A multicenter U.S. trial of neoadjuvant pemetrexed plus cisplatin (PC) followed by extrapleural pneumonectomy (EPP) and hemithoracic radiation (RT) for stage I-III malignant pleural mesothelioma (MPM)

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Background: The optimal management for fit patients with early stage MPM remains controversial. One approach involves neoadjuvant chemotherapy followed by EPP and hemithoracic RT and prior trials using gemcitabine and cisplatin have been reported (Weder JCO 2004, Flores JTO 2006). We administered PC, followed by EPP and RT to further assess feasibility and survival of trimodality therapy in a larger, multicenter study. Methods: Eligibility criteria: Stage T1–3 N0–2, no prior surgical resection, adequate organ function (including predicted post-op FEV1 >35%) and PS 0–1. Pts received pemetrexed 500 mg/m2 plus cisplatin 75 mg/m2 with vitamin supplementation for 4 cycles. Pts without disease progression underwent EPP followed by RT (54 Gy). The primary endpoint was pathologic complete response (pCR) rate. Enrollment was completed in March, 2006. Results: 77 patients were enrolled and 72 are evaluable. Median age 63.5 (range 34–78), M:F = 51:21, Clinical stage I:II:III:IV = 5:31:33:1, epithelial:nonepithelial = 58:15, ECOG PS 0:1:2 = 28:42:2. 83% of patients completed all four cycles of PC. Grade 3/4 events related to chemotherapy included: neutropenia (4%), febrile neutropenia (3%), nausea (1%), vomiting (3%), pneumonia (6%), pulmonary embolism (1%), and chest pain (3%). Of 73 pts assessed for radiologic response, 3 CRs, 21 PRs, 36 SDs, 3 PDs, and 10 were unevaluable; (RR= 33% [95% CI, 0.22, 0.45]). Of 54 pts who underwent surgery, EPP completion rate was 87% (47/54); that is 47/77 (61%) by ITT. Pathologic stage I:II:III:IV:NE = 4:12:24:3:11. One pCR was confirmed. 35/39 completed RT. Preliminary TTP =13.1 mo (95% CI=9.6, 15.9; 48% censored) and median survival=16.6 mo (95% CI=13.9, 19.3; 55% censored;1-yr survival = 68%). Conclusions: This multicenter trial testing trimodality therapy in MPM showed that it is feasible with a high rate of chemotherapy delivery. One pCR was observed. Preliminary survival is below that reported by single institutions for patients undergoing EPP but with a high censorship rate at this early time point. Further analyses are necessary to identify a cohort of patients most likely to benefit. This study was sponsored by Eli Lilly & Company.

No significant financial relationships to disclose.

Impact of pathological staging on survival in patients with epithelial mesothelioma treated with extrapleural pneumonectomy

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Objective: There is no universally accepted staging system in malignant pleural mesothelioma (MPM). A seventeen-year single institution experience of surgically treating a large epithelial MPM cohort with extrapleural pneumonectomy (EPP) gives insight to the applications and limitations of BWH/ DFCI and AJCC staging systems. Methods: We retrospectivly reviewed 526 consecutive patients with epithelial MPM who were surgically explored at our institution since 1988 with intent to perform EPP. Pathologic diagnoses of mesothelioma were confirmed and clinicopathologic data were recorded. Kaplan-Meyer survival from diagnosis was calculated. Those who underwent EPP were staged using BWH / DFCI (J Thorac Cardiov Surg 117:5463;1999) and AJCC (6th Edition) criteria. Operative deaths were included in the analysis and patients received varied adjuvant regimens. Results: Of 526 patients explored for potential EPP, 53 (10%) underwent alternative pleurectomy and 55 (11%) were unresectable. The remaining 418 (79%) underwent EPP. Of these, 307 (73%) were male. Median age at diagnosis was 57.9 years (17–78). Operative mortality was 5%. Median follow-up was 16 months and 23% of observations were censored. Overall median, 1-yr, 3-yr and 5-yr survival was: 18.9 mo., 68.8%, 26.3%, and 13.9%. The table below presents Kaplan-Meyer survival by stage. Conclusions: 1) Both pathological staging systems stratify survival in this cohort, although each system is limited in that a majority of patients are classified as stage 3. 2) BWH / DFCI criteria identify more stage 1–2 patients with favorable prognosis, 164 (39%) vs 46 (11%). 3) AJCC criteria classify more patients to stage 4, 76 (18%) vs 4 (1%), but appear to identify some patients with relatively favorable prognosis. 4) Selected criteria from both systems might be combined to optimally stratify patients with epithelial MPM undergoing EPP.

No significant financial relationships to disclose.

[Table: see text]

K-ras activation generates an inflammatory response in lung tumors

Activating mutations in K-ras are one of the most common genetic alterations in human lung cancer. To dissect the role of K-ras activation in bronchial epithelial cells during lung tumorigenesis, we created a model of lung adenocarcinoma by generating a conditional mutant mouse with both Clara cell secretory protein (CC10)-Cre recombinase and the Lox-Stop-Lox K-ras(G12D) alleles. The activation of K-ras mutant allele in CC10 positive cells resulted in a progressive phenotype characterized by cellular atypia, adenoma and ultimately adenocarcinoma. Surprisingly, K-ras activation in the bronchiolar epithelium is associated with a robust inflammatory response characterized by an abundant infiltration of alveolar macrophages and neutrophils. These mice displayed early mortality in the setting of this pulmonary inflammatory response with a median survival of 8 weeks. Bronchoalveolar lavage fluid from these mutant mice contained the MIP-2, KC, MCP-1 and LIX chemokines that increased significantly with age. Cell lines derived from these tumors directly produced MIP-2, LIX and KC. This model demonstrates that K-ras activation in the lung induces the elaboration of inflammatory chemokines and provides an excellent means to further study the complex interactions between inflammatory cells, chemokines and tumor progression.

Lung cancer in patients under age 40

A retrospective review of patients <40 years (n=91) seen at the Dana-Farber Cancer Institute and Brigham and Women's Hospital from January 1, 1983-January 1, 1993 was carried out. Of 91 patients, there were 43 men and 48 women with a median age of 36 years (range 28-39). Eighty percent of patients were cigarette smokers for a median of 25 pack years (range 2-68). Ninety-one percent were symptomatic at presentation. The ECOG performance status (PS) was 0 or 1 in 83%. At the time of diagnosis 15% had stage I/II, 17% stage IIIA, 22% stage IIIB and 45% stage IV disease. The most common histopathology was adenocarcinoma (46%), followed by small cell carcinoma (14%), squamous cell carcinoma (12%), large cell undifferentiated (8%) and other types (20%). The median survival for all 91 patients was 1 year with 2 and 5 year survivals of 30% and 18% respectively. Five year survival was related to stage of disease: 60% for patients with stage I, 58% for stage II, 36% for stage IIIA, 10% for stage IIIB, and 3% for stage IV disease. Factors that had no significant effect on overall survival included gender, histologic subtype, degree of differentiation, presence or absence of symptoms, and sites of metastases. Factors that adversely affected survival by univariate analysis included advanced stage of disease, poor PS, duration of symptoms for more than 3 months, and 5% or greater body weight loss. By multivariate analysis only stage (P<0.001) and weight loss (P=0.02) affected survival. This data plus results of other published studies show that young patients under age 40 with lung cancer, compared to the more common older patients, have an increased percentage of women, have a longer duration of symptoms, more often have adenocarcinoma with lower frequency of squamous cell carcinoma and sometimes small cell carcinoma, and more often present with advanced disease. Despite these differences, overall patient survival remains poor and is similar to that of older patients.

The alpha folate receptor is highly activated in malignant pleural mesothelioma

OBJECTIVE

To determine whether the folate receptor gene is overexpressed in malignant pleural mesothelioma.

METHODS

Differential display analysis was performed with fresh frozen RNA obtained from normal lung, pleura, and mesothelioma. Sixty differentially expressed genes were identified and characterized. One gene that was over-expressed in mesothelioma versus normal tissue was the human alpha folate receptor. In situ hybridization with antisense probes designed on the basis of the sequence of the folate receptor was performed with frozen sections from 61 patients (33 epithelial and 28 mixed or sarcomatoid tumors) with malignant pleural mesothelioma. The controls included normal pleura, normal lung, other cancers, and sense controls for all of the tumors. Northern analysis with a folate receptor probe and immunohistochemical analysis with anti-alpha folate receptor antibodies were also performed.

RESULTS

Forty-four (72%) of the 61 mesothelioma tumors were found to have between 2-fold and 4-fold higher mRNA expression of the folate receptor when compared with the control tissues. The histologic type of the tumor did not affect the rate of folate receptor activation. Northern analysis and immunohistochemical experiments confirmed these findings.

CONCLUSIONS

A majority of mesothelioma tumors examined overexpress the alpha folate receptor protein when compared with normal adjacent tissues. This finding may help explain the observations that antifolate drugs have activity in the treatment of mesothelioma. It also encourages further study of folate receptor-related treatment strategies in this malignancy.

Preoperative chemoradiotherapy alters the expression and prognostic significance of adhesion molecules in Barrett's-associated adenocarcinoma

A variety of prognostic markers have been related to decreased patient survival in patients with epithelial malignancies. These include expression of the homotypic adhesion molecule E-cadherin (ECAD) and the hyaluronic acid receptor CD44. Expression of ECAD and CD44 was evaluated in Barrett's-associated adenocarcinoma (BAd) from 67 patients. Expression was determined by immunoperoxidase staining and graded semiquantitatively based on the proportion of positively stained cells. These data were then correlated with clinical and pathological parameters, including the presence or absence of chemoradiotherapy (chemrad) and patient survival. There were 56 men and 11 women (mean age, 62 years). Thirty-nine (58%) patients received preoperative chemrad. ECAD expression was detected in all (100%) tumors. The ECAD staining grade did not correlate with other pathological features of the tumors. However, ECAD staining was significantly increased in BAd of patients who received chemrad (P = .003), in comparison with those who did not, and in individual patients when prechemrad biopsies and postchemrad resection specimens were compared (P = .04). In terms of prognosis, increased ECAD expression was associated with shortened patient survival only in BAd patients who had received chemrad (univariate analysis of chemrad patients with stage I and II BAd, P = .02). ECAD expression was not significantly associated with survival in BAd patients who did not receive chemrad. CD44 expression was detected in 88% of cases. CD44 expression did not correlate with any of the pathological features of the tumors or with chemrad status. Increased expression of CD44 was significantly associated with shortened patient survival in chemrad patients only (univariate analysis P = .03, multivariate analysis P = .04), although a strong trend was observed when all patients were analyzed regardless of chemrad status (P = .07). The results of this study indicate that chemrad alters the expression of ECAD in BAd. Thus, the prognostic utility of ECAD expression must be evaluated in the context of chemrad status. CD44 also may be a valuable prognostic marker in BAd.

Pathologic prognostic factors in esophageal squamous cell carcinoma: a follow-up study of 74 patients with or without preoperative chemoradiation therapy

One of the primary goals of pathologic examination of esophageal squamous cell carcinoma resection specimens is to provide information regarding morphologic features which can help prognosticate and guide management of affected patients. The purpose of this study was to determine the prognostic utility of a variety of histopathologic prognostic factors in patients with esophageal squamous cell carcinoma with and without preoperative chemotherapy and radiotherapy (chemrad). Multiple clinical and histologic features such as peri-tumoral lymphocytic infiltrate, Crohn's-like lymphoid reaction, degree of residual tumor, mitosis per 1000 cells, tumor differentiation, lymphatic/vascular invasion, perineural invasion, desmoplastic reaction, and tumor growth pattern were evaluated in patients with (53) and without (21) preoperative chemrad and correlated with survival (mean follow-up, 25 mo). Data were analyzed for the entire cohort and for each separate treatment group by univariate and multivariate analysis. Patients who received chemrad showed no significant survival benefit (hazard ratio = 2.5, P = .10). In the whole cohort of patients, higher pathologic stage (P = .04), poor tumor differentiation (P = .003), increased mitotic count (P = .005), perineural invasion (P = .01), lymphatic/vascular invasion (P = .002), tumor size (P = .05), and absence of a Crohn's-like lymphoid reaction (P = .05) were significantly associated with poor survival by univariate analysis. In multivariate analysis, poor tumor differentiation (P = .005), high mitotic count (P = .01), and vascular invasion (P = .03) were important prognostic features, independent of pathologic stage, for the entire cohort. In the chemrad group only, tumor size (in patients with macroscopic residual tumor) (P = .05), lymph node metastasis (P = .03), mitotic count (P = .01), and lymphatic/vascular invasion (P = .02) were significant prognostic indicators by univariate analysis. Upon multivariate analysis, only lymphatic/vascular invasion (P = .02) and mitotic rate (P = .01) were independent predictors of survival. In the nonchemrad group, only tumor differentiation was significant by both univariate (P = .008) and multivariate analysis (P = .03). The differences in pathologic prognostic factors between chemrad and nonchemrad treated cases suggests that chemrad has a significant effect on the biologic properties of these tumors.

Pathologic prognostic factors in Barrett's associated adenocarcinoma: a follow-up study of 96 patients

BACKGROUND

The objective of this study was to evaluate a variety of histologic features, some of which to our knowledge have never been evaluated in Barrett's-associated adenocarcinoma (BAd) (such as Crohn's-like lymphoid reaction and peritumoral lymphoid response) in patients with and without preoperative neoadjuvant chemotherapy combined with radiotherapy (chemrad) to determine their prognostic significance in these two groups of patients.

METHODS

Tumor sections from 96 patients (83 males and 13 females; mean age, 62 years) with resected BAd (61 with chemrad and 35 without chemrad) were evaluated for numerous histologic features such as pathologic stage according to the American Joint Committee on Cancer TNM staging system, peritumoral lymphoid infiltrate, Crohn's-like lymphoid reaction, and degree of post chemrad residual tumor and correlated with the preoperative chemrad status and with survival (mean follow-up, 23 months).

RESULTS

By univariate analysis, older patient age (P = 0.02), higher pathologic stage (P = 0.02) (including depth of invasion and lymph node status), infiltrative growth pattern (P = 0.05), perineural invasion (P = 0.05), vascular invasion (P = 0.04), and the absence of a peritumoral lymphoid infiltrate (P = 0.04) were associated with shortened survival in the entire cohort and in patients without chemrad, with the exception of infiltrative growth pattern (P = 0.1 in the nonchemrad group only). Higher stage was the only feature associated with decreased survival in the chemrad group. Subcategorization of lymph nodes according to the number involved with metastases (fewer than four, four to seven, and greater than seven) had no further effect on prognosis. However, subcategorization of T1 tumors into Tla and T1b did influence prognosis in a negative manner. Using multivariate analysis, only older patient age (P = 0.005) and the absence of a peritumoral lymphoid infiltrate (P = 0.05) were statistically associated with poor survival independent of stage. In addition, perineural invasion (P = 0.07) showed a trend toward shortened survival in patients with this feature. Preoperative chemrad had no effect on survival in this retrospective nonrandomized cohort of patients.

CONCLUSIONS

This study confirms the strong prognostic usefulness of the TNM staging system in patients with resected BAd, even in those patients who received preoperative chemrad. In addition, older patient age, the absence of a peritumoral lymphoid infiltrate, and possibly perineural invasion correlate with poor survival independent of pathologic stage in patients with these tumors.

Analysis of neuroendocrine markers, HER2 and CEA before and after chemotherapy in patients with stage IIIA non-small cell lung cancer: a Cancer and Leukemia Group B study

Several studies have suggested that biochemical or molecular markers examined in non-small cell lung cancer carry prognostic or treatment response information. Non-small cell lung cancer patients whose tumors have neuroendocrine (NE) features may be more responsive to chemotherapy. In addition, increased expression of HER2 (c-erbB-2), a membrane-bound receptor with tyrosine kinase activity, has been associated with shortened survival. The Cancer and Leukemia Group B (CALGB) performed a study of patients with stage IIIA (N2 nodes positive) non-small cell lung cancer in which patients received initial chemotherapy followed by surgery, then post-operative therapy consisting of sequential chemotherapy and radiation therapy. Since all patients underwent mediastinoscopy, this provided an opportunity to compare pre- and post-chemotherapy tumor specimens to test the hypothesis that these proteins would predict treatment response. In particular, we hypothesized that the post-chemotherapy specimens would be enriched for NE marker negative cells because of the increased sensitivity of NE positive cells to chemotherapy. We performed immunohistochemical analysis for a panel of NE markers [neuron-specific enolase (NSE), Leu-7, chromogranin A (ChrA), synaptophysin (Syn)], HER2 and CEA to determine if there was an effect of therapy on the percentage of cells expressing these markers. Secondary endpoints were a correlation with chemotherapy response and survival. Slides were scored for intensity (0-4) and percentage of cells positive (0-4). Of 61 eligible patients, there were 38 with both pre- and post-chemotherapy specimens. When both intensity of staining and percentage of positive cells were considered, post-chemotherapy specimens had a higher percentage of positive NE markers compared with pre-chemotherapy. In addition, there was no correlation between NE marker, HER2 or CEA expression (prior to or post treatment) and response to chemotherapy or survival. These data do not support the hypothesis that NE positive tumor cells are preferentially killed by chemotherapy in patients with stage IIIA non-small cell lung cancer.

Body mass index as a correlate of postoperative complications and resource utilization

PURPOSE

To describe the relationship of body mass index (BMI) with postoperative complications and resource utilization.

PATIENTS AND METHODS

Two thousand nine hundred and sixty-four patients 50 years or older undergoing elective noncardiac surgery with an expected length of stay > or = 2 days were enrolled in a prospective cohort study to measure major cardiac complications, noncardiac complications, length of stay, and costs. The setting was an urban teaching hospital. A preoperative history, physical, electrocardiogram (ECG), and chart review were performed by study personnel. Postoperative complications were detected by ECGs, creatine kinase and creatine kinase MB levels, and daily chart review. Total costs were obtained from the hospital's computerized database.

RESULTS

Complication rates were not different among BMI groups (underweight < 20, normal 20 to 29, overweight 30 to 34, most overweight > 34), but patients with BMI 30 to 34 and > 34 who underwent abdominal or gynecologic procedures had significantly higher wound infection rates (11% each) than normal weight patients (4.7%) or the underweight (0%). After adjusting for age, race, gender, smoking history, comorbid diseases, procedure type, and insurance status, there were nonsignificant trends toward increased resource utilization by the most overweight patients (BMI > 34). These patients stayed 0.8 days longer (P = 0.13) and had total costs that were $843 higher (P = 0.17) than patients of normal weight (BMI 20 to 29). The underweight patients stayed 0.9 days longer (P = 0.23) and had total costs that were $3,150 higher (P = 0.04) than patients of normal weight. Quadratic models to test for a U-shaped relationship found no correlation between BMI and length of stay, but did find that BMI was significantly correlated with total costs (P = 0.04). This relationship persisted when patients who had complications were excluded from the analysis.

CONCLUSIONS

Overall, BMI was not significantly correlated with postoperative complications or length of stay. However, overweight patients who underwent abdominal or gynecologic procedures had higher wound infection rates, and patients with the highest and lowest BMIs had significantly higher adjusted total costs.

Optimal therapy of malignant pleural effusions

A randomized phase III trial of bleomycin, tetracycline and talc following chest tube drainage and a meta-analysis of relative benefit of bleomycin and tetracycline as sclerosing agents were performed to determine the optimal approach to malignant pleural effusion (MPE). Fifty patients were randomized to receive bleomycin (n=16), tetracycline (n=19) or talc (n=16) following chest tube drainage. Treatment groups were balanced for pretreatment characteristics. The study was ended prematurely because of the removal of parenteral tetracycline from the market. Overall, 52% of randomized patients had successful control of effusion 30 days after sclerosis. There were no differences between any of the three treatment groups in terms of 30 day control of effusion, overall survival (6 months), resclerosis rate, pain with sclerosis, fever, or duration of hospitalization (6 days). A meta-analysis was performed using the four previously reported trials of tetracycline vs. bleomycin and revealed a 20.6% advantage to the use of bleomycin (95% C.I. 7.9%-33.3%) (p=0.002). This phase III failed to demonstrate a significant difference between the three agents in terms of control of MPE at 30 days, side effects or survival. However, because of small sample size, this study lacks sufficient power to observe potentially clinically important differences between treatment groups. Inclusion of data from four previous trials in a meta-analysis showed that bleomycin may be superior. The median duration of hospitalization and the overall success rate of all three sclerosing agents in this study argue convincingly that new approaches to palliate MPE are needed.

Continuous-infusion cisplatin, 5-fluorouracil, and leucovorin for advanced non-small cell lung cancer

BACKGROUND

Cisplatin, 5-fluorouracil, and leucovorin (PFL) have demonstrated synergistic activity in preclinical models. Continuous infusion of these agents maximizes the potential for synergistic interaction and forms the basis of the PFL regimen.

METHODS

Sixty-one patients with advanced (Stages IIIB and IV) non-small cell lung cancer were entered into the study. Thirty-one were treated with cisplatin 25 mg/m2/day on days 1-5, 5-fluorouracil 800 mg/m2/day on days 2-6, and calcium leucovorin 500 mg/m2/day on days 1-6. Because of severe mucositis, the final 30 patients were treated with the same dosage of cisplatin but with the deletion on day 6 of leucovorin and 5-fluorouracil. Cycles were repeated every 28 days. Response was assessed after two cycles. Responding patients received an additional two cycles. Patients with Stage IIIB disease received radiation therapy to the mediastinum and sites of involved disease.

RESULTS

PFL had an overall response rate of 41%. Median survival was 8.1 months, and median time to treatment failure was 4.2 months. Importantly, 68% (17 of 25) of responses were maximal after just two cycles of chemotherapy. Notable toxicities included mucositis (43% > or = Grade 3) and myelosuppression. Response, time to failure, or survival did not differ between the two schedules. Mucositis was less severe with 4-day PFL.

CONCLUSIONS

PFL as given in this manner is an active regimen for the treatment of patients with advanced non-small cell lung cancer. The rapidity of response makes it a regimen for incorporation into protocols for Stage IIIA disease. A neoadjuvant study using PFL is underway.

Nitric oxide synthase in human and rat lung: immunocytochemical and histochemical localization

Nitric oxide synthase (NOS) produces nitric oxide, a mediator of potential importance in numerous physiologic and inflammatory processes in the lung. We localized constitutive NOS (c-NOS) and inducible NOS (i-NOS) within lung tissue by immunoperoxidase labeling with specific antibodies or by histochemical demonstration of the characteristic NADPH diaphorase activity of NOS. We analyzed human airway (n = 4) or parenchyma (n = 10) specimens obtained from uninvolved areas of surgical tumor resections. We also studied human fetal lung samples (n = 6) and normal or inflamed (16 h after intratracheal LPS instillation) rat lung tissue. Immunostaining with anti-c-NOS identified c-NOS antigen in rat lung nerves, endothelium, and airway epithelium. Normal or inflamed rat macrophages were not stained. Human nerve elements and large-vessel endothelium showed immunostaining with the anti-c-NOS, but no labeling of the airway or alveolar epithelium was seen. Immunostaining with anti-i-NOS showed strong labeling of rat macrophages after LPS treatment, in vivo or in vitro, while normals were negative. Human alveolar macrophages were occasionally positive for i-NOS, especially in areas of chronic inflammation, which also showed focal immunolabeling of endothelium. Uniform labeling of epithelium in large, cartilaginous airways was found with anti-i-NOS in both human bronchi and normal rat trachea samples, suggesting a constitutive role for a NOS that shares epitope(s) with or is highly homologous to the inducible, macrophage type of NOS. Histochemical staining for NADPH diaphorase activity was consistent with immunolocalization of NOS antigens.(ABSTRACT TRUNCATED AT 250 WORDS)