Telomere length and TERT polymorphisms as biomarkers in asbestos-related diseases

BACKGROUND

Asbestos exposure has been proposed as a risk factor for shorter telomere length. The aim of our study was to investigate whether telomere length in leukocytes and hTERT genetic polymorphisms may serve as potential biomarkers for the risk of developing asbestos-related diseases and as biomarkers of progression and chemotherapy response rate in malignant mesothelioma (MM).

SUBJECTS AND METHODS

We conducted two retrospective studies. In the first study, a case-control study, telomere length and hTERT polymorphisms were determined in patients with MM, subjects with pleural plaques and controls without the asbestos related disease, who were occupationally exposed to asbestos. In the second study, a longitudinal observational study, telomere length was also determined in samples from MM patients before and after chemotherapy. Telomere length was determined by monochromatic multiplex quantitative polymerase chain reaction (PCR), while competitive allele-specific PCR was used to genotype hTERT rs10069690, rs2736100 and rs2736098. Logistic regression and survival analysis were used in statistical analysis.

RESULTS

Patients with MM had shorter telomere length than subjects with pleural plaques (p < 0.001). After adjustment for age, rs2736098 CT, and rs10069690 TT and CT+TT genotypes were significantly associated with a higher risk of MM (padj = 0.023; padj = 0.026 and padj = 0.017), while rs2736100 AA and CA+AA genotypes conferred to a lower risk for MM compared to all other subjects (padj = 0.017, and padj = 0.026). Telomere length was not associated with a response to chemotherapy (p > 0.05) or time to disease progression (p > 0.05). Carriers of one or two polymorphic rs10069690 T alleles had a good response to chemotherapy (p = 0.039, and p = 0.048), these associations remained statistically significant after adjustment for age (padj = 0.019; padj = 0.017). Carriers of two polymorphic rs2736100 A alleles had a longer time to disease progression (p = 0.038).

CONCLUSIONS

Shorter telomere length and hTERT polymorphisms may serve as a biomarker for the risk of developing MM. Additionally, rs10069690 and rs2736100 polymorphisms, but not telomere length, were associated with a chemotherapy response or MM progression.

The association of genetic factors with serum calretinin levels in asbestos-related diseases

BACKGROUND

Asbestos exposure is associated with different asbestos-related diseases, including malignant mesothelioma (MM). MM diagnosis is confirmed with immunohistochemical analysis of several markers, including calretinin. Increased circulating calretinin was also observed in MM. The aim of the study was to determine if CALB2 polymorphisms or polymorphisms in genes that can regulate calretinin expression are associated with serum calretinin levels or MM susceptibility.

SUBJECTS AND METHODS

The study included 288 MM patients and 616 occupationally asbestos-exposed subjects without MM (153 with asbestosis, 380 with pleural plaques and 83 without asbestos-related disease). Subjects were genotyped for seven polymorphisms in CALB2, E2F2, MIR335, NRF1 and SEPTIN7 genes using competitive allele-specific polymerase chain reaction (PCR). Serum calretinin was determined with ELISA in 545 subjects. Nonparametric tests, logistic regression and receiver operating characteristic (ROC) curve analysis were used for statistical analysis.

RESULTS

Carriers of at least one polymorphic CALB2 rs889704 allele had lower calretinin levels (P = 0.036). Carriers of two polymorphic MIR335 rs3807348 alleles had higher calretinin (P = 0.027), while carriers of at least one polymorphic NRF1 rs13241028 allele had lower calretinin levels (P = 0.034) in subjects without MM. Carriers of two polymorphic E2F2 rs2075995 alleles were less likely to develop MM (odds ratio [OR] = 0.64, 95% confidence interval [CI] = 0.43-0.96, P = 0.032), but the association was no longer significant after adjustment for age (P = 0.093). Optimal serum calretinin cut-off values differentiating MM patients from other subjects differed according to CALB2, NRF1, E2F2, and MIR335 genotypes.

CONCLUSIONS

The results of presented study suggest that genetic variability could influence serum calretinin levels. These findings could contribute to a better understanding of calretinin regulation and potentially to earlier MM diagnosis.

Genetic polymorphisms in aquaporin 1 as risk factors for malignant mesothelioma and biomarkers of response to cisplatin treatment

Background Malignant mesothelioma (MM) is an asbestos related aggressive tumor with poor prognosis. The aim of this study was to investigate if aquaporin 1 (AQP1) genetic polymorphisms influence the risk of MM and the response to cisplatin based MM treatment. Patients and methods The case-control study included 231 patients with MM and a control group of 316 healthy blood donors. All subjects were genotyped for three AQP1polymorphisms (rs1049305, rs1476597 and rs28362731). Logistic and Cox regression were used in statistical analysis. Results AQP1 rs1049305 polymorphism was significantly associated with MM risk in dominant model adjusted for gender and age (OR = 0.60, 95% CI = 0.37-0.96, Padj = 0.033). This polymorphism was also significantly associated with cisplatin based treatment related anaemia (unadjusted: OR = 0.49, 95% CI = 0.27-0.90, P = 0.021; adjusted: for CRP: OR = 0.52, 95% CI = 0.27-0.99, P = 0.046), with leukopenia (OR = 2.09, 95% CI = 1.00-4.35, P = 0.049) in dominant model and with thrombocytopenia (OR = 3.06, 95% CI = 1.01-9.28, P = 0.048) and alopecia (OR = 2.92, 95% CI = 1.00-8.46, P = 0.049) in additive model. AQP1 rs28362731 was significantly associated with thrombocytopenia (unadjusted: OR = 3.73, 95% CI = 1.00-13.84, P = 0.049; adjusted for pain: OR = 4.63, 95% CI = 1.13-19.05, P = 0.034) in additive model. Conclusions AQP1 may play a role in the risk of MM. Furthermore, AQP1 genotype information could improve the prediction of MM patients at increased risk for cisplatin toxicity.

Cancer Etiology: A Metabolic Disease Originating from Life's Major Evolutionary Transition?

A clear understanding of the origins of cancer is the basis of successful strategies for effective cancer prevention and management. The origin of cancer at the molecular and cellular levels is not well understood. Is the primary cause of the origin of cancer the genomic instability or impaired energy metabolism? An attempt was made to present cancer etiology originating from life's major evolutionary transition. The first evolutionary transition went from simple to complex cells when eukaryotic cells with glycolytic energy production merged with the oxidative mitochondrion (The Endosymbiosis Theory first proposed by Lynn Margulis in the 1960s). The second transition went from single-celled to multicellular organisms once the cells obtained mitochondria, which enabled them to obtain a higher amount of energy. Evidence will be presented that these two transitions, as well as the decline of NAD+ and ATP levels, are the root of cancer diseases. Restoring redox homeostasis and reactivation of mitochondrial oxidative metabolism are important factors in cancer prevention.

Breast Metastases from Cutaneous Melanoma a Report of Three Cases

In this report we describe three female patients with breast metastases from cutaneous melanoma (CM) who were treated in Slovenia in the period from 1988 to 1991. We found that in 476 Slovenian patients with this disease diagnosed in the given period CM disseminated to the breast less frequently than in other series. In one pregnant and one perimenopausal patient breast involvement by CM was confirmed at the time of widespread dissemination of the disease. Treatment was not effective and the survival of these patients was four months and two weeks and six months, respectively. A slightly better outcome was observed in a normally menstruating patient referred from another country with an isolated solitary breast metastasis from CM. In this patient quadrantectomy seemed to have been sufficient to achieve a disease-free interval of more than eight months. Special attention should therefore be given to a small subset of patients with isolated solitary breast metastases from CM, since their prognosis may be less dismal than in patients with massively infiltrated breasts and disseminated disease.

High BMI1 mRNA expression in peripheral whole blood is associated with favorable prognosis in advanced non-small cell lung cancer patients

Polycomb group member protein BMI1 is involved in maintaining cell identity, proliferation, differentiation and human oncogenesis. In the present study, we determined BMI1 mRNA expression in whole blood and evaluated the impact of the expression level on the treatment response and survival of 96 advanced NSCLC patients treated with first-line platinum-based chemotherapy. We also determined BMI1 mRNA expression in primary tumors from 22 operable NSCLC patients treated with radical surgery. We found that compared with control subjects, BMI1 mRNA expression in whole blood of advanced NSCLC patients was decreased (P<0.001). Similarly, we observed decreased BMI1 mRNA expression in primary tumors compared to normal lungs from operable NSCLC patients (P=0.001). We found high BMI1 mRNA expression in blood was associated with longer progression-free survival (PFS) (P=0.049) and overall survival (OS) (P=0.012) in advanced NSCLC patients treated with first-line platinum-based chemotherapy. However, no association between the BMI1 mRNA level and response to chemotherapy was found (P=0.21). Multivariate Cox proportional hazards regression analysis showed elevated BMI1 mRNA level in whole blood was an independent prognostic factor for longer PFS (P=0.012) and OS (P<0.001). In conclusion, BMI1 mRNA expression in whole blood might represent a new biomarker for the diagnosis and prognosis of NSCLC.

Long-term survival in glioblastoma: methyl guanine methyl transferase (MGMT) promoter methylation as independent favourable prognostic factor

Background

In spite of significant improvement after multi-modality treatment, prognosis of most patients with glioblastoma remains poor. Standard clinical prognostic factors (age, gender, extent of surgery and performance status) do not clearly predict long-term survival. The aim of this case-control study was to evaluate immuno-histochemical and genetic characteristics of the tumour as additional prognostic factors in glioblastoma.

Patients and methods

Long-term survivor group were 40 patients with glioblastoma with survival longer than 30 months. Control group were 40 patients with shorter survival and matched to the long-term survivor group according to the clinical prognostic factors. All patients underwent multimodality treatment with surgery, postoperative conformal radiotherapy and temozolomide during and after radiotherapy. Biopsy samples were tested for the methylation of MGMT promoter (with methylation specific polymerase chain reaction), IDH1 (with immunohistochemistry), IDH2, CDKN2A and CDKN2B (with multiplex ligation-dependent probe amplification), and 1p and 19q mutations (with fluorescent in situ hybridization).

Results

Methylation of MGMT promoter was found in 95% and in 36% in the long-term survivor and control groups, respectively (p < 0.001). IDH1 R132H mutated patients had a non-significant lower risk of dying from glioblastoma (p = 0.437), in comparison to patients without this mutation. Other mutations were rare, with no significant difference between the two groups.

Conclusions

Molecular and genetic testing offers additional prognostic and predictive information for patients with glioblastoma. The most important finding of our analysis is that in the absence of MGMT promoter methylation, longterm survival is very rare. For patients without this mutation, alternative treatments should be explored.

Intercalated chemotherapy and erlotinib for non-small cell lung cancer (NSCLC) with activating epidermal growth factor receptor (EGFR) mutations

Among attempts to delay development of resistance to tyrosine kinase inhibitors (TKIs) in patients with advanced non-small cell lung cancer (NSCLC) with activating mutations of epidermal growth factor receptor (EGFR), intercalated therapy has not been properly evaluated. In a phase II trial, 38 patients with EGFR mutated NSCLC in advanced stage were treated with 4 to 6 3-weekly cycles of intercalated schedule with gemcitabine (1250 mg/m2, days 1 and 4), cisplatin (75 mg/m2, day 2) and erlotinib (150 mg, days 5 - 15), followed by continuous erlotinib as maintenance. In addition to standard radiologic evaluation according to RECIST, PET/CT was done prior to treatment and at 6 months, using PERCIST as a method for assessment of response. The primary endpoint was progression-free survival (PFS). In general, tolerance to treatment was good, even among 8 patients with performance status 2-3 and 13 patients with brain metastases; grade 4 toxicity included 2 cases of neutropenia and 4 thrombo-embolic events. Complete response (CR) or partial response (PR) were seen in 15 (39.5%) and 17 (44.7%) cases, respectively. All cases of CR were confirmed also by PET/CT. Median PFS was 23.4 months and median overall survival (OS) was 38.3  months. After a median follow-up of 35 months, 8 patients are still in CR and on maintenance erlotinib. In conclusion, intercalated treatment for treatment-naive patients with EGFR activating mutations leads to excellent response rate and prolonged PFS and survival. Comparison of the intercalated schedule to monotherapy with TKIs in a randomized trial is warranted.

Endobronchial ultrasound elastography strain ratio for mediastinal lymph node diagnosis

Background

Ultrasound elastography is an imaging procedure that can assess the biomechanical characteristics of different tissues. The aim of this study was to define the diagnostic value of the endobronchial ultrasound (EBUS) elastography strain ratio of mediastinal lymph nodes in patients with a suspicion of lung cancer. The diagnostic values of the strain ratios were compared with the EBUS brightness mode (B-mode) features of selected mediastinal lymph nodes and with their cytological diagnoses.

Patients and methods

This prospective, single-centre study enrolled patients with an indication for biopsy and mediastinal staging after a non-invasive diagnostic workup of a lung tumour. EBUS with standard B-mode evaluation and elastography with strain ratio measurement were performed before endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Results

Thirty-three patients with 80 suspicious mediastinal lymph nodes were included. Malignant infiltration was confirmed in 34 (42.5%) lymph nodes. The area under the receiver operating characteristic curve for the strain ratio was 0.87 (p < 0.0001). At a strain ratio ≥ 8, the accuracy for malignancy prediction was 86.25% (sensitivity 88.24%, specificity 84.78%, positive predictive value [PPV] 81.08%, negative predictive value [NPV] 90.70%). The strain ratio is more accurate than conventional B-mode EBUS modalities for differentiating between malignant and benign lymph nodes.

Conclusions

EBUS-guided elastography with strain ratio assessment can distinguish malignant from benign mediastinal lymph nodes with greater accuracy than conventional EBUS modalities. This new method may reduce the number of mediastinal EBUS-TBNAs and thus reduce the invasiveness and expense of mediastinal staging in patients with non-small lung cancer (NSCLC).

Fibulin-3 as a biomarker of response to treatment in malignant mesothelioma

Background

Fibulin-3 is a new potential biomarker for malignant mesothelioma (MM). This study evaluated the potential applicability of fibulin-3 plasma levels as a biomarker of response to treatment and its prognostic value for progressive disease within 18 months. The potential applicability of fibulin-3 in comparison with or in addition to soluble mesothelin-related peptides (SMRP) was also assessed.

Patients and methods.

The study included 78 MM patients treated at the Institute of Oncology Ljubljana between 2007 and 2011. Fibulin-3 levels in plasma samples obtained before treatment and in various responses to treatment were measured with the enzyme-linked immunosorbent assay.

Results

In patients evaluated before the treatment, fibulin-3 levels were not influenced by histopathological sub-types, tumour stages or the presence of metastatic disease. Significantly higher fibulin-3 levels were found in progressive disease as compared to the levels before treatment (Mann-Whitney [U] test = 472.50, p = 0.003), in complete response to treatment (U = 42.00, p = 0.010), and in stable disease (U = 542.00, p = 0.001). Patients with fibulin-3 levels exceeding 34.25 ng/ml before treatment had more than four times higher probability for developing progressive disease within 18 months (odds ratio [OR] = 4.35, 95% confidence interval [CI] 1.56–12.13). Additionally, patients with fibulin-3 levels above 34.25 ng/ml after treatment with complete response or stable disease had increased odds for progressive disease within 18 months (OR = 6.94, 95% CI 0.99–48.55 and OR = 4.39, 95% CI 1.63–11.81, respectively).

Conclusions

Our findings suggest that in addition to SMRP fibulin-3 could also be helpful in detecting the progression of MM.

Induction gemcitabine in standard dose or prolonged low-dose with cisplatin followed by concurrent radiochemotherapy in locally advanced non-small cell lung cancer: a randomized phase II clinical trial

BACKGROUND

The optimal combination of chemotherapy with radiation therapy for treatment locally advanced non-small cell lung cancer (NSCLC) remains an open issue. This randomized phase II study compared gemcitabine in two different schedules and cisplatin - as induction chemotherapy, followed by radiation therapy concurrent with cisplatin and etoposid.

PATIENTS AND METHODS

Eligible patients had microscopically confirmed inoperable non-metastatic non-small cell lung cancer; fulfilled the standard criteria for platin-based chemotherapy; and signed informed consent. Patients were treated with 3 cycles of induction chemotherapy with gemcitabine and cisplatin. Two different aplications of gemcitabine were compared: patients in arm A received gemcitabine at 1250 mg/m(2) in a standard half hour i.v. infusion on days 1 and 8; patients in arm B received gemcitabine at 250 mg/m(2) in prolonged 6-hours i.v. infusion on days 1 and 8. In both arms, cisplatin 75 mg/m(2) on day 2 was administered. All patients continued treatment with radiation therapy with 60-66 Gy concurrent with cisplatin 50 mg/m(2) on days 1, 8, 29 and 36 and etoposid 50 mg/m(2) on days 1-5 and 29-33. The primary endpoint was response rate (RR) after induction chemotherapy; secondary endpoints were toxicity, progression-free survival (PFS) and overall survival (OS).

RESULTS

From September 2005 to November 2010, 106 patients were recruited to this study. No statistically signifficant differences were found in RR after induction chemotherapy between the two arms (48.1% and 57.4%, p = 0.34). Toxicity profile was comparable and mild with grade 3/4 neutropenia as primary toxicity in both arms. One patient in arm B suffered from acute peripheral ischemia grade 4 and an amputation of lower limb was needed. With a median follow-up of 69.3 months, progression-free survival and median survival in arm A were 15.7 and 24.8 months compared to 18.9 and 28.6 months in arm B. The figures for 1- and 3-year overall survival were 73.1% and 30.8% in arm A, and 81.5 % and 44.4% in arm B, respectively.

CONCLUSIONS

Among the two cisplatin-based doublets of induction chemotherapy for inoperable NSCLC, both schedules of gemcitabine have a comparable toxicity profile. Figures for RR, PFS and OS are among the best reported in current literature. While there is a trend towards better efficacy of the treament with prolonged infusion of gemcitabine, the difference between the two arms did not reach statistical significance.

Soluble mesothelin-related peptides levels in patients with malignant mesothelioma

Soluble mesothelin-related peptides (SMRP) are a potential tumor marker for malignant mesothelioma. The aim of this study was to determine the differences in SMRP levels in patients with malignant mesothelioma before treatment and in various responses to treatment and to investigate whether SMRP level could be useful in evaluating tumor response to treatment. The study included patients with malignant mesothelioma treated at the Institute of Oncology Ljubljana between March 2007 and December 2009. Blood samples were collected before treatment and/or in various responses to treatment. SMRP levels were determined using ELISA assay based upon a combination of two monoclonal antibodies. Mann-Whitney test was used to determine the differences in SMRP levels in various responses to treatment. Median SMRP was 2.80 nmol/L (range 0.00-34.80) before treatment, 0.00 nmol/L (range 0.00-0.00) in complete response, 0.48 nmol/L (range 0.00-4.40) in partial response, 1.65 nmol/L (range 0.00-20.71) in stable disease and 7.15 nmol/L (range 0.44-31.56) in progressive disease. Pre-treatment SMRP levels were significantly higher than in stable disease, partial response and complete response (p=0.006), as were SMRP levels in progressive disease compared to stable disease, partial response and complete response (p< 0.001). Our findings suggest that SMRP may be a useful tumor marker for detecting the progression of malignant mesothelioma and evaluating tumor response to treatment.

Attitudes of midwifery students towards teaching breast-self examination

BACKGROUND

The purpose of this study was to asses the attitude of undergraduate midwifery students towards teaching other women in methods of breast self-examination (BSE). PARTICIPANTS AND METHODS.: The study was performed at the beginning and at the end of students' study at the Faculty of Health Sciences in Ljubljana, Slovenia. It was carried out during the academic year 2002/2003 and involved 28 first and 25 third year undergraduate midwifery students. The data were gathered from questionnaires and processed with the use of descriptive and inferential statistics.

RESULTS

All study participants were of the opinion that teaching other women in methods of BSE is of great importance for an early detection of breast cancer (BC) and that this task ought to be one of their duties. There were no significant differences between the two groups when the readiness to upgrade their own knowledge of BSE or when the optimism regarding the progress in breast cancer detection and therapy in the future were concerned.

CONCLUSIONS

The readiness of midwifery students to pass the knowledge of BSE to other women could help to increase their breast health awareness and thus improve their willingness and ability to detect early changes, associated with BC.

Predicting the intention to quit smoking and quitting behaviour: extending the theory of planned behaviour

OBJECTIVES

The present study examined the ability of the TPB to predict the intention to quit smoking and quitting behaviour. In addition, the predictive power of future orientation, number of cigarettes smoked, planning, past behaviour and the interactions between intention and other predictors was examined.

MATERIAL AND METHODS

The data were derived from a longitudinal survey among 103 daily smoking students at the University of Oslo (mean age 24.6 years, mean number of years of smoking = 8 years). These data were collected by means of self-administered questionnaires at T1 (October 2003) and at T2 (February 2004) in terms of recording actual quitting.

RESULTS

The TPB components accounted for 30% of the variance in quitting intentions, and affective attitude and descriptive norm emerged as the strongest predictors of quitting intention. Ordinal regression analysis showed that intention was a borderline significant predictor of subsequent quitting behaviour, while the impact of PBC was non-significant (model 1). The inclusion of the additional variables improved the fit of the model, with number of cigarettes and planning appearing as significant predictors of behaviour (model 2). As predicted, there was a significant interaction between perceived control and intentions on quitting (model 3). Nagelkerke R(2) increased from .07 in model 1 to .54 in model 2, and finally to .58 in model 3.

CONCLUSIONS

The results indicate that affective attitude and descriptive norm play a more crucial role than the other TPB predictors in motivating smokers to quit. The results also indicate that self-regulatory strategies are important in relation to addictive behaviours.

Gemcitabine, cisplatin, and hyperfractionated accelerated radiotherapy for locally advanced non-small cell lung cancer

BACKGROUND

Due to potent radiosensitization and potential serious or fatal toxicity, concurrent gemcitabine and irradiation should only be applied within clinical trials. We here present experience from a phase I-II clinical trial for patients with locally advanced non-small cell lung cancer (NSCLC) treated with hyperfractionated accelerated radiotherapy and concurrent low-dose gemcitabine.

METHODS

Eligible patients had locally advanced inoperable NSCLC without pleural effusion, Eastern Cooperative Oncology Group performance status 0-1, were chemotherapy naïve and had no previous radiotherapy to the chest, and had adequate hematopoietic, liver, and kidney function. Routine brain computed tomography was not performed, and positron emission tomography/computed tomography was not available. Treatment consisted of three parts: induction chemotherapy with gemcitabine and cisplatin in standard doses, local treatment with concurrent chemotherapy and radiotherapy, and consolidation chemotherapy. Patients were irradiated with opposed AP-PA and oblique fields, using 2.5-D treatment planning. Although corrections for inhomogeneous tissue were made, volume of total lung receiving > or =20 Gy (V20) could not be determined. The trial started as phase I, aimed to determine the dose-limiting toxicity and maximal tolerated dose (MTD) for concurrent hyperfractionated radiotherapy (1.4 Gy twice daily) and gemcitabine 55 mg/m twice weekly as a radiosensitizer. Phase II of the trial then continued at the level of MTD.

RESULTS

Twenty-eight patients with NSCLC, nine patients with stage IIIA, 16 patients with IIIB, and three patients with an inoperable recurrence after previous surgery, entered the trial. The first 12 patients entered Phase I of the trial at the initial level of 42 Gy in 30 fractions in 3 weeks. Dose-limiting toxicity was acute esophagitis; 47.6 Gy in 34 fractions in 3.5 weeks was the MTD for this regimen of concurrent chemotherapy and radiotherapy. In phase II of the trial, this dose was applied to the next 16 patients. Among all 28 patients, 13 had grade 3 or 4 acute toxicity: esophagitis (eight patients), neutropenia (eight patients), thrombocytopenia (four patients), and anemia (two patients). No pulmonary toxicity and no persistent or serious late toxicity were seen. Local and/or regional relapse was documented in nine patients, distant in five and both locoregional and distant in 10 patients. The most common sites of distant spread were the brain and lung in eight and six patients, respectively. At 2 years, progression-free survival was 43% and overall survival was 57%. After 43 to 85 months of follow-up, seven patients are alive, of whom six (21%) are without evidence of disease and may be regarded as long-term survivors. Among the long-term survivors, one was in the group irradiated to 42 Gy and six in the groups irradiated to 47.6 Gy.

CONCLUSION

Judging from current standards, the methods used in diagnostics and in planning of radiotherapy were suboptimal. Using modern radiotherapy planning, a higher MTD, possibly a different profile of toxicity, and better long-term results may be expected. The high incidence of brain relapse emphasizes the need for careful screening for unsuspected brain disease before treatment and the importance of clinical studies on prophylactic cranial irradiation for patients with locally advanced NSCLC. Although the small number of patients in this study precludes any definitive conclusion, it appears that our program of concurrent chemotherapy and radiotherapy offers a chance for disease control at least comparable to previously described programs for inoperable lung cancer.

Exploratory thoracotomy and its influence on the survival of patients with lung cancer

PURPOSE

To evaluate diagnostic procedures, reasons for exploratory thoracotomy (ET), causes of unresectability of lung cancer, possibility for reducing numbers of ETs, and the influence of ET on survival.

PATIENTS AND METHODS

Between 1990 and 1999, 1808 patients with lung cancer were operated on. ET was performed in 165 (9.1%) of these cases. In total, 131 ET patients were evaluable for analysis. The clinical stages were: three patients in stage IA, 28 in IB, one in IIA, 35 in IIB, 50 in IIIA, 10 in IIIB (all due to invasion of the mediastinum), and four patients in IV (three with ipsilateral pulmonary and one with solitary suprarenal metastasis). The control group for calculating survival difference consisted of 130 consecutive non-operated patients with comparable characteristics (age, sex, clinical stage, performance status, histology and comorbidity) who were diagnosed during the period 1996-1998.

RESULTS

The diagnostic procedure before ET comprised bronchoscopy in all patients, transthoracic needle biopsy in 13, cervical mediastinoscopy in nine, parasternal mediastinotomy in two and thoracoscopy in two, in all patients without proving unresectability. A CT scan was performed in 118 patients indicating resectability in 33%, doubtful resectability in 64% and unresectability in 3%. Clinical and surgical staging were equal in 3% of stage IIB patients, in 24% of stage IIIA, 100% of stage IIIB and 75% of patients in stage IV. The 30-day operative mortality was 4.6%. The reasons for ET were: diagnosis of preoperatively unverified tumor in one patient, necessity for pneumonectomy in the case of poor pulmonary function in 11 patients, and unresectability in 119 (due to invasion of the mediastinum in 98 patients, thoracic wall in three and vertebral body in one, and due to pleural metastases in 17 patients). ET could have been avoided in 15 (11%) patients. The median survival for both ET and control group patients was 11.1 months. The survival difference was not statistically significant (p = 0.420).

CONCLUSION

ET could be partly avoided through a more accurate preoperative staging procedure. It does not appear possible to avoid ET in patients with limited pulmonary reserve precluding a resection larger than that predicted, nor to avoid ET as a consequence of intraoperative complications. Despite operative mortality, ET did not significantly influence the survival rate in the present study.

Phase I-II trial of low-dose gemcitabine in prolonged infusion and cisplatin for advanced non-small cell lung cancer

After monotherapy with gemcitabine in low dose in long infusion, promising results in a variety of advanced chemoresistant tumors have been reported. In a previous phase I trial on heavily pre-treated patients, maximum tolerated dose (MTD) of gemcitabine in a 6 h infusion was 250 mg/m. The objective of our phase I-II trial was to test the combination of gemcitabine in a 6-h infusion and cisplatin in the treatment of advanced non-small cell lung cancer (NSCLC). Eligible patients were chemonaive, had locally advanced or metastatic NSCLC, Eastern Oncology Cooperative Oncology Group performance status 0-2 and normal organ function. Treatment consisted of gemcitabine in a 6-h infusion on days 1 and 8, and cisplatin at 75 mg/m on day 2 of a 3-week cycle. During phase I of the trial, the dose of gemcitabine was escalated from 130 to 170, 210 and 250 mg/m. After establishing dose-limiting toxicity (DLT) and MTD of the combination, the trial continued as phase II. Altogether, 61 patients were enrolled, of whom 54 had stage IV disease. In phase I of the trial, groups of six, seven, eight and eight patients were treated at the four dose levels of gemcitabine. In phase II, the remaining 32 patients all received gemcitabine at 250 mg/m. Serious toxicity included a patient with grade 5 ventricular arrhythmia and another with grade 4 cerebrovascular ischemia; four patients had grade 3 anemia. Reversible thrombocytosis with platelets over 500 was recorded in 32 patients; 42 patients had grade 2 alopecia. In general, tolerance to this treatment was good. One patient had complete response and 27 had partial responses, for a 28 of 61 (46%) response rate. Median progression-free survival, median survival and 1-year survival were 6 months, 9.5 months and 40%, respectively. We conclude that this treatment has an acceptable, yet distinct, toxicity profile; routine thromboprophylaxis is recommended. In our population of chemonaive patients, no DLT has been encountered. Due to the remarkable response rate, further research is warranted.

Meta-analyses of clinical trials in patients with non-small cell lung cancer. Minireview

Currently lung cancer is the most common worldwide cause of major cancer incidence and mortality. The treatment outcome is poor and there are still many questions which remain unanswered such as the interest of the best treatment schedule. To approach the answer what is the best treatment for patients with non-small cell lung cancer (NSCLC) we made a review of the published meta-analyses. Meta-analysis is a systematic approach to identification and abstraction of critical information from different randomized, controlled trials. The review of meta-analyses of clinical trials we had made showed that --in radically operated patients the postoperative radiotherapy should be detrimental if standard fields are used; postoperative chemotherapy with regimens based on cisplatin has an absolute benefit of 5% at 5 years survival; we can improve the survival of patients with locally advanced NSCLC using chemoradiation comparing to radiotherapy alone; chemotherapy with cisplatin can prolong the survival and improve the quality of life in patients with advanced NSCLC; platinum-based doublets remain the standard regimen in patients with advanced NSCLC; there is a slight but significant improvement in efficacy of gemcitabine plus platinum agent when compared with other platinum based comparators in regard to the survival and time to disease progression. In our dealing with NSCLC patients there are still many controversial opinions, and the meta-analyses are seldom the only way to find more effective treatment regimen, while the improvement in lung cancer treatment is a story of small steps.

[Multisegmental posterior wedge osteotomies of the lumbar vertebrae for correction of kyphosis in ankylosing spondylitis. A report on 5 cases]

Operative treatment of Ankylosing spondilitis is usually performed in treatment of extraspinal pathology, i.e. in treatment of hip contractures. Operative treatment of fixed spinal kyphosis in AS is rarely indicated, and patients make their decision for the operation when deformation becomes extreme. Instead of several hundred of operated patients in foreign literature, authors describe only 5 operations from 1989 to 2000. Results suggest that multiple spinal osteotomy in AS is a time consuming operation with a significant intraoperative and postoperative blood loss. Mild, transient radicular irritations are noticed. However, reconstruction of lumbar lordosis significantly improve quality of life in operated patients. It is concluded that indication for the operation in AS should be indicated earlier. Better results with less risk would be achieved.

Scoliosis curve correction, thoracic volume changes, and thoracic diameters in scoliotic patients after anterior and after posterior instrumentation

Thoracic volume was calculated in 50 adolescent patients operated on for severe idiopathic thoracic scoliosis. In 25, anterior instrumentation was used (group 1), and posterior instrumentation in the other 25 patients (group 2). Calculation of thoracic volume was made from measurements of pre-operative and post-operative radiographs. The mean spinal curvature in group 1 was 73+/-12.4 degrees before the operation, and 19+/-15 degrees after the operation, and in group 2 the curvature was 75+/-13 degrees before the operation and 37+/-10 degrees after the operation. The calculated thoracic volume in the group with anterior instrumentation increased from 5234 ml pre-operatively to 6043 ml post-operatively, while with posterior instrumentation it increased from 5155 ml to 5489 ml. The correlation between the change in the Cobb angle and the thoracic volume change was poor for both groups. To determine the role in the thoracic volume increase of the frontal, sagittal and vertical thoracic diameters, further correlation tests were made between these and the thoracic volume increase in each diameter. The best correlation was found between the frontal and vertical increase of diameters in group 1, whereas in group 2 the best correlation was found between the volume increase and the sagittal parameters.

Molecular mechanisms involved in the antiproliferative action of protein tyrosine phosphatase inhibitor potassium bisperoxo(1,10-phenanthroline)oxovanadate

Potassium bisperoxo(1,10-phenanthroline)oxovanadate, bpV(phen), a powerful protein phosphotyrosine phosphatase inhibitor and a potent insulinomimetic, influenced three fundamental cellular processes in HL-60 human leukemic cells: 1) inhibition of proliferation, 2) induction of differentiation and 3) apoptotic cell death. In the presence of micromolar concentrations of bpV(phen) cell number and DNA synthesis decreased progressively with time of incubation. A single treatment with bpV(phen) (3 microM) activated a differentiation program; after 6 days of incubation 82% of cells were differentiated, but differentiation started already within the first 24 h. Concentrations of 5-10 microM bpV(phen) caused the characteristic DNA ladder pattern, starting after 4.5 h. Differentiation in HL-60 cells appear to be associated with activation of extracellular signal-regulated kinase while apoptosis is connected with phosphorylation and activation of both extracellular signal-regulated kinase and c-Jun N-terminal kinase in a concentration and time-dependent manner. The antiproliferative and apoptotic action of bpV(phen) could be exploited in combination chemotherapy in leukemia.

Moiré topography in measurement of the sagittal curvatures of the spine

The purpose of the investigation was to establish the accuracy of moiré topography in the analysis of the kyphotic spine. Using simplified instrumentation, moiré topogram was performed in the 50 outpatients at the Department of Orthopaedic Surgery, School of Medicine, University of Zagreb. Lateral x-ray and meticulous clinical measurements of the spine were included as well. A correlation between the obtained results was established. A high correlation (r = 0.847) was found between the results obtained by means of X-rays and those obtained by means of moiré topography. The authors concluded that the method is ideal for the determination of a morphotypology of the kyphotic spine and can significantly contribute to the differentiation between normal and pathological sagittal curvatures of the spine without the need for x-ray of the spine. The authors conclude that the application of moiré topography in the biomechanical laboratories can contribute to the new cognition on kinematics of the spine. The investigation demonstrated that simple and nonexpensive apparatus can be used for the moiré topography in the follow-up of the sagittal curvatures of the spine.

[The thrombocytopenia syndrome caused by heparin]

Heparin represents the basis for drug treatment and prevention of thrombosis. However, heparin itself may produce side effects, among others two types of heparin-induced thrombocytopenia (HIT). The more frequent type 1 occurs in about 10% of patients within the first days of the treatment and disappears spontaneously without sequelae. HIT type 2 represents a far more serious complication occurring in 0.1-1% of patients somewhat later, between days 4 and 10 of heparin therapy, and may provoke severe arterial and venous thrombosis. Apart from the differences in clinical picture, data regarding platelet count and platelet aggregation test are significant for the diagnosis. Heparin should be discontinued immediately and another anticoagulant therapy introduced. We are presenting the case of a patient with thrombosis of the left external iliac artery following surgery for ovarian cancer as a complication of HIT type 2, which was recanalized successfully and the leg was saved.

Superior sulcus tumor (SST): management at the Institute of Oncology in Ljubljana, Slovenia, 1981-1994

During the 14-year period under study, 48 patients with SST were treated at the Institute of Oncology in Ljubljana, Slovenia. There were 46 males and two females, aged 29-88 years (median, 60 years). Of 37 cytologically or histologically confirmed tumors, 12 were squamous, eight large-cell, one small-cell, eight adeno, and eight unclassified carcinomas. Performance status (Karnofsky) was assessed as > 90 in eight, 70-90 in 31 and < 70 in nine patients. The duration of symptoms before diagnosis ranged from 1 to 36 months (median, 5 months). All patients had pain, while six also had hemophthysis, 14 Horner's syndrome, and four Horner's syndrome and upper limb paresis. Before the first chest X-ray, 19 patients- were treated for shoulder pain by different specialists. Apical tumor infiltration only on the chest X-ray was found in 13, destruction of the ribs in 31, and destruction of the ribs and vertebral bodies in four patients. Treatment was as follows: radiotherapy in 39 patients (22 with radical, 17 with palliative dose), a combination of surgery and radiotherapy in seven, radiotherapy and chemotherapy in one, and symptomatic therapy alone in one patient. One- and four-year survival of all treated patients was 27% and 11%, respectively. One of the seven patients operated on survived for 44 months, and 2/39 irradiated ones survived for 37 and 56 months, respectively, while others died within 24 months from diagnosis. In 81% of patients the pain was subdued after radiotherapy. The disease-specific survival of all patients included in the follow-up correlated with performance status and M stage, while that of those treated by irradiation alone correlated with tumor dose (P < 0.05).

Postoperative radiotherapy for radically resected N2 non-small-cell lung cancer (NSCLC): randomised clinical study 1988-1992

In the period 1988-1992, 74 consecutive radically resected patients with NSCLC were randomised to postoperative radiotherapy or surgery alone in order to evaluate the influence of postoperative radiotherapy on survival. There were 61 males and 13 females, aged 35-80 years, median 59 years. Their distribution by stage was as follows: pT1N2 = 19, pT2N2 = 54, pT3N2 = one patient; histology: 32 squamous, 32 adeno and 10 large cell carcinomas; surgery: atypical resection in six, lobectomy in 27, bilobectomy in ten, and pneumonectomy in 31 patients. In 27 patients, only one lymph node in a single mediastinal lymph node site was affected; in 31 patients more than one lymph node in one site; in 16 patients more sites were affected. In 35/74 patients radiotherapy of hilar and mediastinal sites with 3000 cGy in 2 weeks was performed. On December 31, 1994, 19 patients (26%) were still alive; 39/55 patients died of the following causes: locoregional failure-10(26%), distant metastases- 25 (64%), other tumor-unrelated causes-four patients (10%). Five-year survival rates did not show statistically significant differences between the irradiated and surgically treated patients only with respect to sex, pTNM stage, histology and frequency of locoregional failure. The number of metastatic mediastinal lymph nodes was the only significant prognostic factor (P < 0.005) in both randomised groups.