Overexpression of filamin-A protein is associated with aggressive phenotype and poor survival outcomes in NSCLC patients treated with platinum-based combination chemotherapy

An actin-binding protein filamin A connects the actin filament network to cell membrane receptors, and acts as a scaffold for various signaling pathways related to cancer growth and progression. Recently, it has been reported that filamin A is required for efficient regulation of early stages of DNA repair process. Moreover, some in vitro studies showed that the overexpression of filamin A determines resistance to various cytotoxic drugs, including cisplatin. We aimed to analyse the expression of filamin A protein in resected NSCLC (Non Small Cell Lung Cancer) specimens, to investigate the association of the level of filamin A protein expression and other clinicopathological features, and possible relationship between the expression of filamin A and survival outcome in NSCLC patients, treated with platinum-based combination chemotherapy. We performed filamin A protein immunohistochemistry on formalin-fixed and paraffin-embedded (FFPE) tissue sections from 135 NSCLC patients, using EP2405Y antibody against C-terminus of filamin A. Cytoplasmic, membranous and nuclear positivity of filamin A was evaluated semi-quantitatively and correlated with available clinicopathological data. Patients were divided into two groups for survival analysis (I group - patients treated with adjuvant platinum-based chemotherapy, II group - patients with surgical treatment only). We found significant positive correlation between filamin A protein expression and NSCLC stage (r=0.249; p<0,05), presence of lymph node (N)(r=0.205; p<0,05) and distant metastases (M) (r=0.332; P<0.01). Increased filamin A protein expression was significantly related with poor survival outcomes in patients with adjuvant platinum-based chemotherapy: OS (HR=1.005, 95%CI[1.000;1.010], p=0.037), DFS (HR=1.004, 95%CI [1.001:1.008], p=0,017). Multivariate Cox proportional hazards regression analysis also showed that overexpression of filamin A represents an independent risk factor for disease relapse, in addition to tumor size, stage, and metastases status (HR=1.723, 95%CI [1.021:2.909], p<0.05). Thus, filamin A expression might be a new prognostic marker in patients with NSCLC.

Metastatic Clear Cell Renal Carcinoma Without Evidence of a Primary Renal Tumour Mimicking Advanced Stage of Malignant Lung Tumour

BACKGROUND

Clear cell renal carcinoma (ccRC) accounts for 65-70% of renal carcinomas with peak occurrence at the 6th and 7th age decade, predominantly in males. At the time of diagnosis, especially pulmonary metastases can be found in one-third of patients. There have also been described as late metastases for several decades after nephrectomy. In our case report, clinical course indicated primary lung tumour. Histological differential diagnosis included malignant pleural mesothelioma, lung adenocarcinoma and squamous cell carcinoma with clear cell differentiation or primary clear cell adenocarcinoma of the lung. However, using immunohistochemistry, all these possible diagnoses were excluded.

CASE REPORT

We present a case of 62-year old man with 3 months history of progressive dyspnea accompanied with a cough and recurrent pleural effusions. PET/CT scan revealed metastatic tumour spread with right-sided pleural thickening, multiple pulmonary tumour foci, mediastinal, cervical, abdominal para-aortic and pelvic lymph node involvement and skeletal metastasis. The patient died one day after administration of palliative chemotherapy. The autopsy showed the majority of changes in the right hemithorax, was caused by a diffuse yellowish, extremely tough tumour infiltrating parietal and visceral pleura with adhesions and obliteration of truncus pulmonalis. In left lung and both renal cortices we could see scant nodules, mimicking primary lung tumour metastasis. In close proximity to the left renal hilum we found unusual homogeneous white round to oval tissue of 80 × 86 × 72mm in diameter, with identical histological pattern. Extensive immunohistochemical profile (positivity of CK18, PAX8, vimentin, androgen receptor, napsin A; negativity of mesothelial markers, TTF-1, CK7, CK20, CDX-2, CD10, PSA, CK34B12 and PAS-D) was compatible with metastatic ccRC.

CONCLUSION

We present an extremely rare case of morphologically verified metastatic ccRC without evidence of primary lesion in the kidneys. There is speculated the possibility of spontaneous regression of primary tumour. In our case, however, we cannot exclude the possibility of generalized primary tumour of ectopic kidney. This hypothesis is based on the finding of isolated tumour mass adjacent to left renal hilum.

Geolocation with respect to personal privacy for the Allergy Diary app - a MASK study

Background

Collecting data on the localization of users is a key issue for the MASK (Mobile Airways Sentinel networK: the Allergy Diary) App. Data anonymization is a method of sanitization for privacy. The European Commission's Article 29 Working Party stated that geolocation information is personal data.To assess geolocation using the MASK method and to compare two anonymization methods in the MASK database to find an optimal privacy method.

Methods

Geolocation was studied for all people who used the Allergy Diary App from December 2015 to November 2017 and who reported medical outcomes. Two different anonymization methods have been evaluated: Noise addition (randomization) and k-anonymity (generalization).

Results

Ninety-three thousand one hundred and sixteen days of VAS were collected from 8535 users and 54,500 (58.5%) were geolocalized, corresponding to 5428 users. Noise addition was found to be less accurate than k-anonymity using MASK data to protect the users' life privacy.

Discussion

k-anonymity is an acceptable method for the anonymization of MASK data and results can be used for other databases.

Sleep apnoea in patients with nocturnal hypertension - a multicenter study in the Czech Republic

Sleep apnoea (SA) is common in patients with hypertension. Nowadays, limited data on the prevalence of SA in nocturnal hypertension (NH) exist. Therefore, we studied the occurrence of SA in Czech patients and its association with 24-h ambulatory blood pressure monitoring (ABPM), breathing disturbances in sleep, anthropometric data, Mallampati score and Epworth sleepiness scale (ESS) using the Apnea Link device. Undiagnosed SA was found in 72.9 % patients (29.3 % mild, 26.6 % moderate, 17.0 % severe) of 188 patients with NH measured by ABPM. The median of the apnoea-hypopnoea index (AHI) was 12.0 (25th-75th percentile 5.0-23.8). Moderate/severe SA (AHI>/=15) was associated with BMI, waist circumference, mean night saturation (SpO(2)), t90, oxygen desaturation index (ODI), ESS (daytime BP only) (p</=0.032), but not ABPM parameters and Mallampati score (p>0.09). A likelihood of moderate/severe SA was enhanced by ODI>14.5 events/h (odds ratio=57.49, 95 % CI=22.79-145.01), t90>6.5 % (8.07, 4.09-15.92), mean night SpO(2)<93.5 % (3.55, 1.92-6.59), BMI>29.05 kg/m(2) (6.22, 3.10-12.49), circum waist>105.5 cm (3.73, 1.57-8.83), but not by any ABPM parameter. In conclusion, a high incidence of SA (72.9 %) was observed in Czech patients with NH. SA severity was associated with body characteristics and oxygenation parameters, but not with ABMP parameters and Mallampati score.

Non-Small Cell Lung Cancer with Estrogen Receptors and ALK Positivity

BACKGROUND

Estrogens are steroid hormones that affect a number of physiological functions in cells; these compounds play an irreplaceable role in the reproductive system. Their effects are mediated by the estrogen receptor (ER), of which there are two subtypes - ER&#945; and ER&#946;. ERs are expressed in regions outside the reproductive system, including bone, brain, intestine, endothelium, kidney, and lung. Expression of ER by lung cancer (LC) cells was first described in the early 1980s. The experimental literature also describes co-expression of ER&#946; and an epidermal growth factor activating mutation, and the additive antiproliferative effects of anti-estrogens plus tyrosine kinase inhibitors during treatment of lung adenocarcinoma. However, coincident expression of ER and ALK translocation were not decribed. The 4-year survival for generalized non-small cell lung cancer indicates the possibility that both molecular features (ER and ALK positivity) may be a favorable prognostic biomarker for this tumor.

CASE

A 69-year-old patient presented with generalized lung adenocarcinoma that was positive for ERb and the ALK-EML4 fusion gene. The tumor was stage IV. Additional examinations excluded malignancy of the gynecological area. The patient was treated with chemotherapy and a tyrosine kinase ALK inhibitor.

CONCLUSION

The role of individual ER subtypes in LC carcinogenesis, and the possible therapeutic effects, is unclear. This is the first documented case of co-occurrence of ALK-EML4 and ER&#946; in LC. Key words non-small cell lung cancer - estrogen receptors - ALK translocation - prognosis - treatment This work was supported by Ministry of Health of the Czech Republic, grant AZV 16-32318A, and by Ministry of Education, Youth and Sports of the Czech Republic, grant NPU I LO1304. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 23. 9. 2018 Accepted: 25. 10. 2018.

Transfer of innovation on allergic rhinitis and asthma multimorbidity in the elderly (MACVIA-ARIA) - EIP on AHA Twinning Reference Site (GARD research demonstration project)

The overarching goals of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) are to enable European citizens to lead healthy, active and independent lives whilst ageing. The EIP on AHA includes 74 Reference Sites. The aim of this study was to transfer innovation from an app developed by the MACVIA-France EIP on AHA reference site (Allergy Diary) to other reference sites. The phenotypic characteristics of rhinitis and asthma multimorbidity in adults and the elderly will be compared using validated information and communication technology (ICT) tools (i.e. the Allergy Diary and CARAT: Control of Allergic Rhinitis and Asthma Test) in 22 Reference Sites or regions across Europe. This will improve the understanding, assessment of burden, diagnosis and management of rhinitis in the elderly by comparison with an adult population. Specific objectives will be: (i) to assess the percentage of adults and elderly who are able to use the Allergy Diary, (ii) to study the phenotypic characteristics and treatment over a 1-year period of rhinitis and asthma multimorbidity at baseline (cross-sectional study) and (iii) to follow-up using visual analogue scale (VAS). This part of the study may provide some insight into the differences between the elderly and adults in terms of response to treatment and practice. Finally (iv) work productivity will be examined in adults.

Detection of the etiological agents of hospital-acquired pneumonia - validity and comparison of different types of biological sample collection: a prospective, observational study in intensive care patients

BACKGROUND

There is still a lack of evidence as to which method of biological sample collection is optimal for identifying bacterial pathogens causing hospital-acquired pneumonia (HAP). Much effort has been made to find an easy and valid approach to be used in clinical practice.

METHODS

The primary endpoint of this prospective, observational study was to determine the predictive value of oropharyngeal swab (OS) and gastric aspiration (GA) as simple and non-invasive methods for diagnosing HAP. Their efficacy was compared to endotracheal aspiration (ETA) and protected specimen brushing (PSB), the standard methods approved for HAP diagnosis.

RESULTS

Initially, 56 patients were enrolled. Significant amounts of bacterial pathogens were detected in 48 patients (79 isolates) in Round A and in 39 patients (45 isolates) in Round B (after 72 hours). The sensitivity rates were: ETA 98%, PSB 31%, OS 64% and GA 67% in Round A and ETA 87%, PSB 32%, OS 74% and GA 42% in Round B. Strains of 12 bacterial species were identified in the samples. The three most common etiological agents (both rounds together) were Klebsiella pneumoniae (23.7%), Burkholderia multivorans (21.1%) and Pseudomonas aeruginosa (15.8%).

CONCLUSIONS

Blind ETA is an optimum method for obtaining biological samples for identification of etiological agents causing HAP in intubated patients. Microbial etiological agents were more frequently detected in ETA samples than in those collected by PSB. If ETA/PSB results are negative, samples may be collected by OS and/or GA as these techniques followed ETA in terms of the frequency of pathogen detection.

[Catamenial pneumothorax - case reports and literature review]

AIM

Catamenial pneumothorax is menstrual cycle dependent and represents the most common form of thoracic endometriosis syndrome. Recurrences are very common even after surgical resection.

DESIGN

Case reports and literature overview.

SETTING

Department of Respiratory Medicine, Department of Surgery I, Department of Obstetrics and Gynecology, University Hospital, Palacky University, Olomouc.

CASE REPORT

Two cases of catamenial pneumothorax are presented with repeated recurrences of right-sided pneumothorax even after surgical treatment. Histopathologic finding of pelvic endometriosis was shown in both patients.

CONCLUSION

Catamenial pneumothorax is usually connected with thoracic endometriosis and also includes catamenial hemothorax, recurrent catamenial hemoptysis, catamenial pleural pain as well as endometriosis lung nodules. Multidisciplinary approach including pneumologist, thoracic surgeon and gynecologist with early postoperative hormonal treatment that deals with the main chronic systemic disease may lead to improved results, mainly reduced recurrence rates of catamenial and/or endometriosis related pneumothorax.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5)

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation

Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

[Contemporary trends of the adjutant chemotherapy in non-small cell lung cancer]

BACKGROUND

Adjuvant chemotherapy became a standard of treatment in completely resected non-small cell lung cancer (NSCLC) based on results of big trials meta-analyses, which proved its influence on the decrease of relative mortality risk and absolute improvement of survival. Adjuvant chemotherapy is routinely used according to tumor stage evaluation, performance status (PS) and age of the patients. It is indicated in stage II and IIIA of NSCLC- in frame of clinical studies also in stage IB, in PS 0-1 and in patients under 75 years. Therapy with cisplatin and vinorelbine is a preferred regimen, as well as other drugs, such as paclitaxel, docetaxel, gemcitabine and pemetrexed. The problem is a relatively small dose intensity applied, due to toxic side effects.

AIM

The present work is evaluating contemporary trends of adjuvant therapy in NSCLC according to latest clinical studies, which are finished or running. Efforts are directed to the improvement of treatment effectiveness, decrease of side effects and refinement of patients selection. Potential treatment benefit of better tolerable carboplatin is verified and results of trials with biologically targeted therapy are expected. Large clinical studies are evaluating the effect of tyrosine kinase inhibitors and angiogenesis inhibitors used either in various combinations with chemotherapy or as monotherapy. Application of vaccines is tested.

CONCLUSION

Contemporary trend of adjuvant therapy is leading to the appropriate patient selection with regard to analysis of several prognostic and predictive biomarkers; it is proposed that future adjuvant therapy will be more and more personalized.

[Scoring systems to evaluate prognosis of community-acquired pneumonias]

Several expert systems were developed for assessment of community-acquired pneumonia (CAP) and its severity in individual patients. Scoring systems PSI, CURB-65, and CRB-65 are widely used. They were primarily designed for easier decision on need of CAP patients hospitalization. Newer scoring systems evaluate especially severity of CAP and need of intensive care. This group of systems comprise ATS/IDSA recommendations, CURXO-8O, SMART-COP, and SMRT-CO. The last one appears to be the most appropriate for common practice but more studies are necessary to confirm this opinion. Regardless of the scoring systems the authors recommend more extensive usage of pulse oxymetry in the care of CAP patients.

[Neoadjuvant chemotherapy and surgical treatment in advanced stages of non-small cell lung cancer]

INTRODUCTION

Lung cancer takes first place in both incidence and mortality in the Czech Republic. This is associated with the disease being diagnosed in late stages, which limits the possibility of radical therapy. Five-year survival of patients operated on with stage IIIA is low and doesn't even reach 20%. These poor results and the development of systemic chemotherapy in the 1990's led to an effort to treat locally advanced disease by administering chemotherapy before the surgical procedure- induction chemotherapy. Its benefit, however, unlike that of adjuvant chemotherapy, remains unclear.

AIM

To analyze and compare the results between a set of patients with non-small cell lung cancer (NSCLC) with stage III A-B, operated on at the I. Department of Surgery at the University Hospital and Palacky Medical Faculty in Olomouc between the years 2000-2008, who underwent preoperative chemotherapy with the results of patients with stage III A-B diagnosed after the operation based on histological findings. Three- and five-year survivals, as well as survival median, were evaluated in both groups.

RESULTS

A statistically significant difference in survival between the two groups was not observed.

CONCLUSION

Neoadjuvant chemotherapy remains controversial in the treatment of NSCLC. The initially promising results have not been unequivocally confirmed in later studies and its role remains a question to be answered in future extensive randomized studies.

T-helper cell type-1 transcription factor T-bet is upregulated in pulmonary sarcoidosis

Upregulation of genes for interferon (IFN)-γ and CXC chemokine receptor (CXCR)3 expression, two crucial molecules in sarcoid inflammation and granuloma formation, is directly controlled by the T-helper (Th)1 transcription factor T-bet (T-box, expressed in T-cells). However, there is no information on T-bet expression in sarcoidosis or its relationship with "sarcoidosis-associated" genes. Therefore, we investigated expression of T-bet mRNA and, in parallel, a spectrum of genes known to be involved in sarcoidosis pathogenesis. Transcripts were determined in bronchoalveolar lavage (BAL) cells from 62 sarcoidosis patients and 25 controls by quantitative RT-PCR; T-bet protein was localised by immunohistochemistry. Patient's BAL cells expressed higher mRNA T-bet levels than those of controls (mean ± sd fold change 3.64 ± 1.72; p = 0.00006). T-bet mRNA expression did not vary between clinical phenotypes as assessed by chest radiography stage, presence/absence of Löfgren's syndrome, extrapulmonary/pulmonary involvement or progressing/remitting disease (p > 0.05). T-bet mRNA expression correlated with expression of IFN-γ, CC chemokine ligand 5, CXC chemokine ligand (CXC)10, interleukin (IL)-2 receptor/IL-15 receptor β, CXCR3 and CXCR6 (p < 0.01). T-bet protein was localised to alveolar macrophages and lymphocytes, tissue multinucleated giant cells, macrophages and lymphocytes. In pulmonary sarcoidosis, T-bet upregulation is associated with changes in expression of IFN-γ, CXCR3 and chemokines/receptors involved in the pathogenesis of sarcoidosis, which suggests a role for T-bet in this Th1 disease, including modulation of some sarcoidosis-associated genes.

The CR1 C5507G polymorphism is not involved in susceptibility to idiopathic pulmonary fibrosis in two European populations

Idiopathic pulmonary fibrosis (IPF), a severe lung disease with unknown aetiology, is thought to have an important genetic component. Single nucleotide polymorphism, C5507G, of the complement receptor 1 (CR1) gene, which affects the number of CR1 molecules on erythrocytes, has been associated with susceptibility to IPF in a single European population. To replicate this finding, 53 Czech IPF patients with 203 Czech healthy control subjects and 70 English IPF patients with 149 English controls were investigated. In both populations, there were no significant differences in distribution of CR1 C5507G variants between IPF patients and their appropriate control groups. In conclusion, the association of the CR1 C5507G polymorphism with susceptibility to IPF was not reproducible in Czech and English populations.

Protein levels of CC chemokine ligand (CCL)15, CCL16 and macrophage stimulating protein in patients with sarcoidosis

The objective of this study was to assess protein levels for candidate cytokines, chemokines, growth factors, matrix metalloproteinases and their inhibitors in bronchoalveolar lavage fluid (BALF) in patients with polar forms of pulmonary sarcoidosis, i.e. Löfgren's syndrome (LS) and more advanced chest X-ray (CXR) stage III disease. Twenty-four inflammatory molecules were analysed in unconcentrated BALF samples from 10 sarcoidosis patients with CXR stage III and 10 patients with LS by semiquantitative protein array. Four novel molecules [CC chemokine ligand (CCL)15, CCL16, macrophage migration inhibitory factor (MIF) and macrophage stimulating protein (MSP)], detected for the first time in association with sarcoidosis, were then quantified by enzyme-linked immunosorbent assay in a second cohort of 68 sarcoidosis patients and 17 control subjects. The protein levels of CCL15, CCL16, CCL24, CXCL8, CXCL9, CXCL10, interleukin-16, MIF, MSP and matrix metallopeptidase 1 were increased in CXR stage III patients when compared with patients with LS. CCL15 and MSP up-regulation in CXR stage III patients in comparison with LS patients and controls was confirmed by enzyme-linked immunosorbent assay. Moreover, MSP was associated with treatment requirement (P = 0.001) and CCL15 was elevated in patients with disease progression at 2-year follow-up (P = 0.016). CCL16 levels were increased in sarcoidosis versus controls (P < 0.05), but no difference was observed between patient subgroups. MIF up-regulation was not confirmed in a larger patient group. In conclusion, chemokines CCL15, CCL16 and MSP were found elevated for the first time in BALF from sarcoidosis patients; our results showed that CCL15 and MSP may affect disease course.

[Laboratory diagnostics of pleural effusion]

Pleural effusion is a frequent reason for a pulmonologist's investigation. Many pulmonary and extrapulmonary causes of pleural effusion exist. Heart failure, pneumonia and malignancies are the most frequent among them. Laboratory examination of pleural liquid is a corner stone of diagnostics. We use various biochemical, microbiological, cytologic and other methods. The first step is a differentiation between transudate and exudate. If the laboratory examinations are unsuccessful, we can use invasive procedures - pleural biopsy and thoracoscopy. Despite all modern diagnostic methods the causes of about 15% pleural effusions remain unclear.

Complement receptor 1 single nucleotide polymorphisms in Czech and Dutch patients with sarcoidosis

A single nucleotide polymorphism (SNP) C5507G of the complement receptor 1 (CR1) gene has been associated with genetic susceptibility to sarcoidosis in an Italian population. In order to provide further data on the possible involvement of CR1 gene polymorphisms in sarcoidosis, CR1 SNPs C5507G and A3650G were investigated in Czech (n = 210) and Dutch (n = 116) patients with sarcoidosis with ethnically matched groups of healthy control subjects (Czech, n = 203; Dutch, n = 112). CR1 C5507G and A3650G SNPs were not associated with susceptibility to sarcoidosis or its clinical course. Further, CR1 messenger RNA expression in bronchoalveolar lavage cells investigated by quantitative reverse transcriptase-polymerase chain reaction did not differ between sarcoidosis patients and control subjects and was not associated with the presence of the CR1 5507*G allele.

Expression of CCX CKR in pulmonary sarcoidosis

OBJECTIVE

CCX CKR is a decoy chemokine receptor that specifically binds the chemokines CCL19, CCL25 and CCL21. CCL19 was previously found to be upregulated in pulmonary sarcoidosis. We have, therefore, investigated CCX CKR expression in this inflammatory disease.

METHODS AND RESULTS

CCX CKR mRNA was semiquantitated using RT-PCR in unseparated bronchoalveolar (BAL) cells from sarcoidosis patients (S, n = 29) and healthy control subjects (C, n = 9). CCX CKR transcripts were upregulated in patients (mean +/- SEM); S, 0.82 +/- 0.10; C, 0.44 +/- 0.04; p = 0.01; this upregulation paralleled the disease course as assessed by the chest radiographic stage (p < 0.02). Immunocytochemistry localised the CCX CKR protein to ciliated bronchial cells. Flow cytometric fluorescent ligand uptake assay showed that these cells are able to internalize its ligand.

CONCLUSION

These observations implicate CCX CKR in the modulation of the inflammatory response in sarcoidosis.

[Analysis of regressive changes in the lung carcinoma lymphatic metastases following induction chemotherapy]

BACKGROUND

Prognosis of higher stages of non-small cell lung cancer (NSCLC) is very poor. Only 13% of patients in stage IIIA survive 5 years after the diagnosis determination. The purpose of neoadjuvant (inductive) therapy is to eliminate haematogenous and lymphogenous metastases and to cause a cytoreduction in the primary tumor before the resection. Especially detection of lymphogenous metastases is the main factor in the indication of the pre-operative chemotherapy, but this therapy is frequently indicated according to CT without any bioptic verification. The authors suppose such a discrepancy in radiological and histo-pathological staging to influence in a positive sense rather optimistic results of therapeutic protocols, which include the pre-operative chemotherapy.

METHODS

A biopsy of the lymph nodes was performed as a part of the staging. If the metastasis was proved, the lymph node was labeled and the patient was treated by 3 cycles of the pre-operative chemotherapy. The 57 labeled lymph nodes were removed during the subsequent lung resection and lymphadenectomy. An analysis of regressive alterations in the lymphatic metastases of lung cancer after an inductive chemotherapy and comparison with the pre-operative bioptic findings have quantificated the chance of the inductive therapy to eliminate lymphatic metastases.

RESULTS

The clinical down-staging was stated in 21 cases (36.8%), but the viable malignant cells rested in the majority 50 (87.7%) of the taken labeled lymph nodes 57 (100%) even after the neoadjuvant therapy. On the other hand, the satisfactory tumor regression changes was proven in 49 (86%) lymphatic metastases. CONCLUSIN: The results of the study may modify an indicating judgment in the therapy of locally advanced stages of lung cancer because it has brought a new view to the results of neoadjuvant therapy.

[Pancreaticopleural fistula]

Pancreatic diseases are often accompanied by pleuropulmonal complications. Acute pancreatitis may induce a number of various pathological findings in respiratory tract including hypoxemia, decrease of transfer-factor (DLCO), decrease of transfer-coefficient (DLCO/VO), decrease in forced expiratory flow 25%- 75% of forced vital capacity (FEF25-75%), elevated and/or immobile diaphragm, basal atelectasis, unilateral or bilateral pulmonary infiltrations, mediastinal pseudocyst and pleural effusion. Acute respiratory distress syndrome (ARDS) is the most dangerous complication of acute pancreatitis. Large, recurrent pleural effusion is sometimes present in chronic pancreatitis, typically with a very high concentration of amylase in pleural fluid. Pancreaticopleural fistula (PPF) is the most common cause of this type of pleural effusion. We describe a study group of 3 patients with PPF and pleural effusion, their clinical symptoms, diagnostics and management.

[Prognostic impact of matrix metalloproteinases 2,9, and 11 in stromal cells stage I non-small cell lung cancer]

BACKGROUND

Matrix metalloproteinases (MMPs) belong to proteolytic enzymes. Degradation of the cell basement membrane and the extracellular matrix is one of their functions. In malignant tumors they can hypothetically contribute to the invasion and metastasis formation. They are mostly produced by stromal cells (fibroblasts and endothelial cells) as a response to the presence of tumor cells. MMP-2 (gelatinase A), MMP-9 (gelatinase B) and MMP-11 (stromelysin 3) are often mentioned in regard to Non-small Cell Lung Cancer (NSCLC).

METHODS AND RESULTS

The relation between the expression of the above-mentioned matrix metal-loproteinases in stromal cells and the cancer-related survival in 80 patients after curative resection of NSCLC in stage I according to TNM was studied. The expression of MMP-2 was associated with cancer-related survival but without significant correlation. No correlation was found in MMP-9. There was a statistically near-significant relation between the expression of MMP-11 and cancer-related survival.

CONCLUSIONS

The expression of MMP-11 in stromal cells in surgically treated NSCLC patients in stage I appears useful for evaluation of their prognosis.

Association of tumour necrosis factor-alpha, lymphotoxin-alpha and HLA-DRB1 gene polymorphisms with Löfgren's syndrome in Czech patients with sarcoidosis

Sarcoidosis is a granulomatous disorder showing a clear association with MHC (HLA) class I and class II genes. In order to investigate whether polymorphisms of nearby pro-inflammatory genes located within the MHC class III region may also contribute to susceptibility to sarcoidosis or to its clinical manifestation, tumour necrosis factor-alpha (TNF-alpha) and lymphotoxin-alpha (LT-alpha) genes were chosen for analysis in a case-control association study. In order to evaluate the findings on the TNF-alpha and LT-alpha genes in connection with the closely linked MHC class II region, 'classical' HLA-DRB1 locus was also investigated. Polymerase chain reaction-based methodologies were used in order to characterize two single-nucleotide polymorphisms (TNF-308*G/A and LTAlpha+252*A/G) and HLA-DRB1 allele groups in 114 Czech patients with pulmonary sarcoidosis and 425 healthy controls. LTA+252*G and HLA-DRB1*13 allele carriers were more frequent in patients, compared to those in controls. By contrast, HLA-DRB1*07 carriers were less frequent among sarcoidosis patients. The overrepresentation of TNF-308*A, LTAlpha+252*G and HLA-DRB1*03 allele carriers was found in a subgroup of sarcoidosis patients presenting with Lofgren's syndrome (LS) by comparison with the subgroup of patients without LS (NLS; phenotype frequency LS vs NLS: 68.8 vs 37.1% for TNF-308*A, 93.8 vs 66.3% for LTA+252*G and 68.8 vs 21.3% for DRB1*03). The data suggest that the LTAlpha and HLA-DRB1 genes themselves or a gene located nearby contributes to the susceptibility to sarcoidosis and that TNF-308*A, LTA+252*G and HLA-DRB1*03 alleles are associated (directly or via linkage with unknown causative locus) with LS as a specific manifestation of the disease.

[Complications of extended lung resection procedures following the neoadjuvant therapy]

Local tumor expansion in the sense of the tumor invasion into the extrapulmonary structures, which must be removed in one step, preferably en-bloc, together with the primary tumor, is the reason for extending the lung resection procedure. Although verified lymphogenic metastasing into either unilateral, eventually into contralateral mediastinal lymphonodes (stage N2 resp. N3, according to the TNM), remains the commonest indication for the induction therapy in cases of the lung carcinoma, application of the neoadjuvant therapy in cases when extended resections may be expected, is indicated in case the tumor expands into the surrounding structures, which signifies opening of new, unnatural routes of possible lymphogenic and haematogenic dissemination, and thus, a significantly higher risk of the surgical therapy failure. During the period 1995-2002, our team conducted 15 extended lung resection procedures following the preceding induction therapy in patients suffering from the IIB-IIIB stage of the non-small cellular lung carcinoma (NSCLC). The 30-day lethality rate equalled zero. We recorded two rare complications and the postoperative morbidity was acceptable.

CONCLUSION

Exhausting staging, the best possible prediction of the tumor behaviour following the surgical procedure and minimal surgical complications remain the prerequisite for good long-term results following the extended lung resections for the lung carcinoma. Application of the neoadjuvant therapy prior to the resection procedure need not increase the risk of surgical complications and, furthermore, may positively affect the disease prognosis.

CC and C chemokine expression in pulmonary sarcoidosis

The chemokines RANTES (regulated on activation, T-cell expressed and secreted; CC chemokine ligand (CCL)-5) and monocyte inflammatory protein (MIP)-1alpha (CCL-3) have been implicated in the development of alveolitis in pulmonary sarcoidosis. The novel C chemokine single cysteine motif (SCM)-1alpha (XCL-1) and the CC chemokine monocyte chemoattractant protein (MCP)-1 (CCL-2) are also mononuclear-cell attractants and represent alternative candidate mediators of alveolitis. Therefore, the expression of MCP-1 and SCM-1alpha was investigated together with the expression of RANTES and MIP-1alpha in bronchoalveolar lavage fluid (BALF) from control subjects and patients with sarcoidosis. The relationship between chemokine expression and sarcoidosis clinical course was also explored. Messenger ribonucleic acid (mRNA) expression for all four chemokines was determined by semiquantitative reverse transcriptase-polymerase chain reaction of RNA extracted from unseparated bronchoalveolar cells (17 patients, 12 controls). RANTES, MIP-1alpha and MCP-1 proteins were measured by enzyme-linked immunosorbent assay of unconcentrated BALF (60 patients, 17 controls). MCP-1, and namely RANTES and SCM-1alpha mRNA expression was upregulated in sarcoidosis, particularly in patients with more advanced disease. RANTES, and namely MCP-1 concentrations were elevated in BALF samples obtained from patients; MCP-1 levels were most increased in patients with chest radiographic stage 2 disease and also in patients with persistent and recurrent disease. In conclusion, chemokines monocyte chemotactive protein-1 and single cysteine motif-1alpha are, in addition to RANTES, associated with the development of alveolitis in sarcoidosis and their expression parallels the disease course.

Serum Clara cell protein (CC16), a marker of the integrity of the air-blood barrier in sarcoidosis

To test the hypothesis that sarcoidosis is associated with an intravascular leakage of lung epithelium secretory proteins, the occurrence and determinants in serum of sarcoid patients of CC16, a small size and readily diffusible lung-specific protein of 16 kDa secreted by bronchiolar Clara cells, was investigated. CC16 was measured by a sensitive latex immunoassay in the serum of 117 patients with established sarcoidosis and of 117 healthy subjects matched for age, sex and smoking status. Stepwise regression analysis was used to identify extrapulmonary variables of CC16 changes in serum. These changes were then compared with biochemical and cellular parameters in bronchoalveolar lavage fluid (BALF) as well as with the number of CC16 immunostaining cells on bronchial or pulmonary biopsy samples. CC16 concentration in serum of sarcoid patients was significantly increased, compared to their matched controls (25.9 +/- 16.2 versus 13.9 +/- 5.2 microg x L(-1)). In nonsmoking patients without significant renal impairment, CC16 in serum increased with the severity of the chest radiograph and computed tomography changes, and was on average 50-100% higher when parenchymal involvement was present. Sarcoid patients had, however, normal levels of CC16 in BALF and an unchanged number of CC16-immunopositive cells in lung biopsy samples, suggesting that an increased secretion of CC16 in the sarcoid lung is very unlikely, and that the elevation of CC16 in sarcoidosis results from an increased intravascular leakage of the protein across the air-blood barrier. The present study suggests that CC16 in serum might provide a useful tool to noninvasively evaluate the damage and increased permeability to proteins of the air-blood barrier associated with sarcoidosis.

Human leukocyte antigen-DRB1 position 11 residues are a common protective marker for sarcoidosis

Genetic factors, in particular human leukocyte antigens (HLAs) are important determinants of susceptibility to sarcoidosis, a chronic granulomatous disease of undetermined etiology. To clarify the role of HLA in sarcoidosis we determined HLA-DR and -DQ alleles in case-control samples from three European populations (United Kingdom, Czech, and Polish) and compared these results with those published for three additional populations (Italian, Japanese, and Scandinavian) to determine whether the HLA-DR and/or -DQ alleles act as ethnic-dependent, or ethnic-independent modifiers of disease risk. Although variations were apparent in the alleles associated with susceptibility, reductions in the frequency of alleles associated with protection were remarkably consistent in the six populations. Previously detected associations between single-nucleotide polymorphisms at the TAP2 locus and sarcoidosis were shown to be due to linkage disequilibrium with the HLA-DR locus. The protective HLA-DR alleles, which encode the DR1 and DR4 antigens, were found to share characteristic small hydrophobic residues at position 11, which were replaced by small hydrophilic residues in the remaining, nonprotective, HLA-DR alleles. This residue position is within a pocket of the HLA-DR complex antigen binding groove (designated P6), where it is the only variable amino acid and therefore determines the peptide binding preferences of this pocket. A highly significant reduction in the frequency of individuals carrying HLA-DR alleles with a hydrophobic residue at position 11 was observed in the sarcoidosis cases in the three populations we examined. This suggests this HLA-DR residue is an important protective marker in sarcoidosis.

Ace gene I/D polymorphism and sarcoidosis pulmonary disease severity

Previous studies of the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene in sarcoidosis have revealed both ethnic heterogeneity of I/D frequencies and controversy surrounding the association between the polymorphism and severity of disease. The objective of this study was, therefore, to clarify the role of the ACE I/D polymorphism in (1) disease susceptibility, (2) pulmonary disease severity (with particular reference to pulmonary fibrosis), and (3) pulmonary disease progression, in two distinct European sarcoidosis populations. Standard chest radiographic staging was performed on 118 UK and 56 Czech white patients with sarcoidosis at 2 yr from presentation. Pulmonary function data were analyzed, and patients were then categorized according to disease severity. A PCR-SSP assay was used to determine the ACE I/D genotype of each patient studied. The I/D allele frequencies from these patients were compared with frequencies from ethnically matched UK (n = 386) and Czech (n = 179) control subjects using a chi-square contingency table. No significant differences were seen in the distribution of the ACE I/D genotypes, allele frequencies or phenotype frequencies. Furthermore, no association was found between the ACE I/D polymorphism and pulmonary disease severity, fibrosis, and progression. We conclude that the ACE I/D polymorphism has no role in sarcoidosis susceptibility in European whites and that it is not a regulatory variant in this disease.

[Fire-eater's pneumonia--a difficult differential diagnosis]

Acute aspiration of petroleum or other hydrocarbon products can cause a distinct type of chemical pneumonitis known as fire-eater's pneumonia. Initial findings on chest X-rays are ambiguous and not uniform in nature. Among the most common belong mottled or patchy, local or diffuse perihilar and basal uni- or bilateral infiltrates, areas of atelectasis, tumor-like lesions and rarely pleural effusions. CT finding often shows formation of smaller or larger pneumatoceles. Those cavities tend to regress spontaneously over weeks or months. Clinical diagnosis is sometimes very difficult, especially in cases, when past history of "fire-eating" is not known to the physician. The authors present clinical manifestation, sequential X-ray and CT findings in one patient with fire-eater's pneumonia. To diagnose the disease, not only paraclinical exploration is needed, but also the patient's past history plays an important role. Without it this puzzling clinical unit can remain undiagnosed.