Features of anaplastic lymphoma kinase rearrangement in early-stage lung cancer: Analysis of a nationwide Japanese database

BACKGROUND AND OBJECTIVES

Anaplastic lymphoma kinase (ALK) rearrangement is a representative driver mutation in lung cancer. However, the biology of early-stage ALK-rearranged lung cancer remains unclear. We aimed to assess the clinicopathological features, prognostic implications, and influence of ALK rearrangement on the postoperative course in surgically resected lung cancer.

METHODS

We retrospectively analyzed data from the Japanese Joint Committee of Lung Cancer Registry database. Of the 12 730 patients with lung adenocarcinoma, 794 (6.2%) were tested for ALK rearrangement and were included.

RESULTS

ALK rearrangements were detected in 76 patients (10%). The 5-year overall survival (OS) rate was significantly higher in the ALK rearrangement-positive group than in the ALK rearrangement-negative group (p = 0.030). Multivariable analysis revealed that ALK rearrangement was an independent prognostic factor for improved OS (hazard ratio, 0.521; 95% confidence interval, 0.298-0.911; p = 0.022). Regarding the postrecurrence state, there was no difference in the initial recurrence sites between both groups. Administration of ALK-tyrosine kinase inhibitors (TKIs) improved postrecurrence survival in any treatment lines.

CONCLUSION

In one of the largest national surveys, ALK rearrangement was associated with improved long-term outcomes in surgically resected patients. ALK-TKIs may be an important treatment strategy for ALK rearrangement-positive lung adenocarcinoma in the postrecurrence state.

Adjustment of creatinine (Cr) to avoid severe thrombocytopenia of carboplatin (C) plus gemcitabine (G) in non-small cell lung cancer (NSCLC)

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Background: Carboplatin plus gemcitabine (CG) is a standard regimen for advanced NSCLC. Although the dose of C is calculated from Cr clearance (CCr) by Calvert‘s formula, severe thrombocytopenia sometimes occurs in the CG regimen. Severe thrombocytopenia might arise from differences in the methods of measuring Cr values. We have used two different techniques, the Jaffé method and the enzymatic method. When the enzymatic method was used, CCr overestimated the glomerular filtration rate and the dose of C calculated by Calvert‘s formula leads to overdosing. The aim of this study was to clarify whether severe thrombocytopenia could be avoided by adjusting the CCr in the CG regimen when Cr is measured by the enzymatic method. Methods: All patients (pts) were treated with CG (C, AUC = 5 on day 1; G, 1,000 mg/m2 on days 1 and 8) every 3 weeks for 4 cycles. Serum Cr values were measured by the enzymatic method and CCr was estimated by the Cockcroft-Gault formula in all patients. In the non-adjusted group, the dose of C was calculated by Calvert‘s formula with no adjustment of CCr. In the adjusted group, the dose of C was calculated by Calvert‘s formula, adjusting Cr as follows: (serum Cr +0.2). We compared the correlations between Cr values and the nadir of thrombocytes, and the frequencies of severe thrombocytopenia in both groups. Results: 32 pts and 28 pts were enrolled in the non-adjusted and the adjusted groups, respectively. Grade 3/4 thrombocytopenia was observed in 19 pts (60%) and these pts had low levels of serum Cr values. On the other hand, significantly fewer cases of grade 3/4 thrombocytopenia were observed in the adjusted group (8 pts; 29%, p < 0.0001). In addition, there was a significant correlation between Cr values and the nadir of thrombocytes in the non-adjusted group (R= 0.442, p= 0.0105), but no significant correlation was observed in the adjusted group (R= -0.196, p= 0.3212). These results suggest that adjustment of CCr can reduce the variable nadir of thrombocytes in the CG regimen when Cr is measured by the enzymatic method. Conclusions: If Cr is measured by the enzymatic method, adjustment of Cr is needed to avoid severe thrombocytopenia in the CG regimen.

No significant financial relationships to disclose.

A phase II study of S-1 for previously treated small cell lung cancer (SCLC)

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Background: S-1 is a novel oral 5-fluorouracil derivative that exhibits obvious activity against various tumor types including NSCLC. However, the effects of S-1 against SCLC have not been reported. The present phase II trial assesses the efficacy and safety of S-1 in previously treated SCLC patients. Methods: Eligible patients had pathologically documented SCLC that relapsed after platinum-based chemotherapy, ECOG performance status (PS) 0–2, and adequate bone marrow, kidney and liver function. Patients with untreated or symptomatic brain metastasis were excluded. Treatment comprised the oral administration of S-1 at 40 mg/m2 twice each day for 28 days every 6 weeks. The primary end point was the objective tumor response rate (RECIST). Secondary endpoints included progression-free survival and overall survival. Results: Twenty-six evaluable patients were enrolled (Simon's two-stage optimal design; α = 0.1; β = 0.1; P0 = 0.05; P1 = 0.25) with the following characteristics: male: female, 22/4; median age, 68 (33 - 79) y; PS0–1, n = 21; PS2, n = 5. The median number of prior treatment regimens was 2 (1–3). S-1 was administered for a mean of 1.3 cycles (1 - 5). One patient (3.8%) partially responded, 10 (38.5%) had stable and 15 (57.7%) had progressive disease. The overall response rate was 3.8% and the disease control rate was 42.3%. The median time to progression was 33 days. The median survival time was 8.0 months and the 1-year survival rate was 23%. This regimen was well tolerated. The common grade 3/4 toxicities included neutropenia (7.7%), leukopenia (7.7%), anemia (7.7%), hyponatremia (7.7%), rush (7.7%), infection (7.7%), and diarrhea (3.8%). None of the patients developed febrile neutropenia and no deaths were attributed to treatment. Conclusions: S-1 is well tolerated but has low activity as a single agent in previously treated patients with SCLC.

No significant financial relationships to disclose.

Thoracoscopic removal of middle mediastinal schwannoma originating from recurrent nerve

Schwannomas of the left recurrent nerve are rare and there is no agreement on how to manage them without causing recurrent nerve dysfunction. We present a 63-year-old male with unspecific clinical symptoms in whom a middle mediastinal mass with a diameter of 5 cm was found incidentally. At thoracoscopic surgery,we found that the encapsulated tumor originated from left recurrent nerve and we performed tumor enucleation without sacrificing the recurrent nerve. The patient did experience postoperative hoarseness and vocal cord paralysis even though we preserved the recurrent nerve. To our knowledge, thoracoscopic removal of a left recurrent nerve schwannoma has not been reported in the literature before.

[Esophageal leiomyoma enucleated under the thoracoscopy; report of a case]

We report a case of a 40-year-old male with a posterior mediastinal mass that was 8 cm in size and located behind the trachea. The thoracoscopic surgery was performed. The tumor was located from the level of left brachiocephalic vein to the carina. The mediastinal pleura over the tumor was longitudinally opened by cautery-scissors. The azygos vein lying over the tumor was divided by means of an endoscopic stapler. The muscular layer of the esophagus was also longitudinally opened. The tumor was enucleated. Then, the dissected proper muscle layer of the esophagus was suture-closed. The postoperative course was uneventful. On the first postoperative day Gastrografin was swallowed, showing the absence of leaks. The patient was discharged on the fourth postoperative day. The advantages of the thoracoscopic surgery are as follows: rapid, full recovery of the patient; decreased postoperative pain; short postoperative hospital stay. Esophageal leiomyoma in selected patient was suitable for thoracoscopic enucleation.

[Intraoperative complications of thoracoscopic surgery for mediastinal tumors]

We report intraoperative complications of thoracoscopic surgery for mediastinal tumors. Forty cases of mediastinal tumor were undergone thoracoscopic surgery at the hospital from 1999 to 2002. The patient's ages ranged from 18 to 74 years old with a mean of 47.7. Location of these tumors were anteriormediastinal in 20 cases, middlemediastinal in 6 cases, posteriormediastinal in 11 cases, and superiormediastinal in 3 cases. Intraoperative complications were rupture of the cyst in 9 cases, bleeding over 150 ml in 5 cases, injury of lung caused by adhesiolysis in 5 cases, and injury of nerve in 3 cases. The mean operation time was 103.8 minutes. Postoperative hospital stay ranged from 2 to 22 days with a mean of 5.9 days. All are alive with no recurrences or postoperative complications.

[Lobectomy under video-assisted thoracoscopic surgery for pulmonary aspergillosis]

A 70-year-old man was admitted to our hospital because of hemoptysis and abnormal shadows on chest film. He was given a diagnosis of pulmonary aspergilloma with fungus ball by computed tomography and other evaluations. Success rate of systemic or topical treatment with antifungal agents is reported to be 80%. At this case lobectomy under VATS was chosen because he had chronic liver dysfunction by hepatitis type C and the lesion was localized in the right upper lobe. Bronchial artery embolization was performed prior to the operation in order to minimise bleeding on lysing the adhesion between the chest wall and the lobe with aspergilloma. Operation was underwent safety with a bloodloss of 170 ml. Success rate of operation is reported to be 95.8% in pulmonary resection. If bronchial artery embolization is successful and the lesion is localized, lobectomy under VATS can be good option in selected patients.

[Surgical treatment for bilateral multiple lung cancers]

We reviewed 21 patients with bilateral multiple bronchogenic carcinomas. Eleven of them had synchronous carcinomas and 10 had metachronous carcinomas. We treated 6 patients with lobectomy and wedge resection under median sternotomy synchronously, and 2 patients with lobectomy on both lungs under standard thoracotomy, 2 patients with lobectomy and wedge resection, 1 patient with segmentectomy on both lung, 1 patient with lobectomy and segmentectomy, 1 patient with pneumonectomy and wedge resection, and 8 patients with lobectomy and thoracoscopic wedge resection on each lung metachronously. Two patients who had lobectomy on both lungs were dead, one of whom of pulmonary edema 2 weeks after second operation and the other of respiratory failure 3 years after second operation. We concluded that lobectomy on both lungs are not recommended because of high mortality rate (10%) and the limited resection under thoracoscopic surgery should be considered to treat the other contra lateral primary lung cancers.

[A case of benign schwannoma arising in the brachial plexus with intrathoracic extension]

A case of benign schwannoma originating from the lowest trunk of the left brachial plexus with intrathoracic extension was reported. Intrathoracic growth of a schwannoma of the brachial plexus has been reported in only five cases in the literature. The patient was a 35-year-old man and had been pointed out an abnormal shadow at the left lung apex on the roentgenogram since 20-year-old. The tumor shadow was increased to seven cm from four in size on recent chest X-ray. We performed a video-assisted thoracoscopic surgery with the oblique skin incision at the left neck and removed the tumor completely and safely.