Amiodarone-induced pulmonary toxicity with an excellent response to treatment: A case report

Amiodarone is an anti-arrhythmic drug widely used, but its administration can be associated with several adverse side-effects. Among these, amiodarone-induced pulmonary toxicity (APT) occurs in 4–17% of cases and, if not early diagnosed and treated, may evolve towards pulmonary fibrosis and respiratory failure.

A 76 years-old-man went to the hospital for accidental trauma. The patient did not report respiratory symptoms but was suffering from atrial fibrillation treated with amiodarone 200 mg/day from three years (cumulative dose >150 gr). HRCT showed ground-glass opacities and nodules in both lungs. The patient underwent fibreoptic bronchoscopy with BAL. Cytologic examination of BALF sediment put in evidence foamy macrophages. The electronic microscopy revealed into the alveolar macrophages “… the presence of multilamellar intracytoplasmic bodies and lysosomes, loads of lipid material”. LFTs showed a restrictive syndrome and an impairment of DLCO. Amiodarone discontinuation and steroid administration led to the regression of radiological lesions and the recovery of lung function.

Patients taking amiodarone can experience APT. They should perform a basal chest x-ray with LFTs before starting therapy. Monitoring could reveal early the pulmonary toxicity, and patients can respond favourably to the treatment.

What information could the main actors of liquid biopsy provide? -a representative case of non-small cell lung cancer (NSCLC)

In non-small cell lung cancer (NSCLC), there is a consensus regarding the use of liquid biopsy, generally, to detect "druggable" mutations and, in particular, to monitor tyrosine kinase inhibitor (TKI) treatments. However, whether circulating tumor cells (CTCs) are better tools than cell-free DNA (cfDNA), is still a matter of debate, mainly concerning which antigen(s) we should use to investigating simultaneously both epithelial and epithelial-to-mesenchymal transient (EMT) phenotype in the same sample of CTCs. To address this item, we exploited here a single-tube liquid biopsy, to detect both epithelial cell adhesion molecule (EpCAM)-positive CTCs and EpCAM-low/negative CTCs, because down-modulation of EpCAM is considered the first step in EMT. Furthermore, we analyzed the DNA from CTCs of four different phenotypes (ctcDNA), according to their EpCAM expression and cytokeratin pattern, and circulating tumor DNA (ctDNA) by droplet digital PCR (ddPCR), in order to disclose activating and resistance-driving mutations. Liquid biopsy reflected spatial and temporal heterogeneity of the tumor under treatment pressure. We provide the proof-of-concept that the complementary use of ctDNA and ctcDNA represents a reliable, minimally invasive and dynamic tool for a more comprehensive view of tumor evolution.

BDNF/TrkB axis activation promotes epithelial-mesenchymal transition in idiopathic pulmonary fibrosis

Background

Neurotrophins (NT) belongs to a family of growth factors which promotes neurons survival and differentiation. Increasing evidence show that NT and their receptor are expressed in lung tissues suggesting a possible role in lung health and disease. Here we investigated the expression and functional role of the TrkB/BDNF axis in idiopathic pulmonary fibrotic lung (myo)fibroblasts.

Methods

Lung fibroblast were isolated from IPF patients and characterized for the expression of mesenchymal markers in comparison to normal lung fibroblasts isolated from non-IPF controls.

Results

BDNF treatment promoted mesenchymal differentiation and this effect was counteracted by the TrkB inhibitor K252a. In this regard, we showed that K252a treatment was able to control the expression of transcription factors involved in epithelial to mesenchymal transition (EMT). Accordingly, K252a treatment reduced matrix metalloproteinase-9 enzyme activity and E-cadherin expression while increased cytoplasmic β-catenin expression.

Conclusions

Our results suggest that BDNF/TrkB axis plays a role in EMT promoting the acquisition of (myo)fibroblast cell phenotype in IPF. Targeting BDNF/TrkB seems to represent a viable approach in order to prevent EMT dependent lung fibrosis.

Blockade of Stearoyl-CoA-desaturase 1 activity reverts resistance to cisplatin in lung cancer stem cells

Poor prognosis in lung cancer has been attributed to the presence of lung cancer stem cells (CSCs) which resist chemotherapy and cause disease recurrence. Hence, the strong need to identify mechanisms of chemoresistance and to develop new combination therapies. We have previously shown that Stearoyl-CoA-desaturase 1 (SCD1), the enzyme responsible for the conversion of saturated to monounsaturated fatty acids is upregulated in 3D lung cancer spheroids and is an upstream activator of key proliferation pathways β-catenin and YAP/TAZ. Here we first show that SCD1 expression, either alone or in combination with a variety of CSCs markers, correlates with poor prognosis in adenocarcinoma (ADC) of the lung. Treatment of lung ADC cell cultures with cisplatin enhances the formation of larger 3D tumor spheroids and upregulates CSCs markers. In contrast, co-treatment with cisplatin and the SCD1 inhibitor MF-438 reverts upregulation of CSCs markers, strongly synergizes in the inhibition of 3D spheroids formation and induces CSCs apoptosis. Mechanistically, SCD1 inhibition activates endoplasmic reticulum stress response and enhances autophagy. These data all together support the use of combination therapy with SCD1 inhibitors to achieve better control of lung cancer.

Lung cancer requires multidisciplinary treatment to improve patient survival: A case report

The present study reports two cases of lung cancer with the involvement of the pleura. The diagnosis of adenocarcinoma with epidermal growth factor receptor (EGFR) mutation was made following repeated thoracentesis with cytology of pleural fluid and thoracoscopy with pleural biopsies. Talc pleurodesis was successfully performed in both cases subsequent to diagnosis. Following talc pleurodesis, the first patient (62 years old; male; non-smoker) underwent 3 cycles of cisplatin/vinorelbine chemotherapy, with a poor response. Concurrently, due to the presence of an EGFR mutation, treatment with gefitinib was initiated, with the patient achieving a good response for ~12 months. The residual tumor was treated with stereotactic radiotherapy and the patient continued gefitinib treatment. The patient is presently in good health, has not exhibited any signs of relapse and is continuing gefitinib treatment without side effects. The second patient (53 years old; male ex-smoker) underwent treatment with gefitinib subsequent to talc pleurodesis for a total of 15 months. In addition, radiotherapy (60 Gy) on the residual lesion was performed. Subsequently, second-line therapy with cisplatin/premetrexed was prescribed and followed by maintenance treatment with premetrexed. Three years after diagnosis, the patient did not exhibit any signs of recurrence. These two cases highlight the difficulty in treating advanced stage lung cancer, despite the presence of EGFR mutation. Each lung cancer is different and requires the physician to possess a wide range of knowledge of the therapeutic options available, in addition to careful monitoring in order to adjust the treatment over time. A multidisciplinary approach, involving surgeons, radiation oncologists, pulmonologists and oncologists, is required to optimize the survival and quality of life of patients with lung cancer.

Exogenous lipoid pneumonia induced by nasal decongestant

INTRODUCTION

Lipoid pneumonia is a clinical condition that may be initially asymptomatic or confused with an infectious or malignant lung disease.

OBJECTIVES

We report four cases of this pathological condition.

METHODS

The first case concerned an 85-year old woman with bilateral confluent pulmonary opacities, ground-glass type. Diagnosis was based on the cytology of the bronchoalveolar lavage (BAL) fluid followed by its ultrastructural examination. The second case was a 47-year-old man with an isolated pulmonary nodule, which was surgically removed; the diagnosis of lipoid pneumonia was formulated on the basis of the histological and electron microscopy examination. The third case concerned a 73-year-old woman, with bilateral hypodense areas at the bases of the lungs where FDG PET/CT scan showed an increased uptake. Diagnosis was formulated by BAL cytology and electron microscopy examination. The fourth case was a 69-year-old man, who performed a virtual colonoscopy for diverticulosis putting in evidence a round mass (3 cm in diameter) with two small peripheral nodules, located in the pulmonary left lower lobe. The histopathological examination of transthoracic biopsy confirmed a lipoid pneumonia.

RESULTS AND CONCLUSION

In all four cases, it was put in evidence a prolonged use of a nasal decongestant containing mineral oils. In literature, the most cases described are characterized by a subclinical evolution and were presented as ground glass opacities which evolve, in the later phases, in an interstitial involvement or in a peripheral mass, simulating a lung tumour.

Genetic and Functional Analysis of Polymorphisms in the Human Dopamine Receptor and Transporter Genes in Small Cell Lung Cancer

The regulatory role of dopamine (DA) in endocrine, cardiovascular and renal functions has been extensively studied and used for clinical purposes. More recently DA has been indicated as a regulatory molecule for immune cells and malignant cell proliferation. We assessed the expression and the functional role DA, DA receptors, and transporters in primary small cell lung cancer (SCLC). By HPLC DA plasma levels were more elevated in SCLC patients in comparison with NSCLC patients and healthy controls. SCLC cell expressed DA D1- and D2-like receptors and membrane and vesicular transporters at protein and mRNA levels. We also investigated the effects of independent D1- or D2-like receptor stimulation on SCLC cell cultures. DA D1 receptor agonist SKF38393 induced the increase of cAMP levels and DARPP-32 protein expression without affecting SCLC growth rate. Cell treatment with the DA D1 receptor antagonist SCH23390 inhibited SKF38393 effects. In contrast, the DA D2 receptor agonist quinpirole (10 μM) counteracted, in a dose and time dependent way, SCLC cell proliferation, it did not affect cAMP levels and decreased phosphorylated AKT that was induced by DA D2 receptor antagonist sulpiride. However, in only one SCLC line, stimulation of DA D2 receptor failed to inhibit cell proliferation in vitro. This effect was associated to the existence of rs6275 and rs6277 polymorphisms in the D2 gene. These results gave more insight into DA control of lung cancer cell behavior and suggested the existence of different SCLC phenotypes.

Different clinical and radiological features of solitary fibrous tumor of the pleura: Report of two cases

We report two cases of solitary fibrous tumor of the pleura (SFTP). The first appeared in a young, new mother as a large mass in the upper lobe of the left lung that caused compression of lung parenchyma without significant respiratory symptoms but with polyarticular paraneoplastic syndrome; the other was documented by an occasional chest x-ray in a man affected by chronic obstructive pulmonary disease (COPD) as a small peripheral mass 4 years before and no longer controlled. Both patients underwent surgical resection with quick and full recovery. SFTP is a benign, slow growing neoplasm that is mostly localized. It appears in adult or elderly patients often with few symptoms. The computed tomography (CT) of the chest with contrast medium is important in order to see the shape of the mass and relationships with adjacent structures but only histology can provide the diagnosis. Surgery is the best treatment.

Human lung adenocarcinoma cell cultures derived from malignant pleural effusions as model system to predict patients chemosensitivity

Background

Lung cancer is the leading cause of cancer related deaths and Malignant Pleural Effusion (MPE) is a frequent complication. Current therapies suffer from lack of efficacy in a great percentage of cases, especially when cancer is diagnosed at a late stage. Moreover patients’ responses vary and the outcome is unpredictable. Therefore, the identification of patients who will benefit most of chemotherapy treatment is important for accurate prognostication and better outcome. In this study, using malignant pleural effusions (MPE) from non-small cell lung cancer (NSCLC) patients, we established a collection of patient-derived Adenocarcinoma cultures which were characterized for their sensitivity to chemotherapeutic drugs used in the clinical practice.

Methods

Tumor cells present in MPEs of patients with NSCLC were isolated by density gradient centrifugation, placed in culture and genotyped by next generation sequencing. In a subset of cases patient derived xenografts (PDX) were obtained upon tumor cell inoculation in rag2/IL2 knock-out mice. Isolated primary cultures were characterized and tested for drug sensitivity by in vitro proliferation assays. Additivity, antagonism or synergy for combinatorial treatments were determined by analysis with the Calcusyn software.

Results

We have optimized isolation procedures and culture conditions to expand in vitro primary cultures from Malignant Pleural Effusions (MPEs) of patients affected by lung adenocarcinomas, the most frequent form of non small cell lung cancer. Using this approach we have been able to establish 16 primary cultures from MPEs. Cells were banked at low passages and were characterized for their mutational pattern by next generation sequencing for most common driver mutations in lung cancer. Moreover, amplified cultures were shown to engraft with high efficiency when injected in immunocompromised mice. Cancer cell sensitivity to drugs used in standard chemotherapy regimens was assessed either individually or in combination. Differential chemosensitivity and different mutation profiles were observed which suggests that this isolation method could provide a platform for predicting the efficacy of chemotherapy in the clinical setting. Most importantly for six patients it was possible to establish a correlation between drug response in vitro and response to therapy in the clinic.

Conclusions

Results obtained using primary cultured cells from MPEs underscore the heterogeneity of NSCLC in advanced stage as indicated by drug response and mutation profile. Comparison of data obtained from in vitro assays with patients’ responses to therapy leads to the conclusion that this strategy may provide a potentially useful approach for evaluating individual chemosensitivity profile and tailor the therapy accordingly. Furthermore, combining MPE-derived primary cultures with their genomic testing allows to identify patients eligible to trials with novel targeted agents.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-0816-x) contains supplementary material, which is available to authorized users.

Sleeve Lobectomy Versus Standard Lobectomy for Lung Cancer: Functional and Oncologic Evaluation

BACKGROUND

The purpose of this study was to compare functional and oncologic outcome of sleeve lobectomy (SL) with that of standard lobectomy (STL) in patients with non-small cell lung cancer.

METHODS

Between January 2009 and April 2013, 44 consecutive patients undergoing upper SL (29 right side, 15 left side) were prospectively enrolled to be compared with 44 patients with the same side distribution who were randomly selected from patients undergoing upper STL during the study period. Functional and oncologic results of the two groups were compared.

RESULTS

Pathologic tumor stage ranged between I and IIIa with similar patient distribution between the two groups. Postoperative complication rates were 20.5% in the SL group and 16% in the STL group. There was no postoperative mortality in either group. Mean postoperative decrease in forced expiratory volume in 1 second at 3 months postoperatively was 17.5% ± 6.2% in the SL group and 19% ± 14.8% in the STL group (p = 0.52). There also was no significant difference (p = 0.15) in mean postoperative decrease in 6-minute walk test (64.3 ± 2.5 m versus 69.1 ± 21.4 m) between the two groups. Evaluation of postoperative changes in quality of life at 3 and 6 months based on a standardized questionnaire (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire) did not show significant differences between the SL group and the STL group (p > 0.05) in terms of global health status, physical functioning, and fatigue. Actuarial survival rates at 3 and 5 years, respectively, were 85.3% and 60.1% in the SL group and 88.7% and 58.2% in the STL group, without significant difference (p = 0.68).

CONCLUSIONS

Functional and oncologic results of SL are comparable to those of STL in patients with non-small cell lung cancer.

Modified expression of peripheral blood lymphocyte muscarinic cholinergic receptors in asthmatic children

Lymphocytes possess an independent cholinergic system. We assessed the expression of muscarinic cholinergic receptors in lymphocytes from 49 asthmatic children and 10 age matched controls using Western blot. We demonstrated that CD4+ and CD8+ T cells expressed M2 and M4 muscarinic receptors which density were significantly increased in asthmatic children in comparison with controls. M2 and M4 receptor increase was strictly related with IgE and fraction of exhaled nitric oxide (FeNO) measurements and with impairment in objective measurements of airway obstruction. Increased lymphocyte muscarinic cholinergic receptor expression may concur with lung cholinergic dysfunction and with inflammatory molecular framework in asthma.

Lung cancer and concurrent or sequential lymphoma: Two case reports with hypersensitivity to bevacizumab and a review of the literature

Non-small cell lung cancer (NSCLC) accounts for ~80% of all cases of lung cancer, and is the leading cause of cancer-related mortality worldwide. The majority of NSCLC cases of are diagnosed at an advanced stage. The outcome of patients with advanced NSCLC is poor with a median survival time of ~12 months in European and American populations. Lymphoproliferative disorders (LPDs) represent a heterogeneous group of expanding lymphoid cells, which occurs as a result of immune dysfunction. LPDs are often associated with primary solid cancers. We report two cases of LPD diagnosed concurrently and successively to NSCLC. The first case presents a 65-year-old female patient with advanced IV stage lung cancer, according to the International Association for the Study of Lung Cancer TNM staging system. The patient developed a concurrent lymphoma and was treated with first-line therapy including six cycles of gemcitabine and cisplatin, however, the patient experienced an adverse drug reaction to bevacizumab, which was administered after gemcitabine and prior to cisplatin. The second case presented a 74-year-old male patient diagnosed with large B cell lymphoma. The patient acheived remission of the illness, however, after one year the patient was diagnosed with squamous cell lung cancer. After three years, the patient underwent surgery, however disease recurrence was identified. Subsequently, the patient was treated with sterotactic radiotherapy and oral chemotherapy. A review of the associated literature was also conducted.

Idiopathic Pulmonary Fibrosis (IPF) incidence and prevalence in Italy

BACKGROUND

Studies of Idiopathic Pulmonary Fibrosis (IPF) epidemiology show regional variations of incidence and prevalence; no epidemiological studies have been carried out in Italy.

OBJECTIVE

To determine incidence and prevalence rates of IPF in the population of a large Italian region.

METHODS

in this cross-sectional study study data were collected on all patients of 18 years of age and older admitted as primary or secondary idiopathic fibrosing alveolitis (ICD9-CM 516.3) to Lazio hospitals, from 1/1/2005 to 31/12/2009, using regional hospital discharge, population and cause of death databases. Reporting accuracy was assessed on a random sample of hospital charts carrying the ICD9-CM 516.3, 516.8, 516.9 and 515 codes, by reviewing radiology and pathology findings to define cases as IPF "confident", "possible" or "inconsistent".

RESULTS

Annual prevalence and incidence of IPF were estimated at 25.6 per 100,000 and 7.5 per 100,000 using the ICD9-CM code 516.3 without chart audit while they were estimated at 31.6 per 100,000 and at 9,3 per 100,000 for the IPF "confident" definition after hospital chart audit.

CONCLUSION

The data provide a first estimate of IPF incidence in Italy and indicate that incidence and prevalence in southern European regions may be similar to those observed in northern Europe and North America.

Decreased expression of autophagic beclin 1 protein in idiopathic pulmonary fibrosis fibroblasts

Autophagy is the main cellular pathway for degradation of long-lived proteins and organelles and regulates cell fate in response to stress. Beclin 1 is a key regulator of this process. In some settings autophagy and apoptosis seem to be interconnected. Recent reports indicate that fibroblasts in idiopathic pulmonary fibrosis (IPF) acquire resistance to apoptosis. Here, we examined the expression of beclin 1, and of the anti apoptotic protein Bcl-2 in human IPF fibroblasts using immunohistochemistry and molecular biology in bioptic sections, in primary cultures of fibroblasts taken from patients with IPF and in fibroblast cell lines. Expression of beclin 1 in fibroblasts from IPF was down-regulated in comparison with fibroblasts from normal lungs while the anti-apoptotic protein Bcl-2 expression was over-expressed. Treatment of fibroblast cell cultures with cisplatin induced a significant increase in beclin 1 and caspase 3 protein levels but a reduction in Bcl-2 expression. These observations were confirmed by the analysis of acid compartments and transmission electron microscopy. Our results demonstrate a modified expression of the apoptotic beclin 1 Bcl-2 proteins in human IPF fibroblasts suggesting the existence of an autophagy/apoptosis system dysfunction.

EMT markers in lung adenocarcinoma pleural effusion spheroid cells

Epithelial-to-mesenchymal transition (EMT) is a process in which cells undergo a developmental switch from epithelial to mesenchymal phenotype. This process has been related to embryologic morphogenesis but also to cancer progression and metastasis. The aim of the current study was to investigate the expression of EMT-related markers in adherent and spheroid cell cultures derived from malignant pleural effusions (MPEs) of patients affected by lung adenocarcinoma. On the basis of efficient in vitro propagation, six cases of MPEs were selected and analyzed by immunocytochemistry staining for EMT markers and by RT-PCR for transcription factors known to orchestrate EMT. EMT markers immunostaining showed in spheroids a statistically significant correlation between the loss of E-cadherin immunoreactivity and overexpression of N-cadherin (P < 0.001). Likewise loss of EpCAM epithelial marker was coincident with Vimentin overexpression (P < 0.001). RT-PCR analysis of transcription factors Snail, Slug, and Twist showed a highly variable expression, although a general trend to increase was observed. Importantly, in some selected cases it was possible to establish a precise relationship between spheroid formation, EMT switch and increased upregulation of the marker related to cancer stemness such as ALDH positivity. Therefore, MPE-derived cell cultures, while recapitulating the heterogeneity of lung cancer, are a suitable system to study the mechanisms at the basis of EMT and to understand its relationship with the generation of cancer stem cells.

TrkB is responsible for EMT transition in malignant pleural effusions derived cultures from adenocarcinoma of the lung

Lung cancer is the leading cause of cancer-related mortality worldwide. Recent evidence indicates that tumors contain a subpopulation of cancer stem cells (CSCs) that are responsible for tumor maintenance and spread. CSCs have recently been linked to the occurrence of epithelial-to-mesenchymal transition (EMT). Neurotrophins (NTs) are growth factors that regulate the biology of embryonic stem cells and cancer cells, but still little is known about the role NTs in the progression of lung cancer. In this work, we investigated the role of the NTs and their receptors using as a study system primary cell cultures derived from malignant pleural effusions (MPEs) of patients with adenocarcinoma of the lung. We assessed the expression of NTs and their receptors in MPE-derived adherent cultures vs. spheroids enriched in CSC markers. We observed in spheroids a selectively enhanced expression of TrkB, both at the mRNA and protein levels. Both K252a, a known inhibitor of Trk activity, and a siRNA against TrkB strongly affected spheroid morphology, induced anoikis and decreased spheroid forming efficiency. Treatment with neurotrophins reversed the inhibitory effect of K252a. Importantly, TrkB inhibition caused loss of vimentin expression as well as that of a set of transcription factors known to be linked to EMT. These ex vivo results nicely correlated with an inverse relationship between TrkB and E-cadherin expression measured by immunohistochemistry in a panel of lung adenocarcinoma samples. We conclude that TrkB is involved in full acquisition of EMT in lung cancer, and that its inhibition results in a less aggressive phenotype.

Efficacy and cost effectiveness of rapid on site examination (ROSE) in management of patients with mediastinal lymphadenopathies

BACKGROUND

The diagnostic and staging approach for the mediastinal lymphadenopathies, with or whithout pulmonary lesions endoscopically visible, is based on transbronchial needle aspiration (TBNA) during fiberoptic bronchoscopy and on mediastinoscopy. One important factor impacting on TBNA sensitivity is the rapid on site cytological examination (ROSE).

AIM

The aim of this study was to evaluate the economic impact of TBNA and TBNA + ROSE, in the diagnosis of these lesions.

PATIENTS AND METHODS

120 patients, affected by mediastinal lymphadenopathies suspected for lung cancer, underwent TBNA during fiberoptic bronchoscopy: 60 patients without ROSE (group A) and other 60 with ROSE (group B). Whenever needle aspirations failed to provide diagnosis, the patient underwent mediastinoscopy. The economic impact of the diagnostic process was performed.

RESULTS

In group A, 39 patients (65%) obtained a diagnosis with TBNA while 21 patients (35%) required mediastinoscopy. In group B, 48 patients (80%) obtained a diagnosis with TBNA + ROSE, while 12 patients (20%) required mediastinoscopy. With regards to the costs of the procedures performed in the diagnostic process, the use of TBNA with ROSE as first diagnostic approach has saved a considerable amount of euros (19,413) compared to the use of TBNA without ROSE and the combined procedure increased (p < 0.02; chi square test) the sensitivity of TBNA by 15%.

CONCLUSIONS

ROSE significantly impacts on the diagnostic yield, as well as on the overall management costs of patients with mediastinal lymphadenopathy, suspected for lung cancer.

Abstract 248: Stearoyl-CoA desaturase 1 is a key factor for lung cancer stem cell survival and expansion

In recent years studies of cancer development and recurrence have been significantly influenced by the Cancer Stem Cell (CSC) hypothesis. According to this, cancer is sustained by highly-positioned, chemoresistant cells with extensive capacity of self renewal, which are responsible for disease relapse after treatment with debulking agents. Growth of cancer cells as non-adherent spheroids in non differentiating conditions is regarded as a useful methodology to enrich for cells endowed with CSC-like features. We have recently reported that cell cultures derived from Malignant Pleural Effusions (MPE) of patients affected by adenocarcinoma of the lung are able to form spheroids in non-adherent conditions supplemented with selected growth factors, that these spheroids upregulate markers associated with stemness, can be serially propagated in vitro through several passages and, finally, give rise efficiently to tumors, which reproduce the same histopathological features of the original human tumor when implanted in immunodeficient mice. By expression profiling we also identified a set of genes whose expression is significantly upregulated in lung tumor spheroids vs adherent cultures. One of the most strongly upregulated gene was Stearoyl-CoA desaturase (SCD1), the main enzyme responsible for the conversion of saturated into monounsaturated fatty acids. In the present study we show both by RNA interference or through the use of a small molecule inhibitor that SCD1 is required for lung cancer spheroids propagation both in stable cell lines and in primary tumor cultures. SCD1 inhibition causes a dramatic impairment of survival of cells which express ALDH and other markers of stemness in vitro. Morphological examination and image analysis of the tumor spheroids formed in the presence of SCD1 inhibitors showed a different pattern of growth characterized by irregular cell aggregates. Electron microscopy revealed that the treated spheroids displayed several features of cellular damage and immunofluorescence analysis on optical serial sections showed apoptotic cells positive for the M30 marker, most of them positive also for the stemness marker ALDH, thus suggesting that the SCD1 inhibitor is selectively killing cells with stem like properties. Furthermore, SCD1-inhibited lung cancer spheroids were strongly impaired in their in vivo tumorigenicity. These results suggest that SCD1 is a critical target in lung cancer tumor initiating cells.

Citation Format: Gennaro Ciliberto, Alessia Noto, Claudia De Vitis, Roberta Barzellotti, Giuseppe Roscilli, Luigi Aurisicchio, Salvatore Raffa, Alberto Ricci, Salvatore Mariotta, Maria Rosaria Torrisi, Maria Rosaria Giovagnoli, Rita Mancini. Stearoyl-CoA desaturase 1 is a key factor for lung cancer stem cell survival and expansion. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 248. doi:10.1158/1538-7445.AM2013-248

NT-proatrial natriuretic peptide as a possible biomarker of cardiopulmonary involvement in sarcoidosis

BACKGROUND

Lung diffusion for carbon monoxide (DLCO) has been shown to associate with the risk of pulmonary arterial hypertension development and, most likely, with right ventricular (RV) myocardial dysfunction in sarcoidosis patients. Besides its known role as a marker of left ventricular dysfunction, experimental evidence suggests a role of NT-proAtrial Natriuretic Peptide (NT-proANP) also in modulating pulmonary circulation. We therefore investigated possible relationships between NT-proANP, lung diffusion impairment and RV dysfunction.

METHODS

Thirty-two pulmonary sarcoidosis outpatients and eighteen volunteers underwent full clinical assessment, including full lung function tests and Doppler echocardiography integrated with tissue Doppler imaging (TDI) study. Resting circulating NT-proBNP and NT-proANP plasma levels were also determined.

RESULTS

NT-proANP and RV-myocardial performance index (RV-MPI) were significantly higher in those patients with the greatest DLCO impairment, whereas no differences were found for NT-proBNP values. At multivariable analysis, only DLCO (β: -0.496; standard error: 3.38; p=0.000) and RV-MPI (β: 0.373; standard error: 6.56; p=0.031) remained significantly associated with NT-proANP levels.

CONCLUSIONS

Our finding may support a key role of NT-proANP in the complex mechanisms underlying modulation of lung function. An early increase in pulmonary vascular resistance may stimulate NT-proANP increase, thus explaining its association with signs of early RV myocardial dysfunction. This hypothesis warrants further confirmation.

Metastasis to the colon from lung cancer presenting with severe hyponatremia and dyspnea in a young male: A case report and review of the literature

This study aimed to present the atypical clinical presentation and management of a metastatic lung cancer that had spread to an atypical location. Lung cancer is the most common cause of cancer-related mortality worldwide. The brain, liver, adrenal glands and bone are the most common sites of metastatic disease in patients with lung cancer. The reported incidence of symptomatic gastrointestinal metastases is 0.2–0.5%. Early diagnosis should be based on the observation of clinical symptoms and computed tomography (CT) imaging. In the present study, we describe the case of a 43-year-old male with a primary adenocarcinoma of the lung located in the lower right lobe. Following diagnosis, the patient underwent five lines of chemotherapy with a significant tumor reduction. Two years later, a mass located in the sigmoid colon was detected in the patient following a PET/CT scan. The clinical presentation was unusual with vomiting, headache, dyspnea and laboratory hyponatremia. A rare form of metastatic ulcerating adenocarcinoma was identified with colonoscopy, which was confirmed by immunohistochemical findings. A surgical approach was not performed due to the worsening condition of the patient. The patient demonstrated severe anemia and blood hypoxia, and one month later, the patient succumbed to disease. The metastasis may suggest an increase in tumor aggressiveness.

Homeodomain-interacting protein kinase2 in human idiopathic pulmonary fibrosis

Homeodomain-interacting protein kinase 2 (Hipk2) is an emerging player in cell response to genotoxic agents that contributes to the cell's decision between cell cycle arrest or apoptosis. HIPK2 acts as co-regulator of an increasing number of transcription factors and modulates many different basic cellular processes such as apoptosis, proliferation, DNA damage response, differentiation. Idiopathic pulmonary fibrosis (IPF) is characterized by an anatomical disarrangement of the lung due to fibroblast proliferation, extracellular matrix deposition and lung function impairment. Although the role of inflammation is still debated, attention has been focused on lung cell functions as fibroblast phenotype and activity. Aim of the present study was to analyze the loss of heterozygosity (LOH) at HIPK2 locus 7q32.34 in human lung fibroblasts and the HIPK2 expression in 15 IPF samples and in four primary fibroblast cell cultures isolated from IPF biopsies using semi-quantitative RT-PCR, Western blots and immunohistochemistry. We demonstrated a frequency of LOH in IPF fibroblasts of 46% for the internal D7S6440 microsatellite and 26.6% for the external D7S2468 microsatellite. Furthermore, we demonstrated low HIPK2 protein expression in those fibroblasts from IPF patients that present the HIPK2 LOH. The restoration of HIPK2 expression in IPF derived cells induced a significant reduction of chemoresistance after treatment with cisplatin. The results obtained allow us to hypothesize that HIPK2 dysfunction may play a role in fibroblasts behavior and in IPF pathogenesis. HIPK2 may be considered as a novel potential target for anti-fibrosis therapy.

Reliability of direct sequencing of EGFR: comparison between cytological and histological samples from the same patient

The results of a recent study have shown the superiority of treatment with gefitinib or erlotinib in lung tumors positive for epidermal growth factor receptor (EGFR) mutation. As a consequence, the complete diagnosis of lung cancer cannot be limited to histotype classification, but should include a series of molecular biology analyses. In most cases, the diagnosis of lung cancer is performed on cytological specimens; therefore, there is a need to obtain a complete and reliable molecular diagnosis on cytologic specimens. Brushing, transbronchial needle aspiration (TBNA) and broncho alveolar lavage during fibro-bronchoscopy allow the sampling of the lung and the mediastinal lymph node. The aim of this study was to demonstrate that direct sequencing of exons 19 and 21 of EGFR in lung tumors, carried out on the cytological samples obtained through fibro-bronchoscopy, is as reliable as the same analysis carried out on a histological surgical sample obtained from the same individual. We considered 50 patients with a histological diagnosis of lung adenocarcinoma whose cytological samples, obtained by fibro-bronchoscopy and histological samples, obtained by surgical resection were available. A comparison of the sensitivity and reliability of the molecular biology analyses carried out on histological and cytological samples of the same patient was carried out. The combined mutation percentage of exons 19 and 21 of EGFR was 10%. The results of the analyses carried out on cytological samples matched those obtained from the histological samples. The feasibility of EGFR analysis on cytological samples has already been demonstrated in previous studies, however these studies referred to the method of fluorescence in situ hybridization, or did not perform any comparison between histological samples from the same patient; our work, on the other hand, shows that direct sequencing of exons 19 and 21 of the EGFR gene is feasible on fibro-bronchoscopy cytological samples with the same reliability offered by the histological samples obtained from the same patient.

Spheres derived from lung adenocarcinoma pleural effusions: molecular characterization and tumor engraftment

Malignant pleural effusions (MPEs) could represent an excellent source to culture a wide variety of cancer cells from different donors. In this study, we set up culture conditions for cancer cells deriving from MPEs of several patients affected by the most frequent form of lung cancer, namely the subset of non small cell lung cancers (NSCLC) classified as Lung Adenocarcinomas (AdenoCa) which account for approximately 40% of lung cancer cases. AdenoCa malignant pleural effusions gave rise to in vitro cultures both in adherent and/or in spheroid conditions in almost all cases analyzed. We characterized in greater detail two samples which showed the most efficient propagation in vitro. In these samples we also compared gene profiles of spheroid vs adherent cultures and identified a set of differentially expressed genes. Finally we achieved efficient tumor engraftment in recipient NOD/SCID mice, also upon inoculation of small number of cells, thus suggesting indirectly the presence of tumor initiating cells.

Severe pneumonia caused by Nocardia farcinica and complicated by Staphylococcus haemoliticus superinfection

It is reported the case of a subject 54 years old, painter, drinker and smoker who after an episode of cooling and the occurrence of widespread pain was taking its own initiative, cortisone and analgesics from approximately 30 days. The symptoms worsened and the patient was hospitalized. Chest X-ray and CT scan showed an extensive opacity in the left upper lobe with excavations in the context and also some nodular opacities excavated in the contralateral lung. In the first eight days after admission, the clinical picture despite empirical antibiotic therapy worsened towards adult respiratory distress syndrome (ARDS). On the ninth day after the admission, strains of Nocardia farcinica and Staphylococcus haemoliticus were isolated from the sputum. The targeted therapy (trimethoprim-sulfamethoxazole, amikacin, etc.) induced a rapid improvement of the clinical picture that was resolved in 6 months. Pneumonia caused by Nocardia farcinica is rare but its identification is necessary to set an appropriate therapy.

Cytology on transbronchial needle aspiration (TBNA): not only for lung cancer

Transbronchial needle aspiration (TBNA) is a bronchoscopic technique allowing the sampling of cytological/histological material from mediastinal lymph nodes. TBNA is routinely used only in few centers for the staging of lung cancer, and even less frequently for the diagnosis of mediastinal metastases from extrapulmonary tumors. We illustrate 5 cases of mediastinal metastases from extrapulmonary tumors observed at our center in order to emphasize the usefulness of cytology and TBNA in the diagnosis of these pathologies. The 5 cases illustrated were: seminoma, uterine cervical carcinoma, pleural mesothelioma, pancreatic carcinoma, pericardial mesothelioma. In these 5 cases, albeit not of lung cancer, the cytology on TBNA allowed the rapid formulation of the correct diagnosis; its main advantage is that it can be performed during a simple fiberbronchoscopy under local anesthesia with less risk and at a lower cost than a computed tomography-guided needle biopsy or mediastinoscopy.

Neurotrophin system activation in pleural effusions

Neurotrophins (NTs) expression was assessed in malignant and non-malignant pleural effusions (inflammatory exudates and transudates). Enzyme-linked immunosorbent assay, in malignant exudates from small and non-small cell lung cancer (SCLC and NSCLC), detected nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and neurotrophin-3 (NT-3), and their levels are higher as compared with inflammatory and transudative effusions. By immunoblots, in cultured cancer cells coming from malignant pleural effusions, NTs and low- and high-affinity NT receptors were detected in a percentage of SCLC and NSCLC. Proliferation assay demonstrated that BDNF significantly increased cancer cell proliferation in vitro, on the contrary, NT-3 reduced cancer cell growth rate and NGF did not modify cell growth. Moreover, NGF protects cells from death during starvation. These effects are reverted by the addition of NT receptor antagonists. Cultured cancer cells injected into the lung of immunodeficient mice generate lung tumors expressing NTs and NT receptors. These findings suggest that NTs may be able to modulate cancer cell behavior and their growth.

Influenza A H1N1 and severe asthma exacerbation

The pandemic influenza A H1N1 will affect millions of subjects. This influenza can cause respiratory complications with possible death. We have described two case reports of acute severe asthma exacerbation combined to influenza A H1N1, caracterized by severe respiratory failure. The diagnosis of influenza A H1N1 was confirmed with the multiplex reverse transcription-polymerase chain reaction (RT-PCR) assay. These patients, apart from asthma, do not have other diseases; but they did not take adequate therapy. In addition to conventional therapy (corticosteroids, bronchodilator and antibiotics) oseltamivir 75 mg bid was immediately added. After few days the patients improved and therefore in a short time they were discharged. During this period, in the case of severe asthma exacerbations, one must always think of influenza A H1N1 as the possible cause. It is necessary to use oseltamivir precociously to avoid severe complications. All asthmatic patients must regularly take their therapy especially during pandemic influenza A H1N1.

Primary Cardiac Angiosarcoma in a Young Woman

A 30-year-old woman was admitted to our hospital with severe shortness of breath. A transthoracic echocardiogram showed moderate pericardial effusion with a lesion in the right atrium, confirmed by chest CT scan and cardiac RMN. Pleural and middle lobe involvement occurred within one month. Middle lobe biopsy was performed and pathological examination confirmed the diagnosis of metastatic angiosarcoma. After two months, because of recurrent pleural effusions, chemical pleurodesis was performed. Chemotherapy was started but the patient died four months after the diagnosis. This case highlights the misdiagnosis at initial clinical presentation, available diagnostic approaches and therapeutic options for cardiac angiosarcoma.

Serum CA 15-3 is increased in pulmonary fibrosis

BACKGROUND AND AIM OF THE WORK

Carbohydrate antigen CA 15-3 is a glycoprotein whose expression, aberrant intracellular localization and changes in glycosylation have been associated with a wide range of cancers. Pulmonary fibrosis represents the final evolution of a chronic inflammation and is defined by the overgrowth of fibroblasts and exaggerated extracellular matrix deposition. The aim of the present study was to evaluate the possible diagnostic role of CA 15-3 in fibrosis in different idiopathic interstitial pneumonias.

METHODS

CA 15-3 was measured in serum samples from healthy subjects (n=25) and patients affected with idiopathic pulmonary fibrosis (IPF/UIP) (n=20), sarcoidosis (n=22) at different stages (I, II, and III) and systemic sclerosis (n=25). CA 15-3 protein expression was also evaluated by immunohistochemistry in 21 lung biopsies and in 6 primary lung fibroblasts cell lines.

RESULTS

The CA 15-3 serum levels were significantly higher in patients with IPF/UIP and with clinically advanced sarcoidosis (stage III). Serum CA 15-3 levels were slightly increased in patients with systemic sclerosis. No difference was observed between serum CA 15-3 levels in patients with sarcoidosis at stages I and II compared with control subjects. In IPF/UIP and in sarcoidosis at stage III elevated CA 15-3 serum levels significantly correlated with decreased total lung capacity, decreased diffusing capacity of carbon monoxide and high resolution computed tomography findings. Immunohistochemical analysis showed an intense specific CA 15-3 staining in fibroblasts within fibroblastic foci, surrounding sarcoid granulomas and in all cell cultures of lung fibroblasts from IPF/UIP lungs.

CONCLUSIONS

Our results indicate that increased CA 15-3 levels are associated with pulmonary interstitial damage, fibroblast activity and progression to fibrosis of the lung. Therefore, CA-15-3 may be considered a sensitive marker useful in the identification of patients with advanced fibrosis and more severe prognosis.

When should a reversibility test be performed on patients with early stages of asthma and normal spirometry?

Subjects with bronchial asthmatic symptoms, forced expiratory volume in 1 second (FEV(1)) and FEV(1)/forced vital capacity [FVC] > 80% could show a positive reversibility test with salbutamol in about 25% of the cases. The aim of this study was to evaluate if a limit functional value for spirometry exists where a reversibility test using salbutamol, over this limit, is not necessary to confirm the diagnosis of asthma. Four hundred patients (mean age 31.12 +/- 10.99) with asthmatic symptoms and normal spirometry (mean FEV(1) 96.06 +/- 11.82%, mean FEV(1)/FVC 98.89 +/- 6.03%) were recruited. The number of subjects with reversible airflow obstruction (RAO) was evaluated using the following different criteria of reversibility: FEV(1) and FVC >or= slant 12%, peak expiratory flow (PEF) >or= slant 15%, FEF(25 -75) >or= slant 35%, and at least one of these (ANY). In subjects with baseline FEV(1) > 100% (150 patients), 26 (17.3%) patients showed a FEV(1) increase > 12% and, among the criteria used, 45 patients (30%) showed ANY. In subjects with baseline FEV(1)/FVC > 100% (204 patients), 36 patients (17.6%) showed a FEV(1) increase > 12% and 53 patients (26.8%) showed ANY. In subjects with baseline FEF(25 -75) > 70% (209 patients), 26 (12.44%) and 49 (23.44%) patients, respectively, showed an increase in FEV(1) > 12%, and ANY. In 56 patients with baseline cut-offs (evaluated together) FEV(1) > 100%, FEV(1)/FVC > 100% and FEF(25-75) > 70%, 10 patients (17.85%) showed a RAO with ANY. FEV(1) > 121% or FEV(1)/FVC > 110.8% or FEF(25 -75) > 110% were cut-off values identified in this study where no RAO subjects were found over these limits. In conclusion, baseline FEV(1) > 100%, FEV(1)/FVC > 100% and FEF(25 -75) > 70% cannot be considered cut-offs where it is not necessary to perform a reversibility test with a bronchodilator over these limits. It is improbable to find a positive reversibility test using salbutamol in patients with asthmatic symptoms and FEV(1) > 121% or FEV(1)/FVC > 110.8% or FEF(25 -75) > 110% to confirm the diagnosis of asthma.

Tissue inhibitor of metalloproteinase 2 (TIMP-2) expression in adenocarcinoma pleural effusions

Serous effusions are frequently a clinical manifestation of metastatic disease, with lung, breast and ovarian carcinoma and mesothelioma leading the list. The diagnosis of malignant effusion signifies disease progression and is associated with a worsening patient prognosis. The ability to grow in a dense exudative fluid suggests that the malignant cells are capable of acquiring nutrients, surviving and proliferating, despite the lack of a solid-phase scaffold. During proliferation, neoplastic cells release ligands and matrix metalloproteinases (MMPs) into their environment, which dissolve the extracellular matrix (ECM). Tissue inhibitors of metalloproteinase (TIMPs) are endogenous regulators of MMPs, the principal enzymes responsible for the degradation of ECM in metastasis, and reduce their proteolytic activity. TIMP-2 has demonstrated an association between high tumor tissue expression levels and poor prognosis. The purpose of this preliminary study is to investigate, by immunocytochemistry, TIMP-2 expression in non-neoplastic and metastatic adenocarcinoma pleural effusions. We selected 16 cases of reactive mesothelio, 7 of normal mesothelio, 14 of lung adenocarcinoma, 9 from the ovary, 4 from the gastrointestinal tract and 3 from the breast. In 23/30 cases (76%), we detected adenocarcinoma cells with strong TIMP-2 expression. Positive TIMP-2 expression was found in 2/7 cases (28%) of normal and 2/16 (12%) of reactive mesothelio. A statistical association was detected between TIMP-2 expression and metastatic adenocarcinoma cells compared to reactive and normal mesothelial cells (p<0.00003). The calculated sensitivities for TIMP-2 compared to CEA and Ber-EP4 were, respectively, 76.7, 80.0 and 93.3%, and the specificities 82.6, 95.7 and 87.0%. In conclusion, immunocytochemical detection of TIMP-2 could be considered an interesting marker in metastatic adenocarcinoma pleural effusions, and could possibly be used as a component of an antibody panel in diagnostic cytopathology.

Oral corticosteroids can improve nocturnal isolated hypoxemia in stable COPD patients with diurnal PaO2 > 60 mmHg

The aim of this study was to evaluate whether a short therapy cycle of oral methylprednisolone plus conventional therapy might improve isolated nocturnal hypoxemia evidenced through pulse-oxymetry in 28 patients (19 M/9 F; mean age 71 +/- 8.31) with stable moderate to severe COPD (average FEV1 of 43.33 +/- 9.38 of theoretical) and daytime PaO2 > 60 mmHg. All patients showed oxygen desaturation during the night and apnoea/hypoapnoea index < or = 10, measured by means of a nocturnal polysomnography and were successfully on conventional treatment for COPD. The patients were randomly divided into two groups: 14 (steroid group) were administered methylprednisolone for three weeks at progressively decreasing doses (16 mg/die for the first 7 days, then 8 mg die for another 7 days, and finally 4 mg die for another 7 days) plus conventional therapy (bronchodilators and inhaled corticosteroids). The remaining 14 patients (control group) instead were on conventional therapy only. After 3 weeks for the steroid group, but no for the control group, was improved next parameters (p < 0.0001): VC (L) dropped from 2.53 +/- 0.85 measured at baseline to 2.82 +/- 0.84, FEV1 dropped from 1.07 +/- 0.31 L to 1.23 +/- 0.31 L, the IC dropped from 1.71 +/- 0.48 to 2 +/- 0.37 L, the average nocturnal SpO2% from 90.4 +/- 1.79 to 92.3 +/- 1.72 and the Nocturnal Time % of SpO2 < 90% went from 31.19 +/- 18.12 to 10.88 +/- 11.56 after 3 weeks of therapy. Also dyspnoea, sleep duration and mean heart rate significantly improved (p < 0.0001). There was also a significant correlation between average increase in mean nocturnal SpO2% and in Lowest SpO2% and the variation in inspiratory capacity (IC) and in Sleep Duration % in the steroid group (p < 0.0001). In conclusion, methylprednisolone in combination with conventional medical therapy not only improved lung function values but also mean nocturnal oxyhemoglobin saturation and sleep duration in clinically stabilized COPD patients who experience nocturnal oxyhemoglobin desaturation.

Increased pulmonary neurotrophin protein expression in idiopathic interstitial pneumonias

BACKGROUND AND AIM OF THE STUDY

Idiopathic interstitial pneumoniae (IIPs) are characterized by fibroblast proliferation, extracellular matrix deposition and progressive lung function impairment. Because effective therapeutic strategies still remain limited, research has been directed toward the identification of novel targets for additional therapeutic options. The neurotrophins (NTs) nerve growth factor (NGF), brain derived neurotrophic factor (BDNF) and NT-3, beside their importance in nervous, endocrine and immune system activities, participate in chronic inflammatory disorders and in repair processes.

METHODS

We have investigated NT and high and low affinity NT receptor expression in IIPs using immunoblots and immunohistochemistry. Fourteen idiopatic pulmonary fibrosis/usual interstitial pneumoniae (IPF/UIP), eight non specific pneumoniae (NSIP) and eight respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) were analyzed.

RESULTS

Immunoblots revealed that NT and high affinity NT receptor proteins were more abundantly expressed in IPF/UIP than NSIP and RB-ILD patients. In RB-ILD, a faint expression of NT-3 and NT receptors were detected. NT and NT receptor immunostaining was detected in interstitial cells from IPF/UIP, NSIP and RB-ILD patients by immunohistochemistry. Fibroblastic foci in IPF/UIP strongly stained for BDNF and its high affinity receptor TrkB and in lesser amount for NGF, NT-3 and their respective high affinity receptors TrkA and TrkC. Furthermore, in fibroblast culture derived from IPF/UIP patients, the proliferation rate of primary culture and clones derived from primary lines was stimulated by BDNF but down regulated by NT-3. In contrast, NGF did not influence IPF/UIP fibroblasts proliferation.

CONCLUSIONS

Our data suggest that that NTs may exert differential activities on lung fibroblasts and may be considered as potential regulatory molecules influencing fibroblast behavior in IPF/UIP patients. Therefore, NTs may play a role in IIPs patho-physiology representing novel potential therapeutic targets.

Changes in muscarinic cholinergic receptor expression in human peripheral blood lymphocytes in allergic rhinitis patients

BACKGROUND

Parasympathetic nerves provide the dominant autonomic innervation of the upper and lower airways. They release acetylcholine that, activating post-junctional muscarinic receptors, causes bronchoconstriction, mucous secretion and vasodilation. Dysfunction of the upper and lower airways frequently coexist, and they appear to share key elements of pathogenesis.

OBJECTIVE

The present study has assessed the expression and pattern of cholinergic muscarinic receptor subtypes in peripheral blood lymphocytes harvested from allergic rhinitis patients with different degree of bronchial hyperresponsiveness detected by methacholine challenge test.

METHODS

Radioligand binding assay for determining the density of muscarinic cholinergic receptor subtypes; immunoblot analysis for assessing the characteristic of muscarinic cholinergic receptor subtype protein and immunocytochemical techniques for investigating the cellular localization of receptors.

RESULTS

An increased expression of M2 and M5 receptor proteins was observed in peripheral blood lymphocytes of allergic rhinitis patients in comparison with healthy control individuals. M3 receptor subtype decreased in allergic rhinitis patients with normal or mild responses to methacholine. A trend versus a return to normal value was found in moderate and severe responders. No changes of the M4 receptor subtype were found.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Increase in M2 receptor expression correlated with disease severity and bronchial hyperreactivity. Changes in muscarinic cholinergic receptor expression in allergic rhinitis underline a role of cholinergic system of immune cells in allergic airway disease.

CAPSULE SUMMARY

Studies addressed to rhinitis and asthma have identified many similarities. Our results indicate that changes in peripheral blood lymphocyte muscarinic receptor expression may reflect the cholinergic involvement into allergic airway diseases.

Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: A single-institution experience in 861 cases

OBJECTIVE

We sought to evaluate the outcome of 861 patients treated with videothoracoscopic talc poudrage for primary spontaneous pneumothorax.

METHODS

From September 1995 through January 2004, a total of 861 patients (578 male, 283 female, mean age 28.6 years) underwent videothoracoscopy for recurrent and complicated primary spontaneous pneumothorax. Patients were treated with videothoracoscopic talc poudrage only (group A: Vanderschueren's stage I, 196 patients; stage II, 112 patients) or videothoracoscopic talc poudrage plus stapling of the blebs/bullae (group B: stage III, 391 patients; stage IV 162 patients). Follow-up included clinical interview and chest radiography (805 patients). In 26 patients (follow-up longer than 5 years), respiratory function was investigated to determine residual volume and diffusing lung capacity.

RESULTS

No operative deaths occurred. No patient had adult respiratory distress syndrome. Postoperative complications occurred in 29 patients (3.36%). The conversion rate to an open procedure was 0.46% (4/861). After a mean follow-up of 52.5 months, 14 patients had recurrences (1.73%). The recurrence rate was 2.41% (7/290) in group A and 1.359% (7/515) in group B (chi2 value: 1.207389; P:.27; odds ratio: 0.56; 95% confidence interval: 0.20-1.62). Results of respiratory function tests were within normal ranges (80% or more of predictive value) in all 26 patients.

CONCLUSIONS

Videothoracoscopic talc poudrage achieves a high success rate in the treatment of primary spontaneous pneumothorax with a very low morbidity rate. Recurrences show a statistically significant relationship (P:.037) with smoking habits.

Reversibility test in the early stages of bronchial asthma

In the early stages of bronchial asthma, it is frequent to find subjects with a positive history and an FEV1 or FEV1/FVC > 80% of the predicted value. This study investigated if the test of reversibility showed a reversible airway obstruction (RAO) in 291 subjects with the above clinical and functional features. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and expiratory flows (PEF, MEF50, FEF(25-75)) were registered before and 20 minutes after salbutamol administration (200 mcg by MDI). Of 291 subjects, FEV1 increased in 73 (25%) after bronchodilator > or = 12% compared to baseline; the number of subjects with a > or = 35% increase in MEF50 or FEF(25-75) were similar in terms of percentage (respectively, 29.2% and 29%), whereas those with increases in FVC (> or = 12%) and in PEF (> or = 15%) were significantly lower (respectively, 2.7% and 12.3%). The percentage of subjects with RAO (FEV1 increase after bronchodilator > or = 12%) was lower (12%) in the subgroup (108 subjects), with an MEF50 > or = 70% of the value predicted at the baseline assessment, and higher (36%) in the subjects of the subgroup (183 subjects) with an MEF50 < 70%. In conclusion, it is advisable to carry out reversibility tests in all subjects with symptoms indicative of asthma even if their functional tests are "normal" because in a considerable number of cases the RAO was found to confirm the suspected diagnosis and provided a more reliable classification of the disease.

Neurotrophin system expression in human pulmonary carcinoid tumors

Neurotrophin (NT) and NT receptor expression was assessed in 12 typical (TC) and 8 atypical (AC) human pulmonary carcinoids by Western blot and immunohistochemistry. TC and AC carcinoid express to different extent NT and NT receptor proteins. Nerve growth factor (NGF) was expressed by 83% of the TC but not by the AC carcinoids. Brain derived neurotrophic factor (BDNF) was expressed by 33 and 100% of TC and AC carcinoids, respectively. NT-3 was expressed by 58% of the TC and 38% of AC carcinoids. TC carcinoids express high affinity NT receptors while 50% of the AC carcinoids express the TrkB receptor. Our results demonstrate that NGF/TrkA and BDNF/TrkB signaling need to be considered as regulatory pathways that may address survival, differentiation and/or aggressiveness of human pulmonary carcinoids. Contrarily to the BDNF/TrkB, expression of the NGF/TrkA signaling may overcome aggressiveness of carcinoid cells. NTs may be useful as markers in the clinic.

Neurotrophin system activation in bronchoalveolar lavage fluid immune cells in pulmonary sarcoidosis

BACKGROUND AND AIM OF THE STUDY

Pulmonary sarcoidosis is a chronic granulomatous disease characterized by macrophage and CD4+ T-cell accumulation at the site of inflammation. Analysis of the cytokine network has substantially improved knowledge on immunopathogenesis of sarcoidosis. We hypothesize that neurotrophins (NTs), nerve growth factor (NGF), brain derived neurotrophic factor (BDNF) and NT-3, besides their importance in immune system activities, participate in chronic inflammatory disorders and in repair processes.

METHODS

The expression of NTs and NT receptors was assessed in broncho alveolar lavage (BAL) macrophages, CD4 and CD8 T-cells, from 10 patients with pulmonary sarcoidosis, using molecular biology, Western blotting and immunocytochemistry.

RESULTS

Increased levels of NTs and of high affinity NT receptor (Trks) transcripts and proteins in BAL macrophages, CD4+ and CD8+ T-cells from pulmonary sarcoidosis patients were demonstrated in comparison with healthy controls. Contrarily to healthy controls, in pulmonary sarcoidosis the expression of NGF was increased in alveolar macrophages as well as NGF and BDNF in CD4+ and CD8+ T-cells. An increased expression of TrkA, TrkB and TrkC receptors was also noticeable. Furthermore, BDNF expression in alveolar macrophages and NT-3 expression in the three different BAL immune cell populations investigated were induced during sarcoidosis. A significant correlation was observed between CD4:CD8 ratio, lymphocytosis, radiological stage and CD4 and CD8 NT expression.

CONCLUSIONS

These findings suggest that NTs are exaggeratedly expressed in BAL immune cells in pulmonary sarcoidosis and may participate in the progression of disease modulating immune cell functions.

Time intervals (3' or 5') between dose steps can influence methacholine challenge test

Bronchial hyperresponsiveness (BHR) is a common feature in the majority of asthmatic subjects and methacholine is the most frequently used agent for the test. The influence of 3 or 5 min time intervals between doses steps in a double methacholine challenge test (MCH-3' or MCH-5') was investigated. Using the MCH-3' challenge, 52 intermittent asthmatics were classified as having moderate (BHR-M; 18 subjects), mild (BHR-m; 19 subjects), or bordeline (BHR-B; 15 subjects) BHR. The cumulative dose and the PD20FEV(1) were higher for MCH-5' compared with MCH-3' in BHR-m (p < 0.05) and BHR-B (p < 0.05) but not in the BHR-M group. Also the dose response slopes, FEV(1)% decline/cumulative methacholine dose, calculated for the two challenge tests were statistically different only in BHR-m (p < 0.05) and BHR-B (p < 0.01). At MCH-5', there were 16 subjects with BHR-M, 18 with BHR-m, 12 with BHR-B and 6 subjects with normal reactivity. Results may suggest that in the group of BHR-m and BHR-B subjects, at MCH-5' compared with MCH-3', the cumulative effect of the administered drug, quickly metabolized by cholinesterase, is not complete, thus leading to an incorrect estimation of bronchial hyperresponsiveness degree. It is hoped that time interval between doses be standardized to ensure maximum comparability within and between subjects in challenge tests.

The influence of ipratropium bromide in the recovery phase of methacholine induced-bronchospasm

BACKGROUND

The protective effect of Ipratropium Bromide (IB) in the methacholine-induced bronchospasm is well known from some time. The objective of the present study was to assess whether a pretreatment with IB may influence the subsequent phase of methacholine-induced bronchospasm relief.

METHODS

Sixteen patients with bronchial hyper-reactivity (PD20 FEV1 < 200 microg) were randomly assigned to three methacholine challenge tests at a 48 to 72 hours interval apart. In the first test IB was inhaled before the challenge (pre-IB), in the second IB was administered soon after the PD20 FEV1 (post-IB), and in the third no treatment was given (control).

RESULTS

The pre-IB PD20 FEV1 (695 +/- 587.6 microg) was significantly greater (p < 0.0001) than that of post-IB (82.2 +/- 49.18 microg) and of control (73.9 +/- 41.8 microg). The dose response slope (DRS) (decline percentage of FEV1/cumulative methacholine dose), in pre-IB was greatly lower (p < 0.0001) than that in post-IB and in control. During the bronchospasm relief phase, the increase of FEV1 measured after 5, 10, 15, 30 and 60 minutes from the PD20 FEV1 was significantly greater in post-IB (p < 0.05) compared with the other two conditions. Conversely, the recovery slope (RS) (increase percentage of FEV1 at 60 minutes after PD20 FEV1 x cumulative methacholine dose) was significantly more efficient (p < 0.001) in pre-IB than in post-IB and in control.

CONCLUSION

In conclusion, ipratropium bromide confirmed to have a good protective activity against methacholine-induced bronchospasm; the pre-administration of ipratropium bromide showed also a positive effect on the recovery phase.

Pulmonary alveolar microlithiasis: report on 576 cases published in the literature

BACKGROUND AND AIM OF THE WORK

Pulmonary alveolar microlithiasis (PAM) is a rare disease characterized by intra-alveolar calcium deposits. The etiology of the disease is still unknown and many authors have supposed that an inherited local enzymatic defect is responsible for calcium deposition. The present paper aimed to study the disorder throughout the world, emphasizing the diagnostic and therapeutic views.

METHODS

All the papers published on this subject in the literature were reviewed.

RESULTS

Cases studied were 576 and most of them came from Europe (42.7%) and Asia (40.6%). The countries involved were fifty-one and twelve of them were attributed with at least ten cases each (Bulgaria, France, Germany, India, Italy, Poland, Spain, Russia, Japan, Turkey, USA, ex-Yugoslavia). Symptoms were absent in more than half the patients; dyspnoea, cough and chest pain were reported in the other cases. Family history for the disease was found in one-third of the patients. Chest x-rays and computed tomography were so characteristic that they were enough to diagnose the disease even if microscopic evidence of the microliths into the alveoli was obtained in most cases (e.g. by biopsy, autopsy, bronchoalveolar lavage). Pulmonary tuberculosis or sarcoidosis were misdiagnosed in 88 cases out of the 576. The course of the disease was slow and patients usually died as a result of cardio-respiratory failure.

CONCLUSIONS

This review of PAM has shown that the etiology of the disease is still unknown, it is widespread throughout the world and easy to diagnose; it develops slowly and therapy is ineffective except for lung transplantation.

Elevated neurotrophin and neurotrophin receptor expression in spontaneously hypertensive rat lungs

Spontaneously hypertensive rats represent a widely used animal model of hypertension. Altered neurotrophin regulation has been related to systemic hypertension. Lung cells synthesize and release neurotrophins(NT) which are involved in several pulmonary disturbances. Our study explored the expression of NT and their receptors using molecular biology and immunohistochemistry. Spontaneously 6-, 20- and 29- weeks hypertensive (SHR) and Wistar Kyoto rat (WKY) lungs were used. SHR and WKY lungs expressed neurotrophin and neurotrophin receptor mRNAs and protein transcripts. Age and hypertension dependent increase was clearly noticeable. Furthermore, immunohistochemistry revealed that their increase was mainly noticeable within bronchial and vascular components of the lung. Although the role of NT in sympathetic hyperinnervation and progression of systemic hypertension is a well established phenomenon, their increase in SHR lungs, strongly suggest that NT may be operative during pulmonary hypertension and in subsequent airway and pulmonary vascular remodeling.

Neurotrophin and neurotrophin receptor protein expression in the human lung

Neurotrophins (NTs) promote survival and differentiation of central and peripheral neurons, and display several activities also in non-neuronal cells. Human lungs synthesize and release NTs, which are probably involved in the pathophysiology of pulmonary disturbances. In this article the expression and anatomic localization of nerve growth factor, brain-derived neurotrophic factor, and NT-3 and of corresponding high-affinity receptors TrkA, TrkB (full-length and truncated [TR-] isoforms), TrkC, and of the low-affinity p75 receptor, were assessed in surgical samples from adult human lung by reverse transcriptase-polymerase chain reaction, Western blot, and immunohistochemistry. NTs and their cognate receptor mRNA and protein transcripts were detected by reverse transcriptase-polymerase chain reaction and immunoblotting, respectively, nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) mRNA and corresponding protein transcripts being the most expressed. High levels of TrkB-[TR-] mRNA and of its protein transcript were also demonstrated, whereas a low expression of p75 mRNA and of corresponding protein transcript were found. Microanatomic analysis of immunohistochemical study revealed that bronchial epithelial cells were immunoreactive for different NTs, with a higher intensity of BDNF immune staining compared with other NTs, but did not express NT receptor immunoreactivity. Alveolar cells were immunoreactive for TrkA and TrkC receptor protein, but did not display immunoreactivity for NTs or other receptors investigated. Gland cells expressed NT and high-affinity NT receptor immunoreactivity, but not p75 receptor immunoreactivity. NT and low-affinity receptor immunoreactivity was observed within neurons and satellite cells of parasympathetic ganglia as well as in nerve fiber-like structures supplying the bronchopulmonary tree. An obvious immunoreactivity for NTs and NT receptor protein was also observed in intrapulmonary branches of pulmonary artery. Pulmonary lymphocytes and macrophages express nerve growth factor and high-affinity NT receptor immunoreactivity. The role of NTs in non-neuronal tissue including lung has not been clarified yet. The widespread expression of NTs and their receptors in different components of the lung suggests that these factors may contribute to regulate cell function in human lung.