Serial cfDNA assessment of response and resistance to EGFR-TKI for patients with EGFR-L858R mutant lung cancer from a prospective clinical trial

BACKGROUND

Detecting epidermal growth factor receptor (EGFR) activating mutations in plasma could guide EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment for advanced non-small cell lung cancer (NSCLC). However, dynamic quantitative changes of plasma EGFR mutations during the whole course of EGFR-TKI treatment and its correlation with clinical outcomes were not determined. The aim of this study was to measure changes of plasma EGFR L858R mutation during EGFR-TKI treatment and to determine its correlation with the response and resistance to EGFR-TKI.

METHODS

This study was a pre-planned exploratory analysis of a randomized phase III trial conducted from 2009 to 2014 comparing erlotinib with gefitinib in advanced NSCLC harboring EGFR mutations in tumor (CTONG0901). Totally, 256 patients were enrolled in CTONG0901 and randomized to receive erlotinib or gefitinib. One hundred and eight patients harbored L858R mutation in their tumors and 80 patients provided serial blood samples as pre-planned scheduled. Serial plasma L858R was detected using quantitative polymerase chain reaction. Dynamic types of plasma L858R were analyzed using Ward's hierarchical clustering method. Progression-free survival (PFS) and overall survival (OS) were compared between different types.

RESULTS

As a whole, the quantity of L858R decreased and reached the lowest level at the time of best response to EGFR-TKI. After the analysis of Ward's hierarchical clustering method, two dynamic types were found. In 61 patients, L858R increased to its highest level when disease progressed (ascend type), while in 19 patients, L858R maintained a stable level when disease progressed (stable type). Median PFS was 11.1 months (95 % CI, 6.6-15.6) and 7.5 months (95 % CI, 1.4-13.6) in patients with ascend and stable types, respectively (P = 0.023). Median OS was 19.7 months (95 % CI, 16.5-22.9) and 16.0 months (95 % CI, 13.4-18.5), respectively (P = 0.050).

CONCLUSIONS

This is the first report finding two different dynamic types of plasma L858R mutation during EGFR-TKI treatment based on a prospective randomized study. Different dynamic types were correlated with benefits from EGFR-TKI. The impact of plasma L858R levels at disease progression on subsequent treatment strategy needs further exploration.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01024413.

Leptomeningeal Metastases in Patients with NSCLC with EGFR Mutations

INTRODUCTION

Leptomeningeal metastases (LM) have increased in patients with NSCLC, and prognostic factors and outcomes for LM with EGFR gene mutations have not been well studied.

METHODS

We retrospectively analyzed patients with lung cancer from January 2011 to June 2015 at our institute. Treatments and clinical outcomes of LM were reviewed.

RESULTS

LM were diagnosed in 184 (3.4%) of 5387 patients with lung cancer. Patients with LM harboring EGFR mutations (9.4%) were significantly more frequent than those with wild-type EGFR (1.7% [p < 0.001]). The median overall survival (OS) after LM was 8.7 months (95% confidence interval [CI]: 7.3-10.1). Among the 109 patients with common EGFR mutations, the 88 patients who received tyrosine kinase inhibitor (TKI) therapy demonstrated longer OS than those who did not (10.0 months versus 3.3 months [p < 0.001]), but 42 patients who underwent whole brain radiotherapy (WBRT) did not show longer OS than those without WBRT, and a combination of WBRT and TKIs did not add any survival benefit beyond that in patients receiving only TKIs. A multivariate analysis indicated that TKI therapy (p < 0.001, hazard ratio = 0.218) was an independent predictor of favorable survival, whereas poor Eastern Cooperative Oncology Group performance status (p < 0.001, hazard ratio = 3.657) was a predictor of poor survival.

CONCLUSIONS

LM were much more frequent in patients with NSCLC harboring EGFR mutations. EGFR TKIs were the optimal treatment for LM, and active treatment with WBRT did not prolong OS for EGFR-mutated patients.

Accidental invisible intrathoracic disseminated pT4-M1a: a distinct lung cancer with favorable prognosis

OBJECTIVE

In the 7(th) edition of the TNM classification of malignant tumors, the prognosis for pT4-M1a stage IV lung cancer is better than for stage pIIIB. Subgroups of lung cancer patients who underwent incomplete resection (R1/R2) have a favorable prognosis. This study compares the prognosis between cases of invisible local residual disease and intrathoracic disseminated pT4-M1aIV.

METHODS

Patient characteristics and histological and molecular profiles were retrospectively collected for lung cancer patients who underwent resection intended to be curative but were accidentally incomplete. All patients were divided into either a local residual group or an intrathoracic disseminated pT4M1a group. Progression-free survival (PFS) and overall survival (OS) were evaluated by Kaplan-Meier and Cox regression models.

RESULTS

In total, 1,483 consecutive lung cancer patients receiving thoracotomies at Guangdong Lung Cancer Institute were retrospectively analyzed. Fifty-eight patients receiving incomplete resections (R1/R2) were enrolled, including 38 patients with local residual cancer (2.6% of all patients) and 20 patients with disseminated pM1a (1.3%). Patient characteristics, and histological and molecular profiles of the two groups were different. Compared to the local residual group, the disseminated pT4-M1a group contained more females (P=0.002), more patients younger than 60 years of age (P=0.028), more non-smokers (P=0.037), more adenocarcinomas (20/20 vs. 20/38, P<0.001), more adenocarcinomas with lepidic pattern (11/20 vs. 4/38, P<0.001), higher carcinoembryonic antigen (CEA) levels (P=0.06), higher epidermal growth factor receptor (EGFR) mutation rates (16/20 vs. 7/38, P<0.001), a higher R2/R1 resection ratio (P=0.013), a higher advanced stage IV/IIIB ratio (P<0.001), but fewer lymph node metastases (P=0.013). Median PFS for the local residual and disseminated pT4-M1a groups was 9.0 and 18.0 months, respectively [95% confidence interval (CI), 5.285-16.715; P =0.099]. Median OS was 15.0 and 45.0 months, respectively (95% CI, 18.972-39.028; P=0.001). Cox regression analysis revealed that group (local residual vs. disseminated pT4-M1a) was the only independent prognostic factor (P=0.044) for OS.

CONCLUSIONS

Accidental invisible intrathoracic disseminated pT4-M1a may be a distinct lung cancer subtype with a favorable prognosis. The prolonged PFS and OS might reflect the natural history of this distinct subtype, together with a favorable response to EGFR tyrosine kinase inhibitors (EGFR-TKI). For asymptomatic and slow-growing accidental pT4-M1a disease, the role of a wait-and-see strategy and the appropriate timing of systemic treatment require further investigation.

The BCL11A-XL expression predicts relapse in squamous cell carcinoma and large cell carcinoma

BACKGROUND

The B cell leukemia 11A (BCL11A) gene was identified as a proto-oncogene in hematopoietic cell malignancies and breast cancer. Alternative RNA splicing generates three main transcripts designated as Extra-long (XL; 5.9 kb/125 kD), Long (L; 3.8 kb/100 kD) and Short (S; 2.4 kb/35 kD). Our previous study results demonstrated that BCL11A expression levels were specifically upregulated in non-small cell lung cancer (NSCLC) tissues, especially in squamous cell carcinoma (SCC) and large cell carcinoma (LCC).

METHODS

In this study, we detected the BCL11A protein isoforms with immunohistochemistry (IHC) method in NSCLC with in a cohort (n=40) of BCL11A overexpression NSCLC patients. All 40 cases were BCL11A overexpression including 27 SCCs, 8 LCCs and 5 adenocarcinomas (ACs). Relationship between BCL11A isoforms and the clinicopathological parameters were also analyzed.

RESULTS

Compare to the BCL11A-L and S isoforms, the BCL11A-XL isoform was specifically expressed in SCC and LCC (P=0.006). There were 19 (19/40, 47.5%) cases positive for BCL11A-XL expression, SCC accounted for 63.2% (12/19) and LCC accounted for 36.8% (7/19). The survival analysis indicated that BCL11A-XL expression was an independent prognostic factor for disease-free survival (DFS) [hazards ratio (HR) 0.246; 95% confidence interval (CI), 0.065-0.939, P=0.040] but not for overall survival (OS) in patients with SCC and LCC.

CONCLUSIONS

Our results demonstrated that the BCL11A-XL isoform might be a potential prognostic biomarker of SCC and LCC.

Responses to crizotinib in a patient with c-ros oncogene 1, receptor tyrosine kinase-positive advanced lung adenocarcinoma: A case report

Rearrangements to the c-ros oncogene 1, receptor tyrosine kinase (ROS1) gene are reported in 1–2% of lung adenocarcinomas. These rearrangements are associated with a response to the small-molecule tyrosine kinase inhibitor crizotinib. ROS1 rearrangements can be detected using fluorescence in situ hybridization (FISH), which is considered the gold standard technique in detecting ROS1 rearrangements, and determining whether a patient would respond well to crizotinib treatment. However, FISH is an expensive and time-consuming assay, requiring specialized microscopy equipment and some level of technical expertise. The present report describes the case of a patient with advanced lung adenocarcinoma, who was identified to be negative for ROS-1 rearrangements by FISH, but positive by immunohistochemistry (IHC). The health of the patient improved following treatment with crizotinib. These results indicate that IHC assay could be an alternative option for the detection of ROS1 gene rearrangements.

Genistein-3'-sulfonic acid dihydrate

In the title compound [systematic name: 5-(5,7-dihydr­oxy-4-oxo-4H-chromen­yl)-2-hydroxy­benzene­sulfonic acid dihydrate], C₁₅H₁₀O₈S·2H₂O, the benzopyran­one ring is not coplanar with the phenyl ring, the dihedral angle between them being 41.35 (3)°. No H atom was placed on the sulphonic acid group because it was not possible to distinguish between the two S=O bonds and the S—O bond. In the crystal, the mol­ecules are linked by classical O—H⋯O and C—H⋯O intra- and inter­molecular hydrogen bonds and aromatic π–π stacking inter­actions [centroid–centroid distance of 3.4523 (14) Å between the 1, 4-pyran­one rings and the benzene rings, and 3.6337 (14) Å between the benzene rings] into a supra­molecular structure.

[Effect of trypsinogen 16 on phenotypic switch of airway fibroblasts into myofibroblasts]

OBJECTIVE

To investigate the relation between transdifferentiation of the airway myofibroblasts and the expression level of (trypsinogen16, TG16) in vitro and explore the mechanism of airway basement membrane thickening.

METHODS

The total lung proteins were extracted from normal and OVA-induced asthmatic mice and the protein expression profiles were analyzed with SDS-PAGE. The differentially expressed proteins were isolated for analysis with liquid chromatography-mass spectrometry. TG16 was cloned from mouse lung tissue and subcloned into the expression vector pcDNA3.0 to generate a pcDNA3-TG16 plasmid. The vectors were transfected into mouse embryonic fibroblast 3T3 cells and cultured in MEM in the presence of transforming growth factor-beta1 (TGF-beta1). The mRNA levels of alpha-actin and the housekeeping GAPDH gene were analyzed with RT-PCR. Using RNA interference, TG16 expression was suppressed and the resultant alpha-actin or GAPDH protein levels were analyzed using Western blotting.

RESULTS

In the total lung proteins from OVA-induced mice, a 25 000 Da protein was significantly enhanced in comparison with the protein profiles of normal mice. The protein band was identified to represent the protein of TG16. With TGF-beta1 stimulation, transfection with the plasmid pcDNA3-TG16 significantly suppressed the mRNA expression of alpha-actin (alpha-actin/GAPDH=1.78-/+0.50) in 3T3 cells as compared with the expression in cells transfected with pcDNA3.0 (3.20-/+1.36); transfection of the cells with TG16 stealth RNAi oligonucleotide to decrease TG16 mRNA level upregulated the protein level of alpha-actin (3.60-/+0.44) as compared with the alpha-actin protein level in 3T3 cells transfected with control oligonucleotide (2.78-/+0.50).

CONCLUSION

TG16 can inhibit the expression of alpha-actin in fibroblasts, which might be a protective mechanism in the progression of airway remodeling in asthma.

[Signal transduction in respiratory syncytial virus infection-induced thymic stromal lymphopoietin expression in human epithelial cells]

OBJECTIVE

To explore the mechanism of signal transduction in respiratory syncytial virus (RSV)-induced expression of thymic stromal lymphopoietin (TSLP) in bronchial epithelial cells.

METHODS

The eukaryotic expression vector of RSV F protein, pcDNA3-F, was constructed and transfected into in vitro cultured human bronchial epithelial cell line CRL-9483, which was also transfected with Smad7 expression vector pcDNA3/Smad7 or exposed to p38, ERK1/2, JNK, and JAK/STAT1 inhibitors. The mRNA levels of TSLP and the housekeeping GAPDH gene were analyzed 24 h later with semi-quantitative RT-PCR. In cells with downregulated TSLP mRNA expression due to the addition of the signal inhibitors, cytoplasm TSLP or GAPDH protein levels were further analyzed using Western blotting.

RESULTS

Virtually no TSLP mRNA expression was detected by RT-PCR in cultured CRL-9483 cells transfected with pcDNA3 exclusively (TSLP/GAPDH relative total gray scale of 0.10-/+0.03), while cell transfection with pcDNA3-F resulted in significantly increased TSLP mRNA level (0.42-/+0.20, P=0.024). In the presence of F protein expression, both p38 and JNK inhibitors could downregulate TSLP mRNA levels (0.14-/+0.04, P=0.036; 0.23-/+0.07, P=0.048, respectively), while TGF-beta-Smad inhibiting protein Smad7 (0.60-/+0.25), ERK 1/2 inhibitor (0.45-/+0.23), and JAK/STAT1inhibitor (0.44-/+0.25) failed to block TSLP expression (P>0.05). Western blotting showed that p38 inhibitor (TSLP/GAPDH relative total gray scale=3.67-/+1.18, P=0.018) and JNK inhibitor (1.48-/+0.77, P=0.004) also downregulated the protein levels of TSLP as compared with pcDNA3-F transfection group (8.13-/+2.20).

CONCLUSION

RSV F protein can stimulate TSLP expression in human bronchial epithelial cells mediated partially by p38 and JNK signal pathways.

Vertebral bone marrow perfusion evaluated with dynamic contrast-enhanced MR imaging: significance of aging and sex

PURPOSE

To investigate blood perfusion of nonfractured, normal-appearing vertebral bodies with regard to age and sex.

MATERIALS AND METHODS

Dynamic magnetic resonance imaging (160 images obtained in 80 seconds) was performed from T10 to L5 in 66 patients. Patients were assigned to three groups: group 1, those 50 years or younger without compression fracture; group 2, those older than 50 years without compression fracture; or group 3, those older than 50 years with compression fracture. Peak enhancement percentage and enhancement slope were determined from the time-intensity curve of normal (nonfractured) vertebral body. Comparisons were made between groups, and the effect of age and sex interaction was analyzed.

RESULTS

Higher peak enhancement percentage was demonstrated for group 1 compared with group 2 (58.21 +/- 44.65 [SD] vs 21.88 +/- 14.77, P <.005). Group 1 women revealed a higher enhancement percentage compared with group 1 men (87.17 +/- 54.13 vs 38.16 +/- 21.69, P <.05), which significantly decreased in those older than 50 years (from 87.17 +/- 54.13 to 17.98 +/- 13.80, P <.005). For men, this decrease in those older than 50 years was not as pronounced (from 38.16 +/- 21.69 to 25.38 +/- 15.43, P >.05). Presence of compression fracture at other levels of the spine (group 3) was not associated with a different enhancement percentage for normal vertebrae.

CONCLUSION

Rate of vertebral bone marrow perfusion revealed a significant decrease in subjects older than 50 years. Women demonstrated a higher marrow perfusion rate than men younger than 50 years and a more marked decrease than men older than 50 years.

Effect of theophylline on airway inflammation in asthma

AIM

To investigate whether low dose theophylline has an anti-inflammatory effect in asthma.

METHODS

Nineteen asthmatic subjects were given 200 mg sustained-release theophylline preparation twice daily for 4 weeks. The mean serum concentration of theophylline was 7.9 mg/L. The percentage of eosinophils, EG2+ eosinophils, and the level of eosinophil cationic protein (ECP) in sputum pre- and post-administration were detected by Wright's stain, immunocytochemistry, and immuno-CAP system, and the symptom scores and lung function were evaluated as well. The above indices for 10 healthy subjects were regarded as control.

RESULTS

Before using theophylline, sputum eosinophils, EG2+ eosinophils, and ECP in asthmatic group were much higher than those of healthy group. After four weeks administration, there were great decreases in percentage of total eosinophils (40 % +/- 17 % vs 29 % +/- 11 %, P < 0.01), activated (EG2+) eosinophils (28 % +/- 9 % vs 10 % +/- 8 %, P < 0.01) and in the concentration of sputum ECP [(373 +/- 206) vs (220 +/- 132) microg/L, P < 0.01]. The symptom scores decreased greatly (7.1 +/- 1.2 vs 5.4 +/- 1.6, P < 0.01). There was a marked increased in forced expiratory volume one second (FEV(1.0)) after administration (2.2 +/- 0.6 vs 2.4 +/- 0.5, P < 0.01). The FEV(1.0) % of asthmatic subjects after administration increased (60 % +/- 13 % vs 65 % +/- 13 %, P < 0.01), too.

CONCLUSION

These results indicated that low dose theophylline had inhibitory action on airway inflammation in asthma with noticeable improvement of the patients' symptoms and lung function.

Paget's disease of the bone: a case report

Paget's disease of bone is rare in Asia. We report a case of Paget's disease in a 58-year-old Taiwanese man who was admitted with a 3-month history of bilateral numbness in the buttock region. Laboratory data disclosed an elevated serum alkaline phosphatase level (510 U/L). Plain radiographs of the lumbar spine showed generalized increased density at the third lumbar vertebra, associated with cortical thickening, loss of cortico-cancellous definition, and increased anteroposterior diameter. The T1-weighted magnetic resonance image of the lumbar spine showed diffuse, heterogeneous low signal intensity at the third lumbar vertebral body, pedicle, laminae, and spinal process; these areas showed mixed high and low signal intensity on the T2-weighted image. Technetium-99m bone scan revealed abnormal uptake in the involved vertebra. Histologic examination of the third lumbar spinal process confirmed the diagnosis of Paget's disease of bone. The patient remained well during a follow-up period of 6 months.

Carbon dioxide enhanced ultrasonography of hepatic haemangiomas

The purpose of this study was to characterize the imaging manifestations of carbon dioxide enhanced ultrasonography (CO2US) in hepatic haemangiomas. CO2US was performed for 52 haemangiomas in 25 patients and for 352 various hepatic nodules in 192 patients. Characteristic enhancement patterns for hepatic haemangiomas were noted. All 39 large haemangiomas (> 1 cm) demonstrated peripheral nodular enhancement in the early and parenchymal phases associated with delayed washout character (> 30 min). Centripetal fill-in of CO2 was noted in 82.1% of large haemangiomas. Two enhancing patterns were noted in 13 small haemangiomas (< 1 cm): peripheral nodular (69.2%) and homogeneous (30.8%). Delayed washout was also noted in all small haemangiomas. Centripetal fill-in of CO2 was hard to define in small haemangiomas. None of the other 352 hepatic nodules had the same imaging features. In conclusion we found that CO2US is valuable in differentiating hepatic haemangiomas from other liver tumours in clinically doubtful cases.

Intra-arterial carbon dioxide-enhanced ultrasonogram of hepatocellular carcinoma treated by transcatheter arterial embolization and percutaneous ethanol injection therapy

The purpose of this study was to investigate the value of carbon dioxide-enhanced ultrasonography (CO2-US) in the evaluation of viable hepatocellular carcinomas (HCC) which were treated by transcatheter arterial embolization (TAE), percutaneous ethanol injection (PEI), or a combination treatment (TAE and PEI). Forty-one patients with 66 HCC were included in the study. They underwent CO2-US and angiography were performed in all tumours after they were treated by TAE, PEI or a combination treatment. Forty-six tumours were positively enhanced by CO2-US and 40 of them were positive by angiography. These 46 tumours were proved to be viable tumours either by biopsy or by follow-up studies. The positive predictive value was 100% for CO2-US and 87.8% in angiography. Twenty tumours were negative by CO2-US and these were also negative by angiography. Carbon dioxide-enhanced ultrasonography is a more reliable method for detecting the viable portion of the treated HCC compared with conventional angiography.

Laryngeal tuberculosis: a series of 46 patients

BACKGROUND

The incidence of laryngeal tuberculosis is declining after the advent of anti-tuberculous drugs. The disease itself is changing according to our experience, too. The changing pattern is our interest.

METHODS

A series of 46 cases of laryngeal tuberculosis seen in our institution between 1980 and 1995 were reviewed retrospectively to assess the various features of the disease.

RESULTS

The results showed a mean age of 48 years and a sex ratio of 2:1. Hoarseness is the most frequent presenting symptom (80%), and sore throat (52%) is another important symptom. The frequent locations of lesions are the true cords (57%), epiglottis (39%), false cords (35%), arytenoids (24%) and posterior commissure (7%). Laryngeal tuberculosis was the most common initial working diagnosis before a definite pathological report was completed. In 85% of the patients the disease was transmitted by bronchogenic route, and in the others it was primary laryngeal tuberculosis. Laryngeal tuberculosis responds well to early treatment with anti-tuberculous chemotherapy.

CONCLUSION

The clinical presentation of laryngeal tuberculosis is changing. It is necessary to detect the disease early to prevent the development of severe sequalae or mortality.

The value of ultrasound measurement of gallbladder wall thickness in predicting laparoscopic operability prior to cholecystectomy

We prospectively analysed 51 consecutive cases who underwent laparoscopic cholecystectomy from June 1992 to February 1993. There were 35 cases of chronic cholecystitis and 16 cases of acute cholecystitis. All underwent pre-operative ultrasonography, complete blood cell count, liver function test and endoscopic retrograde cholangiopancreatography. Of those 44 had post-operative ultrasound within the first 2 d and again on the seventh day. In 35 cases of chronic cholecystitis, 31 of 32 cases with a pre-operative gallbladder (GB) wall thickness of less than 6 mm were successfully resected laparoscopically. All three cases with a GB wall thicker than 6 mm were converted to open cholecystectomy. In acute cholecystitis, the wall thickness of the laparoscopic cholecystectomy group ranged from 2 to 9 mm (average 4 mm) and the wall thickness of the conversion group was 4-7 mm (average 6 mm). Post-operative fluid accumulation was noted in 28 (63.6%) cases. There was no correlation between post-operative pyrexia, duration of post-operative pain, clinical complications and the presence of fluid accumulation in the GB fossa. However, of four cases with increasing fluid on the seventh day, three developed complications. We conclude that ultrasonography is valuable in chronic cholecystitis for selecting cases for laparoscopic cholecystectomy.

Carbon dioxide-enhanced ultrasonography of liver tumors

CO2 gas-enhanced ultrasonography was performed in 37 patients (47 studies) for the purpose of detecting small tumors and evaluating differential diagnosis. With conventional ultrasonography, 62 lesions were identified in 25 patients with HCC, 13 tumors were identified in eight patients with hemangioma, and multiple tumors were found in four patients with metastatic adenocarcinoma. CO2-enhanced ultrasonography detected five additional hemangiomas, 12 additional nodules in HCC, and the same number of metastatic nodules. The patterns of CO2 enhancement were characterized as homogeneous, heterogeneous, rim, internal spotted, negative, and mixed (more than one pattern in one lesion). The rim enhancement pattern was found to be specific for hemangioma. The internal spotted enhancement pattern was found exclusively in HCC. All the lesions that demonstrated negative enhancement were treated HCC. All the metastatic tumors demonstrated the mixed rim and internal spotted enhancement pattern. We suggest that CO2-enhanced ultrasonography is a useful tool in detecting small liver tumors. It can also help in the differentiation among various hepatic tumors.

Intravenous double-dose contrast computed tomography in the diagnosis of spinal arteriovenous malformations: report of four cases

Spinal IV double-dose computed tomography (DCT) followed by reformation imagings was performed on 4 patients. Three cases received double-dose contrast injections, one case received a conventional single dose contrast material. 'Dots' enhancement on axial CT scanning and 'vasculature-like' hyperdense enhancement on sagittal and coronal reformation imagings were found in four cases of spinal arteriovenous malformation (AVM). Two were at the cervical region and two at the thoracic level. Typical serpentine filling defects were noted in the myelogram of three cases of spinal AVM. One patient suffered from acute onset of paraplegia (case 2), requiring that she received immediate surgical intervention after DCT scanning without myelography. Time for the whole procedure lasted approximately 20 minutes. In addition DCT followed by reformation imaging may be used as a noninvasive preliminary screening procedure for spinal AVMs.