A phase II trial of gefitinib as first-line therapy for advanced non-small cell lung cancer with epidermal growth factor receptor mutations.

Retrospective analysis has shown that activating mutations in exons 18-21 of the epidermal growth factor receptor (EGFR) gene are a predictor of response to gefitinib. We conducted a phase II trial to evaluate the efficacy and safety of gefitinib as first-line therapy for advanced non-small cell lung cancer (NSCLC) with EGFR mutations. Patients with stage IIIB or IV chemotherapy-naïve NSCLC with EGFR mutation were treated with 250 mg gefitinib daily. For mutational analysis, DNA was extracted from paraffin-embedded tissues and EGFR mutations were analysed by direct sequence of PCR products. Twenty (24%) of the 82 patients analysed had EGFR mutations (deletions in or near E746-A750, n=16; L858R, n=4). Sixteen patients were enrolled and treated with gefitinib. Twelve patients had objective response and response rate was 75% (95% CI, 48-93%). After a median follow-up of 12.7 months (range, 3.1-16.8 months), 10 patients demonstrated disease progression, with median progression-free survival of 8.9 months (95% CI, 6.7-11.1 months). The median overall survival time has not yet been reached. Most of the toxicities were mild. This study showed that gefitinib is very active and well tolerated as first-line therapy for advanced NSCLC with EGFR mutations.

Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions.

The usefulness of endobronchial ultrasonography (EBUS) with guide-sheath (GS) as a guide for transbronchial biopsy (TBB) for diagnosing peripheral pulmonary lesions (PPL)s and for improving diagnostic accuracy was evaluated in this study. EBUS-GS-guided TBB was performed in 24 patients with 24 PPLs of < or =30 mm in diameter (average diameter=18.4 mm). A 20-MHz radial-type ultrasound probe, covered with GS was inserted via a working bronchoscope channel and advanced to the PPL in order to produce an EBUS image. The probe with the GS was confirmed to reach the lesion by EBUS imaging and X-ray fluoroscopy. When the lesion was not identified on the EBUS image, the probe was removed and a curette was used to lead the GS to the lesion. After localising the lesion, the probe was removed, and TBB and bronchial brushing were performed via the GS. Nineteen peripheral lesions (79.2%) were visualised by EBUS. All patients whose PPLs were visible on EBUS images subsequently underwent an EBUS-GS-guided diagnostic procedure. A total of 14 lesions (58.3%) were diagnosed. Even when restricted to PPLs <20 mm in diameter, the diagnostic sensitivity was 53%. In conclusion, endobronchial ultrasonography with guide sheath-guided transbronchial biopsy was feasible and effective for diagnosing peripheral pulmonary lesions.

[A case of severe Legionella pneumonia monitored with serum SP-A, SP-D, and KL-6].

A 67-year-old man was admitted for acute pneumonia on July 20th, 1999. Chest radiographs disclosed dense consolidation in the right lower lung fields. After admission, the pneumonia underwent rapid advance. On the basis of serological findings and cultures of pleural effusion and sputum, the patient was given a diagnosis of acute pneumonia caused by Legionella pneumophila 1 a. He gradually recovered from the pneumonia by means of chemotherapy using EM, RFP, Mino, gammaglobulins and steroids. The serum SP-A, SP-D, and KL-6 peaked on July 23rd, July 30th, and August 12th, respectively.

[A case of small cell lung cancer with paraneoplastic cerebellar degeneration and anti-voltage-gated calcium channel antibody].

A 55-year-old man presenting with 4 weeks of progressive dysarthria, gait ataxia and vertigo was admitted to our hospital. Chest X-ray films revealed a mass shadow in the right upper lobe of the lung, and transbronchial brushing specimens showed small-cell carcinoma. Extensive examination revealed metastatic lesions in the mediastinal lymph nodes and liver, but brain MRI showed no findings suggestive of metastasis or atrophy. A diagnosis of PCD associated with SCLC was made, and the patient had a high titer of anti-P/Q-type VGCC antibody. He was treated by chemotherapy and radiation therapy, which resulted in a transient improvement in the PCD symptoms.

[Primary racemose hemangioma of bronchial artery].

A 38-year-old woman was admitted to the hospital because of massive hemoptysis. A chest X-ray film disclosed an infiltrative shadow. A bronchoscopic examination revealed a small, pulsatile, papillary protrusion in the orifice of the middle lobe bronchus, and massive bleeding from the protrusion was observed during the examination. Bronchial arteriography showed convolution and mild hypervascularization of the right bronchial artery. A middle lobectomy was performed, and the protrusion was histologically shown to be a primary racemose hemangioma of the bronchial artery.

[Pulmonary disease after massive inhalation of Aspergillus niger].

A 60-year-old man was admitted to the hospital because of fever, coughing, and dyspnea that developed after he entered a silo that had been filled with chips of wood in the preceeding 3 months. A chest X-ray film revealed bilateral ground-glass shadows. Histologic study of the lung showed a multifocal acute process; the alveoli and interstitial areas contained many fungal hyphae and spores. Cultures from both bronchoalveolar-lavage-fluid and the chips in the silo revealed Aspergillus niger. Serologic reactions were negative to 10 antigens known to induce hypersensitivity pneumonitis. Furthermore, the patient's serologic reaction to the extracts of fungi obtained from the bronchoalveolar-lavage-fluid was negative. The patients recovered quickly without steroid therapy. We believe that this patient's diseases was "organic dust toxic syndrome".

[Three siblings with interstitial pneumonia].

Patient 1: A 64-year-old woman was admitted for further examination after reticulonodular shadows were found on a chest X-ray film. Idiopathic interstitial pneumonia (IIP) was diagnosed. Patient 2: The 60-year-old sister of patient 1 was admitted for further examination after reticulonodular shadows were found on a chest X-ray film. IIP was diagnosed. About half a year later, her proximal interphalangeal joints had become swollen and the result of a rheumatoid hemagglutination test was positive. Therefore, the pneumonia was suspected to have been caused by a collagen-vascular disease (CVD), rheumatoid arthritis. Patient 3: The 64-year-old brother of patient 1 was examined. A chest X-ray film revealed reticulonodular shadows that were strongly suggestive of IIP. The remaining three siblings were examined. In a 62-year-old sister, the chest X-ray film was normal, but the level of anti-nuclear antigen was elevated. The fact that the level of this antigen was high in these four siblings and that the 60-year-old sister later suffered from rheumatoid arthritis suggested the presence of a factor predisposing to CVD in these siblings. The interstitial pneumonia in these siblings may have been related to CVD.

Quantitative immunocytochemical assays of topoisomerase II in lung adenocarcinoma cell lines. Correlation to topoisomerase II alpha content and topoisomerase II catalytic activity.

The examination of topoisomerase II alpha content by Western blot analysis or topoisomerase II catalytic activity by decatenation of kDNA requires a large number of cells, but it is difficult to collect sufficient cells for these biochemical analyses from lung cancer patients by transbronchial brushing or aspiration. In this study, we explored the relationship between these biochemical analyses and topoisomerase II immunostaining in cytospin preparations of three lung adenocarcinoma cell lines. The levels of topoisomerase II alpha content were about 8.4 for A549, 2.9 for PC-3 and 1 for RERF-LC-MS, and the levels of topoisomerase II catalytic activity were about 4, 2, and 1, respectively. The percentages of strongly positive cells for topoisomerase II immunostaining were 60.9% for A549, 33.3% for PC-3, and 14.3% for RERF-LC-MS, and these were compatible with the levels of topoisomerase II alpha content or topoisomerase II catalytic activity. Our results indicate that topoisomerase II immunostaining can be utilized in place of biochemical analysis.

Tumor angiogenesis in human lung adenocarcinoma.

BACKGROUND: Hematogenous metastasis requires angiogenesis within the tumor. Previous studies have shown that microvessel counts in histologic sections of the primary tumor, which reflect angiogenesis, are correlated with metastasis in breast, prostate and Stage I nonsmall cell lung carcinoma. In this study, the authors investigated the association between angiogenesis, hematogenous metastasis and lymph node metastasis in all stages of lung adenocarcinoma. METHODS: Microvessels were highlighted by immunostaining endothelial cells for factor VIII. We counted microvessels within the tumors of 42 patients who had surgical resection (25 with relapse and 11 without relapse more than 5 years after surgical resection). Without knowledge of patient outcome, microvessels were counted on a 200x field (0.723 mm2) in the most active areas of neovascularization. RESULTS: The microvessel counts from patients with relapse after surgical resection (mean +/- standard deviation, 75.4 +/- 64.3) were significantly higher than those without relapse more than 5 years after surgical resection (42.6 +/- 26.0) (P = 0.027). Analysis of regional lymph node metastases (factor N) revealed that the microvessel counts were 62.6 +/- 35.1 for N0 (no regional lymph node metastasis), 51.7 +/- 22.2 for N1 (metastasis in ipsilateral, peribronchial and/or ipsilateral hilar lymph nodes, including direct extension), 75.4 +/- 75.3 for N2 (metastasis in ipsilateral mediastinal and/or subcarinal lymph nodes), and 74.0 for N3 (metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or supraclavicular lymph node[s]), and these values were not significantly different from each other. CONCLUSIONS: Angiogenesis assessed by microvessel counts, correlated positively with relapse after surgical resection and hematogenous metastasis in all stages of lung adenocarcinoma; there was no correlation with lymph node metastasis in lung adenocarcinoma.

Immunohistochemical study of cathepsin B. Prognostic significance in human lung cancer.

BACKGROUND: The concentration of cysteine proteinase cathepsin B has been shown to be elevated in association with malignancy or metastatic potential of human and rodent tumors, but its prognostic value for human lung cancer remains undetermined. METHODS: Using a polyclonal antibody, immunohistochemical analyses of cathepsin B were performed on paraffin embedded sections of tumors obtained surgically from 108 patients with non-small cell lung cancer (49 squamous cell carcinomas, 59 adenocarcinomas). The immunohistochemical expressions of cathepsin B in the tumors were compared with patient survival. RESULTS: Higher grade expression of cathepsin B was associated significantly with shorter survival in non-small cell lung cancer (P < 0.01), in squamous cell carcinoma (P < 0.05), and in adenocarcinoma (P < 0.01). A similar result also was seen in Stage I non-small cell lung cancer (P < 0.05). CONCLUSIONS: The authors concluded that the immunohistochemical staining pattern of cathepsin B may be a useful predictor of survival for human lung cancer.

A patient with chronic hepatitis C who simultaneously developed interstitial pneumonia, hemolytic anemia and cholestatic liver dysfunction after alpha-interferon administration.

Following a three-week administration of alpha-interferon (IFN-alpha), a 62-year-old woman with chronic hepatitis C manifested fever and dyspnea and showed diffuse infiltrative opacities on chest roentgenograms. Her laboratory data included results of anemia with reticulocytosis, a decreased complement level and hepatitis with elevated ALP, LDH and gamma-GTP. Because laboratory data also revealed a positive lymphocyte stimulation test for IFN-alpha, this cytokine was considered to be responsible for the development of interstitial pneumonia, hemolytic anemia and cholestatic liver dysfunction due to its immunomodulatory effects. Although these three disorders have been reported to develop singly after IFN-alpha therapy, this is the first report of a patient in whom these disorders occurred simultaneously.

[Clinical indicators of malignancy of lung cancer].

To evaluate the malignancy of lung cancer, nuclear DNA content, AgNORs counts and cathepsin B activity were examined. The survival time of small cell carcinoma patients with limited disease of near diploid is longer than that with limited disease of hyperdiploid pattern. By flow cytometric technique, the proportion of DNA aneuploid pattern were higher in adenocarcinoma than in squamous cell carcinoma. In squamous cell carcinoma, the prognosis of patients with DNA aneuploid pattern was worse. However, there was no significant difference in survival time of adenocarcinoma patients. A good correlation between the AgNORs counts and tumor volume doubling time of non-small cell carcinoma of lung was observed. However, the AgNORs counts were an independent prognostic factor for survival time of patients with lung cancer. The survival time of lung cancer patients with the marked intensity of cathepsin B was significantly shorter than that of patients with negative and/or weak positive staining pattern. The AgNORs value and cathepsin B activity can serve as a pertinent marker for clinical assessment of malignancy of lung cancer.

Establishing diagnosis of pulmonary malignant lymphoma by gene rearrangement analysis of lymphocytes in bronchoalveolar lavage fluid.

We report the successful application of gene rearrangement analysis to the lymphocytes obtained by bronchoalveolar lavage (BAL) for the diagnosis of pulmonary malignant lymphoma. A 45-yr-old female patient who had been suffering from back pain was shown to have macroglobulinemia and pulmonary infiltrative shadow by chest radiography. Transbronchial lung biopsy revealed a small B-cell infiltrate with monotypic immunoglobulin expression (IgM/kappa light chain), and malignant lymphoma was highly suspected. BAL was performed to evaluate the cell profiles. The phenotyping of lavaged lymphocytes by flow cytometry revealed that the major component of the lymphocytes was CD3-positive T cells, and that CD21-positive B cells accounted for only 10% of all lymphocytes. This result was contradictory to the immunohistochemical population of lymphocytes in biopsied specimens. However, gene analysis of lavaged lymphocytes revealed positive immunoglobulin heavy chain rearrangement and negative immunoglobulin light chain and T-cell receptor rearrangement, suggesting that B cells making up a minor population of lavaged lymphocytes were proliferating monoclonally. Thus, in this case, gene analysis was an effective procedure for detecting the origin of tumor cells and distinguishing monoclonality from reactive accumulations. To our knowledge, this case represents the first reported application of gene rearrangement analysis to cells obtained by BAL. The sensitivity and usefulness of this analysis for the accurate evaluation of pulmonary lymphoproliferative lesions, when applied to BAL cells, should be emphasized.

Immunohistochemical distributions of cathepsin B and basement membrane antigens in human lung adenocarcinoma: association with invasion and metastasis.

The distributions of cathepsin B (CB) a lysosomal cysteine proteinase, type IV collagen (CIV) and laminin (LM), which are main components of basement membranes (BMs) were studied in a series of 64 human lung adenocarcinomas using an immunohistochemical technique. Over-expression of CB (> 80% positive cells) was significantly associated with the grade of tumour differentiation (p < 0.01), with lymph node metastasis (p < 0.01) and with BM degradation (p < 0.01) detected by the staining pattern of CIV and LM. It was significantly associated with a prognostic disadvantage (p < 0.01). The immunohistochemical staining pattern of CB has a close relationship with degradation of BM, and may be used as a marker for tumour metastasis and prognosis in lung adenocarcinoma.

[A case of round atelectasis associated with spontaneous pneumothorax].

A 59-year-old female was admitted for spontaneous pneumothorax. After evacuation, the chest X-ray film showed a round mass lesion at the left hilum. Following curettage and bronchoalveolar lavage of the left B3c, the mass became smaller, suggesting the diagnosis of round atelectasis. This is the first report of round atelectasis complicated by spontaneous pneumothorax. The mechanism of this case is suggested to resemble that of round atelectasis associated with pleural effusion.

Nucleolar organiser regions as a marker of growth rate in squamous cell carcinoma of the lung.

BACKGROUND: The numbers of nucleolar organiser regions (AgNORs) per cell has been considered as an indicator of the cellular proliferative activity. A study was carried out to examine whether AgNOR numbers relate to the growth rate in squamous cell carcinoma of the lung. METHODS: AgNORs were stained by a one step silver method, and examined in representative paraffin sections from 45 cases of squamous cell carcinoma of the lung treated by surgical resection of the primary tumour. RESULTS: The mean (SD) AgNOR numbers per cell in squamous cell carcinomas (5.3 (0.9)) were significantly higher than those in normal bronchial epithelium (1.2 (0.1)). There was no statistical difference among tumours of different post-surgical stages (stage I = 5.2 (0.8), II = 5.9 (1.4), III A = 5.5 (1.3)). The tumour volume doubling time in these cases ranged from 74 to 208 days (120.7 (40.4)). There was a high inverse correlation between the AgNOR numbers and doubling time. CONCLUSION: The AgNOR numbers were related to the growth rate of squamous cell carcinoma of the lung. Thus the AgNOR count could be used as a useful marker for investigating the cellular proliferative activity.

Correlation between nucleolar organizer regions visualized by silver staining and the growth rate in lung adenocarcinoma.

BACKGROUND: The value of nucleolar organizer regions (NOR) visualized by silver staining (AgNOR) for the histologic differentiation, pathologic staging, and estimation of growth rate was assessed by the investigation of paraffin sections from 58 lung adenocarcinomas. AgNOR consist of NOR-associated proteins, and the number of AgNOR might be related to proliferative activity. METHODS: In lung adenocarcinoma, the growth rate can be measured by means of chest radiographs. Using this technique, the authors studied the correlation between the mean number of AgNOR and growth rate. RESULTS: The mean number of AgNOR ranged from 1.8 to 6.3 (mean +/- standard deviation, 4.0 +/- 0.8). Neither the degree of histologic differentiation nor the pathologic staging was related to the AgNOR count. The tumor growth rate was estimated on the basis of the doubling time in the chest radiographs of 13 patients. The doubling time ranged from 80 to 760 days. There was a high inverse correlation between the AgNOR count and the doubling time (r = -0.910; P less than 0.001). CONCLUSIONS: Thus, it appears to be possible to use the mean number of AgNOR as an index of proliferative activity.

[A case of bronchial actinomycosis associated with bronchoscopically removed broncholith].

A 57-year-old woman with bronchial actinomycosis associated with broncholith is presented. She had suffered from fever and productive cough for 7 years. Her chest roentgenograms showed atelectasis of the middle lobe and calcification in the middle lobe bronchus. Bronchoscopic examination revealed a broncholith covered with pus and granulomatous tissue. The biopsy specimen revealed sulfur granules containing a partially calcified lesion, and it was diagnosed as actinomycosis. After treatment with antibiotics, the broncholith became movable, and it was removed bronchoscopically. Its shape was like a molding of the right middle lobe bronchus. We speculate that the growth of this broncholith partially resulted from chronic inflammation associated with actinomycelial infection.