A prospective, molecular epidemiology study of EGFR mutations in Asian patients with advanced non-small-cell lung cancer of adenocarcinoma histology (PIONEER)

INTRODUCTION

PIONEER (NCT01185314) was a prospective, multinational, epidemiological study of epidermal growth factor receptor (EGFR) mutations in patients from Asia with newly diagnosed advanced lung adenocarcinoma.

METHODS

Eligible patients (aged ≥20 years) had untreated stage IIIB/IV adenocarcinoma. The EGFR mutation status (primary end point: positive, negative, or undetermined) of tumor samples (biopsy, surgical specimen, or cytology) was determined (Scorpion amplification refractory mutation system). EGFR mutation frequency was calculated and compared between demographic and clinical subgroups.

RESULTS

Of 1482 patients from seven Asian regions, 43.4% of patients were female, median age was 60 years (range, 17-94), and 52.6% of patients were never-smokers. EGFR mutation status was evaluable in tumors from 1450 patients (97.8%) (746 [51.4%] positive; 704 [48.6%] negative). Country, sex, ethnicity, smoking status, pack-years (all p < 0.001), disease stage (p = 0.009), and histology type (p = 0.016) correlated significantly with EGFR mutation frequency. Mutation frequency was 61.1% in females, 44.0% in males; lower in patients from India (22.2%) compared with other areas (47.2%-64.2%); highest among never-smokers (60.7%); and decreased as pack-year number increased (>0-10 pack-years, 57.9%; >50 pack-years, 31.4%) (similar trend by sex). Ethnic group (p < 0.001) and pack-years (p < 0.001) had statistically significant associations with mutation frequency (multivariate analysis); sex was not significant when adjusted for smoking status.

CONCLUSION

PIONEER is the first prospective study to confirm high EGFR mutation frequency (51.4% overall) in tumors from Asian patients with adenocarcinoma. The observed high mutation frequency in demographic/clinical subgroups compared with white populations suggests that mutation testing should be considered for all patients with stage IIIB/IV adenocarcinoma, even males and regular smokers, among Asian populations.

Downregulation of EMX2 is associated with clinical outcomes in lung adenocarcinoma patients

BACKGROUND

The 5-year survival rate for stage I non-small-cell lung cancer (NSCLC) of 50% to 70% indicates that our current staging methods do not adequately predict outcome. Empty spiracles homeobox 2 (EMX2) is a homeo-domain-containing transcription factor that regulates a key developmental pathway known to promote lung tumorigenesis. This study assessed the significance of EMX2 as a prognostic biomarker in lung adenocarcinoma including bronchioloalveolar carcinoma (BAC).

PATIENTS AND METHODS

144 patients with lung adenocarcinoma undergoing surgical resection were studied. Quantitative real-time reverse transcriptase polymerase chain reaction and Immunohistochemistry were used to analyze EMX2 mRNA and protein expression, respectively. Association of EMX2 mRNA expression levels with clinical outcomes was evaluated using the Kaplan-Meier method and a multivariate Cox proportional hazards regression model.

RESULTS

EMX2 mRNA expression was significantly downregulated in lung adenocarcinoma compared with matched adjacent normal tissue (P < .001). EMX2 protein expression was similarly found to be downregulated in lung adenocarcinoma. The EMX2-high mRNA expressing group had statistically significant better overall survival (OS) than the EMX2-low mRNA expressing group (P = .005). Subgroup analysis also demonstrated improved survival in stage I patients (P = .01) and patients with BAC (P = .03). Lastly, the EMX2-high mRNA expressing group had statistically significant better recurrence-free survival (RFS) than the EMX2-low mRNA expression group in patients with adenocarcinoma (P < .001).

CONCLUSION

EMX2 expression is downregulated in lung adenocarcinoma. Low EMX2 mRNA expression is significantly associated with decreased OS and RFS in patients with lung adenocarcinoma, particularly with stage I disease and BAC.

[A case of non-small cell lung carcinoma dying of acute respiratory failure due to aerogenous metastasis]

A 63-year-old man was admitted to our hospital, because of exacerbation of backache and erythema. At the time of admission the chest X-ray film showed infiltrative shadows in the left middle and lower lung fields. Our investigation revealed primary mucinous type bronchioloalveolar carcinoma in the left lung (cT4N2M1 Stage IV). Radiotherapy (C7-Th2, L3-L5. Total 30 Gy/10 fr) was administered to relieve his pain. After radiotherapy, he developed respiratory failure, fever, and infiltrative shadow in his chest X-ray. Antibiotic therapy improved his symptoms, laboratory findings and radiological abnormal findings. We suspected complication with nosocomial infection. However the ground-glass appearance appeared in the right lung a few days later. Although antibiotics and steroids were administered, he died of respiratory failure in 6 days. Necropsy findings revealed bronchioloalveolar carcinoma in the right lung suggesting aerogenous metastasis. Considering these facts together, we diagnosed non-small cell lung carcinoma dying of acute respiratory failure due to aerogenous metastasis.

Pilot study of gefitinib and fulvestrant in the treatment of post-menopausal women with advanced non-small cell lung cancer

INTRODUCTION

Estrogen receptor beta (ERbeta) has been detected in non-small cell lung cancer (NSCLC) cell lines and tumor specimens. The ER down-regulator, fulvestrant, blocked estradiol-stimulation of tumor growth and gene transcription in NSCLC preclinical models and showed additive effects with the epidermal growth factor receptor (EGFR) inhibitor gefitinib. The safety and tolerability of combination therapy with the EGFR inhibitor, gefitinib, and fulvestrant was explored.

METHODS

Post-menopausal women with advanced NSCLC received gefitinib 250 mg po daily and fulvestrant 250 mg IM monthly.

RESULTS

Twenty-two patients were enrolled. Eight patients had adenocarcinoma, six NSCLC-NOS, four squamous cell, and four BAC. Seven patients were never-smokers. Eight patients received > or =2 lines of prior chemotherapy, six received one prior chemotherapy, and eight were treatment-naïve. One patient experienced grade 4 dyspnea possibly related to treatment; all other grade 3/4 toxicities were unrelated to treatment. Twenty patients were evaluable for response: three partial responses (PRs) were confirmed (response rate of 15%, 95% CI: 5-36%). The median progression-free survival (PFS), overall survival (OS), and estimated 1-year OS were 12 weeks (3-112 weeks), 38.5 weeks (7-135 weeks), and 41% (95% CI: 20-62%), respectively. Survival outcomes did not differ by prior lines of therapy. A subset analysis revealed that OS in the eight patients whose tumors exhibited at least 60% ERbeta nuclear IHC staining measured 65.5 weeks, while that of the five patients with ERbeta staining of less than 60% was 21 weeks. One patient with bronchioalveolar carcinoma (BAC) and a PR had an EGFR L858R mutation in exon 21. There was no correlation between ERbeta IHC expression and histology or smoking history.

CONCLUSIONS

Combination therapy with gefitinib and fulvestrant in this population was well tolerated and demonstrated disease activity.

Bortezomib plus gemcitabine/carboplatin as first-line treatment of advanced non-small cell lung cancer: a phase II Southwest Oncology Group Study (S0339)

INTRODUCTION

Bortezomib is a small-molecule proteasome inhibitor with single-agent activity in patients with non-small cell lung carcinoma (NSCLC) and synergy with gemcitabine in preclinical studies. This phase II study of bortezomib in combination with gemcitabine/carboplatin was conducted in chemotherapy-naive advanced NSCLC patients to assess efficacy and safety.

METHODS

Patients with selected stage IIIB/IV NSCLC, performance status 0-1, and no history of brain metastasis received up to six 21-day cycles of gemcitabine 1000 mg/m, days 1 and 8, carboplatin area under curve 5.0, day 1, and bortezomib 1.0 mg/m, days 1, 4, 8, and 11.

RESULTS

One-hundred-fourteen patients (52% adenocarcinoma, 85% stage IV) received a median of 3.6 treatment cycles. Median follow-up was >3 years. Median overall survival was 11 months; 1-year and 2-year survival rates were 47% and 19%, respectively. Median progression-free survival was 5 months; 1-year progression-free survival rate was 7%. Response rate was 23%, and disease control rate (responses + stable disease) was 68%. The most common grade 3/4 toxicities were thrombocytopenia (63%) and neutropenia (52%). One patient experienced febrile neutropenia. Grade 3/4 neuropathy occurred in 4%, and a further 6% experienced grade 2 sensory neuropathy.

CONCLUSIONS

Bortezomib plus gemcitabine/carboplatin resulted in a notable survival benefit in patients with advanced NSCLC, with the anticipated primary toxicity of myelosuppression. Further studies designed to investigate the role of bortezomib in advanced NSCLC are warranted.

A phase II study of single-agent oral vinorelbine in patients with pretreated advanced non-small-cell lung cancer

PURPOSE

Intravenous vinorelbine has demonstrated its efficacy and tolerability in advanced non-small-cell lung cancer (NSCLC). An oral formulation of vinorelbine has been developed, and a number of phase II studies have shown its activity in chemotherapy-naive NSCLC, even in elderly patients, but no study has been performed to test activity and toxicity of oral vinorelbine in pretreated patients. The aims of our study were to investigate the activity and toxicity of oral vinorelbine in patients with NSCLC as salvage treatment.

PATIENTS AND METHODS

Twenty pretreated patients with locally advanced (n = 6) and metastatic (n = 14) NSCLC entered the study. The schedule was oral vinorelbine 60 mg/m(2) once a week until progression or development of unacceptable toxicity. Median age was 70 years (range, 49-84 years).

RESULTS

Seventeen patients were evaluable for response and all for toxicity. A median of 9 cycles were administered (range, 2-21 cycles). No objective responses were reported, 5 patients experienced stable disease, and 12 patients had progressive disease. Median time to progression was 2 months (range, 1-6 months), and median survival was 4 months (range, 1-13 months). Treatment was well tolerated, with grade 4 neutropenia in 1 patient (heavily pretreated); grade 2 diarrhea in 2 patients; asthenia in 2 patients; and abdominal pain in 1 patient.

CONCLUSION

Oral vinorelbine 60 mg/m(2) once a week is a very safe schedule in heavily pretreated locally advanced and metastatic NSCLC; however, at this dose, the drug is inactive. Other phase II studies with oral vinorelbine 80 mg/m(2) weekly are warranted.

[Comparison of the characteristics in recurrence and metastasis between bronchioloalveolar carcinoma and other lung adenocarcinomas]

BACKGROUND & OBJECTIVE

The histological definition of bronchioloalveolar carcinoma (BAC) has been changed recently by the revised World Health Organization (WHO) classification. Although bronchioloalveolar carcinoma is a subtype of lung adenocarcinoma, its biological features are better than those of other lung adenocarcinomas. This study was to analyze differences in metastatic activity between bronchioloalveolar carcinoma and other lung adenocarcinomas.

METHODS

The expression of E-Cadherin, Collagen IV, vascular endothelial growth factor receptor-2 (VEGFR-2), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in 28 specimens of stage I bronchioloalveolar carcinoma confirmed pathologically and 40 specimens of other stage I lung adenocarcinomas were detected by immunohistochemistry. Their correlations to tumor recurrence and metastasis were analyzed.

RESULTS

The 5-year survival rate was significantly higher in ths patients with bronchioloalveolar carcinoma than in the patients with other lung adenocarcinomas (88.7% vs. 57.3%, P < 0.05). The intrathoracic recurrence rate was significantly higher and the extrathoracic metastasis rate was significantly lower in the patients with bronchioloalveolar carcinoma than in the patients with other lung adenocarcinomas (75% vs. 33.3%, 25% vs. 66.7%, P < 0.05). The positive rates of Collagen IV, E-Cadherin and TIMP-1 were significantly higher in bronchioloalveolar carcinoma than in other lung adenocarcinomas (78.6% vs. 42.5%, 78.6% vs. 40.0%, 67.5% vs. 42.9%, all P < 0.01). The positive rate of VEGFR-2 was significantly higher in other lung adenocarcinomas than in bronchioloalveolar carcinoma (85.7% vs. 77.5%, P < 0.05). There was no significant difference in the positive rate of MMP-9 between bronchioloalveolar carcinoma and other lung adenocarcinomas (85.0% vs. 78.6%, P = 0.494).

CONCLUSION

As compared with other lung adenocarcinomas, stage I bronchioloalveolar carcinoma is less aggressive in clinical behavior and likely to develop intrathoracic recurrence, with less extrathoracic metastases and better prognosis.

Unusual chemosensitivity of advanced bronchioalveolar carcinoma after gefitinib response and progression: a case report

Bronchioalveolar carcinoma of the lung represents increasingly recognized clinical entity with relatively high probability of response to epidermal growth factor receptor tyrosine kinase inhibitors. Patients who respond to these agents eventually develop resistance. In this case report, we describe a patient who relapsed after gefitinib treatment and achieved unusual response to vinflunine single-agent chemotherapy, despite earlier progression to a combination of another vinca alkaloid and cisplatin. Molecular characterization of the primary tumor before any treatment is provided, and mechanisms of resistance to epidermal growth factor receptor tyrosine kinase inhibitors are briefly discussed.

Long-term survival differences for bronchiolo-alveolar carcinoma patients with ipsilateral intrapulmonary metastasis at diagnosis

BACKGROUND

It has been suggested that the current staging system does not accurately reflect survival outcomes for advanced bronchiolo-alveolar carcinoma (BAC) patients.

METHODS

We conducted a case-only analysis of US Surveillance, Epidemiology, and End Results (SEER) data (1998-2002). Overall survival (OS) and lung cancer-specific survival (LCSS) univariate analyses were conducted using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazards ratios.

RESULTS

2345 incident cases of BAC were analyzed, including 707 patients with stage IIIB or IV BAC. Patients with stage IIIB BAC due to multiple lesions in the same lobe (n=93) had significantly improved median OS (46m) and LCSS (>58m) compared to other stage IIIB BAC patients (n=111; OS=9m, P<0.0001; LCSS=10m, P<0.0001). Among stage IV BAC patients, those with intrapulmonary metastasis (n=278) had significantly improved median OS (13m) and LCSS (15m) compared to those with distant metastasis (n=225; OS=7m, P<0.0001; LCSS=7m, P=0.0001). These survival differences persisted after adjustment for age, gender, ethnicity, and surgical treatment status.

CONCLUSIONS

Among stage IIIB and IV BAC patients, those presenting with ipsilateral intrapulmonary metastasis have improved survival outcomes. Our results add further support for modification to the current staging system for BAC.

[Clinicopathologic characteristics of metastatic carcinomas to spleen]

OBJECTIVE

To study the clinicopathologic characteristics of metastatic carcinomas to the spleen.

METHODS

Sixteen cases of metastatic carcinoma to the spleen were retrieved from archival clinical, surgical pathology and autopsy records. The demographic data (including sex and age of patients), clinical symptoms, primary sites, tumor histologic types, gross appearance of spleen and growth patterns within the spleen were analyzed.

RESULTS

Among the 16 patients studied, 12 were males and 4 were females. The male predilection was obvious. The age ranged from 48 to 90 years, the median age 66.5 years. Major clinical symptoms included discomfort in the left upper quadrant, pain, emaciation and loss of appetite. Splenomegaly was noted in some patients and computerized tomography could show space-occupying lesions in the spleen. In general, lung was the most common primary site for splenic metastasis and accounted for 43.8% of all cases (7/16). In male patients, primary lung tumor was found in 50.0% cases (6/12). On the other hand, primary ovarian tumor was commonly seen in females (2/4). Histologically, undifferentiated carcinoma of lung was frequently encountered (25.0%, 4/16), including 3 cases of small cell undifferentiated carcinoma and 1 case of large cell undifferentiated carcinoma. Other histologic tumor types included bronchioloalveolar carcinoma (2 cases), colonic adenocarcinoma (2 cases), ovarian serous papillary adenocarcinoma (2 cases), and prostatic adenocarcinoma (2 cases). The commonest histologic tumor type found in male patients was pulmonary undifferentiated carcinoma. The growth patterns of metastatic carcinoma in spleen included nodular, diffuse and multinodular. Most cases presented as a single splenic nodule. Sometimes, tumors with high metastatic potential (5/16) showed diffuse and multinodular growth patterns. Examples of these tumors included small cell undifferentiated carcinoma (3 cases), pulmonary adenocarcinoma (1 case) and prostatic adenocarcinoma (1 case).

CONCLUSIONS

Metastatic carcinoma to the spleen is rare. Understanding of the clinicopathologic characteristics is helpful in guiding clinical management and pathologic diagnosis.

Safety and efficacy of gefitinib treatment in elderly patients with non-small-cell lung cancer: Okayama Lung Cancer Study Group experience

We evaluated the safety and efficacy of gefitinib treatment in elderly patients with non-small-cell lung cancer (NSCLC). We retrospectively compared toxicity, response and survival outcomes for gefitinib in patients aged 75 years or older (elderly group) with the same outcomes in patients aged younger than 75 years. In total, 350 patients were eligible for this analysis, of whom 92 were in the elderly group and 258 in the non-elderly group. In the elderly group, adverse events were generally mild to moderate and grade 3-4 adverse events were observed in 8 (9%) patients. The objective response rate (17 vs. 21% for elderly vs. non-elderly, respectively) and median survival time (7.6 vs. 9.3 months) were also similar in the two groups. Multivariate analysis revealed elderly patients with lower Brinkman index tended to be more sensitive to gefitinib (odds ratio: 4.57, 95% confidence interval: 0.91-22.72, p = 0.0642). In this study, treatment with gefitinib appeared to be as safe and effective in elderly patients (aged 75 or older) with NSCLC as in non-elderly patients.

[Prognosis of patients after resection for lung cancer with intrapulmonary metastasis in different lobes]

BACKGROUND

The prognosis of lung cancer patients with intrapulmonary metastasis in different lobes (pm2) is poor. However, some patients achieve long-term survival. We retrospectively investigated the prognosis of resected primary lung cancer patients with pm2.

METHOD

Among 845 patients with primary lung cancer who underwent complete resection from 1984 to 2003, 14 cases that had lung cancer with pm2 were evaluated about prognostic factors.

RESULTS

The overall 5-year survival rate was 9.5%. The analysis of survival curve based on clinicopathological factors (surgical procedure, histology, tumor size, lymph nodal metastasis, pleural invasion, pleural dissemination and number of pm2) revealed that bronchioloalveolar carcinoma (BAC), the absence of pleural invasion and the absence of pleural dissemination are better prognostic factors.

CONCLUSION

Lung cancer patients with pm2 whose lesions show BAC histology, the absence of pleural invasion or pleural dissemination may achieve long-term survival and could be candidates for surgical treatment.

[Bronchioloalveolar carcinoma]

Bronchioloalveolar carcinoma (BALC) is a sub-type of adenocarcinoma, accounting for 3-5% of all lung cancer cases. It is characterized by peripheral location in lung parenchyma, without visible changes in main bronchi and tumor spread occurs along the walls of the peripheral airspaces without destruction of the pulmonary interstitium. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. The disease may take an asymptomatic form for several months or even years. This form of cancer spreads by way of air tracts creating multiple changes in lungs. Metastases to lymph nodes and other organs occur rarely. It is difficult to provide a correct diagnosis. The complete surgical resection of localized BAL C offers the best chances of long-term survival. Patient prognosis is usually more positive than in other histological types, since the disease is frequently diagnosed at its early development stages.

Ultrastructural findings in metastatic bronchioloalveolar carcinoma

This study was prompted by the recent revision of the definition of bronchioloalveolar carcinoma (BAC) that defines BAC, light microscopically, as a non-invasive carcinoma. Doubt has been raised whether BACs retain certain specific microscopic features after becoming invasive or metastatic. We studied 7 cases of metastatic, non-mucinous BAC by electron microscopy. Of these cases, 5 showed Clara cell granules and 1 revealed lamellar bodies. The remaining case did not show ultrastructural features of BAC. These findings suggest that most BACs retain some of their ultrastructural features after becoming metastatic neoplasms.

Diagnosis and treatment of the pituitary metastases

Three cases of pituitary metastases were reported. They all had operations and the pathological examination confirming the diagnosis. The clinical features of diabetes insipidus and extraocular nerve palsy were presented. In two cases, the original tumors were bronchioloalveolar carcinoma; in the other one, the original tumor was unknown. All three cases had poor outcome. These cases illustrate the fact that a pituitary metastasis can closely mimic a pituitary benign tumor, such as pituitary adenoma. Especially in the presence of suggestive symptoms such as diabetes insipidus and/or cranical nerve paralysis, the possibility of metastatic disease in the differential diagnosis of a pituitary mass should always be considered.

[Clinicopathologic features of small-sized peripheral lung cancer; is intentional limited resection appropriate for selected patients?]

We sought to determine the eligibility of patients with early peripheral lung cancer for intentional limited resection. The clinicopathologic features of 103 patients who underwent lobectomy and mediastinal nodal dissection for early stage peripheral lung cancer measuring 2 cm or less in maximum dimension between 1992 and 2002 were examined retrospectively. The lymph node metastasis and residual cancer after thoracoscopic partial resection were analyzed by the following categories. Three groups were divided by maximum dimension of the primary lesion in the resected specimen; 10 mm or less (n = 11), 15 mm or less (n = 33), and 20 mm or less (n = 59). Two groups were divided by lesion histology; bronchioloalveolar adenocarcinoma (BAC) [n = 42] and invasive lung cancer (n = 61). Residual cancer was found in the residual lobe after thoracoscopic partial resection in 3 of 43 patients who had no diagnosis preoperatively. Their maximum dimensions were 15 mm or less. No lymph node metastasis was detected in the patients with tumor measuring 10 mm or less, and BAC. Intentional limited resection without mediastinal nodal dissection is appropriate for patients with tumor measuring 10 mm or less and BAC. Further investigation associated with partial resection is necessary.

Ovarian metastasis originating from bronchioloalveolar carcinoma: a rare presentation of lung cancer

Ovarian metastasis originating from bronchioloalveolar carcinoma (BAC) has not been reported previously. We report a 63-year-old Chinese woman who was diagnosed as BAC with pleural metastasis in 1997. Four years later, she complained of vaginal bleeding, and a pelvic mass was discovered by an abdominal computerized tomography scan. Tumor debulking and total hysterectomy with bilateral salpingo-oopherectomy were performed. Pathology disclosed well-differentiated adenocarcinoma, with abundant clear cytoplasm, in the ovaries. Furthermore, immunohistochemical staining revealed that the tumor cells from the ovary and pleura were reactive to thyroid transcription factor 1 (TTF-1) and cytokeratin-7 (CK-7) but were negative for cytokeratin-20 (CK-20). The results of immunohistochemical staining, clinical course, and pathological features were compatible with the diagnosis of BAC with ovarian metastasis. In conclusion, to investigate the primary site of a metastatic ovarian cancer, clinicians should not forget the lungs since the incidence of lung cancer in females is increasing. Moreover, a monoclonal antibody panel for TTF-1, CK-7, and CK-20 may facilitate discrimination between primary and metastasized ovarian adenocarcinomas and/or identifying tumors of pulmonary origin.

Expression of the TSLC1 adhesion molecule in pulmonary epithelium and its down-regulation in pulmonary adenocarcinoma other than bronchioloalveolar carcinoma

TSLC1 (tumor suppressor in lung cancer-1) is an adhesion molecule of the Ig superfamily that binds homophilically and mediates cell-cell interactions. Originally, TSLC1 was cloned as a candidate tumor suppressor from the genomic region that frequently exhibits loss of heterogeneity in human non-small-cell lung cancer (NSCLC). However, there have been no studies on TSLC1 expression in normal lungs or NSCLC. Here we show that pulmonary epithelial cells express TSLC1 and its expression levels are often decreased or lost in primary pulmonary adenocarcinoma, a major histologic type of NSCLC. Immunohistochemistry revealed that TSLC1 was localized at cell-cell boundaries of all columnar epithelial cells in mouse embryonic lungs of 10.5 and 13 days postcoitus. Similar staining patterns were observed in bronchiolar and alveolar epithelial cells of adult human lungs, suggesting a physiologic role for TSLC1 in interactions of these cells. Next we performed Western blot analyses of TSLC1 in 47 primary pulmonary adenocarcinomas and judged each tumor as either decreased or nondecreased by comparing TSLC1 expression levels of the tumor with the levels of normal lungs. The expression profiles had a significant relation to histologic subtypes but not to other clinicopathologic parameters. Sixteen bronchioloalveolar carcinomas (BACs) were all judged nondecreased, while 19 of 31 (63%) adenocarcinomas other than BAC were judged decreased (p < 0.0001). Immunohistochemistry of tumors judged nondecreased revealed that not only BAC cells but also tumor cells in lepidic growth components of adenocarcinomas other than BAC expressed TSLC1 on their lateral plasma membranes. These tumor cells are considered less invasive because they proliferate in a lepidic growth pattern along alveolar walls. Thus, the present results not only support the hypothesis that TSLC1 is a tumor suppressor of NSCLC but also suggest that preserved integrity of TSLC1 may contribute to less invasive phenotypes of lepidic growth tumor cells.

Lung adenocarcinoma with mixed bronchioloalveolar and invasive components: clinicopathological features, subclassification by extent of invasive foci, and immunohistochemical characterization

A significant proportion of small lung adenocarcinomas consists of two components: bronchioloalveolar carcinoma (BAC) and invasive carcinoma. The purpose of this study was to compare their clinicopathologic features with those of BAC and those of invasive cancer without BAC, and to define "early invasive" lesions based on the extent of invasive foci. We reviewed 484 lesions of resected lung adenocarcinoma and classified them into three groups according to tumor growth pattern: group 1 (n = 102, BAC), group 2 (n = 216, adenocarcinoma consisting of BAC and invasive carcinoma), and group 3 (n = 166, invasive adenocarcinoma without BAC component). Group 2 was further subdivided according to the extent of the invasive area: group 2a (n = 54), BAC with invasive foci 5 mm. These groups were compared with regard to their clinicopathologic features, expression of Ki-67 and p53, and expression of laminin-5, a putative marker for tumor invasion. The positivity rates of vascular, lymphatic, and pleural invasion in each group were as follows: 0%, 0%, and 0% in group 1; 5.5%, 14.8%, and 1.9% in group 2a; 45.7%, 41.4%, and 25.9% in group 2b; and 84.9%, 61.4%, and 60.8% in group 3. Notably, no lymph node metastasis occurred in either group 2a or group 1, but it was observed in 24.1% of group 2b and 47.0% of group 3. The mean Ki-67 labeling index, the frequency of p53 overexpression, and the frequency of laminin-5 overexpression increased from group 1 (11%, 4%, and 0%) to group 2a (16%, 20%, and 7%) to group 2b (24%, 41%, and 23%) to group 3 (35%, 38%, and 38%). In contrast, no clear differences were observed when lesions were subdivided according to size. Based on the distribution pattern of Ki-67-positive tumor cells, lesions were classified into two groups: marginal type (63%) and nonmarginal type (37%). The latter showed a significantly higher labeling index than the former. Moreover, the proportion of the marginal type clearly decreased from group 1 (85%) and group 2a (87%) to group 2b (55%) to group 3 (19%). Group 2 lesions showed characteristics intermediate between the BAC and invasive adenocarcinoma. According to the extent of the invasive area, we were able to define a subgroup of mixed-type adenocarcinomas (group 2a) that could be regarded as early invasive cancer because they showed low rates of vascular, lymphatic, and pleural invasion, and no nodal involvement.

Unusual radiographic appearance of lung carcinoma in a cat

A 15-year-old, female Siamese cat presented with multiple cavitary lung lesions on thoracic radiographs. This was confirmed histologically to be a well-differentiated bronchioloalveolar carcinoma. To the authors' knowledge, this radiographic pattern has not previously been reported in association with bronchioloalveolar carcinoma in cats.

Stage I pure bronchioloalveolar carcinoma: recurrences, survival and comparison with adenocarcinoma of the lung

OBJECTIVE

Bronchioloalveolar carcinoma (BAC) is considered a subtype of adenocarcinoma of the lung, without pleural, stromal or vascular invasion (World Health Organization (WHO) classification). Previous reports had demonstrated a better prognosis following surgery for patients affected by early stage BAC than those affected by other type of non-small cell lung cancer (NSCLC). We aim to analyse differences between stage I peripheral nodular BAC and stage I peripheral adenocarcinoma of the lung,

METHODS

From January 1, 1993 to December 31, 1999, 1158 patients were submitted to surgical resection for NSCLC. Out of them, 28 patients (2.4%) resulted affected by stage I peripheral pure BAC and 80 (6.9%) by stage I peripheral adenocarcinoma. We made a comparison between these two groups.

RESULTS

The percentage of females in BAC patients was similar to that registered in adenocarcinoma patients (21.4 vs. 17.5%). No differences were detected between smokers in BAC and adenocarcinoma patients (P=0.331). The upper lobes were the most common sites of the primary tumour in both tumour subtypes (71.4 vs. 67.5%). Relapse of disease was less frequent in BAC than in adenocarcinoma patients (14.2 vs. 33.7%); recurrent disease developed intrathoracic with higher frequency in BAC patients (75 vs. 33.3%). Both 5-year disease-free and long-term survival were significantly higher in patients affected by BAC (81 vs. 51% and 86 vs. 71%, respectively) (P<0.05); when analysis is performed by dividing stage IA from IB tumours, BAC patients resulted to have higher DFS (stage IA, 93 vs. 58% - P=0.044; stage IB, 61 vs. 32.5%) and higher long-term survival (stage IA, 92 vs. 79%; stage IB, 75 vs. 56%).

CONCLUSION

Patients with stage I pure BAC have significantly longer disease-free and overall survival than those with similar stage adenocarcinoma. Even if classified as subtype of adenocarcinoma, BAC is characterised by clinical behaviour less aggressive than similar stage adenocarcinoma.

Intramedullary spinal cord metastases: case report and review of literature

Intramedullary spinal cord metastasis (ISCM) is a rare condition that causes serious diagnostic and therapeutic problems. ISCM is usually discovered in less than 1% of autopsies, with fewer than 5% being diagnosed antemortem. The uncertain and non-standardized treatment of patients diagnosed with ISCM is a major concern of neurosurgeons today. Presented is a case of ISCM detected in an 80-year-old man with a history of lung carcinoma. The progression of his illness, diagnostic role of MRI, and ISCM management options are discussed.

Detection of early invasion on the basis of basement membrane destruction in small adenocarcinomas of the lung and its clinical implications

To evaluate the correlation between the degree of basement membrane (BM) preservation and clinicopathological characteristics in the replacement-growth type (lepidic growth type) of small peripheral adenocarcinomas of the lung, the BM components of 72 surgically resected replacement-growth type adenocarcinomas of the lung, 2 cm or less in diameter, were evaluated immunohistochemically by using a monoclonal antibody to Type IV collagen and polyclonal antibodies to 7S collagen and laminin. The tumors were classified into the following three distinctive histological types according to the condition of the elastic framework: Type I, bronchioloalveolar carcinoma without fibrotic foci; Type II, sclerosing bronchioloalveolar carcinoma without elastic framework destruction; and Type III, sclerosing bronchioloalveolar carcinoma with elastic framework destruction. The BM was well preserved in the area of bronchioloalveolar spread along fully expanded alveoli in all tumor types; however, BM preservation was significantly lost in the areas of collapsed alveoli in Type III tumors. There were no BM component staining reactions in the scarred regions of Type III tumors. In addition, lymph node metastasis was significantly greater in Type III tumors and BM-destroyed tumors. We concluded that the BM was largely destroyed by tumor cell invasion in the scarred region of Type III adenocarcinomas. Type III tumors had discontinuous BMs in the area of collapsed alveoli, indicating that this BM-destructive pattern must be the first step in tumor invasion. Type I and II tumors were concluded to be noninvasive adenocarcinomas, because their BM components were well preserved and they had a good outcome.

Prognostic significance of percentage of bronchioloalveolar pattern in adenocarcinomas of the lung

Bronchioloalveolar (BA) carcinoma of the lung is considered to have a better prognosis than that of common adenocarcinomas of the lung. However, a minor component of the BA pattern is common in many lung adenocarcinomas and the criteria for designating an adenocarcinoma as BA are not well defined. We assessed the clinicopathologic features of 238 cases of lung adenocarcinoma with a partial or predominant BA pattern. Tumors were classified as BA if more than 75% of the tumor had a BA growth pattern. In other words, the tumor grew along pre-existing lung structures without invasion or destruction of parenchyma. Tumors with 50% to 75% BA pattern were considered mixed and tumors with less than 50% BA pattern were designated as solid/acinar (S/A). Fixed, paraffin-embedded tissue sections of each neoplasm were also assessed using immunohistochemical methods with a panel of antibodies specific for p53, retinoblastoma protein, p16, cyclin D1, and cyclin E, and the results were correlated with clinical and pathologic parameters. Our results show that the 5-year survival rate of patients with BA and mixed tumors, 63% and 60%, respectively, was significantly better than that of patients with S/A tumors (P =.026). Patients with BA tumors were more frequently women (55.9%) compared with patients with mixed (48.3%) and S/A (43.8%) tumors. Bronchioloalveolar and mixed tumors were similarly associated with tobacco use, 88.2% and 85%, respectively; slightly less than S/A tumors (93.8%). Clinical and pathologic parameters did not correlate with immunohistochemical results. In conclusion, patients with BA or mixed tumors have similar 5-year survival, better than that of patients with S/A tumors, suggesting that adenocarcinomas can be designated as BA when at least 50% of the tumor has a BA pattern.

Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution

BACKGROUND

Alveolar soft part sarcoma (ASPS) is a rare form of soft tissue sarcoma. Brain metastases have been reported to be a common feature of Stage IV ASPS, and recent practice guidelines recommend routine intracranial imaging as part of the staging evaluation in all patients who present with ASPS.

METHODS

The authors performed a comprehensive retrospective review of the clinical presentation, treatment, outcome, and patterns of failure in a consecutive series of patients with localized (American Joint Committee on Cancer [AJCC] Stages II/III) or metastatic (AJCC Stage IV) ASPS who presented to a tertiary care cancer center between 1959 and 1998.

RESULTS

Seventy-four patients were identified from the database searches. The anatomic distribution of their primary tumors included: extremities, 44 patients (60%); trunk, 15 patients (20%); head and neck, 9 patients (12%); and retroperitoneum, 6 patients (8%). The median tumor size was 6.5 cm (range, 1.2-24 cm). The AJCC stage at presentation was Stage II or III in 35% of the patients and Stage IV in 65% of the patients. The 5-year actuarial local recurrence free, distant recurrence free, disease free, and overall survival rates among the 22 patients with localized ASPS were 88%, 84%, 71%%, and 87%, respectively. At a median follow-up of 9 years, 2 of 22 patients with localized disease had developed local recurrences and 3 had developed metastatic disease (all to the lung only). Brain metastases were noted in 9 of 48 patients who presented with Stage IV (M1) disease (19%) and always were noted in association with metastasis to other sites. The median survival of patients with M1 disease was 40 months, with a 5-year survival rate of 20%.

CONCLUSIONS

Long term follow-up of patients with localized ASPS reveals a relatively indolent clinical course with relatively low rates of local and distant recurrence. In patients with Stage IV ASPS, brain metastases were observed only as part of more disseminated disease. The observations of the current study do not support current practice guidelines for the staging of patients with ASPS and suggest that selective rather than routine intracranial imaging should be used in patients presenting with ASPS.

Bronchorrhea revealing cervix adenocarcinoma metastastic to the lung

Copious bronchorrhea can be related to bronchioloalveolar carcinoma, but reports of bronchorrhea related to lung metastasis are rare. We report the case of a woman presenting lung metastases of a cervical adenocarcinoma revealed by bronchorrhea, eventually identified as ectopic cervical mucus. Treatment included anticancer drugs and erythromycin, the latter in order to reduce the bronchorrhea, with eventually poor efficacy. This observation illustrates the importance of respiratory signs in the post-therapeutic follow up of cancer, especially cough and bronchorrhea in adenocarcinoma.

Tumor metastasis and the reciprocal regulation of prometastatic and antimetastatic factors by nuclear factor kappaB

To investigate the role of the transcription factor nuclear factor kappaB (NFkappaB) in tumor metastasis, we generated a murine lung alveolar carcinoma cell line (Line 1) defective in NFkappaB-signaling by retroviral delivery of a dominant negative inhibitor of NFkappaB. The NFkappaB signal blockade resulted in the down-regulation of prometastatic matrix metalloproteinase 9, a urokinase-like plasminogen activator, and heparanase and reciprocal up-regulation of antimetastatic tissue inhibitors of matrix metalloproteinases 1 and 2 and plasminogen activator inhibitor 2. NFkappaB signal blockade did not affect tumor cell proliferation in vitro or in vivo but prevented intravasation of tumor cells in an in vivo chick chorioallantoic membrane model of metastasis as well as spontaneous metastasis in a murine model. These findings suggest that NFkappaB plays a central and specific role in the regulation of tumor metastasis and may be an important therapeutic target for development of antimetastatic cancer treatments.

[Transhiatal esophagectomy in esophageal carcinoma and subsequent lung carcinoma 6 years later]

The author describes an interesting case primary oesophageal carcinoma. Well differentiated spinocellular carcinoma of the middle third of the oesophagus (T1 N0 MX stage) was diagnosed in a 42-year-old male. He underwent transhiatal oesophagectomy without thoracotomy with a survival period of over 6 year with no relapse. During the last 2 months he developed serious psychiatric and neurological symptoms and neurosurgical craniotomy was performed. The operation presented a metastases of alveolar lung carcinoma in the cerebrum. The primary source was not localised but autopsy revealed a small carcinoma of the left lung with metastases in the cerebellum and basal brain structures causing death. There were no signs of relapse of oesophageal carcinoma during the period after oesophagectomy verified by autopsy. Survival the period after operation was 6 years, 2 months and 2 weeks. Death was caused by subsequent lung carcinoma.

Immunohistochemically detected micrometastases in peribronchial and mediastinal lymph nodes from patients with T1, N0, M0 pulmonary adenocarcinomas

The T1, N0, M0 subset of stage I lung adenocarcinoma is a tumor that has a 5-year disease-free survival rate of 66% to 85%. To date, there has not been a rigorous immunohistochemically detected lymph node micrometastasis study composed of patients with identical stage and type of tumors, and in which standard histologic features were incorporated into multivariate analyses. We immunohistochemically examined the peribronchial and mediastinal lymph nodes from 80 consecutively accrued patients with T1, N0, M0 adenocarcinomas and bronchioloalveolar carcinomas unselected for distant metastasis, and an additional 39 patients with similar stage and type neoplasms who were selected for their development of metastases to evaluate the prevalence of micrometastases, their association with distant metastases, and their relationship with other pathologic prognostic features. All slides were stained with keratin AE1/3. Micrometastases were confirmed with Ber-Ep4. Three immunohistochemically detected lymph node micrometastases were identified in three of 80 consecutively accrued patients (4%). These three positive stains constituted 0.5% of the 573 stains required to immunohistochemically screen all of the lymph node blocks from these patients. Among the 39 patients who were selected because they developed distant metastases, three immunohistochemically detected lymph node micrometastases from three patients were identified, which constituted 8% of patients in this group and 1% of the 280 stains required to screen all of these patients' lymph nodes. Small vessel invasion, maximum tumor dimension, and immunohistochemically detected lymph node micrometastases were independently associated with metastases on multivariate analysis. Among patients who developed metastases, there was no significant difference in the disease-free survival rate between those with and those without immunohistochemically detected lymph node micrometastases. Given the low sensitivity in terms of the number of immunohistochemical stains performed, and the prognostic significance of standard histologic features, the use of immunohistochemical screening lymph nodes from all patients with T1, N0, M0 adenocarcinomas is questionable.

Probable hypercalcemia of malignancy in a cat with bronchogenic adenocarcinoma

An eight-year-old, neutered male, domestic shorthair cat was referred with a four-day history of acute vomiting. Hypercalcemia was identified on serum biochemical testing. Thoracic radiographs showed multiple pulmonary nodular densities. Postmortem and histopathological examination identified the nodules as bronchogenic adenocarcinoma with metastases to the tracheobronchial lymph nodes, diaphragm, and parietal pleura. To the authors' knowledge, this is the first reported case of hypercalcemia of malignancy associated with bronchogenic adenocarcinoma in a cat.

Prognostic value of bronchiolo-alveolar carcinoma component of small lung adenocarcinoma

BACKGROUND

Bronchiolo-alveolar carcinoma (BAC) is often observed in lung adenocarcinoma, but its clinicopathological and prognostic significance, especially in small peripheral lung adenocarcinoma, remains undetermined.

METHODS

We assessed 206 consecutive cases of surgically resected small peripheral lung adenocarcinoma (less than 2 cm in diameter) recorded between 1973 and 1997. According to the component area of well differentiated BAC within maximally cut surface specimens of tumor tissue, we semiquantitatively classified the tumors into four types: those in which the BAC component comprised 0% (type I), 1% to 49% (type II), 50% to 99% (type III), and 100% (type IV) of the tumor tissue.

RESULTS

Forty tumors were classified as type I, 75 as type II, 74 as type III, and 17 as type IV. The tumors with less BAC, especially type I and II, showed a significantly more aggressive nodal involvement and tumor stage, and consequently a worse prognosis, while type IV tumors had no nodal involvement and the most favorable prognosis. The patients with type III showed clinicopathological characteristics somewhere between those of type II and type IV patients. Among stage I patients, however, those with type II had the worst prognosis, while those with type I showed as good a prognosis as the other two groups.

CONCLUSIONS

This novel classification based on the degree of BAC involvement in small peripheral lung adenocarcinoma may reflect clinicopathological and prognostic characteristics. This classification may prove practical for planning therapeutic strategies, in particular surgical treatment.

Bronchoalveolar carcinoma: clinical, radiologic, and pathologic factors and survival

BACKGROUND

The principal feature of bronchoalveolar carcinoma is that it spreads along airways or aerogenously with multifocality, but many issues are unresolved.

METHODS

We studied 119 patients with pathologically confirmed bronchoalveolar carcinoma. Symptoms, smoking status, radiologic findings, the size of tumor, operative procedures, and complications were reviewed. We studied the pathologic features: presence or absence of aerogenous spread, patterns of growth, cell type, nuclear grade, mitosis, rate of bronchoalveolar carcinoma in adenocarcinoma, and lymphocyte infiltration. The correlation among clinical, radiologic, and pathologic findings was examined, and the factors affecting survival were analyzed.

RESULTS

Symptomatic patients had more infiltrative radiographic features, and asymptomatic patients tended to have more mass-like features (P <.0001). Tumors with radiographically infiltrating lesions tended to have mucinous histologic features (P =.006). Tumors with mass lesions by radiograph tended to have nonmucinous and sclerosing histologic features (P =.003). Aerogenous spread was seen in 94% of specimens. The presence of a variety of cell types suggested multiple clonal origin. The overall survival in those patients undergoing resection was 69.1% at 5 years and 56.5% at 10 years. The significant factors affecting survival were radiologic presence of a mass or infiltrate, pathologic findings of the presence of sclerosis, association with a scar, the rate of bronchoalveolar carcinoma in adenocarcinoma, lymphocyte infiltration grade, nodal involvement, and status of complete resection. Mitosis or nuclear grade of tumor cells did not correlate with survival.

CONCLUSIONS

Bronchoalveolar carcinoma showed good overall survival with appropriate surgical procedures. Certain radiologic or pathologic findings correlated with survival. These findings may enhance the ability to predict long-term survival.

Bronchioloalveolar carcinoma with metastasis to the pituitary gland: a case report

An unusual case of metastatic bronchioloalveolar carcinoma of the lung presented as a pituitary tumour in a young adult Chinese female, who subsequently died after having undergone trans-sphenoidal resection. Metastatic cancers of the pituitary are uncommon even in necropsy series and rarely give rise to clinical symptoms. This case draws attention to the fact that, although uncommon, pituitary metastases have been noted with increasing frequency and their distinction from primary pituitary tumours is often difficult. A metastatic pituitary tumour may be the initial presentation of an unknown primary malignancy, wherein the metastatic deposits may also be limited to the pituitary gland. Clinicians and pathologists alike should consider a metastatic lesion in the differential diagnosis of a non-functioning pituitary tumour.

Bronchioloalveolar lung carcinoma: results of surgical treatment and prognostic factors

STUDY DESIGN

To determine the long-term results after surgical treatment of bronchioloalveolar lung carcinoma (BALC) and to identify prognostic factors.

PATIENTS AND METHODS

A retrospective study of 70 patients (49 men, 21 women), mean age 61+/-10 years, was carried out. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. All the diagnosed BALC cases were reviewed and were classified into histologic types: mucinous, nonmucinous (including fibrotic center), and mixed tumors. Univariate and multivariate analyses were carried out.

RESULTS

The nodular or tumoral type was identified in 42 patients, pneumonic in 21, and diffuse in seven. Histologically, there were 36 mucinous, 25 nonmucinous, and nine mixed tumors. Resection was complete in 61 instances (87%) and incomplete in five. The 5-year survival rate was 34% in patients with curative resections. Five prognostic factors were identified by univariate analysis, but in multivariate analysis, only three factors remained significant: the absence of symptoms, the TNM stage, and completeness of resection. Thirty-six patients with curative resection (59%) developed recurrences (in the lung in 26 patients; mediastinal lymph nodes, four; distant metastases, nine). The frequency of recurrence was significantly greater in patients with pneumonic-type BALC than in nodular or tumoral types (p<0.01), and pulmonary recurrences were significantly more frequent in pneumonic than in tumoral types (p<0.02).

CONCLUSIONS

This study confirmed that the overall prognosis of BALC is not significantly different from that of the other non-small cell lung cancers. We found that the lungs are the predominant site of recurrence in BALC, especially in the pneumonic types. The complete surgical resection of localized BALC offers the best chances of long-term survival.

Bronchoalveolar carcinoma: histopathologic study of evolution in a series of 105 surgically treated patients

STUDY OBJECTIVE

The clinical characteristics, histopathologic condition, and outcome of bronchoalveolar carcinoma (BAC) were studied to detect possible prognostic indicators.

DESIGN

A retrospective review was conducted of 97 patients who had a curative resection for BAC between 1975 and 1993.

PATIENTS

There were 83 men and 14 women with a mean age of 59 years (30 to 75 years).

INTERVENTIONS

Resection comprised lobectomy in 84 cases (87%), bilobectomy, pneumonectomy, and a wedge excision.

RESULTS

Sixty-two percent of patients were asymptomatic. The radiographic pattern was a solitary nodule in 85% of patients and lobar pneumonitis or diffuse infiltrate in 15%. In 12% of patients, the solitary lesion had been stable for period of 2 to 7 years before diagnosis. The TNM staging of the disease included 71 patients with stage I, 14 with stage II, and 12 with stage IIIA. Review of the gross pathologic features revealed well-circumscribed tumors in 88% of patients and diffuse or multifocal tumors in 12%. Mucinous differentiation was present in 43% of patients, vascular invasion in 22%, and aerogenous spread in 49%. Overall survival was 89% at 1 year, 76% at 2 years, 48% at 5 years, and 39% at 10 years. The survival curves according to histologic features showed a statistically significant difference between diffuse lesions and nodular lesions, between lesions with and without aerogenous spread (diffuse lesions excluded), and between lesions with and without vascular invasion.

CONCLUSIONS

The natural history of BAC is especially influenced by its nodular or diffuse nature, vascular invasion, and aerogenous spread.

Bronchiolar-alveolar carcinoma in a cow

Bronchiolar-alveolar carcinoma was observed in the lung of an 8-year-old Holstein cow. Grossly, the lung contained multiple tumour masses, which were solid, yellowish-white in colour, and firm in consistency. These tumours also occurred in the liver, pancreas, uterus and lymph nodes in the thoracic, abdominal and pelvic cavities. Histologically, the masses were composed of abundant fibrous stroma and proliferating atypical cuboidal epithelial cells, occasionally forming glandular structures. Electron microscopy revealed that the neoplastic cells had microvilli and lamellar bodies in the cytoplasm, suggesting that they originated from immature respiratory epithelial cells differentiating towards either Clara cells or type II pneumocytes.

[Anatomo-clinical conference: bronchiolo-alveolar cancer and confusion]

A 67 year old man is admitted with mental confusion. He has been treated 10 months before the present complication for a diffuse bronchiolo-alveolar carcinoma with a good response to chemotherapy. Brain imaging shows symmetrical lesions in the periventricular areas and in the semi-oval centers. A test will allow to obtain the diagnosis.

[Choroidal metastases as the form of presentation of 2 bronchiolo-alveolar carcinomas]

We report here two cases presenting with visual symptoms secondary to choroidal metastases, without any other remarkable systemic symptom. After an exhaustive investigation in both patients the diagnosis was obtained of bronchoalveolar carcinoma as primary tumor responsible for such lesions. Bronchoalveolar carcinoma is a type of pulmonary adenocarcinoma which rarely begins with clinical symptoms attributable to metastases and even rarer of choroidal location. The presence of such choroidal lesions are usually associated with visual clinical symptoms and they are a diagnostic challenge when manifested as the presenting symptoms. Therapy is directed to the primary tumor usually associated with palliative radiotherapy of choroidal metastases. Their presence implies a poor survival rate.

Cardiac tamponade as the initial presentation of malignancy: is it as rare as previously supposed?

Advanced malignant disease frequently involves the heart and pericardium, and pericardial effusion is a common postmortem finding in such patients. Identification of pericardial effusions in life is uncommon, however, even when symptomatic. Cardiac tamponade occurring as the first presentation of malignancy appears to be uncommon. We present five cases of cardiac tamponade due to undiagnosed malignancy which presented to a general medical unit over 18 months. The availability of echocardiography was an important factor in correct diagnosis, since clinical features were non-specific. Bronchial adenocarcinoma was the cause in three of the five cases. Review of the literature confirms adenocarcinomas of the bronchus as the most common cause of this complication. The majority of cases have presented with large volume, haemorrhagic effusions, and cytology (with or without carcinoembryonic antigen measurement) was diagnostic in most patients. Immediate treatment with subxiphoid pericardiotomy is recommended; the role of balloon catheter pericardiotomy remains to be established. Combined chemotherapy and radiotherapy appears to extend survival, which in some cases may be prolonged. We recommend that early echocardiography should be obtained in all patients presenting with apparent cardiac failure, since early treatment of malignant effusions provides symptomatic relief.

Alveolar cell carcinoma presenting as malignant pericardial effusion: diagnosis by electron microscopy

The cytologic, immunocytochemical, and ultrastructural findings in a 68-year-old man who presented with a malignant pericardial effusion are reported. Radiologic studies failed to identify a primary neoplasm over the next 6 months. Ultrastructural examination of a repeat pericardiocentesis fluid specimen revealed cells with intranuclear tubular inclusions and cytoplasmic lamellar bodies typical of alveolar cell carcinoma. Review of the chest radiographs showed nonresolving patchy infiltrates in the upper lobe of the left lung clinically thought to represent pneumonia; in retrospect, however, these were consistent with the pneumonic form of alveolar cell carcinoma.

Metastatic bronchioloalveolar carcinoma and metastatic adenocarcinoma of the lung: comparison of clinical manifestations, chemotherapeutic responses, and prognosis

Between 1975 and 1985, 25 patients with metastatic bronchioloalveolar carcinoma and 223 patients with metastatic adenocarcinoma of the lung received experimental cisplatin-based chemotherapy at the Mayo Clinic. The chemotherapeutic response rates were 32% and 33%, respectively. The median times to progression of disease were identical (3 months in both groups). The median survival times were 4 months and 6 months, respectively. Metastatic bronchioloalveolar carcinoma is an aggressive disease that is associated with a poor prognosis, similar to metastatic adenocarcinoma of the lung.

Bronchioalveolar carcinoma with renal and hepatic metastases in a degu (Octodon degus)

A primary bronchioloalveolar carcinoma with renal and hepatic metastases was diagnosed in a mature male degu (Octodon degus) that was found dead in a zoological exhibit (Buffalo Zoological Gardens, Buffalo, New York, USA). Grossly, a discrete 0.5 cm diameter nodule was seen in the lung. Smaller, but similar nodules were present scattered in the liver and kidneys. Histologically, nests and sheets of an infiltrating population of cuboidal to low columnar neoplastic epithelial cells partially effaced pulmonary architecture. Vascular invasion was evident. Similar nests and sheets of neoplastic cells were present within the renal cortex and medulla, and a small nest was present within the hepatic parenchyma. This is the first record of this neoplasm in a degu.

Pulmonary nodules resembling bronchioloalveolar carcinoma in adolescent cancer patients

Pulmonary nodules morphologically indistinguishable from bronchioloalveolar carcinoma (BAC) were found in two adolescent cancer patients postchemotherapy. A solitary nodule was noted at thoracotomy for a single computerized tomography (CT) scan lesion in a 16-yr-old male, 6 yr after diagnosis of Ewing's sarcoma. A similar nodule was found in a 19-yr-old male coincident with resection of multiple lung metastases of a testicular germ cell tumor. Both lesions were discrete nodular masses (1 cm and 0.5 cm) consisting of atypical epithelial cells with a papillary and lepidic growth pattern and surrounded by histologically normal appearing lung. Immunohistochemistry of both cases was positive for laminoorganel (LO) antigen, which is found in normal type II pneumocytes, and one nodule showed carcinoembryonic antigen (CEA) staining. Quantitative DNA analysis in one case indicated aneuploidy. Thus the morphology, immunohistochemistry, and DNA content of these lesions suggest that they may represent early lung cancers despite the highly unusual clinical context. The extreme rarity of BAC in this age group makes this report significant in light of heightening concern about second malignancies in pediatric cancer patients and reports of chemically induced pulmonary adenomas in mice. It also underscores the importance of basing therapeutic decisions on a histologic diagnosis of lung nodules in cancer patients rather than assuming the presence of metastatic disease.

Lung metastasis of malignant epithelioid hemangioendothelioma mimicking a primary intravascular bronchioalveolar tumor. A histologic, ultrastructural, and immunohistochemical study

A 40-year-old woman presented with multiple nodules in both lungs and a small tumoral mass at the level of the left brachial artery. A pathologic diagnosis of pulmonary intravascular bronchioloalveolar tumor (IVBAT) and epithelioid hemangioendothelioma of the limb was established. Morphologic and immunohistochemical studies highly suggest that both tumors are manifestations of the same neoplastic process. In this case a metastatic nature of the IVBAT is suggested. The diagnosis of pulmonary IVBAT should be followed by a search for sclerosing vascular tumors elsewhere. Finally, the results substantiate the vascular origin of the IVBAT.

Aggressive nature of a "cold" lesion depicted by positive flow and blood pool phases of a bone scan

One of the explanations of a cold lesion on static bone imaging is the presence of an aggressive, destructive lesion. This is the first reported case of such a lesion with an aggressive nature that was confirmed by abnormal flow and pool images.