Development of artificial intelligence prognostic model for surgically resected non-small cell lung cancer

There are great expectations for artificial intelligence (AI) in medicine. We aimed to develop an AI prognostic model for surgically resected non-small cell lung cancer (NSCLC). This study enrolled 1049 patients with pathological stage I-IIIA surgically resected NSCLC at Kyushu University. We set 17 clinicopathological factors and 30 preoperative and 22 postoperative blood test results as explanatory variables. Disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) were set as objective variables. The eXtreme Gradient Boosting (XGBoost) was used as the machine learning algorithm. The median age was 69 (23-89) years, and 605 patients (57.7%) were male. The numbers of patients with pathological stage IA, IB, IIA, IIB, and IIIA were 553 (52.7%), 223 (21.4%), 100 (9.5%), 55 (5.3%), and 118 (11.2%), respectively. The 5-year DFS, OS, and CSS rates were 71.0%, 82.8%, and 88.7%, respectively. Our AI prognostic model showed that the areas under the curve of the receiver operating characteristic curves of DFS, OS, and CSS at 5 years were 0.890, 0.926, and 0.960, respectively. The AI prognostic model using XGBoost showed good prediction accuracy and provided accurate predictive probability of postoperative prognosis of NSCLC.

Impact of the pretreatment prognostic nutritional index on the survival after first-line immunotherapy in non-small-cell lung cancer patients

BACKGROUND

Immunotherapy has become a standard-of-care for patients with non-small-cell lung cancer (NSCLC). Although several biomarkers, such as programmed cell death-1, have been shown to be useful in selecting patients likely to benefit from immune checkpoint inhibitors (ICIs), more useful and reliable ones should be investigated. The prognostic nutritional index (PNI) is a marker of the immune and nutritional status of the host, and is derived from serum albumin level and peripheral lymphocyte count. Although several groups reported its prognostic role in patients with NSCLC receiving a single ICI, there exist no reports which have demonstrated its role in the first-line ICI combined with or without chemotherapy.

MATERIALS AND METHODS

Two-hundred and eighteen patients with NSCLC were included in the current study and received pembrolizumab alone or chemoimmunotherapy as the first-line therapy. Cutoff value of the pretreatment PNI was set as 42.17.

RESULTS

Among 218 patients, 123 (56.4%) had a high PNI (≥42.17), while 95 (43.6%) had a low PNI (<42.17). A significant association was observed between the PNI and both the progression-free survival (PFS; hazard ratio [HR] =  0.67, 95% confidence interval [CI]: 0.51-0.88, p =  0.0021) and overall survival (OS; HR = 0.46, 95% CI: 0.32-0.67, p < 0.0001) in the entire population, respectively. The multivariate analysis identified the pretreatment PNI as an independent prognosticator for the PFS (p =  0.0011) and OS (p  < 0.0001), and in patients receiving either pembrolizumab alone or chemoimmunotherapy, the pretreatment PNI remained an independent prognostic factor for the OS (p = 0.0270 and 0.0006, respectively).

CONCLUSION

The PNI might help clinicians appropriately identifying patients with better treatment outcomes when receiving first-line ICI therapy.

Necitumumab plus gemcitabine and cisplatin in previously treated lung squamous cell carcinoma

BACKGROUND

The efficacy and safety of the anti-EGFR antibody necitumumab combined with gemcitabine and cisplatin (N + GC) in the first-line treatment of advanced lung squamous cell carcinoma (LSCC) have been proven. However, the efficacy and safety of N + GC in the second line or later treatment remain unclear.

METHODS

Eleven patients who received N + GC for advanced-stage or recurrent LSCC were enrolled. We retrospectively assessed the patients' clinical characteristics and efficacy and safety of treatment.

RESULTS

The median patient age was 73 years (range, 63-77 years). The cohort included nine (81.8%) men and two (18.2%) women. Two (18.2%) patients had postoperative recurrence, and one (9.1%), three (27.3%), one (9.1%), and four (36.4%) patients were diagnosed with stage IIIA, IIIB, IVA, and IVB disease, respectively. Concerning the best overall response, partial response was achieved in five (45.5%) patients, four (36.4%) patients displayed stable disease, and two (18.2%) patients were not evaluable. Median progression-free survival was 6.8 months (range, 1.4-10.3 months). The grade 3 or higher neutropenia, thrombocytopenia, and anemia occurred in six (54.5%), three (27.3%), and two (18.2%) patients, respectively. Additionally, grade 3 skin reaction, rash, lung infection, duodenal ulcer, and febrile neutropenia were observed in one (9.1%) patient each. Two (18.2%) patients required treatment interruption because of adverse events.

CONCLUSION

N + GC displayed good efficacy in the second line or later treatment among patients with LSCC. This study suggested that N + GC is a useful option even after second-line treatment of advanced-stage or recurrent LSCC, although the management of adverse events is essential.

Skeletal muscle area predicts the outcomes of non-small-cell lung cancer after trimodality therapy

OBJECTIVES

Sarcopenia correlates with poor prognosis in various malignancies. However, the prognostic significance of sarcopenia remains to be determined in patients with non-small-cell lung cancer who undergo surgery after receiving neoadjuvant chemoradiotherapy (NACRT).

METHODS

We retrospectively reviewed the patients with stage II/III non-small-cell lung cancer who underwent surgery following NACRT. The paravertebral skeletal muscle area (SMA) (cm2) at the 12th thoracic vertebra level was measured. We calculated the SMA index (SMAI) as SMA/squared height (cm2/m2). Patients were divided into low and high SMAI groups, and the association of SMAI with clinicopathological factors and prognosis was assessed.

RESULTS

The patients' [men, 86 (81.1%)] median age was 63 (21-76) years. There were 106 patients including 2 (1.9%), 10 (9.4%), 74 (69.8%), 19 (17.9%) and 1 (0.9%) patients with stage IIA, IIB, IIIA, IIIB and IIIC, respectively. Of the patients, 39 (36.8%) and 67 (63.2%) were classified in the low and the high SMAI groups, respectively. Kaplan-Meier analysis showed that the low group had a significantly shorter overall survival and disease-free survival than the high group. Multivariable analysis identified low SMAI as an independent poor prognostic factor for overall survival.

CONCLUSIONS

Pre-NACRT SMAI correlates with poor prognosis; therefore, assessing sarcopenia based on pre-NACRT SMAI may help determine optimal treatment strategies and suitable nutritional and exercise interventions.

Clinical significance of the combination of preoperative SUVmax and CEA in patients with clinical stage IA lung adenocarcinoma

BACKGROUND

Preoperative maximum standardized uptake value (SUVmax) of 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography and serum carcinoembryonic antigen (CEA) have been reported as prognostic factors for lung adenocarcinoma. However, the significance of combined SUVmax and CEA in early-stage lung adenocarcinoma is not well known.

METHODS

We retrospectively evaluated the relationship between the combination of SUVmax and CEA and the prognosis of 410 patients with clinical stage IA lung adenocarcinoma who underwent resection. The cutoff values for SUVmax and CEA were determined by receiver operating characteristic curve analysis, and patients were categorized into high SC (SUVmax and CEA) group (SUVmax ≥2.96 and CEA ≥5.3), moderate SC group (either SUVmax <2.96 and CEA ≥5.3 or SUVmax ≥2.96 and CEA <5.3) and low SC group (SUVmax <2.96 and CEA <5.3).

RESULTS

Kaplan-Meier curve analysis showed that patients with clinical stage IA lung adenocarcinoma in the high SC group had significantly shorter overall survival (OS) and recurrence-free survival (RFS) than the other groups (p = 0.011 and p < 0.0001, respectively). Multivariate analysis showed that high SC was an independent prognostic factor of OS (p = 0.029) and RFS (p < 0.0001).

CONCLUSIONS

High values of SUVmax and CEA were associated with poor OS and RFS in patients with stage IA lung adenocarcinoma. Simultaneous evaluation of SUVmax and CEA may be an effective prognostic marker to determine the optimal treatment strategy of early-stage lung adenocarcinoma.

Predictive model of the prognosis in non-small cell lung cancer treated with first-line immunotherapy based on machine learning

e21125

Background: In recent years, there have been expectations for the application of artificial intelligence (AI) in the clinical practice of lung cancer. In the first-line setting, immune checkpoint inhibitors (ICIs) in combination with cytotoxic agents (CTx) have become a standard-of-care for patients with non-small cell lung cancer (NSCLC); however, no absolute biomarkers have been established for the prediction of the response to such therapy. In this study, we aimed to construct a new prognostic model by using AI in NSCLC patients treated with first-line ICI plus CTx. Methods: We retrospectively identified 218 NSCLC patients with advanced or postoperatively recurrent disease. They received first-line treatment with ICI alone or in combination with cytotoxic agents between January 2016 and October 2020. AI model using Gradient Boosting Decision Tree (GBDT) was used to identify predictors (explanatory variables) of the survivals (objective variables). A total of 53 factors were selected for the explanatory variables including clinical, hematological and pathological information. The objective variables were overall survival (OS) and progression-free survival (PFS). GBDT constructed the optimal predicting model, and calculated the contribution of each explanatory variable to the objective variables. Additionally, the importance of each feature was interpreted by SHapley Additive exPlanation (SHAP). Results: The median follow-up period was 14.4 months (range: 0.5-52.0) after the initiation of the therapy. The characteristics were shown below; the median age was 69 years old (range: 36-85); males and females were 165 (75.7%) and 53 (24.3%); patients with ICI alone or combination with cytotoxic anticancer agents were 91 (41.7%) or 127 (58.3%); the distributions of performance status (PS) were 107 (49.1%), 94 (43.1%), 13 (6.0%) with PS 0, 1 and 2; the Sq, non-Sq and others were found in 51 (23.4%), 165 (75.7%) and 2 (0.9%); 170 patients (78.0%) showed a PD-L1 expression of > 1% and 36 (16.5%) patients had no PD-L1 expression. The median PFS and OS were 10.2 and 21.8 months, respectively. The predicting optimal model for OS and PFS were constructed by GBDT, and the respective area under the curves (AUC) were 0.724 and 0.656. The explanatory variables indicating high contribution to OS were serum C-reactive protein (CRP), cytokeratin subunit 19 fragment (CYFRA), alkaline phosphatase (ALP), peripheral lymphocyte count and chloride ion level. As for PFS, the highest five contributions were CYFRA, CRP, immune-related adverse events, ALP and peripheral platelet count. Furthermore, all of these factors were explained their importance by SHAP. Neither PD-L1 expression nor PS were predictors of the survivals. Conclusions: Machine learning identified several novel factors possibly contributing to the prognoses in NSCLCs patients treated with the first-line immunotherapy.

Long-term complete response to gefitinib after treatment termination in a patient with recurrent post-operative EGFR-mutated lung adenocarcinoma: case report and literature review

Non-small-cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations is highly sensitive to EGFR-tyrosine kinase inhibitor (EGFR-TKI). However, few cases of advanced NSCLC completely cured by EGFR-TKIs have been reported. We present an extremely rare case of lung adenocarcinoma that was completely cured by gefitinib administration. A 36-year-old Japanese woman was diagnosed with clinical Stage IIIB (T2N3M0) lung adenocarcinoma originating from the left upper lobe in April 2006. After the two cycles of chemotherapy, it was down-staged to ycStage IA (T1N0M0). She underwent a thoracotomy with left upper lobectomy, pulmonary angioplasty, and mediastinal nodal dissection in July 2006 [ypStage IIIA (T3N1M0)]. Eighteen months later, she was found to have lymphadenopathy of the right supraclavicular nodes. Fine needle aspiration cytology of the lymph node indicated adenocarcinoma. She started gefitinib therapy for recurrent lung cancer with EGFR mutation (exon 19 deletion) in January 2008. Four months afterward, computed tomography (CT) showed her right supraclavicular nodes had shrunk dramatically. Treatment with gefitinib was continued. Thereafter, no disease progression was observed throughout her approximately 8-year gefitinib treatment, and gefitinib was terminated in November 2016. Although the patient received no other treatment, she has suffered no recurrence in the 4 years since. A review of the literature, including our case, is also presented.

Prognostic Impact of Albumin-bilirubin (ALBI) Grade on Non-small Lung Cell Carcinoma: A Propensity-score Matched Analysis

BACKGROUND/AIM

Albumin-bilirubin (ALBI) grade is an indicator of liver dysfunction and is useful for predicting postoperative prognosis of hepatocellular carcinomas. However, the significance of ALBI grade in non-small cell lung carcinoma (NSCLC) has not been elucidated.

PATIENTS AND METHODS

We analyzed 947 patients with pStage IA-IIIA NSCLC. We divided patients into ALBI grade 1 and grade 2/3 groups. We then analyzed the association of ABLI grade with clinicopathological characteristics and prognosis in NSCLC by using propensity-score matching.

RESULTS

ALBI grade 2/3 was significantly associated with older age, male sex, advanced pT status, and histological type. Even after propensity-score matching, ALBI grade 2/3 patients had significantly worse cancer-specific survival (CSS) than ALBI grade 1 patients (5-year CSS: 87.3% versus 92.8%; p=0.0247). In multivariate analysis, ALBI grade 2/3 was an independent predictor of CSS (HR=1.9; 95%CI=1.11-3.11; p=0.0177).

CONCLUSION

ALBI grade was an independent prognostic factor in surgically resected NSCLC.

Interleukin-38 promotes tumor growth through regulation of CD8+ tumor-infiltrating lymphocytes in lung cancer tumor microenvironment

BACKGROUND

Interleukin (IL)-38 was discovered in 2001 and is a member of the IL-1 family of cytokines. IL-38 shows anti-inflammatory activity in several inflammatory diseases. In lung adenocarcinoma, we previously demonstrated that high IL-38 expression in tumor cells was associated with poor prognosis. However, the role of IL-38 in the tumor microenvironment has not been clarified.

METHODS

IL-38-plasmid-transfected Lewis lung carcinoma cells (LLC-IL38) and empty vector-transfected LLC cells (LLC-vector) were established. Cell proliferation in vitro and tumor growth in vivo were examined, and immunohistochemical staining was used to assess tumor-infiltrating lymphocytes (TILs). A CD8⁺ lymphocyte depletion model was established to show the association between IL-38 and CD8⁺ lymphocytes. Moreover, we examined the association between IL-38 expression and CD8⁺ TILs in human samples, analyzing immunohistochemical staining in 226 patients with radically resected lung adenocarcinoma.

RESULTS

Tumor growth of LLC-IL38 in vivo was significantly increased compared with that of LLC-vector, although cell proliferation of LLC-IL38 in vitro was lower than that of LLC-vector. CD8⁺ TILs were significantly decreased in LLC-IL38 tumor compared with LLC-vector tumor. The difference in tumor growth between LLC-IL38 and LLC-vector became insignificant after depletion of CD8⁺ lymphocytes. In immunohistochemical staining in tissues from patients with lung adenocarcinoma, multivariate analysis showed high IL-38 expression was an independent negative predicter of high density of CD8⁺ TILs.

CONCLUSION

We demonstrated that high IL-38 expression in tumor cells was significantly associated with reduction of CD8⁺ TILs and tumor progression. These results suggest that IL-38 could be a therapeutic target for lung cancer.

Both hypo- and hyperglycaemia are associated with increased fracture risk in Japanese people with type 2 diabetes: the Fukuoka Diabetes Registry

AIM

The impact of glycaemic control on fracture risk is controversial, which may be due to the possible presence of hypoglycaemia. The aim of this study was to separately investigate the impacts of severe hypoglycaemia and poor glycaemic control on fracture risk in people with type 2 diabetes.

METHODS

Overall, 4706 Japanese participants (2755 men and 1951 postmenopausal women) with type 2 diabetes (mean age 66 years) were followed prospectively (a median of 5.3 years; follow-up rate, 97.6%), and were stratified by severe hypoglycaemia status and glycaemic control. The primary outcome was fractures at any anatomic site.

RESULTS

Fractures occurred in 662 participants (249 men and 413 women). The age- and sex-adjusted incidence rates (expressed per 1000 person-years) were: 71.2 (multiple episodes of severe hypoglycaemia), 43.1 (one episode), 25.2 [HbA_1c < 53 mmol/mol (< 7%) without severe hypoglycaemia], 28.7 [HbA_1c 53 to < 64 mmol/mol (7% to < 8%) without severe hypoglycaemia], 27.7 [HbA_1c 64 to < 75 mmol/mol (8% to < 9%) without severe hypoglycaemia] and 40.5 [HbA_1c ≥ 75 mmol/mol (≥ 9%) without severe hypoglycaemia]. Multivariate-adjusted hazard ratios (95% confidence intervals) for fractures were 2.24 (1.56, 3.21) in those with multiple episodes of severe hypoglycaemia, and 1.42 (1.04, 1.95) in those with HbA_1c ≥ 75 mmol/mol (≥ 9%) without severe hypoglycaemia, compared with those with HbA_1c < 53 mmol/mol (< 7%) without severe hypoglycaemia.

CONCLUSIONS

Both severe hypoglycaemia and poor glycaemic control were significantly related to an increased risk of fracture in people with type 2 diabetes, although severe hypoglycaemia conferred a stronger risk.

Combined Evaluation of Tumor-Infiltrating CD8 + and FoxP3 + Lymphocytes Provides Accurate Prognosis in Stage IA Lung Adenocarcinoma

BACKGROUND

Immunotherapy has become a standard treatment option for non-small cell lung cancer (NSCLC), with the tumor microenvironment attracting significant attention. CD8 + and forkhead box protein P3 + (FoxP3 +) tumor-infiltrating lymphocytes (TILs) influence the tumor microenvironment, but the clinical significance of CD8 + and FoxP3 + TILs in stage IA lung adenocarcinoma (LAD) is poorly understood.

METHODS

We analyzed 203 patients with stage IA primary LAD who had undergone surgery at Kyushu University from January 2003 to December 2012. We evaluated CD8 + and FoxP3 + TILs by immunohistochemistry. We set the cutoff values at 50 cells/0.04 mm² for CD8 + TILs and 20 cells/0.04 mm² for FoxP3 + TILs, respectively. We divided the patients into four groups: CD8-Low/FoxP3-Low; CD8-High/FoxP3-Low; CD8-Low/FoxP3-High; and CD8-High/FoxP3-High. We compared clinical outcomes among them. Programmed cell death ligand-1 (PD-L1) expression by tumor cells was also evaluated as previously reported.

RESULTS

Respectively, 104 (51.2%), 46 (22.7%), 22 (10.8%), and 31 (15.3%) patients were classified as CD8-Low/FoxP3-Low, CD8-High/FoxP3-Low, CD8-Low/FoxP3-High, and CD8-High/FoxP3-High. Both disease-free survival (DFS) and overall survival (OS) were significantly worse in the CD8-Low/FoxP3-High group than the other groups (5-year DFS: 66.3% vs. 90.5%; P = 0.0007, 5-year OS: 90.9% vs. 97.0%; P = 0.0077). In the multivariate analysis, CD8-Low/FoxP3-High and PD-L1 expression were independent prognostic factors of DFS, and lymphatic invasion, surgical procedure, and PD-L1 expression were independent prognostic factors of OS.

CONCLUSIONS

CD8-Low/FoxP3-High was an independent prognostic factor of DFS (hazard ratio: 3.22; 95% confidence interval: 1.321-7.179; P = 0.0121) in stage IA LAD. Immunosuppressive conditions were associated with poor prognosis in stage IA LAD.

Effects of pharmacological lesion of the nucleus retroambiguus region on the pharyngeal phase of swallowing

Pharyngeal swallowing is controlled by synaptic interactions within a swallowing central pattern generator (sw-CPG) that is composed of a dorsal and a ventral swallowing group (VSG). Here, we used electrical stimulation (10 s) of the superior laryngeal nerve (SLN; 20 Hz; pulse width: 100 μs) to explore the role of the VSG in an arterially-perfused brainstem preparation of rats. To investigate the effects of pharmacological lesion (local microinjection of an GABA(A)-R agonist) of the nucleus retroambiguus (NRA), a designated component of the VSG, we recorded phrenic (PNA) and vagal nerve (VNA) activities. Control SLN stimulation with stepwise increasing stimulus intensities (from 20 μA to 160 μA) elicited robust suppression of PNA and evoked sequential swallowing activity in the VNA. Lesioning of the NRA had no effect on the pattern of pharyngeal swallowing, but significantly increased the sensory gating of SLN inputs. We conclude that the NRA is not part of the VSG, but appears to have important roles for the central gating of swallowing.

Postoperative Management of Multiple Primary Cancers Associated with Non-small Cell Lung Cancer

BACKGROUND/AIM

Modern treatment for primary cancers has improved survival. Therefore, increased numbers of patients with multiple primary cancers (MPC) associated with lung cancer may be expected. The aim of the present study was to report MPC associated with lung cancer and discuss patients' characteristics and postoperative management.

PATIENTS AND METHODS

Overall, 973 consecutive patients who underwent surgery for non-small cell lung cancer (NSCLC) were retrospectively studied.

RESULTS

NSCLC with MPC was observed in 148 patients (15.2%). MPC comprised 24 synchronous (2.5%) and 124 metachronous (12.7%) diseases. Of the 124 metachronous patients, NSCLC was detected before cancers were detected in other organs (lung cancer first (LCF)) in 25 (20.2%) patients and subsequently in other organs after treatment (other organs, primary cancer-first (OCF)) in 99 (79.8%) patients. MPC was significantly associated with advanced age (p<0.0001) and chronic obstructive pulmonary disease (COPD) (p=0.0040). The leading sites of MPC in patients with synchronous tumors and those with OCF were the digestive organs. In contrast, the leading site of MPC in patients with LCF was the lung. In the latter, at least two primary lung cancers were detected within 5 years as well as 5 years after surgery for the treatment of the first detected lung cancer, while primary cancers of other organs were detected within 5 years.

CONCLUSION

Advanced age and COPD may represent a high-risk of MPCs. Therefore, we recommend careful follow-up to detect MPC in the lung as well as the digestive organs beyond 5 years after treatment of the first cancer.

Impact of Preoperative Ultrasonography Screening for Carotid Artery Stenosis in Lung Cancer Patients

BACKGROUND

Stroke is a major cause of morbidity or death after lung operations. Carotid artery screening (CAS) is useful for detecting carotid artery stenosis, which is one of the causes of stroke. This study investigated the frequency of and risk factors for preoperative carotid artery stenosis to determine whether CAS with ultrasonography contributes to preventing postoperative stroke or cardiovascular comorbidities in lung cancer patients.

METHODS

This retrospective study included 1,676 consecutive lung cancer patients who underwent surgical resection.

RESULTS

Of the 1,342 patients who underwent CAS, 173 (12.9%) had carotid artery stenosis. Significant associations with carotid artery stenosis were found for older patients (p < 0.0001), men (p < 0.0001), smoking history (p < 0.0001), history of stroke (p = 0.0037), cardiovascular diseases (p < 0.0001), hypertension (p = 0.0353), diabetes mellitus (p = 0.0037), and peripheral vascular diseases (p < 0.0001). Patients with the three independent risk factors of age, male sex, and history of cardiovascular diseases had a 6.43-fold higher prevalence of carotid artery stenosis (odds ratio, 6.43; 95% confidence interval, 3.80 to 10.89) than those with none of these factors. Propensity score-matched analysis showed that incidences of postoperative stroke and cardiovascular comorbidities were both lower in patients who underwent CAS and received appropriate anticoagulant therapy than in those who did not (p = 0.0619 and p = 0.0319, respectively).

CONCLUSIONS

Preoperative CAS is a simple and useful tool for detecting carotid artery stenosis. Administration of perioperative anticoagulant therapy to preoperative patients with lung cancer and carotid artery stenosis identified by CAS may prevent postoperative stroke and cardiovascular events.

An epidemiological survey of echinococcosis in intermediate and definitive hosts in Qinghai Province, China

In order to understand the epidemiological status of alveolar and cystic echinococcosis in intermediate and definitive hosts in Qinghai Province, China, during the period 2007-2011, we investigated the infection in humans and animals, including yaks, Tibetan sheep, Tibetan dogs, and wild foxes distributed in different counties around the province. Sera from local residents were examined using a rapid serodiagnostic kit to detect specific antibodies against Echinococcus. Seropositive samples were confirmed with B-scan ultrasonography and X-ray examinations. Yaks and Tibetan sheep were checked at slaughterhouses, and cysts and suspicious lesions were collected for analysis. A rapid diagnostic strip was used to detect Echinococcus adults in Tibetan dogs. Positive dogs were dewormed and the parasites collected. Wild foxes were trapped and necropsies performed with particular attention to the intestine. Forty-eight of 735 (6.4%) humans tested were positive and 475 of 854 (55.6%) Tibetan sheep and 85 of 352 (24.15%) yaks were infected with Echinococcus. Across different counties, 214 of 948 (22.57%) Tibetan dogs were positive, and five of 36 (13.9%) wild foxes were infected with Echinococcus. Molecular studies showed that all the infections detected in humans, domestic yaks, and Tibetan sheep were the G1 genotype (E. granulosus), whereas the parasites from Tibetan foxes and Tibetan dogs were E. shiquicus and E. multilocularis, respectively. In conclusion, Echinococcosis is hyperendemic in Qinghai Province in both its intermediate and definitive hosts and the G1 genotype of cystic Echinococcus is the dominant strain.

Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery

Background

Defaecatory function is often poor after anterior resection. Denervation of the neorectum following high ligation of the inferior mesenteric artery (IMA) is a possible cause of impaired defaecatory function. The purpose of this randomized clinical trial was to clarify whether the level of ligation of the IMA in patients with rectal cancer affects defaecatory function.

Methods

Between 2008 and 2011, patients who underwent anterior resection for rectal cancer were randomized to receive either high or low ligation of the IMA. The primary endpoint was to demonstrate the superiority of low ligation in terms of defaecatory function.

Results

One hundred patients were enrolled in the study; 51 were randomized to high ligation of the IMA and 49 to low ligation. There were no differences between the groups in terms of clinical data, except tumour stage, which was more advanced in the high-ligation group (P = 0·046). Nor were there any differences in defaecatory function, self-assessment of defaecation, Faecal Incontinence Quality of Life scale or continence score between groups at 3 months and 1 year. The number of harvested lymph nodes was similar. The rate of symptomatic anastomotic leakage was 16 per cent in the high-ligation group and 10 per cent in the low-ligation group (P = 0·415).

Conclusion

The level of ligation of the IMA in patients with rectal cancer did not affect defaecatory function or the incidence of postoperative complications. Registration number: NCT00701012 (http://www.clinicaltrials.gov).

Coprological survey of alimentary tract parasites in dogs from Zambia and evaluation of a coproantigen assay for canine echinococcosis

Faecal samples were collected from the rectum of 540 domestic dogs from four districts (Lusaka, Katete, Petauke and Luangwa) in Zambia between 2005 and 2006 and prevalences of canine alimentary tract parasites were determined by coprological examination. Thirteen different ova and parasites including strongyle (43.3%), Spirocerca lupi (18.7%), taeniid (13.1%), Toxocara canis (7.6%), Sarcocystis sp.* (7.5%), Isospora sp.* (5.7%), Physaloptera sp.* (4.6%), Capillaria sp.* (2.8%), Dipylidium caninum (2.2%), Mesocestoides sp.* (2.0%), Ascaris sp.* (1.7%), Trichuris vulpis* (0.4%) and Schistosoma mansoni* (0.4%) were detected, Ascaris and Schistosoma probably originating from coprophagy. The species with asterisks and later-described Taenia multiceps are for the first time reported from dogs in Zambia. A coproantigen enzyme-linked immunosorbent assay (CoproAg-ELISA) developed for Echinococcus spp. revealed 43 positive dogs and 37 of these harboured taeniid eggs. From 63 of the 71 taeniid egg-positive samples, eggs and DNA thereof were isolated and subjected to a multiplex polymerase chain reaction for differentiating E. granulosus sensu lato, E. multilocularis and Taenia spp. Amplicons indicative for Taenia spp. were obtained from 60 samples. Sequencing of amplicons spanning part of the mitochondrial cytochrome c oxidase subunit 1 gene, which was possible with 38 samples, revealed 35 infections with T. hydatigena and 3 with T. multiceps. Therefore, the CoproAg-ELISA showed some positives, but concrete evidence for the existence of canine E. granulosus infection could not be established. Comparison of the results of the CoproAg-ELISA and Taenia species identification indicated that the CoproAg-ELISA cross-reacts with patent infections of T. hydatigena (57%) and T. multiceps (33%).

Comparison of clinical, tumour-related and dosimetric factors in grade 0-1, grade 2 and grade 3 radiation pneumonitis after stereotactic body radiotherapy for lung tumours

OBJECTIVE

The aim of this study was to investigate significant clinical, tumour-related and dosimetric factors among patients with grade 0-1, grade 2 and grade 3 radiation pneumonitis (RP) after stereotactic body radiotherapy (SBRT) for lung tumours.

METHODS

Patients (n=128) with a total of 133 lung tumours treated with SBRT of 50 Gy in 5 fractions were analysed. RP was graded according to the Common Terminology Criteria for Adverse Events v.3.0. Significant factors were identified by univariate and multivariate analyses. Threshold dose-volume histograms (DVHs) were constructed to identify the incidence of RP.

RESULTS

The median follow-up period was 12 months (range, 6-45 months). In univariate analyses, gender, operability, forced expiratory volume in 1 s (FEV1), internal target volume, lung volumes treated with doses >5-30 Gy (V5-30) and mean lung dose were significant factors differentiating between grade 0-1 and grade 2 RP, and V15-30 were significant factors differentiating between grade 2 and grade 3. However, no factors were significant between grade 0-1 and grade 3 RP. Multivariate analysis showed that female gender, high FEV1 and high V15 were significant factors differentiating between grade 0-1 and grade 2 RP. Threshold DVH curves were created based on ≤5% and ≤15% risk of grade 2 RP among patients with grade 0-2 RP.

CONCLUSIONS

Grade 0-2 RP was dose-volume dependent, and female gender and high FEV1 were significant predictive clinical factors for grade 2 RP among patients with grade 0-2 RP. However, incidences of V15-30 in grade 3 RP were significantly lower than those in grade 2 RP, and no significant clinical or tumour-related factors were found. Further studies are needed to identify the mechanism underlying the development of grade 3 RP after SBRT for lung tumours.