attention, and emotion or AD. Smelling problems are frequent symptoms of dementia. The aim of this study was to evaluate whether it is possible to predict if someone with anosmia or hyposmia has a higher risk of getting dementia or even AD.

Methods

This study was a retrospective longitudinal study, and the data used were part of a larger research project, the Vienna Conversion to Dementia Study. The 173 participants were divided into four groups based on cognitive features such as healthy control (HC), subjective cognitive decline (SCD), non-amnestic mild cognitive impairment (naMCI), and amnestic mild cognitive impairment (aMCI). Olfactory assessment and neurocognitive assessment were administered.

Results

We found that 30.5% of aMCI patients converted into AD after an average of about two years. The corresponding ROC analyses for olfactory testing showed that Sniffin’ Sticks revealed significant results regarding the conversion to AD, whereas the Assessment of Self-Reported Olfactory Functioning and olfaction-related quality of life (ASOF) inventory using the Subjective Olfactory Capability (SOC) subscale, the Smell-Related Problems (SRP) subscale, and the Olfaction-Related Quality of life (ORQ) did not. A logistic regression showed that among the olfactory test procedures, only the Sniffin’ Sticks enabled a relevant prognosis. Including neurocognitive measures in the model, only VSRT and the Trail Making Test-B. The other predictors did not contribute to the prediction of conversion to AD.

Conclusion

Unlike self-reporting of olfactory functioning, olfactory testing using standardized tests may have potential for predicting dementia, especially AD. However, olfactory tests have lower predictive power than neurocognitive tests such as verbal memory and divided attention tests.

Implications

Diagnostic tools for predicting dementia as accurately and early as possible are important. Olfactory assessment, compared to neurocognitive tests for verbal memory and divided attention, is inferior in predicting the prognosis of AD.

Case report: BRAF A598-T599insV mutation as a potential resistance mechanism to alectinib in ALK-rearranged lung adenocarcinoma

Anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) have improved the prognosis of advanced-stage non-small cell lung cancer (NSCLC) with ALK rearrangement, but resistance mechanisms limit their efficacy. We describe the case of a 63-year-old man with a stage cIVA ALK-rearranged lung adenocarcinoma who developed a BRAF A598-T599insV mutation as a potential resistance mechanism to alectinib, a second-generation ALK TKI. He was treated with an association of BRAF and MEK inhibitors but death occurred two months after treatment initiation in a context of tumor progression and toxicity. Based on this first report of BRAF A598-T599insV mutation occurring in lung cancer, we discuss resistance mechanisms to ALK TKIs, implications of BRAF mutation in NSCLC, and BRAF A598-T599insV mutation in other cancers.

A comparison of hernia sac ligation versus invagination in Lichtenstein tension-free mesh hernioplasty: does the type of hernia play a role in outcomes?

BACKGROUND

Management of the indirect hernial sac in inguinal hernia repairs has long been a subject of debate among general surgeons. Although hernial sac high ligation (HL) is a time-honored concept in groin hernia surgery, non-ligation/invagination is gaining popularity. This study was intended to compare the effects of hernia sac ligation and invagination in patients undergoing Lichtenstein mesh hernioplasty (LMH). Another aim was to investigate the possible association between the hernial defect size and postoperative early pain in both groups.

METHODS

Patients with indirect inguinal hernia undergoing elective LMH under spinal anesthesia were included in this prospective randomized study. Patients were classified according to European Hernia Society (EHS) criteria and were randomized into two groups, HL and non-HL/invagination. Postoperative pain levels at 6, 12, and 24 h, 7 days, and 1 year were compared using a ten-point visual analog scale (VAS). In addition, recurrence was examined in the postoperative first year. Postoperative complications, length of hospital stay, drain use, and surgery times were evaluated as secondary outcomes. This study was registered at www.

CLINICALTRIALS

gov . (The clinicaltrials.gov ID number is: NCT05308251).

RESULTS

Ninety-three out of a total of 108 patients were included in the study between January 2020 and January 2021 (HL group n = 44, non-HL group n = 49). Demographic characteristics were comparable between the groups. Mean VAS scores were significantly higher in the HL group at 6 and 12 h postoperatively (p < 0.05 and p = 0.036 respectively). While there was no difference in pain levels between the groups in EHS 1 and EHS 2 hernias (p > 0.05 for all), VAS scores were significantly higher in the ligation group in EHS 3 hernias (p < 0.05 for all). Recurrence and complication rates were unaffected with non-ligation at a median 18 months follow-up.

CONCLUSION

Hernia sac invagination was superior to ligation in patients who underwent LMH, as it reduced early postoperative pain levels without disturbing repair integrity. We therefore recommend that ligating the hernial sac be avoided, especially in EHS 3 patients who undergo LMH.

Targeting BRAF Activation as Acquired Resistance Mechanism to EGFR Tyrosine Kinase Inhibitors in EGFR-Mutant Non-Small-Cell Lung Cancer

Osimertinib has become a standard of care in the first-line treatment of advanced-stage non-small-cell lung cancer (NSCLC) harboring exon 19 and 21 activating mutations in the EGFR gene. Nevertheless, the 18.9-month median progression-free survival emphasizes the fact that resistance to osimertinib therapy is inevitable. Acquired resistance mechanisms to osimertinib in EGFR-driven NSCLC include MET amplification, EGFR C797S mutation, neuroendocrine differentiation, small-cell lung carcinoma histologic transformation, PD-L1 and KRAS amplifications and ESR1-AKAP12 and MKRN1-BRAF translocations, as well as BRAF V600 mutation. This last one represents 3% of the acquired resistance mechanisms to osimertinib. In this review, we discuss the rationale for EGFR/BRAF/MEK co-inhibition in the light of a clinical case of EGFR-mutant NSCLC developing a BRAF V600 mutation as an acquired resistance mechanism to osimertinib and responding to the association of osimertinib plus dabrafenib and trametinib. Additionally, we discuss the acquired resistance mechanisms to osimertinib plus dabrafenib and trametinib combination in that context.

Therapeutic depletion of CCR8+ tumor-infiltrating regulatory T cells elicits antitumor immunity and synergizes with anti-PD-1 therapy

BACKGROUND

Modulation and depletion strategies of regulatory T cells (Tregs) constitute valid approaches in antitumor immunotherapy but suffer from severe adverse effects due to their lack of selectivity for the tumor-infiltrating (ti-)Treg population, indicating the need for a ti-Treg specific biomarker.

METHODS

We employed single-cell RNA-sequencing in a mouse model of non-small cell lung carcinoma (NSCLC) to obtain a comprehensive overview of the tumor-infiltrating T-cell compartment, with a focus on ti-Treg subpopulations. These findings were validated by flow cytometric analysis of both mouse (LLC-OVA, MC38 and B16-OVA) and human (NSCLC and melanoma) tumor samples. We generated two CCR8-specific nanobodies (Nbs) that recognize distinct epitopes on the CCR8 extracellular domain. These Nbs were formulated as tetravalent Nb-Fc fusion proteins for optimal CCR8 binding and blocking, containing either an antibody-dependent cell-mediated cytotoxicity (ADCC)-deficient or an ADCC-prone Fc region. The therapeutic use of these Nb-Fc fusion proteins was evaluated, either as monotherapy or as combination therapy with anti-programmed cell death protein-1 (anti-PD-1), in both the LLC-OVA and MC38 mouse models.

RESULTS

We were able to discern two ti-Treg populations, one of which is characterized by the unique expression of Ccr8 in conjunction with Treg activation markers. Ccr8 is also expressed by dysfunctional CD4+ and CD8+ T cells, but the CCR8 protein was only prominent on the highly activated and strongly T-cell suppressive ti-Treg subpopulation of mouse and human tumors, with no major CCR8-positivity found on peripheral Tregs. CCR8 expression resulted from TCR-mediated Treg triggering in an NF-κB-dependent fashion, but was not essential for the recruitment, activation nor suppressive capacity of these cells. While treatment of tumor-bearing mice with a blocking ADCC-deficient Nb-Fc did not influence tumor growth, ADCC-prone Nb-Fc elicited antitumor immunity and reduced tumor growth in synergy with anti-PD-1 therapy. Importantly, ADCC-prone Nb-Fc specifically depleted ti-Tregs in a natural killer (NK) cell-dependent fashion without affecting peripheral Tregs.

CONCLUSIONS

Collectively, our findings highlight the efficacy and safety of targeting CCR8 for the depletion of tumor-promoting ti-Tregs in combination with anti-PD-1 therapy.

The daily practice reality of PD-L1 (CD274) evaluation in non-small cell lung cancer: A retrospective study

Treatment with pembrolizumab, an anti-programmed cell death-1 (PDCD-1) monoclonal antibody for the treatment of non-small cell lung cancers (NSCLCs) requires prior immunohistochemical (IHC) analysis of the expression of the programmed death-ligand 1 (PD-L1) (also known as CD274 molecule) which is a heterogeneous and complex marker. The present study aimed to investigate how pathological and technical factors (such as tumor location and sampling type, respectively) may affect the PD-L1 evaluation in patients with NSCLC in the daily practice of pathology laboratories. The current study was retrospective, and included 454 patients with NSCLC, for whom PD-L1 expression analysis by IHC was prospectively performed between November 2016 and January 2018. The association between PD-L1 expression and the clinicopathological characteristics of patients was statistically investigated using either the χ2 and Fisher exact tests or the Mann-Whitney and Kruskal-Wallis tests, depending on whether PD-L1 expression was assessed in three large categories (<1, 1-49, ≥50%) or in more precise percentages. Furthermore, the same statistical methodology was used to analyze the heterogeneity of PD-L1 expression according to its sampling type (cytology, biopsy or surgical specimen) and its location (primary tumor, lymph node or distant metastasis). Intra- and inter-observer discrepancies were also studied using double-blind evaluation and concordance analyses based on the weighted κ coefficient. The results demonstrated a significant association between PD-L1 expression and sample location (P=0.005), histological type (P=0.026), total number of mutations (P=0.004) and KRAS proto-oncogene, GTPase mutations (P=0.024). In addition, sampling type did not influence PD-L1 expression. The inter- and intra-observer discrepancies were 15% and between 16 and 17.5%, respectively. The present study confirmed that evaluation of PD-L1 expression by IHC can be performed on all types of samples. In addition, the results from the current study highlighted the heterogeneity of PD-L1 expression among the different types of sample location. In complex cases, a second evaluation of PD-L1 expression by IHC would be performed due to intra- and inter-observer discrepancies.

Role of Focal Adhesion Kinase in Small-Cell Lung Cancer and Its Potential as a Therapeutic Target

Small-cell lung cancer (SCLC) represents 15% of all lung cancers and it is clinically the most aggressive type, being characterized by a tendency for early metastasis, with two-thirds of the patients diagnosed with an extensive stage (ES) disease and a five-year overall survival (OS) as low as 5%. There are still no effective targeted therapies in SCLC despite improved understanding of the molecular steps leading to SCLC development and progression these last years. After four decades, the only modest improvement in OS of patients suffering from ES-SCLC has recently been shown in a trial combining atezolizumab, an anti-PD-L1 immune checkpoint inhibitor, with carboplatin and etoposide, chemotherapy agents. This highlights the need to pursue research efforts in this field. Focal adhesion kinase (FAK) is a non-receptor protein tyrosine kinase that is overexpressed and activated in several cancers, including SCLC, and contributing to cancer progression and metastasis through its important role in cell proliferation, survival, adhesion, spreading, migration, and invasion. FAK also plays a role in tumor immune evasion, epithelial-mesenchymal transition, DNA damage repair, radioresistance, and regulation of cancer stem cells. FAK is of particular interest in SCLC, being known for its aggressiveness. The inhibition of FAK in SCLC cell lines demonstrated significative decrease in cell proliferation, invasion, and migration, and induced cell cycle arrest and apoptosis. In this review, we will focus on the role of FAK in cancer cells and their microenvironment, and its potential as a therapeutic target in SCLC.

Increased Expression and Activation of FAK in Small-Cell Lung Cancer Compared to Non-Small-Cell Lung Cancer

INTRODUCTION

Focal adhesion kinase (FAK) plays a crucial role in cancer development and progression. FAK is overexpressed and/or activated and associated with poor prognosis in various malignancies. However, in lung cancer, activated FAK expression and its prognostic value are unknown.

METHODS

FAK and activated FAK (phospho-FAK Y397) expressions were analyzed by multiplex immunofluorescence staining in formalin-fixed paraffin-embedded tissues from 95 non-small-cell lung cancer (NSCLC) and 105 small-cell lung cancer (SCLC) patients, and 37 healthy donors. The FAK staining score was defined as the percentage (%) of FAK-stained tumor area multiplied by (×) FAK mean intensity and phospho-FAK staining score as the (% of phospho-FAK-stained area of low intensity × 1) + (% of phospho-FAK-stained area of medium intensity × 2) + (% of the phospho-FAK-stained area of high intensity × 3). FAK and phospho-FAK staining scores were compared between normal, NSCLC, and SCLC tissues. They were also tested for correlations with patient characteristics and clinical outcomes.

RESULTS

The median follow-up time after the first treatment was 42.5 months and 6.4 months for NSCLC and SCLC patients, respectively. FAK and phospho-FAK staining scores were significantly higher in lung cancer than in normal lung and significantly higher in SCLC compared to NSCLC tissues (p < 0.01). Moreover, the ratio between phospho-FAK and FAK staining scores was significantly higher in SCLC than in NSCLC tissues (p < 0.01). However, FAK and activated FAK expression in lung cancer did not correlate with recurrence-free and overall survival in NSCLC and SCLC patients.

CONCLUSIONS

Total FAK and activated FAK expressions are significantly higher in lung cancer than in normal lung, and significantly higher in SCLC compared to NSCLC, but are not prognostic biomarkers in this study.

Long term outcome after 48 Gy stereotactic ablative body radiotherapy for peripheral stage I non-small cell lung cancer

Background

To evaluate the outcome of patients treated with stereotactic ablative body radiotherapy (SABR) with curative intent for stage I non-small cell lung cancer (NSCLC) with regard to local, regional and distant tumor control, disease-free survival (DFS), overall survival (OS) and toxicity.

Methods

Data of 300 patients treated with SABR for NSCLC cancer for the period of November 2007 to June 2016 were retrospectively analyzed. Of which, 189 patients had single primary lung lesion and were included in the study. The prescribed dose for the tumor was 48 Gy, given in 12 Gy × 4 fractions for all patients. In 2010, an improved protocol was established in advanced technology for the planning CT, dose calculation and imaging. Cumulative incidence function (CIF) of local, regional, distant or any recurrences were computed using competing risk analysis with death as a competing event. Survivals (DFS and OS) were estimated using the Kaplan-Meier method and Cox proportional regression was used for comparisons. Toxicities were graded according to the common terminology criteria for adverse events version 4.0 (CTCAE v.4).

Results

Diagnosis was histologically confirmed in 42% of the patients (N = 80). At 1, 2 and 4 years, the cumulative incidence function (CIF) of local relapses were 8% [4–13%], 15% [10–21%] and 18% [12–25%], the CIF of regional relapses were 4% [2–8%], 10% [6–16%] and 12% [8–19%], the CIF of distant relapses were 9% [5–14%], 15% [11–22%] and 20% [15–28%] and the CIF of any relapses were 14% [10–20%], 28% [22–36%], 34% [27–43%], respectively. After 1, 2 and 4 years, the OS rates were 83% [95% CI: 78–89%] (N = 128), 65% [95% CI: 57–73%] (N = 78) and 37% [95% CI: 29–47%] (N = 53), respectively. The median survival time was 37 months. The DFS after 1, 2 and 4 years reached 75% [95% CI: 68–81%] (N = 114), 49% [95% CI: 42–58%] (N = 60) and 31% [95% CI: 24–41%] (N = 41), respectively. No grade 4 or 5 toxicity was observed.

Conclusions

We observed a long-term local control and survival after SABR for peripheral stage I NSCLC in this large series of patients with the expected low toxicity.

Therapeutic Potential of Focal Adhesion Kinase Inhibition in Small Cell Lung Cancer

Small cell lung cancer (SCLC) has a poor prognosis. Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase regulating cell proliferation, survival, migration, and invasion, which is overexpressed and/or activated in several cancers, including SCLC. We wanted to determine whether FAK contributes to SCLC aggressive behavior. We first evaluated the effect of FAK small-molecule inhibitor PF-573,228 in NCI-H82, NCI-H146, NCI-H196, and NCI-H446 SCLC cell lines. PF-573,228 (0.1-5 μmol/L) inhibited FAK activity by decreasing phospho-FAK (Tyr397), without modifying total FAK expression. PF-573,228 decreased proliferation, decreased DNA synthesis, induced cell-cycle arrest in G₂-M phases, and increased apoptosis in all cell lines. PF-573,228 also decreased motility in adherent cell lines. To make sure that these effects were not off-target, we then used a genetic method to inhibit FAK in NCI-H82 and NCI-H446, namely stable transduction with FAK shRNA and/or FAK-related nonkinase (FRNK), a splice variant lacking the N-terminal and kinase domains. Although FAK shRNA transduction decreased total and phospho-FAK (Tyr397) expression, it did not affect proliferation, DNA synthesis, or progression through cell cycle. However, restoration of FAK-targeting (FAT) domain (attached to focal adhesion complex where it inhibits pro-proliferative proteins such as Rac-1) by FRNK transduction inhibited proliferation, DNA synthesis, and induced apoptosis. Moreover, although FAK shRNA transduction increased active Rac1 level, FRNK reexpression in cells previously transduced with FAK shRNA decreased it. Therefore, FAK appears important in SCLC biology and targeting its kinase domain may have a therapeutic potential, while targeting its FAT domain should be avoided to prevent Rac1-mediated protumoral activity.

Systemic treatments for thymoma and thymic carcinoma: A systematic review

Thymic tumours are rare diseases that for most of the cases are cured with surgery and eventually adjuvant radiotherapy. However, about 30% of patients present with advanced stage or relapsing tumours, which require administration of chemotherapy. While cisplatin-adriamycin-cyclophosphamide combination is regularly prescribed, other drugs have been assessed in the literature. Our aim is to evaluate the effectiveness (response rate) of systemic treatments, whatever the therapeutic line, including chemotherapy, targeted therapies and immunotherapies, in thymoma and thymic carcinoma, using the principles of evidence-based medicine. A systematic review was designed using the PICO system, by an experienced librarian and clinicians' experts in thoracic oncology, through the Ovid Medline system. Only phase II-IV trials and retrospective studies including at least 14 patients treated with the same regimen were considered. Articles were independently selected by at least two investigators. Fifty-five eligible articles were retrieved. Sixty% were dealing with platinum-based regimens, mainly cisplatin, and showed overall similar activity (mostly response rate above 50%) independently of the line of treatment or histological type (thymoma versus thymic carcinoma). Non-platinum based regimens included octreotide-prednisone and capecitabine-gemcitabine. Promising data of immunotherapy with antiPDL1 antibody (pembrolizumab) requires confirmation. Based on available data, the most popular and active regimens are cisplatin-anthracycline (CAP or ADOC) or cisplatin-etoposide combinations that should be recommended when considering first-line chemotherapy in thymoma or thymic carcinoma.

Computation of gamma radioactivity of natural rocks in the vicinity of Antalya province and its effect on health

The aim of this study is to determine uranium (238U), potassium (40K) and thorium (232Th) in the radioactive elements by measuring the natural rocks in the vicinity of Antalya province by using High-purity Germanium (HPGe) Detector with gamma spectrometry 69. At the end of the measurements, total absorbed dose rates of the rock samples have been found to be within the normal range of values between 3.10 nGy/h and 117.35 nGy/h. While the minimum value of Raeq has been determined to be 6.36 Bq/kg at sample S8, the maximum value has been determined as 250.15 Bq/kg at sample S4. All of the values obtained at the end of the study have been determined to be lower than the maximum Raeq value (370 Bq/kg) and the limit values for industrial products which ranges between 370 – 740 Bq/kg. ARa, ATh and AK; 232Th, 40K and 226Ra of radionuclides are the activity concentrations in terms of Bq/kg. The hex value should be less than 1. The value is based on the upper limit of Raeq (370 Bq/kg). All of the results obtained are less than the limit value of 1.

Comparison of East and West Survival Nomograms in Turkish Gastric Cancer Patients Who Underwent Radical Surgery

BACKGROUND AND AIM:

The clinicopathological demonstrations of gastric cancer vary widely between Eastern and Western countries. Turkey is situated in Europe and Middle East which acts as a bridge between east and west. We aimed to validate the two popular nomograms of east and west origin by means of patients who underwent curative surgery for gastric cancer in our country.

MATERIAL AND METHODS:

Of the 202 patients diagnosed with gastric cancer between the years 2006 and 2013, 145 of these patients whose data were sufficient were included in the study. For all patients, demographic, laboratory, operative, and pathologic findings were documented. For each patient, prognostic factors were incorporated into the nomograms for estimating 5-year survival probability.

RESULTS:

For a Turkish cohort, the western nomogram showed a better discriminative capacity (AUC = 0.721, 95% confidence interval 0.637-0.806) and was better calibrated (the Hosmer-Lemeshow goodness-of-fit test p = 0.323), as compared to the eastern nomogram with AUC = 0.615, 95% confidence interval 0.522-0.708, and p = 0.077, respectively.

CONCLUSION:

Western nomogram was found to be more effective than eastern nomogram in prediction of estimating 5-year survival probability in patients with resectable gastric cancer in Turkish population.

Good Tolerance to Full-Dose Crizotinib in a Patient with Anaplastic Lymphoma Receptor Tyrosine Kinase-Rearranged Lung Adenocarcinoma and Preexisting Renal Impairment

Background

Crizotinib is an approved tyrosine kinase inhibitor in the treatment of advanced-stage non-small-cell lung cancer patients with anaplastic lymphoma receptor tyrosine kinase (ALK) rearrangement. Renal dysfunction after crizotinib administration was recently reported, but the physiopathological explanation and the safety in patients with preexisting renal dysfunction are still not clear.

Case Presentation

A 44-year-old female and current smoker was diagnosed with a stage IV lung adenocarcinoma and treated with five lines of chemotherapy during a 4-year period of time. While she developed symptomatic tumor progression with deterioration of her performance status and renal dysfunction after these five lines of treatment, we discovered that her lung cancer was ALK-rearranged. We therefore proposed a treatment with full-dose crizotinib despite the renal impairment (creatinine clearance: 33 mL/min/1.73 m²) of unknown origin. A renal function worsening occurred after the initiation of crizotinib but we did not reduce the dose as recommended and this did not induce further deterioration. During the 15 months under crizotinib, the patient had a good general status, no clinically noticeable side effect, and a stable renal dysfunction, which even improved after the initial worsening and almost returned to the baseline (pre-crizotinib) status.

Conclusion

This case report suggests that full-dose crizotinib may be continued even in patients with severe renal dysfunction and deterioration at treatment initiation, in parallel to careful follow-up of renal function and particular attention to avoid the use of concomitant nephrotoxic drugs.

Effectiveness of crizotinib in a patient with ALK IHC-positive/FISH-negative metastatic lung adenocarcinoma

We report a case of crizotinib effectiveness in a heavily pretreated patient with a metastatic NSCLC initially considered IHC-positive and FISH-negative for ALK rearrangement. After repeated analyses of tumor samples, borderline ALK FISH-positivity (18.5% positive cells) was demonstrated.

Systematic qualitative review of randomised trials conducted in nonsmall cell lung cancer with a noninferiority or equivalence design

The use of noninferiority randomised trials for patients with advanced non-small cell lung cancer has emerged during the past 10–15 years but has raised some issues related to their justification and methodology. The present systematic review aimed to assess trial characteristics and methodological aspects.

All randomised clinical trials with a hypothesis of noninferiority/equivalence, published in English, were identified. Several readers extracted a priori defined methodological information. A qualitative analysis was then performed.

We identified 20 randomised clinical trials (three phase II and 17 phase III), 11 of them being conducted in strong collaboration with industry. We highlighted some deficiencies in the reports like the lack of justification for both the noninferiority assumption and the definition of the noninferiority margin, as well as inconsistencies between the results and the authors' conclusions. CONSORT guidelines were better followed for general items than for specific items (p<0.001).

Improvement in the reporting of the meth"odology of noninferiority/equivalence trials is needed to avoid misleading interpretation and to allow readers to be fully aware of the assumptions underlying the trial designs. They should be restricted to limited specific situations with a strong justification why a noninferiority hypothesis is acceptable.

Combined endoscopic ultrasonography and endobronchial ultrasound-fine-needle aspiration for evaluation of mediastinal lymph nodes

OBJECTIVES

Endoscopic ultrasonography (EUS) and endobronchial ultrasound-fine-needle aspiration (EBUS-FNA), is an accurate technique for evaluation of mediastinal lymph nodes (MLN) and stadification of lung cancer. The aims of the study are to evaluate the feasibility and the efficacy of the combined technique compared with mediastinoscopy for the diagnosis of MLN.

DESIGN AND METHODS

All patients with suspected malignant MLN and/or lung lesion identified by positron emission tomography-computed tomography underwent combined EUS-EBUS-FNA. The combined procedure was performed in outpatients under general anesthesia for EUS and sedation by intravenous midazolam for EBUS when performed separately, using linear-array echoendoscopes. The MLN were punctured during the EUS and EBUS-FNA procedures with a 22 gauge needle.

RESULTS

Thirty-four patients underwent consecutively EUS and EBUS-FNA between September 2011 and November 2013 (8 women, 26 men, mean age of 65.9 year, range: 51-83). Combined EUS-EBUS-FNA was performed in a single time procedure in 26 patients (mean time 50 min) and in two different times in eight patients (mean delay 3 days). Twenty-five malignant and 9 inflammatory lesions were diagnosed. Mediastinoscopy was performed in nine patients and confirmed in eight patients the initial combined EUS-EBUS-FNA diagnosis. The diagnosis was obtained in 91.2% with EUS-FNA, 70.6% with EBUS-FNA and 97% when combined procedure was performed. The overall sensitivity, specificity, positive and negative predictive values of EUS-EBUS-FNA for diagnosing malignancy were 96.5%, 100%, 100% and 90% respectively. No complications related to the procedure were observed.

CONCLUSION

Combined EUS-EBUS-FNA represents an accurate technique in the diagnosis of MLN, can be done in a single time procedure and has the advantage of being less invasive than mediastinoscopy.

Anesthesia for adult rigid bronchoscopy

Rigid bronchoscopy under general anesthesia enables performing diagnostic and/or therapeutic procedures in the tracheobronchial tree. This technique is characterized by specific technical problems, insofar as the anesthesiologist and the operators share the same space, namely the airway. Several potential complications (hemorrhage inside the airway, threat to ventilation ...) may arise. These challenges render the ability to use the variable available techniques essential, as well as knowledge of the complications they could entail, and the ability to rapidly solve them. General anesthesia is usually total intravenous anesthesia, using short acting agents. Ventilation can be spontaneous, but more often insured using high-frequency jet ventilation. The hospital infrastructure and staff must have the expertise to perform this particular procedure, in order to limit the complication rate.

Relationship between placental traits and maternal intrinsic factors in sheep

The relationship between maternal intrinsic factors and placental traits was investigated on three Southern Mediterranean breed of sheep; Cukurova Assaf (CA), Cukurova (C) and Cukurova Meat Sheep (CMS). The effect of parity and birth type were also considered in the study as a potential influencing factor. Our hypothesis was to show that while differences in placental traits between breed, parity and birth type affected lamb condition and survivability, its correlation to maternal intrinsic behavioral factors may also be a strong indicator. The study found breed related differences of maternal behavioral factors and also showed significant correlation of these behavioral patterns to various placental traits. It confirmed earlier findings that parity played a major role in the refinement of these behavioral patterns. Significant differences in birth weight (P<0.05), placental weight (P<0.05), number of cotyledons (P<0.01) and cotyledon length (P<0.05) was seen between breeds. Cotyledon weight (P<0.05), width (P<0.01) and length (P<0.05) were found to differ by parity. Breed and parity interaction significantly influenced cotyledon quantity. While we detected breed specific differences in relation to maternal intrinsic factors we also noticed significant variance within breeds to these behavioral patterns when linked to placental traits. Further study is required on the correlation between placental traits and postnatal behavior on not just the ewes but also on their lambs. This could have a significant bearing on how producers manage and maximize lamb survivability.

Loss of polymeric immunoglobulin receptor expression is associated with lung tumourigenesis

Polymeric immunoglobulin receptor (pIgR) expression is downregulated in lung cancer, but its implications in lung tumourigenesis remain unknown. We hypothesised that loss of pIgR expression occurs early, and is associated with cell proliferation and poor prognosis. pIgR expression was evaluated by immunohistochemistry in airways of patients with normal mucosa, pre-invasive lesions and invasive lesions, and correlated with clinical outcomes. 16-HBE and A549 cells stably transfected with pIgR were tested for proliferation, apoptosis and cell cycle progression. Immunostaining was strong in normal epithelium, but severely reduced in pre-invasive lesions and most lung cancers. Persistent expression was associated with younger age and adenocarcinoma subtype but not survival. pIgR overexpression significantly reduced A549 and 16-HBE proliferation. Growth inhibition was not due to cell cycle arrest, increased apoptosis or endoplasmic reticulum stress, but we observed altered expression of genes encoding for membrane proteins, including NOTCH3. Interestingly, NOTCH3 expression was inversely correlated with pIgR expression in cell lines and tissues. pIgR expression was lost in most lung cancers and pre-invasive bronchial lesions, suggesting that pIgR downregulation is an early event in lung tumourigenesis. pIgR overexpression in A549 and 16-HBE cells inhibited proliferation. Future investigations are required to determine the mechanisms by which pIgR contributes to cell proliferation.

Placental traits and maternal intrinsic factors affected by parity and breed in goats

The relationship between placental traits and maternal intrinsic factors of Saanen, German Fawn and Damascus goats was investigated. Data was collected from 93 goats. The results of the study demonstrated that there were positive correlations between placental weight (PW) and cotyledon number (CN) (r=0.498, P<0.01), cotyledon weight (CW) (r=0.880, P<0.01), cotyledon density (CD) (r=0.538, P<0.01), cotyledon width (CWI) (r=0.500, P<0.01) cotyledon length (CL) (r=0.414, P<0.01) and cotyledon density (CD) (r=0.278, P<0.05). CN was negatively correlated with placental efficiency (PE) (r=-0.421, P<0.01) and CD (r=-0.325, P<0.05). While expulsion of placenta, right teat length and cotyledon length were affected by parity of doe (P<0.05) birth weight (BW), CN, right teat diameter (RTD), left teat diameter (LTD), CD, and CL were affected by breed (P<0.01). Breed×parity was found significant both for expulsion time of placenta and left teat length (LTL) (P<0.05). Damascus goats had a significantly longer duration of licking and grooming events than others. Saanen was more likely to require birth assistance compared to the German Fawn.

Bronchial secretory immunoglobulin a deficiency correlates with airway inflammation and progression of chronic obstructive pulmonary disease

RATIONALE

Although airway inflammation can persist for years after smoking cessation in patients with chronic obstructive pulmonary disease (COPD), the mechanisms of persistent inflammation are largely unknown.

OBJECTIVES

We investigated relationships between bronchial epithelial remodeling, polymeric immunoglobulin receptor (pIgR) expression, secretory IgA (SIgA), airway inflammation, and mural remodeling in COPD.

METHODS

Lung tissue specimens and bronchoalveolar lavage were obtained from lifetime nonsmokers and former smokers with or without COPD. Epithelial structural changes were quantified by morphometric analysis. Expression of pIgR was determined by immunostaining and real-time polymerase chain reaction. Immunohistochemistry was performed for IgA, CD4 and CD8 lymphocytes, and cytomegalovirus and Epstein-Barr virus antigens. Total IgA and SIgA were measured by ELISA and IgA transcytosis was studied using cultured human bronchial epithelial cells.

MEASUREMENTS AND MAIN RESULTS

Areas of bronchial mucosa covered by normal pseudostratified ciliated epithelium were characterized by pIgR expression with SIgA present on the mucosal surface. In contrast, areas of bronchial epithelial remodeling had reduced pIgR expression, localized SIgA deficiency, and increased CD4(+) and CD8(+) lymphocyte infiltration. In small airways (<2 mm), these changes were associated with presence of herpesvirus antigens, airway wall remodeling, and airflow limitation in patients with COPD. Patients with COPD had reduced SIgA in bronchoalveolar lavage. Air-liquid interface epithelial cell cultures revealed that complete epithelial differentiation was required for normal pIgR expression and IgA transcytosis.

CONCLUSIONS

Our findings indicate that epithelial structural abnormalities lead to localized SIgA deficiency in COPD airways. Impaired mucosal immunity may contribute to persistent airway inflammation and progressive airway remodeling in COPD.

Expression of focal adhesion kinase in small-cell lung carcinoma

BACKGROUND

The focal adhesion kinase (FAK) is a non-receptor tyrosine kinase linked to tumor growth, invasion, and metastasis. FAK is overexpressed and associated with prognosis in many cancers, but its prognostic value in small-cell lung carcinoma (SCLC) is unknown and was the focus of this study.

METHODS

Total FAK expression was analyzed via immunohistochemistry in tissue microarrays consisting of formalin-fixed, paraffin-embedded SCLC specimens from 85 patients. FAK staining scores were tested for correlations with pathological characteristics and clinical outcomes. Phospho-paxillin was also tested in 35 of the 85 specimens to evaluate whether FAK expression was associated with downstream signaling.

RESULTS

Specific FAK expression was localized to the cytoplasm of 78/85 (92%) SCLCs. FAK expression was scored low in 11 (13%), moderate in 17 (20%), and high in 50 (59%) SCLCs. FAK staining scores treated as continuous variables did not correlate with SCLC disease stage, response to therapy, recurrence/progression-free survival, or overall survival. Moreover, total FAK expression did not correlate with phospho-paxillin Tyr(118) expression.

CONCLUSIONS

Total FAK is strongly expressed in a majority of SCLC tumors. However, the expression evaluated via immunohistochemistry is not a prognostic factor in patients with SCLC.

Risk of malignancy in non-diagnostic thyroid fine-needle aspiration biopsy in multinodular goitre patients

OBJECTIVE

Although the majority of biopsies is adequate for a cytological diagnosis, 5-20 % will be insufficient or nondiagnostic. Patients with nondiagnostic FNABs (ND-FNAB) may be further managed by continued observation, repeated FNAB, or thyroidectomy. The aim of this study was to determine the risk of malignancy in ND-FNAB, and to determine if there are any clinical factors that can be used to distinguish malignant versus benign disease in multinodular goitre patients with ND-FNAB.

METHODS

A total of 411 multinodular goiter patients who underwent both a FNAB and thyroidectomy was the subject of study. Seventy nine of these patients with ND-FNAB were further reviewed retrospectively, and demographical and clinical factors were investigated to determine if there is any predictor of malignancy in this group of patients. Among these patients, FNAB has been repeated one more time in 5 (6.3 %) patients, and two more times in 9 (11.3 %) patients.

RESULTS

Among 79 patients with ND-FNAB, 10 patients (12.6 %) had malignancy as found postoperatively. There were no differences in age, sex, functional status of the thyroid gland, and nodule size between patients with benign versus malignant disease.

CONCLUSION

Nondiagnostic FNAB remains a significant problem in the evaluation of thyroid nodules. Despite ultrasound guidance, clinicians should inform patients that there is a 5-15 % malignancy risk of initial nondiagnostic specimens.

DNA copy number aberrations in small-cell lung cancer reveal activation of the focal adhesion pathway

Small-cell lung cancer (SCLC) is the most aggressive subtype of lung cancer in its clinical behavior, with a 5-year overall survival as low as 5%. Despite years of research in the field, molecular determinants of SCLC behavior are still poorly understood, and this deficiency has translated into an absence of specific diagnostics and targeted therapeutics. We hypothesized that tumor DNA copy number alterations would allow the identification of molecular pathways involved in SCLC progression. Array comparative genomic hybridization was performed on DNA extracted from 46 formalin-fixed paraffin-embedded SCLC tissue specimens. Genomic profiling of tumor and sex-matched control DNA allowed the identification of 70 regions of copy number gain and 55 regions of copy number loss. Using molecular pathway analysis, we found a strong enrichment in these regions of copy number alterations for 11 genes associated with the focal adhesion pathway. We verified these findings at the genomic, gene expression and protein level. Focal Adhesion Kinase (FAK), one of the central genes represented in this pathway, was commonly expressed in SCLC tumors and constitutively phosphorylated in SCLC cell lines. Those were poorly adherent to most substrates but not to laminin-322. Inhibition of FAK phosphorylation at Tyr(397) by a small-molecule inhibitor, PF-573,228, induced a dose-dependent decrease of adhesion and an increase of spreading in SCLC cell lines on laminin-322. Cells that tended to spread also showed a decrease in focal adhesions, as demonstrated by a decreased vinculin expression. These results support the concept that pathway analysis of genes in regions of copy number alterations may uncover molecular mechanisms of disease progression and demonstrate a new role of FAK and associated adhesion pathways in SCLC. Further investigations of FAK at the functional level may lead to a better understanding of SCLC progression and may have therapeutic implications.

Clinical significance of Hürthle cells in fine needle aspiration biopsy for multinodular goitre

OBJECTIVE

So far, the significance of Hürthle cell predominance in fine needle aspiration biopsy (FNAB) in multinodular goitre (MNG) appears not definitely clarified. The aim of this study was to determine if there are any clinical factors that can be used to distinguish either malignant or benign disease with the aid of FNAB specimen that contains a predominance of Hürthle cells in multinodular goitre patients.

METHODS

Among 623 patients who were evaluated for multinodular goitre between July 2004 and March 2009, 411 had a FNAB specimen. In 37 (9% of them) the FNAB specimen was interpreted as consistent with a Hürthle cell lesion. These patients comprised the study population and were reviewed retrospectively and their demographical and clinical factors were investigated to determine if there is any predictor of malignancy.

RESULTS

Among 37 patients with Hürthle cell predominance in FNAB, 29 had benign diseases and 8 had malignant diseases resulting in 21.6% prevalence of malignancy. There were no differences in age, sex, functional status of the thyroid gland, and nodule size between patients with benign versus malignant disease.

CONCLUSION

Total thyroidectomy should be recommended for all multinodular goitre patients with Hürthle cell predominance in FNAB, since there is no preoperative predictor of malignancy in these cases.

High-throughput molecular analysis in lung cancer: insights into biology and potential clinical applications

During the last decade, high-throughput technologies including genomic, epigenomic, transcriptomic and proteomic have been applied to further our understanding of the molecular pathogenesis of this heterogeneous disease, and to develop strategies that aim to improve the management of patients with lung cancer. Ultimately, these approaches should lead to sensitive, specific and noninvasive methods for early diagnosis, and facilitate the prediction of response to therapy and outcome, as well as the identification of potential novel therapeutic targets. Genomic studies were the first to move this field forward by providing novel insights into the molecular biology of lung cancer and by generating candidate biomarkers of disease progression. Lung carcinogenesis is driven by genetic and epigenetic alterations that cause aberrant gene function; however, the challenge remains to pinpoint the key regulatory control mechanisms and to distinguish driver from passenger alterations that may have a small but additive effect on cancer development. Epigenetic regulation by DNA methylation and histone modifications modulate chromatin structure and, in turn, either activate or silence gene expression. Proteomic approaches critically complement these molecular studies, as the phenotype of a cancer cell is determined by proteins and cannot be predicted by genomics or transcriptomics alone. The present article focuses on the technological platforms available and some proposed clinical applications. We illustrate herein how the "-omics" have revolutionised our approach to lung cancer biology and hold promise for personalised management of lung cancer.

Dissection of the abdominal aorta in a child with Takayasu's arteritis

Takayasu's arteritis is a chronic inflammatory disease that primarily involves the aorta and its main branches. Varying degrees of narrowing, occlusion, or dilatation develop in the involved vessel segments. However, dissection of the aorta is quite rare in this disease, and it may develop particularly after angioplasty. We report a very rare case of Takayasu's arteritis with dissection of the abdominal aorta just distal to the origin of the inferior mesenteric artery in a 9-year-old girl. She was treated conservatively with close follow-up. At the end of 1 year's follow-up, the dissection of the aorta did not show progression, and new lesions were not identified. To our knowledge, this patient is the youngest child presented with arterial dissection as the initial manifestation of the disease.