Multimodality therapy for Pancoast tumor

Hairpin Oligonucleotide Can Functionalize Gold Nanorods for in Vivo Application Delivering Cytotoxic Nucleotides and Curcumin: A Comprehensive Study in Combination with Near-Infrared Laser

We prepared a multimodality nanocomplex by functionalizing gold nanorods (GNRs) with a cytotoxic nucleoside, 5-fluoro-2'-deoxyuridine (FdU) containing a DNA hairpin, along with complexation of pleiotropic molecule curcumin. Conjugates were investigated for anti-tumor activity using an Ehrlich carcinoma model in combination with 808 nm laser irradiation. We demonstrated that hairpin-functionalized GNRs are suitable for intravenous administration, including delivery of cytotoxic nucleotides and curcumin. Curcumin binding with FdU-hairpin-functionalized GNRs displayed improved anti-tumor activity in part by inducing a lymphocyte-mediated immune response. The complex showed notable photothermal activity in vitro; however, 808 nm laser irradiation of the tumor following treatment with the complex did not increase the anti-tumor effect significantly. Biodistribution studies depicted that the nanoconjugates localized primarily in the sinusoidal structures of the liver and spleen with minimal tumor accumulation. Curcumin complexation alleviated the reduction in the RBC count that was observed for the conjugate without curcumin, especially in combination with laser irradiation. Localization of FdU-hairpin-GNR conjugates in the liver and spleen evoked an inflammatory response, which was mitigated by curcumin complexation. However, no functional abnormality was found in the liver in any case. Curcumin binding also notably decreased nanoconjugate accumulation in lungs and significantly reduced inflammation. Biodistribution studies were consistent with previous reports, suggesting that optimization of the GNR size and surface coating is required for more efficient tumor localization via the enhanced permeability and retention (EPR) effect. Our studies demonstrate that DNA/RNA hairpins are suitable for GNR surface functionalization and enable delivery of cytotoxic nucleotides as well as curcumin in vivo with potential for synergistic anti-cancer therapy.

Trimodality therapy for superior sulcus non-small cell lung cancer: Southwest Oncology Group-Intergroup Trial S0220

BACKGROUND

Although preoperative chemotherapy (cisplatin-etoposide) and radiotherapy, followed by surgical resection, is considered a standard of care for superior sulcus cancers, treatment is rigorous and relapse limits long-term survival. The Southwest Oncology Group-Intergroup Trial S0220 was designed to incorporate an active systemic agent, docetaxel, as consolidation therapy.

METHODS

Patients with histologically proven and radiologically defined T3 to 4, N0 to 1, M0 superior sulcus non-small cell lung cancer underwent induction therapy with cisplatin-etoposide, concurrently with thoracic radiotherapy at 45 Gy. Nonprogressing patients underwent surgical resection within 7 weeks. Consolidation consisted of docetaxel every 3 weeks for 3 doses. The accrual goal was 45 eligible patients. The primary objective was feasibility.

RESULTS

Of 46 patients registered, 44 were eligible and assessable; 38 (86%) completed induction, 29 (66%) underwent surgical resection, and 20 (45% of eligible, 69% surgical, and 91% of those initiating consolidation therapy) completed consolidation docetaxel; 28 of 29 (97%) underwent a complete (R0) resection; 2 (7%) died of adult respiratory distress syndrome. In resected patients, 21 of 29 (72%) had a pathologic complete or nearly complete response. The known site of first recurrence was local in 2, local-systemic in 1, and systemic in 10, with 7 in the brain only. The 3-year progression-free survival was 56%, and 3-year overall survival was 61%.

CONCLUSIONS

Although trimodality therapy provides excellent R0 and local control, only 66% of patients underwent surgical resection and only 45% completed the treatment regimen. Even in this subset, distant recurrence continues to be a major problem, particularly brain-only relapse. Future strategies to improve treatment outcomes in this patient population must increase the effectiveness of systemic therapy and reduce the incidence of brain-only metastases.

Pancoast tumors: characteristics and preoperative assessment

Superior sulcus tumors (SSTs), or as otherwise known Pancoast tumors, make up a clinically unique and challenging subset of non-small cell carcinoma of the lung (NSCLC). Although the outcome of patients with this disease has traditionally been poor, recent developments have contributed to a significant improvement in prognosis of SST patients. The combination of severe and unrelenting shoulder and arm pain along the distribution of the eighth cervical and first and second thoracic nerve trunks, Horner's syndrome (ptosis, miosis, and anhidrosis) and atrophy of the intrinsic hand muscles comprises a clinical entity named as "Pancoast-Tobias syndrome". Apart NSCLC, other lesions may, although less frequently, result in Pancoast syndrome. In the current review we will present the main characteristics of the disease and focus on the preoperative assessment.

Postoperative radiotherapy for incompletely resected non-small cell lung cancer: clinical outcomes and prognostic value of the histological subtype

The purpose of this study was to evaluate the efficacy and toxicity of the postoperative radiotherapy in patients with incompletely resected NSCLC, and to investigate whether the histological subtype is a prognostic factor. Forty-one incompletely resected NSCLC patients who underwent postoperative radiotherapy were retrospectively analyzed. The microscopic residual tumor (R1 group) was recognized in 23 patients, and the macroscopic residual tumor (R2 group) in 18. The postoperative pathological stages were I (n = 3), II (n = 8), IIIA (n = 17), and IIIB (n = 13). The histology included squamous cell carcinoma (n = 23), adenocarcinoma (n = 14) or other types (n = 4). The first site of disease progression was distant metastases alone for 3 (13%) of 23 with squamous cell carcinoma, and for 9 (64%) of 14 with adenocarcinoma (p < 0.01). The 5-year overall, local control, disease-free, and distant metastasis-free survival rates were 56%, 63%, 37% and 49%. Univariate analyses showed that squamous cell carcinoma histology, N0-1 stage and the R1 group were significant predictors for better disease-free and distant metastasis-free survival. Multivariate showed that squamous cell carcinoma and N0-1 stage were significant predictors for better distant metastasis-free survival. Toxicity was generally mild; Grade 3 toxicities occurred in 3 patients (neutropenia, radiation pneumonia and esophageal stenosis), and no acute and late toxicities of Grade 4 to 5 were observed. In conclusion, postoperative radiotherapy for incompletely resected NSCLC could achieve a relatively high local control rate without severe toxicity. However, different treatment strategies for non-squamous cell carcinoma should be considered, because of the higher risk for the distant metastases.

Bone single photon emission computed tomography (SPECT) in a patient with Pancoast tumor: a case report

CONTEXT

Non-small cell lung carcinomas (NSCLCs) of the superior sulcus are considered to be the most challenging type of malignant thoracic disease. In this disease, neoplasms originating mostly from the extreme apex of the lung expand to the chest wall and thoracic inlet structures. Multiple imaging procedures have been applied to identify tumors and to stage and predict tumor resectability in surgical operations. Clinical examinations to localize pain complaints in shoulders and down the arms, and to screen for Horner's syndrome and abnormalities seen in paraclinical assessments, have been applied extensively for differential diagnosis of superior sulcus tumors. Although several types of imaging have been utilized for diagnosing and staging Pancoast tumors, there have been almost no reports on the efficiency of whole-body bone scans (WBBS) for detecting the level of abnormality in cases of superior sulcus tumors.

CASE REPORT

We describe a case of Pancoast tumor in which technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs. In describing this case, we stress the clinical and diagnostic points, in the hope of stimulating a higher degree of suspicion and thereby facilitating appropriate diagnosis and treatment. From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended.

[A 67-year old man with right arm paresthesias]

A 63-year-old man was admitted to the emergency room with chest pain. He had experienced a painful, tingling sensation in the right arm for the last three months, as well as pain in the right scapula. ECG and standard blood samples were normal. An X-ray of the thorax showed a mass in the superior sulcus on the right side. Further investigation with CT and MRI identified a large tumour, about 6 cm in size, with infiltrative growth involving the upper costae. Biopsy revealed a non-small cell carcinoma of the lung. The patient underwent a tri-modal treatment regimen with induction chemotherapy (two courses of cisplatin and etopside) and concomitant radiotherapy (50 Gy in 2 Gy fractions) before a right upper lobectomy was performed. 1 year after surgery the patient is alive, with no signs of recurrent or metastatic disease. Pancoast tumours are an infrequent subtype of lung cancers. Diagnostic delay is not uncommon. The peripheral location of the tumour generates symptoms that may easily be attributed to other causes, such as those of a musculoskeletal origin. Pre-operative chemo-radiotherapy has showed improved survival outcomes compared to pre-operative radiotherapy alone.