Frequency and spatial distribution of cartilage thickness change in knee osteoarthritis and its relation to clinical and radiographic covariates - data from the osteoarthritis initiative

OBJECTIVE

Estimate the frequency and spatial location of rapid femorotibial cartilage thinning or thickening in knees with, or at risk of, osteoarthritis (OA) and examine their association with clinical and radiographic covariates.

DESIGN

Knee cartilage thickness change over 12 months was measured using magnetic resonance imaging in the right knee of 757 Osteoarthritis Initiative (OAI) participants that had radiographic findings of osteophytes or joint space narrowing (JSN). Thickness changes in individual knees were classified as having rapid thinning or thickening or no detectable OA-related change when compared to asymptomatic OAI Control cohort knees.

RESULTS

Cartilage thinning, found in 18.5% of subjects, was more frequent in knees with OAI calculated Kellgren-Lawrence grade (cKLG) > 2 (P < 0.001) and with frequent pain (P = 0.047). No link was found between body mass index, sex, and age and cartilage thinning (P > 0.15). The percent of knees with thickening was small (4.4%), but greater in knees with frequent pain (P = 0.02). Rapid thinning was most common in the central (36.4%) and external (32.1%) subregions of the medial weight-bearing femur. Mean cartilage loss in rapidly thinning subregions ranged from 11.2%/y to 24.6%/y. Knees with cKLG > 2, but classified as having no detectable OA-related change had mean cartilage loss rates significantly >0 (0.4%/y-1.3%/y) in 10 subregions.

CONCLUSION

Most observed subregional changes in OA knees were indistinguishable from changes found in an asymptomatic cohort, but a fraction of subregions showed rapid progression. The relative frequency of rapid thinning increases when cKLG > 2, a classification closely associated with JSN and/or frequent knee pain are present.

MRI-based extended ordered values more efficiently differentiate cartilage loss in knees with and without joint space narrowing than region-specific approaches using MRI or radiography--data from the OA initiative

OBJECTIVE

The sensitivity to change of quantitative analysis of cartilage in knee osteoarthritis using magnetic resonance imaging (MRI) is compromised by the spatial heterogeneity of cartilage loss. We explore whether extended (medial-lateral) "ordered values" (OVs) are superior to conventional approaches of analyzing subregional cartilage thickness loss and to radiography, in differentiating rates of progression in knees with and without joint space narrowing (JSN).

METHODS

607 Osteoarthritis Initiative (OAI) participants (308 without and 299 with baseline JSN at baseline) were studied over 12 months. Subregional femorotibial cartilage loss was determined in all knees, and changes in minimum joint space width (mJSW) in a subset of 290 knees. Subregional thickness changes in medial and lateral tibial and femoral cartilages were sorted in ascending order (OV1-16). A Wilcoxon rank-sum test was used to compare rates of change in knees with and without JSN.

RESULTS

JSN-knees displayed greater cartilage loss than those without JSN, with minimal P-values of 0.008 for femorotibial subregions, 3.3×10(-4) for medial OV1, and 5.4×10(-7) for extended (medial and lateral) OV1. mJSW measurements (n=290) did not discriminate between longitudinal rates of change in JSN vs no-JSN knees (P=0.386), whereas medial OV1 (P=5.1×10(-4)) and extended OV1 did (P=2.1×10(-5)).

CONCLUSION

Extended OVs showed higher sensitivity to detecting differences in longitudinal rates of cartilage loss in knees with and without baseline JSN than anatomical (sub)regions and radiography. The OV technique also circumvents challenges of selecting particular regions "a priori" in clinical trials and may thus provide a powerful tool in studying risk factors or treatment efficacy in osteoarthritis.

Cytokeratin profiles of male breast cancers

AIMS

The prognostic factors and expression of molecular markers in male breast carcinomas are similar to those in female breast cancers. The identification of distinct cytokeratin (CK) profiles (basal as opposed to luminal cells) helps to identify subsets of tumours with different clinical behaviour. The aim of this study was to investigate CK expression in male breast cancer.

METHODS AND RESULTS

Thirty-two cases of male breast cancer were studied. The panel of CKs studied by immunohistochemistry included: 5/6, 14, 17, 18 and 19. Pathological findings and CK expression were analysed in all cases. Histological patterns included ductal carcinoma in situ, invasive ductal carcinoma and mixed patterns. Four cases were positive for CK5/6 and CK14, identifying a basal-like phenotype. CK17 was negative in all but two cases. All cases expressing either CK5/6 or CK14 were invasive carcinomas of high nuclear and histological grade and were also larger compared with the tumours not expressing CK5/6 and CK14. All tumours except three (also negative for CK5/6) expressed CK18 and CK19. The four basal-like tumours were negative for Her-2 expression.

CONCLUSIONS

Male breast carcinomas have a basal-like phenotype that is similar in frequency to that of female breast carcinomas. The expression of CK5/6 and CK14 identifies a subset of pathologically aggressive male breast cancers.

Hydrophilic poly(DL-lactide-co-glycolide) microspheres for the delivery of DNA to human-derived macrophages and dendritic cells

Biodegradable poly(lactide-co-glycolide) (PLGA) microspheres have a proven track record for drug delivery and are suggested to be ideal carrier systems to target therapeutics into phagocytic cells such as macrophages (MPhis) and dendritic cells (DCs). Microspheres prepared by spray-drying from different PLGA-type polymers were evaluated regarding their effect on phagocytosis, intracellular degradation and viability of human-derived macrophages MPhis and DCs. Even the microspheres prepared from the most hydrophilic polymer RG502H, were efficiently phagocytosed by primary human MPhis and DCs. Interestingly, uptake of PLGA microspheres by DCs as potent immune modulator cells was almost as efficient as uptake by the highly phagocytic MPhis. Phagocytosed microspheres remained inside the cells until decay with none of the microsphere preparations induced significant apoptosis or necrotic cell death. Acidic pH and the phagosomal environment inside the cells enhanced microsphere decay and release of encapsulated material. Degradation of microspheres consisting of the most hydrophilic PLGA polymer RG502H occurred in a reasonable time frame of less than 2 weeks ensuring the release of encapsulated drug during the life span of the cells. To explore important technical and biological aspects of DNA microencapsulation, we have studied DNA loading and in vitro DNA release of microspheres from different PLGA type polymers. Hydrophobicity and molecular weight of the PLGA polymers had profound influence on both the encapsulation efficiency of DNA and its release kinetics in vitro: the hydrophilic polymers showed higher encapsulation efficiency and faster release of intact DNA compared to the hydrophobic ones. These results suggest that microspheres from the PLGA polymer RG502H have improved characteristics for DNA delivery to human MPhis and DCs.

Genetic background of attenuated Salmonella typhimurium has profound influence on infection and cytokine patterns in human dendritic cells

Salmonella typhimurium (ST) can cause infection in man, and attenuated strains are under consideration as live vaccine vectors. However, little is known about the interaction of ST with human dendritic cells (DC). Here, we compared the consequences of exposure of human, monocyte-derived DC with different attenuated strains of ST. Infection was observed with all four strains tested (wild type, PhoP-, PhoPc, and AroA), but the PhoPc strain was by far the most efficient. Intracellular persistence of wild type and PhoP- was longer than that of PhoPc and AroA, both of which were largely eliminated within 24 h. Most DC survived infection by the attenuated strains, although apoptosis was observed in a fraction of the exposed cells. All strains induced DC maturation, independent from the extent of infection. Although all strains stimulated secretion of TNF-alpha and IL-12 strongly, PhoPc induced significantly less IL-10 than the other three strains and as much as 10 times less IL-10 than heat-killed PhoPc, suggesting that this mutant suppressed the secretion of IL-10 by the DC. These data indicate that infectivity, bacterial elimination, and cytokine secretion in human DC are controlled by the genetic background of ST.

New strategies against an old plague: genetically engineered tuberculosis vaccines

The failure of BCG vaccination to control the global tuberculosis epidemic and the spread of multidrug resistance underline the need for a better vaccine. Recent advances in molecular microbiology, gene therapy, and, last but not least, immunobiology, provide a rational basis for the development of more efficient vaccines against tuberculosis. The complete sequencing of the M. tuberculosis genome marked a turning point in tuberculosis vaccine research. The advent of genetic vaccination with either naked DNA, live recombinant, or artificial vaccine vectors holds out great promise of more efficient immunisation, in particular against intracellular pathogens such as M. tuberculosis. Our new understanding of how the immune response is orchestrated by dendritic cells makes it possible to design vaccines which specifically exploit the functions of these antigen presenting cells. Yet M. tuberculosis has kept many of its secrets, and although functional genomics, molecular medicine and immunotherapy are evolving rapidly, much empiric search and discovery are needed until the "captain of all these men of death" gives up his ghost to biotechnology.

Antigen presentation in the lung: dendritic cells and macrophages

Antigen presentation is a required prime event before T-cell activation can occur. Cells which constitutively express major histocompatibility antigen class I or II are responsible for presenting antigens. These are essentially alveolar macrophages (AM) residing mostly in the air spaces, and dendritic cells (DC), which create a tight surveillance network just below the epithelial cells of the airways and in the loose connective tissue around the vessels or in the pleura. AM are poor antigen presenting cells compared to DC. AM when encountering foreign particles or organisms may, however, influence the degree of activity or maturation of neighbouring DC, by releasing cytokines. Thus, we will describe how the innate immune processes may influence specific immunity and perhaps Th1 and Th2 differentiation. Following the description of the differences in phenotype and functions of AM and DC, we will provide data showing that in some pathological conditions, such as sarcoidosis, AM can acquire some specificities of DC.

Selective induction of the glucose-regulated protein grp78 in human monocytes by bacterial extracts (OM-85): a role for calcium as second messenger

Heat shock/stress proteins (HSP) act as molecular chaperones, protect cells from injury, and are involved in the immune response. We investigated the effects of the immunomodulating bacterial extracts OM-85 on the stress response in normal human peripheral blood monocytes. While OM-85 did not induce the classical HSP, we show here, using 2D gel electrophoresis combined with immunoblotting, the induction of the glucose regulated protein grp78 (the immunoglobulin heavy chain binding protein BiP) along with the described accumulation of pro-interleukin-1 beta. The increased Ca2+ mobilization observed with OM-85 is the likely second messenger for grp78 induction. Recent studies are in favor of a protective role of grp78 against cytokine-mediated cytotoxicity and apoptosis. We suggest that grp78 induction following exposure to OM-85 explains, at least in part, the immunodulatory and protective effects of the bacterial extracts.

Role of oxygen free radicals in cancer development

In aerobic life, oxidative stress arises from both endogenous and exogenous sources. Despite antioxidant defence mechanisms, cell damage from oxygen free radicals (OFR) is ubiquitous. OFR-related lesions that do not cause cell death can stimulate the development of cancer. This review discusses the effects of oxidative stress at the different stages of carcinogenesis. Mutagenesis through oxidative DNA damage is widely hypothesised to be a frequent event in the normal human cell. A large body of evidence suggests important roles of OFR in the expansion of tumour clones and the acquisition of malignant properties. In view of these facts, OFR may be considered as an important class of carcinogens. Therefore, the ineffectiveness of preventive antioxidant treatments, as documented in several recent clinical trials, is surprising. However, the difficulties of antioxidant intervention are explained by the complexity of both free radical chemistry and cancer development. Thus, reducing the avoidable endogenous and exogenous causes of oxidative stress is, for the present, the safest option. In the near future, new insights in the action of tumour suppressor genes and the DNA repair mechanisms may lead the way to additional tools against carcinogenesis from OFR.

Effects of oxidative stress and Ca2+ agonists on molecular chaperones in human umbilical vein endothelial cells

Endothelial cell dysfunction is a key factor in oxidative stress-related pathology. Disruption of Ca2+ homeostasis is thought to be responsible for much of the endothelial cell dysfunction in oxidative stress. The expression of molecular chaperones (MC), which stabilize protein structures in normal and in stress conditions, reflects the Ca(2+)-dependent and -independent stress effects in the different cell compartments. By two-dimensional (2-D) gel electrophoresis combined with immunoblotting or microsequencing, we have identified 12 major MC in human umbilical vein endothelial cells (HUVEC): (i) the endoplasmic reticulum-located MC GRP78, GRP94, protein disulfide isomerase, and calreticulin; (ii) the mitochondrial MC HSP65 and GRP75; and (iii) the cytosolic/nuclear MC HSP27, HSC70, HSP70, HSP90, cyclophilin, and ubiquitin. To differentiate oxidative stress- and Ca(2+)-mediated effects, HUVEC were exposed to 1) xanthine oxidase plus hypoxanthine to generate oxidative stress, 2) ionomycin plus ethylene glycol-bis(beta-aminoethylether)-N,N,N', N'-tetraacetic acid (EGTA) to deplete intracellular Ca2+ stores, or 3) thrombin to increase cytosolic Ca2+. De novo protein synthesis after exposure was quantified by the incorporation of [35S]methionine. Image processing with the MELANIE system was used to create and compare the 2-D maps of [35S]methionine-labeled proteins under conditions 1)-3) with those of the controls. In a total of 24 2-D gels, 9 different MC were detected in at least 5 out 6 experimental replicates and were subjected to numeric analysis. The statistics showed a > 10% increase in GRP78 (p < 0.05), HSP27, cyclophilin, and ubiquitin after oxidative stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Presence of two isoforms of Na, K-ATPase with different pharmacological and immunological properties in the rat kidney

Previous studies have demonstrated the presence of two populations of Na,K-ATPase with distinct kinetic, pharmacological and immunological characteristics along the rabbit nephron, indicating that the proximal segments of the nephron express exclusively the alpha 1 isoform of the catalytic subunit, whereas the collecting duct expresses an alpha 3-like isoform. Because pharmacological studies have shown the existence of two populations of Na,K-ATPase with different sensitivities to ouabain in the rat cortical collecting duct, which may result from the presence in the same nephron segment of the two isoforms demonstrated in the different segments of the rabbit nephron, the present study was undertaken to characterize the properties of Na,K-ATPase along the rat nephron. Results indicate that each segment of the rat nephron contains two subpopulations of Na,K-ATPase: a component highly sensitive to ouabain (IC50 approximately 5.10(-6) M) which is recognized by an anti-alpha 3 antibody and another moiety of lower affinity for ouabain (IC50 approximately 5.10(-4) M) which is recognized by an anti-alpha 1 antibody. Whether these two subpopulations correspond to different isoforms of the alpha subunit of Na,K-ATPase (alpha 1 and alpha 3-like) remains to be determined.

Effects of hypoxanthine-xanthine oxidase on Ca2+ stores and protein synthesis in human endothelial cells

We have investigated the effects of reactive O2 metabolites generated by the hypoxanthine-xanthine oxidase (HX-XO) system on intracellular Ca2+ and its relation with protein synthesis in human umbilical vein endothelial cells (HUVECs). Spectrofluorometry with fura 2 showed that the oxidative stress induced a rapid transient rise in cytosolic [Ca2+], followed by a sustained elevation above the baseline value. In the presence of La3+, which blocks Ca2+ influx from the extracellular medium, a transient [Ca2+] increase was still observed, but the sustained rise was suppressed. The HX-XO-related [Ca2+] changes were completely prevented by pretreatment with thapsigargin, which depletes intracellular Ca2+ stores. Hence, the effects of HX-XO on Ca2+ homeostasis were due to mobilization of Ca2+ from the intracellular stores with subsequent influx of extracellular Ca2+. HX-XO mobilized more of sequestered Ca2+ than did thrombin, a receptor agonist that depletes only a part of the intracellular Ca2+ stores (the hormone-sensitive stores). To determine the relevance of the HX-XO-related depletion of Ca2+ stores for cell function, we investigated the role of Ca2+ mobilization in the regulation of protein synthesis. Overall protein synthesis in HUVECs was markedly reduced by thapsigargin, which depletes both hormone-sensitive and -insensitive stores, but was not substantially affected by thrombin. Manipulation of the refilling of the Ca2+ stores via the availability of extracellular Ca2+ significantly influenced the thapsigargin-related and the HX-XO-related inhibition of overall protein synthesis. A corresponding effect of extracellular [Ca2+] was seen in polyribosome distribution profiles, which reflected an inhibition of translation initiation in both treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential effects of superoxide, hydrogen peroxide, and hydroxyl radical on intracellular calcium in human endothelial cells

Changes in intracellular Ca2+ homeostasis are thought to contribute to cell dysfunction in oxidative stress. The hypoxanthine-xanthine oxidase system (X-XO) mobilizes Ca2+ from intracellular stores and induces a marked rise in cytosolic calcium in different cell types. To identify the reactive O2 species involved in the disruption of calcium homeostasis by X-XO, we studied the effect of X-XO on [Ca2+]i by spectrofluorimetry with fura-2 in human umbilical vein endothelial cells (HUVEC). The [Ca2+]i response to X-XO was essentially diminished by superoxide dismutase (SOD) (200 U/ml) and catalase (CAT) (200 U/ml), which scavenge the superoxide anion, O2-, or H2O2, respectively. The [Ca2+]i increase stimulated by 10 nmol H2O2/ml/min, generated from the glucose-glucose oxidase system, or 10 microM H2O2, given as bolus, was about a third of that induced by X-XO (10 nmol O2-/ml/min) but was comparable to that induced by X-XO in the presence of SOD. The X-XO-stimulated [Ca2+]i increase was significantly reduced by 100 microM o-phenanthroline, which inhibits the iron-catalysed formation of the hydroxyl radical. On the other hand, the [Ca2+]i response to low dose X-XO (1 nmol O2-/ml/min) was markedly enhanced in the presence of 1 microM H2O2, which itself had no effect on [Ca2+]i. More than 50% of this synergistic effect was prevented by o-phenanthroline. These results indicate that the effect of X-XO on calcium homeostasis appears to result from an interaction of O2- and H2O2, which could be explained by the formation of the hydroxyl radical.

[Results of short-term tuberculosis therapy with isoniazid, rifampicin and pyrazinamide]

Short-course chemotherapy of six-month duration with an initial combination of three drugs (isoniazid [H], rifampin [R] and pyrazinamide [Z]) is recommended as the treatment of choice in tuberculosis today. Use of fixed-combination tablet (Rifater) prevents prescription errors by physicians and selective intake by noncompliant patients. It should therefore assist in the prevention of emergence of drug resistance. In a controlled study at a chest hospital in Switzerland involving 261 patients with culture proven tuberculosis, the following two regimens were compared: 1) Six-month therapy (n = 128) with daily Rifater for two months, followed by H and R for four months. 2) Nine-month therapy (n = 133) with H and R daily for nine months, supplemented by ethambutol for the first two months. The two patient groups were comparable except for initial drug resistance (16% vs 8%, p < 0.05). Overall resistance to H was 10%. Five patients had initial resistance to two or more drugs. 227 patients were re-examined 1-8, and on average 4 years after therapy: four patients relapsed after 12, 20, 36 and 90 months. Two patients with initial drug resistance to H later developed resistance to R; both of these, as well as a third relapse patient, were cured with subsequent multi-drug therapy. Despite two and a half years of chemotherapy and repeated surgery, the fourth patient with initial resistance to H and R could not be cured. All relapse patients with initial drug resistance were randomized into the six-month therapy group.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperoxia induces alkalinization and dome formation in MDCK epithelial cells

We observed that confluent Madin-Darby canine kidney (MDCK) epithelial cells exposed to 95% O2 showed intensive dome formation, a manifestation of cell differentiation and transepithelial fluid transport, whereas cells exposed to 40% O2 or to normoxia did not. Hyperoxia-induced dome formation (HIDF) was preceded and accompanied by a significant rise in intracellular pH (pHi) on days 2 (7.53 vs. 7.42) and 3 (7.62 vs. 7.45), as compared with controls. Inhibition of the Na(+)-H+ exchanger by 0.1 or 1.0 mM amiloride caused 29 or 69% reduction of HIDF and completely abolished hyperoxia-induced alkalinization of the cells. HIDF was altered by modification of extracellular pH (pHo); there was a decrease by 84% with pHo 6.8, while pHo 7.8 led to earlier and more intensive dome formation (day 2, +472%; day 3, +27%). We also found that adenosine 3',5'-cyclic monophosphate (cAMP) was increased in hyperoxic cells, a change that was independent from the rise of pHi. We conclude that high-level hyperoxia induces dome formation in MDCK epithelial monolayers by a process involving activation of the Na(+)-H+ exchanger, together with increased intracellular cAMP.

Quality of life measures for patients receiving adjuvant therapy for breast cancer: an international trial. The International Breast Cancer Study Group

Serial quality of life (QL) assessments are being obtained every 3 months for 2 years from patients with operable breast cancer in two ongoing International Breast Cancer Study Group (IBCSG) randomised clinical trials of adjuvant treatment. The QL-assessments include patient-derived perceived coping (PACIS, personal adjustment to chronic illness scale), well-being (Bf-S, Befindlichkeitsskala von Zerssen), mood, physical well-being and appetite (LASA, linear analogue self assessments). The first assessment within 6 weeks of surgery was performed by 70% of the patients. The analysis of serial assessments for 265 patients with each of the first four assessments completed showed that all measures improved with increasing time from study entry; that the degrees of improvement for the four major language groups were similar; and that measures were sensitive to treatment difference. In conclusion, measurement of QL related aspects in a multicultural clinical trial is feasible and possibly relevant for the evaluation of treatment results.

Circadian rhythms of specific airway conductance and bronchial reactivity to histamine: the effects of parasympathetic blockade

In ten healthy, nonsmoking, non-atopic, young volunteers, specific airway conductance and bronchial response to aerosolized histamine were measured plethysmographically at intervals of 4.8 h during two periods of 24 h, i.e. one day without, the other with, a parasympatholytic aerosol (0.20-0.24 mg ipratropium bromide) inhaled 1 h before each measurement, in order to determine the role of the parasympathetic innervation in the circadian rhythms of the airways. Specific airway conductance and bronchial reactivity showed clear circadian variations with corresponding peak times (16.11 and 04.41 h, respectively). Topical vagal blockade markedly increased specific conductance and resulted in a significant reduction of its rhythm amplitude, whereby the strong correlation between specific conductance and heart rate was significantly diminished. On the other hand, bronchial reactivity to histamine was lowered without flattening of its circadian rhythm. It is concluded that central parasympathetic outflow is an essential factor for the circadian rhythm of bronchial tone and, thus, for the increase in bronchial resistance at night.

Circadian rhythms of specific airway conductance and bronchial reactivity to histamine: the effects of parasympathetic blockade

In ten healthy, nonsmoking, non-atopic, young volunteers, specific airway conductance and bronchial response to aerosolized histamine were measured plethysmographically at intervals of 4.8 h during two periods of 24 h, i.e. one day without, the other with, a parasympatholytic aerosol (0.20-0.24 mg ipratropium bromide) inhaled 1 h before each measurement, in order to determine the role of the parasympathetic innervation in the circadian rhythms of the airways. Specific airway conductance and bronchial reactivity showed clear circadian variations with corresponding peak times (16.11 and 04.41 h, respectively). Topical vagal blockade markedly increased specific conductance and resulted in a significant reduction of its rhythm amplitude, whereby the strong correlation between specific conductance and heart rate was significantly diminished. On the other hand, bronchial reactivity to histamine was lowered without flattening of its circadian rhythm. It is concluded that central parasympathetic outflow is an essential factor for the circadian rhythm of bronchial tone and, thus, for the increase in bronchial resistance at night.

[Course and prognosis of chronic obstructive lung disease over 5 and 10 years]

453 patients aged over 40 hospitalized with severe COPD, a mean age of 66 years and mean FEV1 of 1.24 litres (49% predicted) were prospectively followed up for 5 years (341) and 10 years (195) respectively. 5-year survival was 47%, while 10-year survival was severely limited despite uniform therapy (23%). Average survival was only 4.4 years. Of the 15 prognostic factors considered, initial FEV1, body-weight, smoking behavior, diagnosis of bronchial asthma or emphysema, finding of p pulmonale and reversibility of bronchodilation had a significant influence on survival. The average decrease in FEV1 per year was only 28 ml in the surviving patients. It was lowest in those with FEV1 reversibility of more than 105 ml after bronchodilation. A maximum increase of FEV1 of more than 485 ml during the initial hospitalization, together with stopping smoking, were the next two important factors in FEV1 decrease. Mean annual NO2 concentration at home did not correlate significantly with survival and FEV1 decrease.

[Quality of life and time of survival following diagnosis of a bronchus carcinoma in 267 patients from 1977 to 1984]

The data of all patients diagnosed and/or treated for lung cancer at the Zürcher Höhenklinik Wald in the years 1977 to 1984 were analyzed retrospectively. In 1986 follow-up interviews were conducted with surviving patients and physicians of all patients. Quality of life was assessed by a performance scale in three stages, adapted from Karnofsky. Overall survival in the 267 patients (age 65 +/- 10 years, 85% males, 91% smokers) was 18 months. 14 patients have thus far lived longer than 5 years after diagnosis, resulting in a 5-year survival (Kaplan-Meier) of 9.6%. Statistical analysis showed survival to be significantly influenced by the performance scale and stage of disease at the time of diagnosis. Decision trees or algorithms calculated with a new computer program (CART) established the importance of performance scale, stage of disease and patients' age, followed by histology and patient's sex for therapeutic decisions and prognosis in lung cancer. Surgical resection in stage I and II was feasible in 20% of all patients only, with a 5-year survival rate of 36%.