Abstract B13: Non-small cell lung cancer with double driver mutations

Background: Driver mutations, such as an epidermal growth factor receptor (EGFR) mutation or an echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) fusion, generally occur independently in non-small cell lung cancer (NSCLC), as such driver mutations are able to cause cancers by themselves. However, we discovered the first reported lung cancer case that simultaneously harbored both an EML4-ALK fusion and an exon 19 EGFR mutation. We subsequently examined the driver gene mutations in a panel of consecutive, surgically resected, pathological Stage I lung adenocarcinomas to determine the frequency and clinicopathological characteristics in cases with double driver mutations.

Patients and Methods: The initial case, which we reported previously (J Thorac Oncol. 2012, 7:e39-41), was a 72-year-old male ex-smoker who underwent right lower lobectomy for a lung peripheral mass of 4.5 cm in diameter. An EGFR mutation and EML4-ALK fusion were found in the tumor by immunohistochemistry and direct sequencing. To further examine the frequency of double driver mutations, a consecutive panel of 256 patients with pathological Stage I lung adenocarcinoma was analyzed for mutations of EGFR, K-ras, EML4-ALK and BRAF.

Results: The initial case turned out to have both an exon 19 EGFR mutation and EML4-ALK fusion. Pathologically, the tumor comprised mixed papillary, acinar and lepidic adenocarcinoma, with small cell carcinoma in the central area. An EML4-ALK fusion was detected from the small cell component, while the EGFR mutation was detected from the peripheral lepidic adenocarcinoma component. Next, we analyzed the driver gene mutations in 256 Stage I lung adenocarcinoma cases. Mutations of the EGFR, K-ras, EML4-ALK and BRAF genes were detected in 120 (46.8%), 14 (5.5%), seven (2.7%) and three (1.2%) cases, respectively. Among them, double driver mutations were detected from two cases; one had an EML4-ALK fusion and exon 19 EGFR mutation, and another had a BRAF mutation (V600E) and exon 19 EGFR mutation.

Discussion: Although the tumor from the initial case exhibited double driver mutations as a whole, a detailed examination of each histological component enabled us to distinguish one mutation from another. In other words, the driver mutations did not co-exist in a single cancer cell. Accordingly, similar molecular pathological investigations need to be done on newly identified cases with double driver mutations, because such studies may clarify how multiple mutations occur in one tumor.

Conclusion: We demonstrated the frequency and the manifestations of rare double driver mutations in NSCLC. Further studies are warranted to clarify the mechanisms underlying the development of double driver mutations.

Citation Format: Atsushi Osoegawa, Gouji Toyokawa, Taro Ohba, Michiyo Miyawaki, Masafumi Yamaguchi, Kenichi Taguchi, Takashi Seto, Mitsuhiro Takenoyama, Yukito Ichinose, Kenji Sugio. Non-small cell lung cancer with double driver mutations. [abstract]. In: Proceedings of the AACR-IASLC Joint Conference on Molecular Origins of Lung Cancer; 2014 Jan 6-9; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2014;20(2Suppl):Abstract nr B13.

A single-arm, phase 2 study of adjuvant chemotherapy with oral tegafur-uracil for pathologically lymphovascular invasion positive stage IA non-small cell lung cancer: LOGIK0602 study

BACKGROUND

Lymphovascular invasion (LVI), which includes vascular or lymphatic invasions, is a representative prognostic factor even in patients with resected stage IA non-small cell lung cancer (NSCLC). Because tegafur-uracil is effective on cancers with LVI, we conducted a multi-center single-arm phase II study to estimate the efficacy of adjuvant tegafur-uracil in patients with LVI-positive stage IA NSCLC.

METHODS

Patients with completely resected LVI-positive stage IA NSCLC were registered. LVI was diagnosed by consensus of two of three pathologists. Adjuvant chemotherapy consisted of 2 years of oral tegafur-uracil at 250 mg/m²/day. Fifty-five patients from 7 institutions were enrolled from June 2007 to September 2012.

RESULTS

Among the 52 eligible patients, 36 (69.2%) completed the treatment course. There were 39 male and 13 female patients. The observation period was calculated as 562 to 3107 days using the reverse Kaplan-Meier method. The 5-year overall and relapse free survival rates were 94.2 and 88.5% respectively, which were significantly better than that of any other studies conducted on patients with LVI-positive stage IA NSCLC. Notably, the overall survival rate was 15% better than that of our prior retrospective study. The retrospective analysis of stage IA NSCLC patients who had received an operation in the same period revealed that the 5-year overall survival rate of the LVI positive group was 73.6% when adjuvant chemotherapy was not applied. Among 55 safety analysis sets, 4 cases of grade 3 hepatic function disorder (9.1%) and 5 cases of grade 2 anorexia (10.9%) were most frequently observed. No grade 4 adverse effects were encountered.

CONCLUSION

A 2-year course of oral tegafur-uracil administration is feasible and might have a significant benefit in the adjuvant treatment of LVI-positive stage IA NSCLC.

TRIAL REGISTRATION

UMIN identifier: UMIN000005921 ; Date of enrolment of the first participant to the trial: 19 June 2007; Date of registration: 5 July 2011 (retrospectively registered).

Effects of forskolin and prostaglandin E1 on leukotriene C- and D-induced plasma exudation in the rat skin

Leukotriene C and D markedly enhanced plasma exudation in rat skin, using [131I]-labeled human serum albumin ([131I]-HSA) to measure vascular permeability. The adenylate cyclase activator forskolin only slightly increased plasma exudation, while markedly potentiating the leukotriene response. Prostaglandin E1 increases plasma exudation in rat skin, but appears to act by a different mechanism than leukotrienes, since the responses to combinations of prostaglandin and leukotrienes are synergistic and the responses to prostaglandins are inhibited by forskolin. The phosphodiesterase inhibitor, isobutylmethylxanthine also potentiated the leukotriene C-induced response. The effects of the various agents on leukotriene responses are similar to effects of these agents on bradykinin and histamine-induced plasma exudation. These results suggest that an increase in the cyclic AMP in the rat skin, elicited by forskolin or prostaglandin potentiates the leukotriene C and D-induced plasma exudation and that leukotriene C and D increase the vascular permeability through the same type of mechanism that pertains for histamine and bradykinin.

[Experience with atrioventricular valve replacement in infants and children]

From 1980 to 1989, nine infants and children underwent valve replacement. These replacements consisted of seven mitral valve replacement (MVR), one left atrioventricular valve replacement, and one aortic valve (AVR) replacement. We excluded AVR from this report. Follow-up period of 8 cases were 68 months in an average. During this period, 2 cases were not thought to be satisfactory as antithrombotic therapy, in which one revealed malfunctioning prosthesis, and secondary MVR implantation was performed. Another one is free from any complications. We experienced the difficulty of antithrombotic therapy following valve replacement in infants and children. It is supposed that combined use of anticoagulant therapy agent and antiplatelet agent may be necessary as antithrombotic therapy, especially in childhood.

[A case of a traumatic diaphragmatic true hernia manifesting itself 12 years after the accident]

A case of surgical treatment of a traumatic diaphragmatic true hernia was presented, which manifested itself as symptoms of left chest oppression 12 years after the accident. The patient was a 66-year-old woman, who met traffic accident in 1976. She was first pointed out abnormal shadow on the chest X-ray in 1981 and began to feel chest oppression in 1988. Barium examination of the upper gastrointestinal tract and chest CT scan revealed a part of corpus ventriculi and colon herniated into the left hemithorax. Diaphragmatic hernia was diagnosed and the operation was performed through the thoracic approach in June 1991. The diaphragm was found to have a hernia sac and a defect at the central tendon. The hernia sac containing the stomach and colon was opened to reduce it's contents into the abdominal cavity. The defect was closed by mattress suture with pledgets and continuous over and over suture. The patient ran a favorable post operative course. A true type among traumatic diaphragmatic hernia is a very rare case in the literature.

Laparoscopic pylorus-preserving gastrectomy with intracorporeal hand-sewn anastomosis

To prevent stapled stenosis after laparoscopic local gastric resection by using autosuturing devices, we developed a technique for laparoscopic pylorus-preserving gastrectomy with intracorporeal hand-sewn anastomosis. We describe this procedure and present two case reports. The intracorporeal hand-sewn anastomotic technique is an important advance in the field of minimally invasive laparoscopic surgery.

[Assessment of prognosis and p 53 mutations in patients with multiple tumors of the lung; intrapulmonary metastasis or double primary cancers?]

To assess whether a satellite lesion in the primary-tumor lobe is intrapulmonary metastasis from primary cancer (pm 1) or they are double primary lung cancers, we examined the postoperative prognosis of patients with pm 1 and the p 53 genetic differentiation between a satellite lesion and a primary lesion. Of 772 consecutive patients with N0-2M0 non-small cell lung cancer who underwent surgical resections between 1979 and 2000, 31 patients had a satellite lesion in the primary-tumor lobe. The 5-year survival rate was 26.3% in the pm 1 (+) T 4 group (n = 37), 14.7% in the pm 1 (-) T 4 group (n = 43), and 32.5% in the T 3 group (n = 132), suggesting that pm 1 cases should be classified as T 3. We examined 16 of 37 patients with pm 1 for mutations of the p 53 gene occurring exons 5 through 8 by the fluorescence-based polymerase chain reaction single-strand conformation polymorphism. Seven of the 16 patients analyzed had at least one p 53 mutations in their tumors. The mutational status of the p 53 gene was discordant in 5 patients, suggesting they were double primary lung cancers. The mutational status including DNA sequencing of the p 53 gene was concordant in 2 patients, suggesting they were intrapulmonary metastases. It remains arguable in the TNM staging system whether a satellite lesion in the primary-tumor lobe is intrapulmonary metastasis from primary cancer or they are double primary lung cancers.

Clinical significance of the Rb expression in adenocarcinoma of the lung

BACKGROUND

Altered retinoblastoma gene expression has been found in various types of cancers including non-small cell lung cancer (NSCLC) and some reports have shown it also to be associated with a poor clinical prognosis in NSCLC.

MATERIALS AND METHODS

We evaluated the expression of Rb protein by immunohistochemistry in 90 patients with lung adenocarcinoma who underwent surgical resection and determined its prognostic significance. Also, the expression of p27 by immunohistochemistry and the mutations of the p53 gene by PCR-SSCP were evaluated.

RESULTS

Fifty-one out of 90 tumors (56.7%) had reduced expression of the Rb gene. There were no statistical differences between the Rb expression level and clinicopathological status. There was no correlation between the Rb expression level and the p53 mutations or the p27 expression level. The 5-year survival rate in the normal group was 55.1%, which was poorer than that of 73.0% in the reduced group, but showed no statistical difference (p=0.0981). In patients with a reduced Rb-expression, the survival rate of the p53 mutation group tended to show a poorer prognosis than that of the p53 normal group (p=0.0880). In addition, the survival rate of the negative p27 expression group tended to show a poorer prognosis than that of the positive p27 expression group (p=0.0537).

CONCLUSIONS

The Rb expression status was not significant as an individual factor for evaluating the prognosis in adenocarcinoma of the lung. Analyses of the accumulation of genetic alteration are necessary to identify the subset of patients with a poor prognosis.

Final analysis of a phase II, open label, randomized study of osimertinib versus osimertinib plus carboplatin/pemetrexed for patients with locally advanced or metastatic non-small cell lung cancer whose disease has progressed with previous EGFR-TKI and whose tumours harbour a T790M mutation (LOGIK1604/NEJ032A)

e21594

Background: Osimertinib is now available not only as a second line treatment for the patients with EGFR and T790M-mutation positive non-small cell lung cancer (NSCLC) after initial tyrosine kinase inhibitors (TKIs) but as a first line treantment for those who are TKI-naive. The efficacy and the safety of osimertinib plus palatinum-based chemotherapy has not yet been evaluated. Methods: This phase 2, open-label, randomized study enrolled adult patients (pts) with clinical stage IIIB or IV, or postoperative recurrent NSCLC harbouring susceptible EGFR and T790M mutations after preceded EGFR-TKI failure. Pts were randomly assigned to receive either an osimertinib [80 mg/day 1-21; q3w] or a combination of osimertinib [80 mg/day 1-21] with carboplatin/pemetrexed (hereafter combination) [area under the curve (AUC) = 5 and 500 mg/m2 day 1; q3w]. The primary endpoint was progression-free survival (PFS). Secondary endpoints included incidence of adverse events, response rate and overall survival. As indiction of osimertinib was expanded to a first line, we amended the protocol to discontinue the enrollment and perform final analyses. Results: From October 2016 to January 2019, 62 pts were enrolled [31 pts osimertinib; 31 pts combination] (median age 68 (37-80); 53.2% male; 83.3% stage IV; 100% adenocarcinoma; 59.7% exon 19 deletion and 40.3% L858R; 45.2% never smoker). The rate of grade (G) ≥ 3 treatment-related adverse events was 32.2% in the osimertinib group and 83.9% in the combination group. Neutropenia, anemia and thrombocytopenia were more common in the combination group and the rates of G ≥ 3 were 0%, 0% and 6.4% in the osimertinib group and 38.7%, 25.8% and 29.1% in the combination group, respectively. Three episodes (9.7%) of G ≥ 3 infection and one episode (3.2%) of G ≥ 3 febrile neutropenia were uniquely observed in the combination group, however, these were well managed. Two episodes (6.5%) of G ≥ 3 pneumonitis was observed only in the osimertinib group. Exaggeration of adverse events specific for osimertinib or any unknown adverse event was not observed in the combination group. Final PFS analysis is to be demonstrated in the presentation. Conclusions: Combination of osimertinib with carboplatin and pemetrexed demonstrated safety in patients with EGFR and T790M mutation-positive NSCLC and the efficacy should be validated in the future phase 3 study. Clinical trial information: 000024438.

[Molecular targeted therapy and tailor-made therapy for lung cancer]

Somatically acquired mutations in the epidermal growth factor receptor (EGFR) gene in lung cancer are associated with significant clinical responses to gefitinib, a tyrosine kinase inhibitor (TKI) that targets EGFR. In our previous report, 42.2% of adenocarcinoma patients has EGFR mutations, and these mutations were more frequently found in women than in men, in well differentiated tumors than poorly differentiated tumors, and in patients who were never smokers than in patients who were current/former smokers. Retrospectively, we screened the EGFR gene of tumors in 37 NSCLC patients who had been treated with gefitinib. EGFR mutations were found in 22 patients. Gefitinib was effective (CR/PR) in 15 of 22 (68.2%) patients with mutations compared with none of 15 patients without mutations. Patients with EGFR mutations survived for a longer period than without the mutations after initiation of gefitinib treatment (p = 0.0005). Gefitinib was not effective in 3 patients with K-ras mutations. Three of 4 tumors obtained from patients with acquired resistant to gefitinib, had a secondary T790M mutation. No T790M mutation was detected in pretreatment tumors. Molecular targeted therapy using TKI indicates an effective therapy specifically in lung cancer patients with EGFR mutations, and analyses of mechanisms of resistance to TKI are necessary for establishment of tailor-made therapy.

Expression of deltaNp63 in squamous cell carcinoma of the esophagus

BACKGROUND

The p63 gene is present as two isoforms, namely TAp63 and deltaNp63. The biological role of deltaNp63 in the progression of esophageal cancer is still controversial.

PATIENTS AND METHODS

The expression of deltaNp63, as well as that of p63, was immunohistochemically examined in 61 resected specimens of squamous cell carcinoma of the esophagus.

RESULTS

The incidences of a positive deltaNp63 expression were 32 and 64% in carcinomas with and without adventitial invasion, respectively, and 37 and 65% in those with and without lymph node metastasis, respectively (p<0.05). The prognosis was significantly better in the positive deltaNp63 group than in the negative group (p<0.01). However, a multivariate analysis revealed deltaNp63 not to be an independent prognostic factor. Regarding p63, diminished expression was more frequently observed in advanced carcinomas, however, there were no statistically significant differences.

CONCLUSION

The impaired deltaNp63 reflects the progression of squamous cell carcinoma of the esophagus.

Results of surgical treatment for lung cancer in young adults

In this study, we evaluated the results of surgical treatment in young adults and compared the clinico-pathological features between young and elderly patients. We reviewed the clinical records of 1185 lung cancer patients who underwent surgery in our department. A total of 20 (1.7%) primary lung cancer patients (14 men and 6 women) < or =40 years of age were retrieved. The age range was from 26 to 40 years. Histological type included 10 adenocarcinomas (50%), 3 large cell carcinomas (15%), 3 carcinoids (15%), 2 squamous cell carcinomas (10%), and 2 others. The surgical procedure included 7 (35%) pneumonectomies, 11 (55.0%) lobectomies, and 1 (5%) partial resection. The proportion of pneumonectomies was significantly higher than among elderly patients. Clinical stage was underestimated in 7 of 20 patients, and among these, mediastinal lymph node metastases were revealed by pathological examination in 6 patients. Postoperative 5-year survival rates were 50.2%, 50.4%, and 43.8% in patients < or =40, 41-70, and > or =71 years old, respectively. There were no significant differences in survival rates between younger group and elderly groups. This study suggests that surgical resection is also recommended as the first-line treatment for younger patients with lung cancer.

Slowly progressive adenocarcinoma of the lung: report of a case

A case report of a slowly progressive adenocarcinoma of the lung, followed by computed tomography is herein discussed. The patient was a 76-year-old woman, who was operated on about four years after a small lung nodule on her left upper lobe was discovered. The tumor was suspected to be either well differentiated adenocarcinoma or atypical adenomatous hyperplasia (AAH) by the findings of chest computed tomography before the operation, and the resected specimen demonstrated well differentiated adenocarcinoma, without lymph node metastasis. This case demonstrates the possibility that some adenocarcinomas with particular histology are slowly progressive, and also there might be the option of lobectomy or segmentectomy for treating such tumors.

Tracheal injury from dog bite in a child

BACKGROUND

Dog bites associated with the head and neck area in children are a common problem. Most of the lacerations are found in the upper lip and the nose region, and tracheal injury is rare [1]. Tracheal injury requires prompt and accurate diagnosis and treatment to rescue the patient. Especially in children, securing the airway is often more difficult than in adults because of their short neck and narrow trachea. In this report, we experienced a pediatric case of multiple dog bites with tracheal injuries in the neck.

CASE PRESENTATION

We report the case of a 3-year-old girl who presented with multiple dog bites. There were multiple wounds on the head, face, neck, and anterior chest, and air leakage was observed from the cervical wound at the time of transfer. It was difficult to perform oral endotracheal intubation, therefore, we extended the neck wound, probed the trachea with finger, and inserted a tracheal tube directly from the cervical wound in the emergency room. Tracheoplasty and another wound cleansing were performed in the operating room. The patient was discharged on the 18th day after surgery, without further complications.

CONCLUSION

Tracheal injury from a dog bite is rare. It is important to prompt and accurate diagnosis and treatment. Children should be especially careful because of their short necks and narrow tracheas.