COVID-19 or Cancer Stress? Anxiety and Depressive Symptoms in Patients with Advanced Lung Cancer

BACKGROUND

Of all cancer patients, those with lung cancer are among the highest risk for infection, pneumonia, hospitalization, and early death from COVID-19. As cancer stress is ubiquitous, this exploratory study examines patients' COVID-19 stress and cancer stress in relation to their depressive and anxiety symptoms.

METHOD

Newly diagnosed advanced lung cancer patients (N = 76) completed measures of cancer stress, COVID-19 illness perceptions and stress, and depressive and anxiety symptoms at a single monthly follow-up early in the pandemic (May 2020 to July 2020; Clinicaltrials.gov #NCT03199651). Hierarchical linear multiple regression analysis was used to identify the relationship of stressor variables to depressive and anxiety symptoms in this cross-sectional study.

RESULTS

Hierarchical linear models revealed cancer stress was a significant predictor of both depressive symptoms (F(14,30) = 5.327, p < 0.001, R2 = 0.71, adjusted R2 = 0.58) and anxiety symptoms (F(14,30) = 4.513, p < 0.001, R2 = 0.68, adjusted R2 = 0.53) for patients at the start of the COVID-19 pandemic. By contrast, COVID-19 stress was not a significant predictor of depressive (F(13,31) = 1.415 p = .21, R2 = .37, adjusted R2 = .11) or anxiety symptoms (F(13,31) = 1.23, p = .30, R2 = .34, adjusted R2 = - .07).

CONCLUSIONS

Advanced lung cancer patients during the early phase of the COVID-19 pandemic reported cancer stress as more important than COVID-19 stress in relation to their mental health. Empirically supported biobehavioral and cognitive behavioral treatments remain important to reducing psychological symptoms and enhancing patients' quality of life.

Accelerated epigenetic age, inflammation, and gene expression in lung: comparisons of smokers and vapers with non-smokers

BACKGROUND

Cigarette smoking and aging are the main risk factors for pulmonary diseases, including cancer. Epigenetic aging may explain the relationship between smoking, electronic cigarette vaping, and pulmonary health. No study has examined smoking and vaping-related epigenetic aging in relation to lung biomarkers.

METHODS

Lung epigenetic aging measured by DNA methylation (mAge) and its acceleration (mAA) was assessed in young (age 21-30) electronic cigarette vapers (EC, n = 14, including 3 never-smoking EC), smokers (SM, n = 16), and non-EC/non-SM (NS, n = 39). We investigated relationships of mAge estimates with chronological age (Horvath-mAge), lifespan/mortality (Grim-mAge), telomere length (TL-mAge), smoking/EC history, urinary biomarkers, lung cytokines, and transcriptome.

RESULTS

Compared to NS, EC and SM had significantly older Grim-mAge, shorter TL-mAge, significantly accelerated Grim-mAge and decelerated TL-mAge. Among SM, Grim-mAA was associated with nicotine intake and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL). For EC, Horvath-mAA was significantly correlated with puffs per day. Overall, cytokines (IL-1β, IL-6, and IL-8) and 759 transcripts (651 unique genes) were significantly associated with Grim-mAA. Grim-mAA-associated genes were highly enriched in immune-related pathways and genes that play a role in the morphology and structures of cells/tissues.

CONCLUSIONS

Faster lung mAge for SM is consistent with prior studies of blood. Faster lung mAge for EC compared to NS indicates possible adverse pulmonary effects of EC on biological aging. Our findings support further research, particularly on epigenetic markers, on effects of smoking and vaping on pulmonary health. Given that most EC are former smokers, further study is needed to understand unique effects of electronic cigarettes on biological aging.

Untargeted Metabolomics and Body Mass in Adolescents: A Cross-Sectional and Longitudinal Analysis

Obesity in children and adolescents has increased globally. Increased body mass index (BMI) during adolescence carries significant long-term adverse health outcomes, including chronic diseases such as cardiovascular disease, stroke, diabetes, and cancer. Little is known about the metabolic consequences of changes in BMI in adolescents outside of typical clinical parameters. Here, we used untargeted metabolomics to assess changing BMI in male adolescents. Untargeted metabolomic profiling was performed on urine samples from 360 adolescents using UPLC-QTOF-MS. The study includes a baseline of 235 subjects in a discovery set and 125 subjects in a validation set. Of them, a follow-up of 81 subjects (1 year later) as a replication set was studied. Linear regression analysis models were used to estimate the associations of metabolic features with BMI z-score in the discovery and validation sets, after adjusting for age, race, and total energy intake (kcal) at false-discovery-rate correction (FDR) ≤ 0.1. We identified 221 and 16 significant metabolic features in the discovery and in the validation set, respectively. The metabolites associated with BMI z-score in validation sets are glycylproline, citrulline, 4-vinylsyringol, 3'-sialyllactose, estrone sulfate, carnosine, formiminoglutamic acid, 4-hydroxyproline, hydroxyprolyl-asparagine, 2-hexenoylcarnitine, L-glutamine, inosine, N-(2-Hydroxyphenyl) acetamide glucuronide, and galactosylhydroxylysine. Of those 16 features, 9 significant metabolic features were associated with a positive change in BMI in the replication set 1 year later. Histidine and arginine metabolism were the most affected metabolic pathways. Our findings suggest that obesity and its metabolic outcomes in the urine metabolome of children are linked to altered amino acids, lipid, and carbohydrate metabolism. These identified metabolites may serve as biomarkers and aid in the investigation of obesity's underlying pathological mechanisms. Whether these features are associated with the development of obesity, or a consequence of changing BMI, requires further study.

A Pilot Cross-Sectional Study of Immunological and Microbiome Profiling Reveals Distinct Inflammatory Profiles for Smokers, Electronic Cigarette Users, and Never-Smokers

Smokers (SM) have increased lung immune cell counts and inflammatory gene expression compared to electronic cigarette (EC) users and never-smokers (NS). The objective of this study is to further assess associations for SM and EC lung microbiomes with immune cell subtypes and inflammatory gene expression in samples obtained by bronchoscopy and bronchoalveolar lavage (n = 28). RNASeq with the CIBERSORT computational algorithm were used to determine immune cell subtypes, along with inflammatory gene expression and microbiome metatranscriptomics. Macrophage subtypes revealed a two-fold increase in M0 (undifferentiated) macrophages for SM and EC users relative to NS, with a concordant decrease in M2 (anti-inflammatory) macrophages. There were 68, 19, and 1 significantly differentially expressed inflammatory genes (DEG) between SM/NS, SM/EC users, and EC users/NS, respectively. CSF-1 and GATA3 expression correlated positively and inversely with M0 and M2 macrophages, respectively. Correlation profiling for DEG showed distinct lung profiles for each participant group. There were three bacteria genera-DEG correlations and three bacteria genera-macrophage subtype correlations. In this pilot study, SM and EC use were associated with an increase in undifferentiated M0 macrophages, but SM differed from EC users and NS for inflammatory gene expression. The data support the hypothesis that SM and EC have toxic lung effects influencing inflammatory responses, but this may not be via changes in the microbiome.

Selective suppression of de novo SARS-CoV-2 vaccine antibody responses in patients with cancer on B cell-targeted therapy

We assessed vaccine-induced antibody responses to the SARS-CoV-2 ancestral virus and Omicron variant before and after booster immunization in 57 patients with B cell malignancies. Over one-third of vaccinated patients at the pre-booster time point were seronegative, and these patients were predominantly on active cancer therapies such as anti-CD20 monoclonal antibody. While booster immunization was able to induce detectable antibodies in a small fraction of seronegative patients, the overall booster benefit was disproportionately evident in patients already seropositive and not receiving active therapy. While ancestral virus- and Omicron variant-reactive antibody levels among individual patients were largely concordant, neutralizing antibodies against Omicron tended to be reduced. Interestingly, in all patients, including those unable to generate detectable antibodies against SARS-CoV-2 spike, we observed comparable levels of EBV- and influenza-reactive antibodies, demonstrating that B cell-targeting therapies primarily impair de novo but not preexisting antibody levels. These findings support rationale for vaccination before cancer treatment.

Lung mitochondrial DNA copy number, inflammatory biomarkers, gene transcription and gene methylation in vapers and smokers

BACKGROUND

Mitochondrial DNA copy number (mtCN) maintains cellular function and homeostasis, and is linked to nuclear DNA methylation and gene expression. Increased mtCN in the blood is associated with smoking and respiratory disease, but has received little attention for target organ effects for smoking or electronic cigarette (EC) use.

METHODS

Bronchoscopy biospecimens from healthy EC users, smokers (SM), and never-smokers (NS) were assessed for associations of mtCN with mtDNA point mutations, immune responses, nuclear DNA methylation and gene expression using linear regression. Ingenuity pathway analysis was used for enriched pathways. GEO and TCGA respiratory disease datasets were used to explore the involvement of mtCN-associated signatures.

FINDINGS

mtCN was higher in SM than NS, but EC was not statistically different from either. Overall there was a negative association of mtCN with a point mutation in the D-loop but no difference within groups. Positive associations of mtCN with IL-2 and IL-4 were found in EC only. mtCN was significantly associated with 71,487 CpGs and 321 transcripts. 263 CpGs were correlated with nearby transcripts for genes enriched in the immune system. EC-specific mtCN-associated-CpGs and genes were differentially expressed in respiratory diseases compared to controls, including genes involved in cellular movement, inflammation, metabolism, and airway hyperresponsiveness.

INTERPRETATION

Smoking may elicit a lung toxic effect through mtCN. While the impact of EC is less clear, EC-specific associations of mtCN with nuclear biomarkers suggest exposure may not be harmless. Further research is needed to understand the role of smoking and EC-related mtCN on lung disease risks.

FUNDING

The National Cancer Institute, the National Heart, Lung, and Blood Institute, the Food and Drug Administration Center for Tobacco Products, the National Center For Advancing Translational Sciences, and Pelotonia Intramural Research Funds.

Functional Trajectories and Resilience Among Adults With Advanced Lung Cancer

Introduction

To evaluate whether and the degree to which patients with advanced NSCLC (aNSCLC) receiving lung cancer treatments will experience functional disability or have resilience and to identify characteristics associated with functional disability.

Methods

We evaluated longitudinal data of patients with aNSCLC receiving treatment in the Beating Lung Cancer in Ohio prospective cohort study. Disability versus resilience in functional status (usual activities, mobility, and self-care) was measured monthly for 8 months using the EuroQol-5D-5L. Data captured included baseline demographics (Eastern Cooperative Oncology Group performance status), comorbidities, cancer and depressive symptoms (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7 scale), and cancer stress (impact of events). Group-based latent class trajectory modeling was used to determine clinically distinct functional disability trajectories jointly with attrition probability (death or withdrawal) in the study period.

Results

Among 207 participants, the mean age was 63.5 years (range: 34-92 y), 58.9% were male, 6.8% were African American or Black, 73.3% were former smokers, and 35% resided in rural areas. At baseline, participants had adenocarcinoma histological subtype (74.9%), 40.3% had brain metastases, and 46.1% had bone metastases. Participants received chemotherapy plus immunotherapy (46.9%), immunotherapy single agent (21.7%), targeted treatments (18.8%), or no treatment (12.6%). Three distinct functional trajectory groups were identified, as follows: none/mild (n = 79, 38.2%), moderate (n = 99, 47.8%), and severe disability (n = 29, 14.0%). Characteristics associated with severe disability included baseline Eastern Cooperative Oncology Group performance status greater than 1, worse dyspnea and pain, and higher Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 scale scores. At month 8, 95 participants (45.9%) displayed resilience, 11 (5.3%) experienced functional decline, and 69 (33.3%) were deceased.

Conclusions

We identified three distinct functional trajectories among patients with aNSCLC. Risk stratification tools and targeted interventions designed to target these three groups are needed to improve functional resilience and prevent disability.

Cancer Treatment During COVID-19: Resilience of Individuals With Advanced Non-Small Cell Lung Cancer Versus Community Controls

BACKGROUND

Among all patients with cancer, those with advanced non-small cell lung cancer (NSCLC) experience the most distress. Although new therapies are improving survival, it is unknown whether receiving immunotherapy or targeted therapy during the COVID-19 pandemic increases patients' psychological vulnerability. To meet clinical needs, knowledge of patients' COVID-19 perceptions and safety behaviors is essential. Thus, this study compared patients' psychological responses at diagnosis and during COVID-19 and compared patients with similar individuals without cancer during the same period.

PATIENTS AND METHODS

Patients with advanced NSCLC enrolled at diagnosis for cohort study participated (ClinicalTrials.gov identifier: NCT03199651). Those with follow-ups from April 28, 2020, through July 14, 2020 (n=76), were assessed again including COVID-19 measures. Simultaneously, community controls with similar sociodemographics and smoking histories were solicited (n=67). Measures were COVID-19 perceptions (Brief Illness Perception Questionnaire), social distancing, and depressive (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) symptoms. First, analyses evaluated differences in the psychological responses of patients with NSCLC at diagnosis and during COVID-19. Second, patients and controls were contrasted on COVID-19 perceptions, social distancing, and psychological symptoms.

RESULTS

The depressive and anxious symptoms of patients with NSCLC were greater at diagnosis (P<.02) than during COVID-19, approximately 1 year later. Patients with NSCLC and controls did not differ in terms of sociodemographics, except those with NSCLC were more racially diverse and older, and had greater smoking history (P<.03). Groups did not differ regarding concern, understanding, or perceived control over COVID-19 (P>.406). Notably, controls anticipated the COVID threat would last longer, practiced more social distancing, were more concerned about family (P<.04), and reported worse psychological symptoms (P<.023). With less depression and anxiety, patients with NSCLC viewed COVID-19 as a shorter-term threat and had fewer COVID-19-related worries than did controls. For controls, COVID-19 was more salient, heightening worries and psychological symptoms.

CONCLUSIONS

Despite multiple health stressors, patients with NSCLC demonstrated resilience when receiving cancer treatment during COVID-19. Nonetheless, this population remains psychologically vulnerable, requiring support at diagnosis and thereafter.

The experimental tobacco marketplace: Effects of low-ventilated cigarette exposure

OBJECTIVES

Regulating filter ventilation will change the relative reinforcing value of products resulting in nicotine/tobacco users facing the explore/exploit dilemma (ie, choice between unfamiliar and familiar options). This study examined the effects of price increases in higher-ventilated cigarettes (HVCs) and exposure to lower-ventilated cigarettes (LVCs) on explore/exploit patterns of tobacco-product purchasing in the Experimental Tobacco Marketplace (ETM).

METHODS

HVC smokers (N = 20) completed one assessment session and 3 ETM sessions separated by weeks of at-home LVC exposure. In each ETM session, participants made 7-days of tobacco-product purchases as HVCs price increased across trials.

RESULTS

Prohibitive prices of HVC decreased the likelihood of HVCs purchases and increased the likelihood of LVC purchases. Initial exposure (week 1) to LVC reduced the number of cigarettes purchased when HVC prices were high and increased exploration of alternative tobacco products. Successive exposure to LVC (repeated access in weeks 2,5,6,9,10) decreased likelihood of HVCs and alternative product purchases and increased the likelihood of LVCs purchases.

CONCLUSIONS

Regulating filter ventilation may initially increase exploration of alternative tobacco products but lead to exploitation of LVCs over time. Tobacco control strategies should take advantage of this transition period when smokers seek information on unfamiliar products to implement harm reduction strategies.

Abstract 751: Lung mitochondrial DNA copy number variations: E-cig users, smokers, and never-smokers

Background: Electronic cigarettes (e-cigs) are one of the most popular tobacco products in the US. Little is known regarding their pulmonary effects. E-cigs induce similar oxidant reactivity as cigarette smoke and promote oxidative damage/inflammation in airway cells. Given that mtDNA is more prone to oxidative stress than nuclear DNA because of a less effective proofreading system, mtDNA alterations may be important indicators of e-cigs' toxic effects. Clinically, mitochondrial DNA alteration is an emerging biomarker of respiratory diseases.

Methods: We compared mtDNA copy number (mtDNA-CN) from lung brushings in a cross-sectional bronchoscopy study of healthy young adults, e-cig users (EC)(n=15), non-smokers, non-EC users (NS)(n=43), and smokers (SM)(n=26). We examined associations of mtDNA-CN with immune response (differential cell counts and cytokines in bronchoalveolar lavage), DNA methylation and gene expression brushings. Associations for: 1) EC vs NS vs SM, and 2) tobacco product users (EC+SM) vs NS for MtDNA-CN with immune response, methylation, and expression were made using linear regression. Further, significant features by group interactions were followed up by within-group tests. False Discovery Rate (FDR) at 0.1 was considered significant. Ingenuity pathway analysis was used to identify the most significantly enriched pathways/molecular functions/diseases.

Results: MtDNA-CN was not significantly different among the three groups (P=0.06). MtDNA-CN was higher in SM than NS (P=0.02), and in tobacco product users than NS (P=0.02); EC mtDNA-CN tended to be intermediate between the 2 other groups. There were significantly positive associations of IL-2 and IL-4 with mtDNA-CN in EC, but not in SM or NS (Interaction FDR=0.06 for both). We found 147 transcripts (60 genes) and 1,153 CpGs (713 genes) to be significantly associated with mtDNA-CN in all three groups. The most common canonical pathway of the signatures for both expression and methylation were immune responses. The top molecular and cellular functions for both included cell death and survival. Ten transcripts (LINC01184, SNU13, RPL35A, COLCA1, HLA-DRB1, LOC105379655, TRIM9, TCIRG1, CLPB, MIR2114) and 3,929 CpGs (top: ULK4, STARD13, HLCS, FLT1, TMEM91, CYP2J2) were associated with mtDNA-CN in E-cig users only. Some of these genes are known to play a role in lung diseases, including cancer. For the signatures associated in all groups, we found many more significant signatures (236 vs 147 transcripts and 40,830 vs 1,153 CpGs) in the two group vs. three group comparisons, respectively.

Conclusion: While the sample size was small, this study is the first to suggest that mtDNA-CN is a site of pulmonary toxic effects. We found associations of mtDNA-CN with inflammatory markers among EC users, and with a number of biological signatures, particularly genes related to immune response, in the lungs of EC, SM, and NS, but differently by groups for some.

Citation Format: Kellie M. Mori, Joseph P. McElroy, Daniel Y. Weng, Sangwoon Chung, Sarah A. Reisinger, Kevin L. Ying, Quentin A. Nickerson, Theodore M. Brasky, Mark D. Wewers, Jo L. Freudenheim, Peter G. Shields, Min-Ae Song. Lung mitochondrial DNA copy number variations: E-cig users, smokers, and never-smokers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 751.

Lipid laden macrophages and electronic cigarettes in healthy adults

Background

An outbreak of E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) with significant morbidity and mortality was reported in 2019. While most patients with EVALI report vaping tetrahydrocannabinol (THC) oils contaminated with vitamin E acetate, a subset report only vaping with nicotine-containing electronic cigarettes (e-cigs). Whether or not e-cigs cause EVALI, the outbreak highlights the need for identifying long term health effects of e-cigs. EVALI pathology includes alveolar damage, pneumonitis and/or organizing pneumonia, often with lipid-laden macrophages (LLM). We assessed LLM in the lungs of healthy smokers, e-cig users, and never-smokers as a potential marker of e-cig toxicity and EVALI.

Methods

A cross-sectional study using bronchoscopy was conducted in healthy smokers, e-cig users, and never-smokers (n = 64). LLM, inflammatory cell counts, and cytokines were determined in bronchial alveolar fluids (BAL). E-cig users included both never-smokers and former light smokers.

Findings

High LLM was found in the lungs of almost all smokers and half of the e-cig users, but not those of never-smokers. LLM were not related to THC exposure or smoking history. LLM were significantly associated with inflammatory cytokines IL-4 and IL-10 in e-cig users, but not smoking-related cytokines.

Interpretation

This is the first report of lung LLM comparing apparently healthy smokers, e-cig users, and never-smokers. LLM are not a specific marker for EVALI given the frequent positivity in smokers; whether LLMs are a marker of lung inflammation in some e-cig users requires further study.

Funding

The National Cancer Institute, the National Heart, Lung, and Blood Institute, the Food and Drug Administration Center for Tobacco Products, the National Center For Advancing Translational Sciences, and Pelotonia Intramural Research Funds

Quantitation by liquid chromatography-nanoelectrospray ionization-high resolution tandem mass spectrometry of DNA adducts derived from methyl glyoxal and carboxyethylating agents in leukocytes of smokers and non-smokers

A liquid chromatograpy-nanoelectrospray ionization-high resolution tandem mass spectrometry (LC-NSI-HRMS/MS) method was developed for quantitation of the DNA adducts 7-(2'-carboxyethyl)guanine (7-2'-CEG) and N2-(1'-carboxyethyl)guanine (N2-1'-CEG), as their methyl esters, in human leukocyte DNA from smokers and non-smokers. 7-2'-CEG has been previously identified in all human liver samples analyzed and is formed from an unknown carboxyethylating agent while N2-1'-CEG is formed from the advanced glycation endproduct methyl glyoxal. The method was applied for the analysis of these two DNA adducts in leukocyte DNA from 20 smokers and 20 non-smokers, in part to test the hypothesis that 7-2'-CEG could be formed by endogenous nitrosation, as previously observed in rats treated with nitrosodihydrouracil and nitrite. Levels of 7-2'-CEG (mean ± S.D.) were 0.6 ± 0.2 pmol/μmol dG in smokers and 0.5 ± 0.2 pmol/μmol dG in non-smokers, while those of N2-1'-CEG were 4.5 ± 1.9 pmol/μmol dG in smokers and 4.6 ± 2 pmol/μmol dG in non-smokers. These results did not support our hypothesis that endogenous nitrosation of dihydrouracil in smokers leads to higher levels of 7-2'-CEG in leukocyte DNA than in non-smokers. However the study provides the first data on levels of these DNA adducts in human leukocyte DNA, and the LC-NSI-HRMS/MS method developed for their quantitation could be important for future studies of DNA damage by methyl glyoxal.

A Randomized Clinical Trial Examining the Effects of Instructions for Electronic Cigarette Use on Smoking-Related Behaviors and Biomarkers of Exposure

INTRODUCTION

Electronic cigarettes (e-cigarettes) have the potential to significantly reduce exposure to harmful constituents associated with cigarette smoking when smokers completely substitute cigarettes with e-cigarettes. This study examined patterns of e-cigarette and cigarette use, and extent of toxicant exposure, if smokers were instructed and incentivized to completely switch to e-cigarettes compared to instructions to use the product ad libitum.

AIMS AND METHODS

US adult daily smokers (n = 264; 49.2% female; Mage = 47.0), uninterested in quitting smoking immediately, were recruited from Minneapolis, MN, Columbus, OH, and Buffalo, NY. Participants were randomized to 8 weeks of instructions for (1) ad libitum use of e-cigarettes (AD-E), (2) complete substitution of cigarettes with e-cigarettes (CS-E), (3) complete substitution of cigarettes with nicotine gum or lozenge (CS-NRT), or (4) continue smoking of usual brand cigarettes (UB). Participants were incentivized for protocol compliance, including complete switching in the CS-E and CS-NRT groups. Outcome variables were cigarette smoking rate and tobacco-related biomarkers of exposure.

RESULTS

Smokers in the CS-E and CS-NRT groups showed lower rates of smoking and lower exposure to carbon monoxide, tobacco carcinogens, and other toxicants than smokers in the AD-E group. In general, no significant differences were observed between CS-E versus CS-NRT or between AD-E versus UB for most biomarkers. Significantly higher 7-day point prevalence smoke-free rates were observed for CS-E versus CS-NRT.

CONCLUSIONS

Smokers instructed and incentivized to completely switch to e-cigarettes resulted in lower smoking rates and greater reductions in exposures to harmful chemicals than smokers instructed to use the product ad libitum.

IMPLICATIONS

Smokers instructed to completely substitute e-cigarettes for cigarettes displayed significantly lower levels of smoking and biomarkers of exposure to carcinogens and toxicants, compared to smokers instructed to use e-cigarettes ad libitum and similar levels as smokers instructed to completely substitute with nicotine replacement therapies. Furthermore, a higher rate of complete switching was achieved with e-cigarettes versus nicotine replacement therapies. Approaches to maximize complete substitution with e-cigarettes are an important area for future research.

Abstract LB-159: The association of alveolar lipid laden macrophages with inflammatory cytokines in electronic cigarette users

Introduction: Lipid laden macrophages (LLM) from lung bronchoscopies have been identified as characteristic for some patients with e-cigarette (e-cig) or vaping product use associated lung injury (EVALI). While vaping with THC oils containing vitamin E acetate is thought to have caused the outbreak, there is a subset of the EVALI cases who reported vaping only with nicotine-containing e-cigs. A recent animal study showed that propylene glycol (PG) and vegetable glycerin altered lipid homeostasis and induced LLM. In addition to the associations with EVALI, understanding the health effects of vaping with e-cigs in general needs additional investigation. Objective: We examined alterations in alveolar lipid homeostasis comparing e-cig users to cigarette smokers and never-smokers. Further, we determined the association of LLM with inflammatory cytokines. Methods: LLMs, inflammatory cell counts, and cytokines were determined in bronchial alveolar fluids (BAL) from a cross-sectional study of 62 volunteer subjects, age 21-45. Participants who were e-cig users were either never-smokers or former smokers. Cigarette smoking and e-cig use were confirmed by biomarkers of exposure, including lung and urine cotinine and 3-hydroxycotinine and urine anatabine, nicotelline, and PG. Results: High LLM counts were found in the lungs of almost all smokers and about half of the e-cig users, but not in any never-smokers (P&lt;0.001). LLMs were significantly correlated with the inflammatory cytokines IL-4 and IL-10 in e-cig users (P=0.01). Smoking history, including cigarettes per day and biomarkers of exposure, e-cig use history, and gender were not associated with LLMs (all P&gt;0.05). LLMs were not related to THC exposure. Discussion: This is the first report comparing LLMs in the lungs of e-cig users with smokers and never-smokers. LLMs were found in lungs of both smokers and a portion of e-cig users. Given their presence among smokers, they are not likely to be useful as a marker identifying those with EVALI. However, LLMs may be one of the markers for specific disease risks associated with e-cig usage, but not smoking.

Citation Format: Min-Ae Song, Peter G. Shields, Jo L. Freudenheim, Theodore M. Brasky, Joseph P. McElroy, Joseph P. McElroy, Sarah A. Reisinger, Daniel Y. Weng, Rongqin Ren, Thomas Eissenberg, Mark D. Wewers, Konstantin Shilo. The association of alveolar lipid laden macrophages with inflammatory cytokines in electronic cigarette users [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-159.

A Randomized Clinical Trial of Snus Examining the Effect of Complete Versus Partial Cigarette Substitution on Smoking-Related Behaviors, and Biomarkers of Exposure

INTRODUCTION

This 8-week multisite, randomized controlled trial of snus examined the differential effects of instructions on (1) snus use, (2) smoking and smoking-related measures, and (3) exposure to tobacco-related constituents.

METHOD

US adult daily cigarette smokers (n = 150; 43.3% female; Medianage = 43.5) were recruited from Minneapolis, Minnesota; Columbus and Coshocton, Ohio; and Buffalo, New York. Following a 1-week sampling phase of snus, participants who used at least 7 pouches were randomized to either (1) partial substitution (PS; "use snus as you like with your cigarettes"), (2) complete substitution (CS; "avoid cigarettes"), or (3) usual brand cigarettes (UB). Analyses included between-group analyses (eg, PS vs. CS) using Wilcoxon rank sum test of cigarettes per day and snus pouches per day, and a linear mixed model (biomarkers).

RESULTS

Compared to the PS and UB groups, smokers assigned to CS reported greater reductions in cigarettes per day (ps < .001), using more snus pouches per day (p = .02), and more smoke-free days (CS median = 14.5, PS and UB medians = 0, p < .001). In addition, results demonstrated reductions in carbon monoxide (p < .001), total nicotine equivalents (p = .02), and four out of five measured volatile organic compounds (ps < .01) over time among the CS group. Exposure to N'-nitrosonornicotine increased by trial end only among the PS group (p < .04). Phenanthrene tetraol increased among all groups by trial end (p = .02) with no difference between groups.

CONCLUSIONS

Instructions to completely switch from cigarettes to snus resulted in the greatest reduction in cigarettes and exposure to harmful constituents.

IMPLICATIONS

Directly instructing smokers to switch completely to snus, rather than using ad libitum (with no instructions to avoid cigarettes), is necessary for reductions in smoking and subsequent exposure to harmful constituents.

Biomarkers of Exposure and Effect in the Lungs of Smokers, Nonsmokers, and Electronic Cigarette Users

BACKGROUND

Nicotine-containing electronic cigarette (e-cig) use has become widespread. However, understanding the biological impact of e-cigs compared with smoking on the lung is needed. There are major gaps in knowledge for chronic effects and for an etiology to recent acute lung toxicity leading to death among vapers.

METHODS

We conducted bronchoscopies in a cross-sectional study of 73 subjects (42 never-smokers, 15 e-cig users, and 16 smokers). Using bronchoalveolar lavage and brushings, we examined lung inflammation by cell counts, cytokines, genome-wide gene expression, and DNA methylation.

RESULTS

There were statistically significant differences among never-smokers, e-cig users, and smokers for inflammatory cell counts and cytokines (FDR q < 0.1). The e-cig users had values intermediate between smokers and never-smokers, with levels for most of the biomarkers more similar to never-smokers. For differential gene expression and DNA methylation, e-cig users also more like never-smokers; many of these genes corresponded to smoking-related pathways, including those for xenobiotic metabolism, aryl hydrocarbon receptor signaling, and oxidative stress. Differentially methylated genes were correlated with changes in gene expression, providing evidence for biological effects of the methylation associations.

CONCLUSIONS

These data indicate that e-cigs are associated with less toxicity than cigarettes for smoking-related pathways. What is unknown may be unique effects for e-cigs not measured herein, and a comparison of smokers completely switching to e-cigs compared with former smokers. Clinical trials for smokers switching to e-cigs who undergo serial bronchoscopy and larger cross-sectional studies of former smokers with and without e-cig use, and for e-cigs who relapse back to smoking, are needed.

IMPACT

These data can be used for product regulation and for informing tobacco users considering or using e-cigs. What is unknown may be unique effects for e-cigs not measured herein, and clinical trials with serial bronchoscopy underway can demonstrate a direct relationship for changes in lung biomarkers.

Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review

Introduction

Scientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States.

Methods

We searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson’s economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes.

Results

All 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson’s recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800.

Conclusion

All community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.

Effects of Electronic Cigarette Constituents on the Human Lung: A Pilot Clinical Trial

Electronic cigarette (e-cig) use is continuing to increase, particularly among youth never-smokers, and is used by some smokers to quit. The acute and chronic toxicity of e-cig use is unclear generally in the context of increasing reports of inflammatory-type pneumonia in some e-cig users. To assess lung effects of e-cigs without nicotine or flavors, we conducted a pilot study with serial bronchoscopies over 4 weeks in 30 never-smokers, randomized either to a 4-week intervention with the use of e-cigs containing only 50% propylene glycol (PG) and 50% vegetable glycerine or to a no-use control group. Compliance to the e-cig intervention was assessed by participants sending daily puff counts and by urinary PG. Inflammatory cell counts and cytokines were determined in bronchoalveolar lavage (BAL) fluids. Genome-wide expression, miRNA, and mRNA were determined from bronchial epithelial cells. There were no significant differences in changes of BAL inflammatory cell counts or cytokines between baseline and follow-up, comparing the control and e-cig groups. However, in the intervention but not the control group, change in urinary PG as a marker of e-cig use and inhalation was significantly correlated with change in cell counts (cell concentrations, macrophages, and lymphocytes) and cytokines (IL8, IL13, and TNFα), although the absolute magnitude of changes was small. There were no significant changes in mRNA or miRNA gene expression. Although limited by study size and duration, this is the first experimental demonstration of an impact of e-cig use on inflammation in the human lung among never-smokers.

Insurance Stability and Cancer Screening Behaviors

Background: Disparities in rates of cancer screening are observed in underserved populations. Lack of stable health insurance may contribute to these disparities. The goal of this study was to examine the association between insurance stability and up-to-date cancer screening in underserved populations.

Methods and Findings: We enrolled 333 community participants aged 40–74 years across four different sites in three states: Chinese Americans in Boston, Massachusetts; Hispanics in Columbus, Ohio; Appalachian populations from Ohio's Appalachian counties; and Blacks and African Americans in Philadelphia, Pennsylvania. Self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer (CRC). Screening rates fell short of Health People 2020 targets for breast, colorectal, and cervical cancer screenings. Being currently insured was associated with current CRC screenings (69.7% among insured vs. 30.7% among uninsured, p=0.0055), but not with breast or cervical cancer screenings. Stable 12-month insurance coverage was not statistically associated with up-to-date screenings.

Conclusion: Having current insurance was associated with CRC screening; stability of insurance was not associated with cancer screening. Insurance coverage alone is not the main driver of cancer screening.

Abstract 3237: Electronic cigarettes and inflammation in the human lung

Background: The use of electronic cigarettes (e-cigs) is increasing rapidly among both adults and youth, including among both smokers and never-smokers, and is thought to be less harmful than cigarettes. However, biological changes including inflammation have not been studied in target organs such as the lung, particularly for e-cigs; further, it is not known if changes are reversible in smokers who switch to e-cigs.

Methods: We conducted a cross-sectional bronchoscopy study of e-cig users (n=13), cigarette smokers (n=16), and never-smokers (n=40), age 21-30, to assess inflammatory cell counts and cytokines in bronchoalveolar lavages (BAL) fluids. BAL total cell counts were measured using the Countess Automated Cell Counter. Differential cells were performed on stained cytospins by a blinded clinical histopathologist. Smoking-associated inflammatory cytokines were measured using a V-PLEX Plus Pro-inflammatory Panel. Non-parametric Mann-Whitney and Kruskal-Wallis tests were used for cell counts. Log10 transformed cytokines were used for 1-way ANOVA.

Results: Smokers averaged 16 cigarettes/day (SD: 4.7) for 7 years (SD: 4.1). E-cig users vaped an average e-liquid nicotine content of 12 mg/ml (SD: 7.6) and 8 ml/day (SD: 3.9), for an average of 3 years (SD: 0.9); mean time since smoking among e-cig users was 24 months (SD: 16) (2 were never-smokers). Smokers compared to never-smokers had significantly increased total cell counts, macrophages and neutrophils, and decreased lymphocytes (7.15E-05&lt;P&lt;0.05). Total cell concentration for the e-cig users were 35% lower than the smokers and 30% higher than the never smokers (overall P=0.0005). Total and differential cell counts were borderline or significantly different for the smokers compared to e-cig users, and followed the same trends for never-smokers compared to e-cig users. Inflammatory cytokines IL-1β, IL-6, and IL-8 were significantly higher for smokers compared to never-smokers, and were lower for IL-2 and IFN-γ (all P's &lt;0.002). Levels of these cytokines in e-cig users were corroborated by patterns of differences for the cell counts, where overall differences were highly significantly different; e-cig users were intermediate. IL-4, IL-10, IL-12p70, IL-13, and TNF-α did not differ across the groups. Time since last cigarette and cigarettes/day among e-cig users was not significantly correlated with any of the cell counts or cytokine levels.

Discussion: Inflammation differed for never-smokers and smokers, with markers of inflammation intermediate for e-cig users, consistent with the hypothesis that e-cigs are less harmful. Study of whether e-cig use is more harmful than never-use and never-smoking is warranted. Because this cross-sectional study provides only indirect evidence of causation, additional observation studies and randomized trials are needed to understand changes in inflammation for e-cig users, both former- never-smokers.

Citation Format: Min-Ae Song, Theodore M. Brasky, Jo L. Freudenheim, Joseph P. McElroy, Daniel Y. Weng, Kevin L. Ying, Quentin A. Nickerson, Sarah A. Reisinger, Mark D. Wewers, Peter G. Shields. Electronic cigarettes and inflammation in the human lung [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3237.

Abstract C77: Impact of insurance and primary care stability on cancer screening behaviors

Background: Disparities in rates of cancer screening are observed in racial and ethnic minority, immigrant, low-income, and low-education populations. One of the means by which these vulnerable populations may not receive screening is due to lack of stable health insurance. The goal of the present study is to examine the association between current insurance status, insurance stability, and up-to-date cancer screening in underserved populations.

Methods: As part of the Cancer Disparities Research Network pilot cohort, the study recruited participants across four sites: Boston Chinatown, African American communities in Philadelphia, Hispanic communities in Columbus, and rural white communities in Appalachia, Ohio. Enrolled participants were eligible if they were 40-74 years old, did not live in a nursing home or other facility, and had no prior invasive cancer diagnosis. Additionally, each participant met at least one of the following criteria indicating being medically underserved: living in a medically underserved area, having low literacy, low income (defined as 100% of the 2015 Federal Poverty Level) or being uninsured, having gaps in insurance, or receiving subsidized health insurance coverage.

Participants completed a baseline survey of demographic data, health insurance status, primary care physician (PCP) status, and most recent breast, cervical, and colorectal cancer screenings. Using the USPSTF guidelines, breast cancer screening was considered up to date if women ages 40–74 had a mammogram within the past 2 years. Cervical cancer screenings were up to date if women had a Pap test within the last 3 years or both a Pap test and an HPV test within the last 5 years. Colorectal cancer screening was current if participants had either a colonoscopy within the last 10 years, a flexible sigmoidoscopy within the last 5 years, or a fecal occult blood test (FOBT) within the last year. To assess participants' consistency of coverage, we defined stable insurance coverage as continuous coverage over the prior 12 months, and unstable insurance coverage as being uninsured, losing insurance, or having switches across major insurance categories at any point in the prior 12 months.

Results: Of the 333 participants enrolled in the study, 65.5% were women, 14.1% were 40-50 years of age, 59.8% were 51-64 years, and 26.1% were 65-74. The cohort was racially and ethnically diverse: 8.4% participants identified as Hispanic, 30.3% as non-Hispanic White, 31.2% as non-Hispanic Black, 29.4% as non-Hispanic Asian, and 0.6% as Other. 62.2% spoke English, 8.1% Spanish, and 29.7% Chinese as their primary language. Low incomes were common: 33.6% reported incomes $15,000 or less, and 25.8% reported incomes between $15,000 and $24,999.

Overall self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer. 90.7% of participants reported being currently insured at the time of the interview, and 70% reported stable insurance coverage. Being currently insured was associated with colorectal cancer screenings [69.5% among insured vs. 30.8% among uninsured (p= 0.0059)] but not with breast or cervical cancer screenings. Stable insurance coverage was not statistically associated with up-to-date screenings.

Conclusion: Overall screening rates meet Healthy People 2020 targets for breast cancer, but fall short for cervical and colorectal cancer screening. Rates of insurance are high at 90%, reflecting adoption of Medicaid expansion in all three states. In spite of low income, this population reported being up to date on colorectal cancer screenings if they had current health insurance. The low overall rates of colorectal cancer screening might be related to the lower prevalence of free or low-cost colon cancer screening programs.

Citation Format: Karen M. Freund, Sarah A. Reisinger, Amy LeClair, Sarah Al-Najar, Gregory S. Young, Jill Oliveri, Evelyn Gonzalez, Electra Paskett. Impact of insurance and primary care stability on cancer screening behaviors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C77.

Abstract 3236: Lung epithelium DNA methylation: Electronic cigarette users, smokers, and never-smokers

Background: The use of electronic cigarettes (e-cigs) among smokers and never-smokers is increasing, and is considered to be less harmful than cigarettes. However, this has not been studied in target organs for smoking-related diseases, especially the lung. Altered DNA methylation is seen in smokers and contributes to lung carcinogenesis. However, it is not known how e-cigs affect methylation in the lung or whether smoking-induced DNA methylation changes can be reversed in former smokers who switch to e-cigs.

Methods: We conducted a cross-sectional bronchoscopy study of e-cig users (n=12), cigarette smokers (n=10), and never-smokers (n=10) (age 21-30, 84% European-American, 66% male). Bisulfite-converted DNA extracted from lung epithelium collected by bronchial brushing was analyzed for 865,859 CpGs with the llumina Infinium Methylation EPIC Chip in a single batch. Probes were filtered out if on sex chromosomes, cross-reactive, or SNP associated, leaving 735,317 CpGs for analysis. One-way analysis of covariance using M-values was used to identify CpGs differentially methylated for the three groups. False Discovery Rate (FDR) of q&lt;0.1 was considered significant. Ingenuity pathway analysis (IPA) was used for potential biologic implications of identified CpGs.

Results: Smokers averaged 18 cigarettes/day (SD: 4.2) and 6 years of smoking (SD: 4.5). E-cig users vaped an average e-liquid nicotine content of 10 mg/mL (SD: 11) and 8 mL/day (SD: 4), for an average of three years (SD: 1). Mean time since smoking among the e-cig users was 31 months (SD: 15); 3 were never-smokers. We identified 517 differentially methylated CpGs among the three groups (FDR q&lt;0.1). Of them, 128 (25%) were in enhancers, 165 (47%) in promoters, and 162 (31%) in CpG islands/surroundings. For e-cig users, methylation of most differentially methylated CpGs (n=505) was between those for smokers and never-smokers. For smoking- and/or lung cancer-related genes: AHRR, ALDH3A1, ALPK3, CYP1B1, and OXCT1, CpGs were less methylated in smokers than in never-smokers; e-cig users were intermediate. There were 330 unique genes with differentially methylated CpGs; 319 were included in an IPA analysis. The most significantly associated disease was cancer (n=283) and biologic function was drug metabolism (n=10). The top canonical pathways included xenobiotic metabolism signaling (n=13) and wnt/β-catenin signaling (n=9).

Discussion: DNA methylation differed for never-smokers and smokers, with e-cig users' methylation intermediate, consistent with the hypothesis that e-cigs are less harmful than smoking; whether e-cig use is more harmful than never-smoking needs to be studied. Because this study is cross-sectional, association, and not causation, is indicated. Additional observational studies and randomized trials are warranted to understand biologic changes in the lung for smokers and never-smokers using e-cigs.

Citation Format: Min-Ae Song, Dominic J. Smiraglia, Theodore M. Brasky, Daniel Y. Weng, Joseph P. McElroy, Sarah A. Reisinger, Kevin L. Ying, Quentin A. Nickerson, Mark D. Wewers, Peter G. Shields, Jo L. Freudenheim. Lung epithelium DNA methylation: Electronic cigarette users, smokers, and never-smokers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3236.

Small-cell lung carcinoma: an analysis of 194 consecutive patients

The treatment of small-cell lung carcinoma (SCLC) requires the careful combination of chemotherapy and radiation therapy. To understand the factors involved in the outcome of these patients, the authors undertook a study of patients treated for limited stage SCLC. The charts of 194 consecutive patients treated at our facilities between 1986 and 1994 were reviewed. All patients underwent thoracic radiation therapy (TRT), 50% received prophylactic cranial irradiation (PCI), and all but one received chemotherapy. The probability of survival at 5 years was 14%, and the disease-free survival (DFS) was 17%. Patients receiving a combination of platinum and etoposide (PE) and Cytoxan (Bristol-Myers, Evansville, IN, U.S.A.), Adriamycin (Adria Laboratories, Dublin, OH, U.S.A.), and Vincristine (Eli Lilly, Indianapolis, IN, U.S.A.) (CAV) experienced a DFS at 3 years of 31%, versus 14% for CAV only and 18% for PE only (p = 0.004). In a multivariate survival analysis, only PCI (p = 0.001), having received PE and CAV (p = 0.01), and response to treatment (p = 0.001) were significant. Radiation dose and field size did not influence outcome. The combination of PE and CAV chemotherapy produced the best results in our series. Unanswered questions regarding the optimal TRT dose, field size, and timing of TRT await the results of ongoing randomized trials.

A phase I study of weekly cisplatin and whole abdominal radiation for the treatment of stage III and IV endometrial carcinoma: a Gynecologic Oncology Group pilot study

A Gynecologic Oncology Group Phase I study was designed to evaluate the toxicity of whole abdominal radiation therapy with concurrent weekly cisplatin in patients with surgical International Federation of Gynaecology and Obstetrics (FIGO) Stage III and IV endometrial carcinoma. Cisplatin 15 mg/m2 was given once weekly during radiation therapy to the whole abdomen with a pelvic boost and optional para-aortic radiation. All eight patients received the prescribed dose of radiation therapy. Cisplatin chemotherapy was halted in one patient due to increased serum creatinine after three cycles. Acute adverse effects were within acceptable limits, with one patient admitted to the hospital after completion of treatment for diarrhea. Hematopoietic toxicity was clinically unimportant. Serious late toxicities included one radiation enteritis requiring a bowel resection and chylous ascites in one patient. There was no late renal damage reported. This regimen appears to be tolerated acutely and the late toxicities were similar to those seen with whole abdominal radiation therapy alone.

Potential underdosing with the use of electron beam therapy in patients with cervical adenopathy and advanced head and neck cancer

To define the adequacy of electron beam therapy in the treatment of N1-N3 head and neck cancer, 24 patients with primary head and neck cancers and N1-N3 cervical adenopathy received primary radiation therapy with or without chemotherapy for definitive control of their disease. All patients underwent computerized tomography (CT) to assist in the design of treatment to the posterior neck with electron beams after photon therapy to the level of spinal cord tolerance. Treatment with electrons to the posterior neck in patients with N1 disease was adequate in 92% (11/12) of patients. However, in patients with N2 and N3 disease, electron beam treatment failed, because of spinal cord tolerance problems, to cover the disease adequately in 92% (11/12). It is concluded that CT should be employed routinely in patients with N1-N3 neck disease to determine the proper electron energy prescription. For some patients, electron beam may not be appropriate, making it necessary to use individual planning to treat adequately the neck disease and avoid the spinal cord.

Potential underdosing with the use of electron-beam therapy in patients with cervical adenopathy and advanced head and neck cancer

To define the adequacy of electron-beam therapy in the treatment of N1-N3 head and neck cancer, 24 patients with primary head and neck cancers and N1-N3 cervical adenopathy received primary radiation therapy with or without chemotherapy for definitive control of their disease. All patients underwent computerized tomography (CT) to assist in the design of treatment to the posterior neck with electron beams after photon therapy to the level of spinal cord tolerance. Treatment with electrons to the posterior neck in patients with N1 disease was adequate in 92% (11/12) of patients. However, in patients with N2/N3 disease, electron beam failed, because of spinal-cord tolerance problems, to adequately cover disease in 92% (11/12). It is concluded that CT should be routinely employed in patients with N1-N3 neck disease to determine the proper electron-energy prescription. For some patients, electron beam may not be appropriate, making it necessary to use individual planning to treat adequately the neck disease and avoid the spinal cord.

Preoperative radiation therapy in clinical stage II endometrial carcinoma

From 1980 to 1987, 30 patients with FIGO clinical Stage II carcinoma of the endometrium were treated with 5000 cGy preoperative pelvic radiation therapy at Thomas Jefferson University Hospital. Patients with gross cervical disease received additional intracavitary irradiation with a tandem and ovoids for a combined total dose of 7000 cGy to point A. All patients then underwent exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy (TAH/BSO). The 5-year actuarial survival for the entire group was 69%. The 5-year actuarial survival for the 8 patients with papillary serous, clear cell, and undifferentiated small cell carcinoma was 38%, with most patients failing in the upper abdomen. The 5-year actuarial survival for the remaining 22 patients was 82%. The only local failure occurred in the patient with an undifferentiated small cell carcinoma. Although preoperative pelvic radiation therapy together with TAH/BSO appears to offer excellent local control in all patients with Stage II endometrial carcinoma, additional treatment options should be considered for patients with papillary serous and clear cell histologies because of the poor survival and high failure rate in the upper abdomen.

Vertex field verification in the treatment of central nervous system neoplasms

Increasing sophistication of computerized brain tumor treatment plans has enabled clinicians to devise increasingly complex field combinations to spare as much normal brain tissue as possible. These treatment plans often call for the use of a vertex field. This report describes a simple, useful technique for the verification of the vertex (or any non-coplanar) field on the treatment machine--a procedure that is impossible with conventional port film techniques.

Endometrial cancer with para-aortic adenopathy: patterns of failure and opportunities for cure

PURPOSE

To examine the outcome of patients with advanced endometrial cancer whose para-aortic involvement was diagnosed pathologically or lymphographically.

METHODS AND MATERIALS

Fifty patients from four institutions were treated between 1959 and 1990 with preoperative, post-operative, and primary radiotherapy. Para-aortic disease was diagnosed pathologically in 26 patients and lymphographically in the remaining 24 patients. Pathologically diagnosed patients underwent debulking of grossly involved nodes. All patients received external beam treatment through pelvic and para-aortic portals. Median prescribed dose to the pelvic and para-aortic fields was 50 and 47 Gy, respectively. Those treated with primary or pre-operative irradiation also received intrauterine brachytherapy.

RESULTS

The actuarial 5-year disease-free survival was 46% for all patients. Para-aortic failure was significantly decreased among patients undergoing lymph node resection (13% versus 39%, respectively). Relapse-free survival and pelvic control tended to improve among patients receiving surgery plus irradiation in comparison to those treated by irradiation alone. Distant metastases were most common among patients with high grade lesions.

CONCLUSIONS

Long-term disease-free survival is achievable in endometrial cancer patients with para-aortic lymphadenopathy who are treated with extended-field radiotherapy. Cure is mot attainable among patients with well differentiated, early clinical stage disease who receive combined modality treatment. Survival and local failure are similar for radiologically and pathologically diagnosed patients; however, para-aortic failure as a component of local failure was increased in patients who did not undergo surgical debulking of the adenopathy.

Combined pre- and postoperative adjuvant radiation therapy for bladder cancer--a ten year experience

From 1978 through 1987, 78 patients with carcinoma of the bladder were treated with combined pre- and postoperative adjuvant radiation therapy. All were given a single dose of pre-operative radiation therapy, 500 cGy, either on the day of or the day before cystectomy. Histological staging on the cystectomy specimens according to the TNM classification system was performed. Forty patients with Stage P2 (high grade III and IV), P3A, P3B, P4A, or N+ underwent planned high dose postoperative radiation therapy (4000-4500 cGy) in 5 weeks. The whole pelvis was treated with conventional fractionation of 180 cGy 5 days per week. Median follow-up was 52 months, with 36 months minimum follow-up. There was a 67% overall 5-year survival, and those with P1 and P2 (Grade I and II) had an 84% 5-year survival. Survival for patients with P2 tumor (Grade III and IV), P3A, P3B, and P4/N+ stages was 57%, 56%, 39%, and 50%, respectively. Bowel obstructions developed in 8% of patients who received no postoperative radiation therapy and 37% in those who did. Genitourinary complication rates were similar in both groups, 13% in the group that received no postoperative radiation therapy and 10% in the group that did. Although the planned approach of combined pre- and postoperative radiation therapy for unfavorable stages of bladder cancer is associated with a better than 50% 5-year survival rate (except in Stage P3B cancer), the bowel toxicity was unacceptably high.

Survival and failure analysis in stage II endometrial cancer using the revised 1988 FIGO staging system

Fifty-one patients with Stage II endometrial carcinoma diagnosed between 1974 and 1987 were restaged according to the FIGO 1988 revisions for endometrial carcinoma. Patients were divided into Stage IIA, those patients with cervical glandular involvement without stromal invasion, and Stage IIB, those patients having stromal invasion of the cervix. Tumor grade was also assessed. Patients were treated with radiation therapy alone, pre-operative radiation therapy followed by a simple hysterectomy, or a simple hysterectomy followed by postoperative radiation therapy. The 5-year actuarial survival for Stage IIA was 86% and the 5-year actuarial survival for Stage IIB was 46% (p = 0.06). The 5-year local recurrence rate in each group was 9%. Stage IIA had a distant metastases rate of 14% whereas 44% of the patients in Stage IIB developed distant disease (p = 0.06) at 5 years. The grade of the tumor did not play a role in local recurrence. However, when tumor grade was analyzed with respect to distant disease, 14% of patients with grade 1 tumors developed distant metastases, 31% of patients with grade 2 tumors developed distant metastases, and most significantly, 63% of patients with grade 3 tumors developed distant metastases (p = 0.004). There was no statistically significant relationship between stromal invasion and tumor grade. This study concludes that grade is the greatest predictor of survival, with only 37% of grade 3 patients surviving at 5 years. As a predictor of survival, stromal invasion is of less significance than grade (p = 0.06 vs. p = 0.004). Death most often occurs because of distant metastases, and local failure is rare and is not dependent on the degree of cervical involvement or grade.

Stage IB glassy cell carcinoma of the cervix diagnosed during pregnancy and recurring in a transposed ovary

A case report of glassy cell carcinoma of the cervix occurring during pregnancy is presented. Clinical staging was FIGO IB and treatment consisted of a radical hysterectomy, bilateral ovarian transposition, and postoperative pelvic radiation therapy. The patient had a relapse in one of the transposed ovaries. A review of ovarian conservation in Stage IB carcinoma of the cervix is discussed.