Large Cell Neuroendocrine Carcinoma of Gallbladder: A Case Report

Large cell neuroendocrine carcinoma of the gallbladder is an extremely rare tumour with aggressive behaviour and a bad prognosis. Here, we report a case of a 65-year-old lady suspected of carcinoma of the gallbladder and underwent extended cholecystectomy. The histopathology report revealed neuroendocrine carcinoma of a large cell type of gall bladder infiltrating the liver and three periportal and pericholedochal lymph nodes. She had an uneventful perioperative period and was doing good till 6 months of follow-up. The only potentially curative treatment for large cell neuroendocrine carcinoma of the gallbladder is aggressive surgical resection, owing to its aggressive behaviour and bad prognosis.

Keywords

carcinoma; case reports; cholecystectomy; gallbladder.

Spontaneous histological transformation of lung squamous-cell carcinoma to large cell neuroendocrine carcinoma and small cell lung cancer

BACKGROUND

Histopathological transformation between different types of lung cancer cells has been reported following a variety of anti-tumor treatments. Examples include transformation from lung adenocarcinoma to squamous-cell carcinoma (SCC) and transformation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC).

CASE REPORT

A patient with intermittent hemoptysis for 2 days underwent a computed tomography (CT) scan that revealed interstitial pneumonia in addition to two enlarged paratracheal lymph nodes: one on the right (4R) and one on the left (4L) measuring 10 and 7 mm in diameter, respectively (Fig. 1). There was no evidence of a lung or bronchial mass. Bronchoscopy identified an endoluminal primary mass in a superior segmental bronchus of the left lower lobe and pathological examination following surgery confirmed it to be SCC. At 15 months post operation, a CT scan detected that the 4R lymph node had increased in size from 10 to 16 mm in diameter. At the next follow-up 7 months later, a CT scan showed that the R4 lymph node had further increased in size from 16 to 40 mm in the short axis, making it difficult for a surgeon to resect it "en bloc" immediately. The maximum standardized uptake value was 7.5 on PET-CT images. One month following completion of one cycle of neoadjuvant chemotherapy with gemcitabine and nedaplatin, a further CT scan indicated that the lymph node had decreased in size from 40 to 30 mm in the short axis. A complete mediastinal lymphadenectomy via open thoracotomy was performed and the lymph node was resected. Histological examination identified a main large cell neuroendocrine carcinoma (LCNEC) component with a small fraction of small cell carcinoma, confirmed by immunohistochemical analysis and genetic evidence.

CONCLUSION

Histopathological transformation from SCC to LCNEC with a small fraction of SCLC may have occurred spontaneously without any treatment.

Outcomes for Surgery in Large Cell Lung Neuroendocrine Cancer

INTRODUCTION

There are limited small, single-institution observational studies examining the role of surgery in large cell neuroendocrine cancer (LCNEC). We investigated the outcomes of surgery for stage I to IIIA LCNEC by using the National Cancer Database.

METHODS

Patients with stage I to IIIA LCNEC were identified in the National Cancer Database (2004-2015) and grouped by treatment: definitive chemoradiation versus surgery. Overall survival, by stage, was the primary outcome. Outcomes of surgical patients were also compared with those of patients with SCLC or other non-small cell histotypes.

RESULTS

A total of 6092 patients met the criteria: 96%, 94%, 75%, and 62% of patients received an operation for stage I, II, IIIA, and cN2 disease, respectively. Complete resection was achieved in at least 85% of patients. The 5-year survival rates for patients undergoing an operation for stage I and II LCNEC were 50% and 45%, respectively. Surgical patients with stage IIIA and N2 disease had 36% and 32% 5-year survival rates, respectively. When compared with stereotactic body radiation in stage I disease and chemoradiation in patients with stage II to IIIA disease, surgery was associated with a survival benefit. Patients with LCNEC who underwent an operation generally experienced worse survival by stage than did those with adenocarcinoma but experienced improved survival compared with patients with SCLC. Perioperative chemotherapy was associated with improved survival for pathologic stage II to IIIA disease.

CONCLUSIONS

Surgery is associated with reasonable outcomes for stage I to IIA LCNEC, although survival is generally worse than for adenocarcinoma. Surgery should be offered to medically fit patients with both early and locally advanced LCNEC, with guideline-concordant induction or adjuvant therapy.

Survival : a rare outcome in large cell neuroendocrine carcinoma of the gallbladder

Large cell neuroendocrine carcinoma of the gallbladder is extremely rare. We present a case report and review of literature. We report the rare outcome of survival at 19 month follow-up and hope to raise awareness about this lesion, its treatment modalities and lend credence to the proposed mechanism of its pathogenesis.

Establishment, functional and genetic characterization of a colon derived large cell neuroendocrine carcinoma cell line

AIM

To establish cell line and patient-derived xenograft (PDX) models for neuroendocrine carcinomas (NEC) which is highly desirable for gaining insight into tumor development as well as preclinical research including biomarker testing and drug response prediction.

METHODS

Cell line establishment was conducted from direct in vitro culturing of colonic NEC tissue (HROC57). A PDX could also successfully be established from vitally frozen tumor samples. Morphological features, invasive and migratory behavior of the HROC57 cells as well as expression of neuroendocrine markers were vastly analyzed. Phenotypic analysis was done by microscopy and multicolor flow cytometry. The extensive molecular-pathological profiling included mutation analysis, assessment of chromosomal and microsatellite instability; and in addition, fingerprinting (i.e., STR analysis) was performed from the cell line in direct comparison to primary patient-derived tissues and the PDX model established. Drug responsiveness was examined for a panel of chemotherapeutics in clinical use for the treatment of solid cancers.

RESULTS

The established cell line HROC57 showed distinct morphological and molecular features of a poorly differentiated large-cell NEC with KI-67 > 50%. Molecular-pathological analysis revealed a CpG island promoter methylation positive cell line with microsatellite instability being absent. The following mutation profile was observed: KRAS (wt), BRAF (mut). A high sensitivity to etoposide, cisplatin and 5-FU could be demonstrated while it was more resistant towards rapamycin.

CONCLUSION

We successfully established and characterized a novel patient-derived NEC cell line in parallel to a PDX model as a useful tool for further analysis of the biological characteristics and for development of novel diagnostic and therapeutic options for NEC.

Alveolar architectures preserved in cancer tissues may be potential pitfalls for diagnosis and histological subtyping of lung cancer: Three case reports

RATIONALE

Lung cancer is a leading cause of cancer-related deaths globally. Appropriate histopathological diagnosis and subtyping form the basis and are critical for clinical therapies.

PATIENT CONCERNS

Here, we report about 3 patients who had a nodule in the lung. Cancer cells grow in the alveolar cavity in many lung carcinomas. In all our 3 cases preserved alveolar architectures were found in tumor tissues which may lead to diagnostic pitfalls.

DIAGNOSES

Three patients had tumors that were diagnosed as nonsmall cell lung cancers, including large-cell carcinoma, peripheral squamous cell carcinoma, and large-cell neuroendocrine carcinoma, all of which contained structures of preserved alveolar cells that could be mistaken as malignant glandular components. The preserved alveolar cells formed acinar or duct-like structures enwrapped in the lung cancer tissues or surrounded the nests of cancer cells. Proliferative alveolar cells adjacent to cancer tissues were observed, and papillary structures and marked atypia, both of which may be mistaken as part of adenocarcinoma or carcinoma with glandular differentiation, were also observed.

INTERVENTIONS

All patients underwent surgery and postoperative chemotherapy.

OUTCOMES

The patients had no recurrence at 5-, 8-, or 10-month follow-up after the last surgery.

LESSONS

Preserved alveolar cells with different architectures may be observed in various lung cancer tissues and may be mistaken as adenocarcinoma or carcinoma with glandular differentiation. Distinct morphological and immunohistochemical features may help distinguish preserved alveolar cells from tumor components.

Clinicopathological, treatment, and prognosis study of 43 gastric neuroendocrine carcinomas

AIM

To provide more information and therapeutic methods about gastric neuroendocrine carcinomas (G-NECs) which occur rarely but are highly malignant and clinically challenging.

METHODS

We retrospectively analyzed the clinicopathological characteristics, treatments, and prognosis of 43 G-NEC patients at our hospital between January 2007 and December 2014. The diagnosis was based on the 2010 World Health Organization criteria.

RESULTS

Forty-three G-NECs containing 39 small cell carcinomas and 4 large cell NECs with Ki67 > 60% were included in this study, accounting for only 0.95% of all gastric carcinomas. The median patient age was 62 years (range, 33-82) and the male-to-female ratio was 4.4:1. All patients underwent surgery, including 38 curative resections and 5 palliative resections. Among these 43 patients, nearly half (48.84%) of these tumors were located in the cardiac region of the stomach, regional lymph node metastasis was found in 31 cases (72.09%), and liver metastasis was found in 6 cases (13.95%). Follow-up information was got for 40 patients. Twenty-three die of this disease with a median survival of 31 mo (range 1-90). The 1-year, 2-year, 3-year, and 5-year survival rate was 77.50%, 57.04%, 44.51%, and 35.05%, respectively. Survival was better in patients with tumor located in the cardiac region of the stomach, less than 7 lymph nodes metastasis and no liver metastasis. Five patients did not undergo postoperative chemotherapy, and the median survival time for these patients was 15 mo. For the remaining 34 patients who received postoperative chemotherapy, the median survival time was 44 mo and those received etoposide, cisplatin, and Paclitaxel survived the best. One patient with resected liver metastasis who received postoperative Capecitabine plus Oxaliplatin and Paclitaxel systemic chemotherapy plus octreotide LAR (30 mg intramuscularly, every 4 wk, for 2 years) has survived for 74 mo with no recurrence.

CONCLUSION

G-NECs are mostly nonfunctioning, which lead to a delay in detection. Local and/or distant metastases were noticed in most patients when diagnosed, and they required postoperative medical treatment. Adjuvant etoposide, cisplatin plus Paclitaxel systemic chemotherapy is recommended for these patients.

Large-cell lung cancer originating from tracheal bronchus - A rare case

Tracheal bronchus is a rarely seen congenital anomaly generally originating from the right lateral wall of the trachea and approximately 2 cm above the carina. It was firstly defined by Sandifort in 1785 and its frequency of incidence in normal population changes between 0.1% and 2%. There are two types called ''Supernumerary'' and ''Displaced''. It is a rarely seen kind of tracheal anomaly although fairly well defined. The cases accompanied by lung cancer are seen more rarely. Nine cases of this association were reported in literature and tracheal bronchus-lung cancer association whose pathological result is undifferentiated large-cell carcinoma has not been stated so far. We present a 75 years old male patient as possibly the first case having tracheal bronchus and large-cell carcinoma association in literature.

[A Case of Oropharyngeal Large Cell Neuroendocrine Carcinoma]

The large cell neuroendocrine carcinoma (LCNEC) of the lung was first reported in detail by Travis et al. in 1991. Extrapulmonary LCNEC rarely occurs, and only 22 cases have been reported in the head and neck mucosal regions. Today LCNEC of the larynx is contained in the moderately differentiated/Grade 2 category. However some authors advocate that LCNEC of the larynx should be separated from this category because of the difference in the clinical manifestations and pathological features. Standard treatment for head and neck mucosal LCNEC (M-LCNEC) has not been confirmed. However we suggested the efficacy of postoperative chemotherapy for M-LCNEC. This report describes a case of an LCNEC of the oropharynx. The patient was a 64-year-old man. We treated him with surgery and chemoradiotherapy. He has been disease-free for 36 months after adjuvant-chemotherapy.

Clinical Outcomes in Early-stage NSCLC Treated with Stereotactic Body Radiotherapy Versus Surgical Resection

BACKGROUND

Surgical resection is the treatment of first choice for patients with stage I-II non-small cell lung cancer (NSCLC). However, stereotactic body radiotherapy (SBRT) has been shown to be a good alternative treatment.

PATIENTS AND METHODS

Overall survival (OS), progression-free survival (PFS) and recurrence rates were compared between patients with stage I-II NSCLC treated with SBRT (n=53) and those treated with surgical resection (n=175). The propensity score method was used to correct for confounding by indication.

RESULTS

Before correction, the OS and PFS rates at 1 and 3 years were significantly different between SBRT and surgery, in favor of surgery. After correction, the OS and PFS after SBRT were not significantly different compared to surgery. The recurrence rates for the two treatments were also similar both before and after correction.

CONCLUSION

This retrospective study showed that clinical outcomes after SBRT are equal to those after surgery in patients with stage I-II NSCLC.

De novo large cell neuroendocrine carcinoma of the prostate gland with pelvic lymph node metastasis: a case report with review of literature

Neuroendocrine (NE) differentiation in prostate carcinomas can be seen in two settings: as a focal finding in conventional acinar adenocarcinoma, identifiable by immunohistochemical staining, or as a primary NE tumor of the prostate gland, such as carcinoid, small cell carcinoma, or large cell NE carcinoma. Of particular interest is the large cell NE carcinoma, which had been previously reported in isolated cases or in limited case series. In this report, we describe a case of a large cell NE carcinoma diagnosed in a 48-year-old man who presented with difficulty in voiding and urine retention. A cystoscopy revealed an enlarged, elongated prostate with an intra-urethral obstructing mass in the prostatic urethra. Subsequently, a transurethral resection of prostate (TURP) was performed at an outside hospital under the clinical diagnosis of benign prostatic hyperplasia (BPH). Microscopic examination of the TURP specimen revealed several foci of low-grade transitional-zone-type adenocarcinoma corresponding to Gleason score 5 (3 + 2), and a focus of high-grade large cell NE carcinoma. Concurrent x-ray computed tomography scans of the chest, abdomen, and pelvis demonstrated an enlarged left pelvic lymph node, which was biopsied and the patient was diagnosed with metastatic large cell NE carcinoma. He subsequently underwent 8 cycles of neoadjuvant chemotherapy with Lupron, a laparoscopic robotic-assisted radical retropubic prostatectomy, and pelvic lymphadenectomy. He died of widely metastatic prostatic carcinoma with leptomeningeal metastases 13 months after radical prostatectomy. Here, we present a rare case of large cell NE carcinoma with a review of the published literature.

Treatment outcomes of patients with different subtypes of large cell carcinoma of the lung

BACKGROUND

Although large cell neuroendocrine carcinoma (LCNEC) and lymphoepithelioma-like carcinoma (LELC) are the variants of large cell carcinoma (LCC) of lung, there are few studies comparing them. The aim of this study was to compare the clinical characteristic and treatment outcomes of LCNEC, LELC, and classic LCC.

METHODS

Patients with LCNEC, LELC, or classic LCC were identified in a prospectively collected database, and their data were analyzed.

RESULTS

A total of 46 patients with classic LCC, 30 with LCNEC, and 18 with LELC, who received surgical resection with curative intent, were identified and included in the analysis. Patients with LELC were younger, and the frequency of nonsmokers was greater than in patients with classic LCC or LCNEC. In patients with LCNEC or LELC, most lesions were located on the left side. There were 5 surgical deaths, and the median follow-up time of the surviving patients was 44.1 months. The 5-year disease free survival among the three subgroups was similar (p = 0.601), but patients with LELC had a significantly better overall survival than the other two subgroups (LELC vs classic LCC, p = 0.009; LELC vs LCNEC, p = 0.002). Multivariate analysis showed tumor location site, tumor stage, and LELC were independent prognostic factors of overall survival.

CONCLUSIONS

The clinical manifestations and treatment outcomes of LCNEC, LELC, and classic LCC are different. LCNEC has a poor survival, and survival is not different than that of classic LCC. LELC is associated with younger age and a higher frequency of nonsmokers, and the treatment outcomes are better than those of other subtypes.

Synchronous double cancers of colonic large cell neuroendocrine carcinoma and gastric squamous-cell carcinoma: a case report and review of literature

Either colonic large cell neuroendocrine carcinoma (LCNEC) or gastric squamous-cell carcinoma (SCC) is extremely rare, with a very poor prognosis due to the high rate of distant metastases. Here, we report the first case of synchronous double malignancies in form of colonic LCNEC and gastric SCC. A 66-year male underwent a right hemicolectomy for a mass obstructing the ascending colon and an emergent gastroscopic hemostasis for another hemorrhagic stomach mass. Histopathological examination confirmed colonic LCNEC displaying the characteristic of large, vesicular nuclei with variable amounts of cytoplasm and gastroscopic biopsy revealed poorly-differentiated gastric SCC. Immunohistochemical staining of LCNEC demonstrated positive activities for chromogranin A, synaptophysin, CD56, NSE, ki-67 (>95%), but negative for CD99, CK20 and TTF-1. The patient had suffered from an accelerated growth of multiple liver metastases after surgery, suggestive of concomitant tumor resistance (CR), and survived 2 months after discharge.

Allelic imbalance in the miR-31 host gene locus in lung cancer--its potential role in carcinogenesis

Small non-protein coding RNA, microRNA (miR), which regulate messenger RNA levels, have recently been identified, and may play important roles in the pathogenesis of various diseases. The present study focused on miR-31 and investigated its potential involvement in lung carcinogenesis. The expression of miR-31 was altered in lung cancer cells through either the amplification or loss of the host gene locus. The strong expression of miR-31 in large cell carcinomas was attributed to the gene amplification. Meanwhile, the loss of miR-31 expression was more frequently observed in aggressive adenocarcinomas. Thus, miR-31 may play a pleiotropic role in the development of lung cancers among different histological types. To the best of our knowledge, this is the first study to show the potential causative mechanism of the altered expression of miR-31 and suggest its potentially diverse significance in the different histological types of lung cancers.

"Pure" primary large cell neuroendocrine carcinoma of the urinary bladder: case report, literature review and diagnostic criteria

INTRODUCTION

Large cell neuroendocrine carcinoma (LCNC) is defined in the urinary bladder, as in other sites, as a high-grade neoplasm exhibiting neuroendocrine features at the H&E level, high mitotic activity and evidence of neuroendocrine differentiation by immunohistochemistry. We report a case of pure bladder LCNC with review of the literature.

METHODS

A 68-year-old male presented with gross haematuria of two weeks' duration in October 2011. Transurethral resection and subsequently radical cystoprostatectomy (CP) with bilateral lymphadenectomy (L) were performed in December 2012.

RESULTS

Urinary cytology identified malignant cells. Histologically, the tumour showed organoid nesting, trabecular growth, rosettes and perilobular palisading patterns, suggesting neuroendocrine differentiation. Immunohistochemical staining showed intense positivity for CD56.

DISCUSSION

We examined all published pure bladder LCNC (12 cases) excluding mixed neoplasms. Small cell carcinoma of the urinary bladder pure LCNC of the bladder is a very aggressive malignancy, unresponsive to therapy, presents in an advanced stage and has a propensity for early metastasis. Prior to the advent of immunohistochemistry, such cases would most likely have been categorised as poorly differentiated, high-grade urothelial carcinomas.

Immunohistochemical comparison of biomarker expression in biopsy and surgical specimens of non-small cell lung cancer

BACKGROUND

Single tumors may show heterogeneity, and it is unclear whether biomarker expression in surgical and diagnostic biopsy samples correlates.

MATERIALS AND METHODS

We retrospectively identified lung cancer patients who were diagnosed by biopsy and underwent surgery between January 2007 and October 2010 at the Shimane University Hospital, Shimane, Japan. Thirty-two patients were identified. The expression of four predictive biomarkers was assessed, namely excision repair cross-complementing gene 1 (ERCC1), ribonucleotide diphosphate reductase M1 (RRM1), thymidylate synthase (TS), and class III beta-tubulin (BT). We also compared immunohistochemical staining in diagnostic biopsy and corresponding resected surgical samples.

RESULTS

Moderate correlation was seen between the expression of ERCC1, RRM1, TS, and BT in the biopsy and surgical specimens, with r values of 0.512 (p=0.003), 0.411 (p=0.020), 0.475 (p=0.006), and 0.404 (p=0.027), respectively.

CONCLUSION

Assessment of biopsy samples with immunohistochemical staining is a feasible and reliable method for use in clinical decision making.

Non-small cell lung cancer in surgically treated women

AIM AND BACKGROUND

To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients.

METHODS AND STUDY DESIGN

We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008.

RESULTS

Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P = 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05).

CONCLUSIONS

Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.

Stress protein Hsp27 expression predicts the outcome in operated small cell lung carcinoma and large cell neuroendocrine carcinoma patients

PURPOSE

Heat shock protein (Hsp)27 is overexpressed in a range of human cancers and is implicated in tumor cell proliferation, differentiation, invasion, metastasis, and survival. The aim of the present study was to determine the prognostic significance of Hsp27 expression in small cell lung carcinoma (SCLC) and large cell neuroendocrine carcinoma (LCNEC).

METHODS

Surgically resected SCLCs (N=51) and LCNECs (N=15) were studied. The Hsp27 expression was detected immunohistochemically.

RESULTS

Hsp27 positive immunoreaction in the cytoplasm was observed in 45 (88%) SCLCs and 14 (93%) LCNECs. A combination of cytoplasmic with nuclear Hsp27 expression was observed in 28 (62%) SCLCs and 14 (100%) LCNECs. There was a correlation between Hsp27 cytoplasmic overexpression and Hsp27 nuclear expression with patient survival confirmed by Cox multivariate analysis.

CONCLUSION

We conclude that the higher Hsp27 cytoplasmic expression and nuclear expression may represent favorable prognostic factors in SCLC and LCNEC.

Neuroendocrine carcinoma of the extrahepatic bile duct: Case report and literature review

Neuroendocrine carcinoma (NEC) of the extrahepatic bile duct is rare, and only 22 cases have been reported. Only two of these were large-cell NEC (LCNEC); the vast majority were small-cell NEC. Here, we report a third case of LCNEC of the extrahepatic bile duct. A 76-year-old male presented to a local hospital with painless jaundice. Imaging studies revealed a tumor at the hepatic hilum. The patient underwent right hepatic lobectomy, bile duct resection, and cholecystectomy. The resection specimen showed a 5.0-cm invasive neoplasm involving the hilar bile ducts and surrounding soft tissue. Histologically, the tumor consisted of nests of medium to large cells with little intervening stroma. The tumor invaded a large portal vein branch. All four excised lymph nodes were positive for metastasis, and metastatic deposits were also present in the gallbladder wall. The tumor was diffusely positive for synaptophysin and focally positive for chromogranin A. Approximately 70%-80% of the tumor cells were positive for Ki-67, indicating strong proliferative activity. A diagnosis of LCNEC was made. A few bile ducts within and adjacent to the invasive tumor showed dysplasia of the intestinal phenotype and were focally positive for synaptophysin and chromogranin A, suggesting that the dysplastic intestinal-type epithelium played a precursor role in this case. A postoperative computer tomography scan revealed rapid enlargement of the abdominal and retroperitoneal lymph nodes. The patient died 21 d after the operation. NEC of the bile duct is an aggressive neoplasm, and its biological characteristics remain to be better defined.

High grade neuroendocrine lung tumors: pathological characteristics, surgical management and prognostic implications

Among non-small cell lung cancers (NSCLC), large cell carcinoma (LCC) is credited of significant adverse prognosis. Its neuroendocrine subtype has even a poorer diagnosis, with long-term survival similar to small cell lung cancer (SCLC). Our purpose was to review the surgical characteristics of those tumors. The clinical records of patients who underwent surgery for lung cancer in two French centers from 1980 to 2009 were retrospectively reviewed. We more particularly focused on patients with LCC or with high grade neuroendocrine lung tumors. High grade neuroendocrine tumors were classified as pure large cell neuroendocrine carcinoma (pure LCNEC), NSCLC combined with LCNEC (combined LCNEC), and SCLC combined with LCNEC (combined SCLC). There were 470 LCC and 155 high grade neuroendocrine lung tumors, with no difference concerning gender, mean age, smoking habits. There were significantly more exploratory thoracotomies in LCC, and more frequent postoperative complications in high grade neuroendocrine lung tumors. Pathologic TNM and 5-year survival rates were similar, with 5-year ranging from 34.3% to 37.6% for high grade neuroendocrine lung tumors and LCC, respectively. Induction and adjuvant therapy were not associated with an improved prognosis. The subgroups of LCNEC (pure NE, combined NE) and combined SCLC behaved similarly, except visceral pleura invasion, which proved more frequent in combined NE and less frequent in combined SCLC. Survival analysis showed a trend toward a lower 5-year survival in case of combined SCLC. Therefore, LCC, LCNEC and combined SCLC share the same poor prognosis, but surgical resection is associated with long-term survival in about one third of patients.

Urinary bladder urothelial carcinoma with expression of KIT and PDGFRA and showing diverse differentiations into plasmacytoid, clear cell, acantholytic, nested, and spindle variants, and into adenocarcinoma, signet-ring cell carcinoma, small cell carcinoma, large cell carcinoma, and pleomorphic carcinoma

Various tumors can arise in the urinary bladder (UB); most common is urothelial carcinoma (UC). UC of the UB have many variants. Other types of carcinomas such as adenocarcinoma (AC) and small cell carcinoma (SmCC) can occur in UB carcinomas. Expression of KIT and PDGFRA has not been reported. A 66-year-old man admitted to our hospital because of hematuria. Cystoscopy revealed papillary invasive tumor and a transurethral bladder tumorectomy (TUR-BT) was performed. The TUR-BT showed UC, AC, SmCC, large cell carcinoma (LCC), and pleomorphic carcinoma (PC). The UC component showed plasmacytoid, spindle, nested, clear cell, acantholytic variants. The AC element showed tubular adenocarcinoma and signet-ring cell carcinoma (Sig). Immunohistochemically, all of these subtypes were positive for cytokeratin (CK) AE1/3, CK CAM5.2, CK34BE12, CK5, CK6, CK7, CK8, CK18, CK19, CK20, EMA, CEA, p63, CA19-9, p53 (positive 45%), MUC1, NSE, NCAM, KIT, PDGFRA, and Ki-67 (87%). They were negative for vimentin, chromogranin, synaptophysin, S100 protein, CD34, CD14, α-smooth muscle actin, CD31, caldesmon, CD138, CD45, κ-chain, λ-chain, MUC2, MUC5AC and MUC6. Mucin histochemistry revealed mucins in AC element including Sig. A molecular genetic analysis using PCR-direct sequencing method identified no mutations of KIT (exons 9, 11, 13, and 17) and PDGFRA (exons 12 and 18) genes. The carcinoma was highly aggressive and invaded into muscular layer. The nuclear grade was very high, and there were numerous lymphovascular permeations were seen. The surface showed carcinoma in situ involving von-Brunn's nests. This case shows that carcinoma of UB can show diverse differentiations into numerous histological types and variants, and can express KIT and PDGFRA. The both genes showed no mutations in the present case.

Primary large cell neuroendocrine carcinoma of the ureter

Large cell neuroendocrine carcinoma (LCNEC) is the rarest type of urinary tract malignancy. Herein, we report a case of LCNEC that arose in the ureter of a 78-year-old Japanese man with a history of ascending colon cancer that had been excised by a right hemicolectomy. Left-sided hydronephrosis associated with the ureteral tumor was discovered during follow-up. A left nephroureterectomy combined with a partial resection of the urinary bladder was performed because atypical cells were detected using voided urine cytology. A histopathological examination revealed that the ureteral tumor contained large atypical epithelial cells of neuroendocrine morphology without a urothelial carcinomatous component. The neoplastic cells were immunohistochemically positive for synaptophysin, chromogranin A, CD56, and cytokeratins, but they were negative for uroplakin III and thyroid transcription factor-1. The Ki-67 labeling index of the neoplastic cells was 50%. Transmission electron microscopy demonstrated the presence of numerous dense granules in the cytoplasm of the neoplastic cells. The ureteral lesion was finally classified as stage III, pT3 cN0 cM0. The patient's postoperative course was uneventful without chemoradiotherapy, and LCNEC did not recur in the subsequent nine months. This case demonstrates that LCNEC can occur in the ureter, which normally does not contain neuroendocrine cells in the urothelium.

[Endovascular stent-graft insertion followed by resection of a locally-advanced lung tumor that invaded the thoracic aorta]

A 52-year-old man with fever and dyspnea was admitted to our hospital. Chest computed tomography showed a mass measuring 3.5×3.0 cm in the S(1+2) segment of the left lung with involvement of the aorta. Although cytological examination using broncho fiberscopy did not show any malignancy, we suspected the mass to be T4N0M0 lung cancer. The tumor was diagnosed as having invaded the aorta using intravascular ultrasound. First, an endovascular graft was inserted, and then, a left upper lobectomy with resection of the infiltrated aortic wall was performed without cardiopulmonary bypass. The patient had an uneventful recovery without any complications. Pathological examination revealed the tumor to be a large-cell carcinoma. We think that an aortic endograft can be useful for resection of an infiltrated aortic wall, although further studies are necessary.

[Application of photodynamic therapy to reduce the amount of resection for non-small cell lung cancer]

A prospective analysis of results of combined treatment of 22 patients with central stage II-III non-small cell lung cancer (NSCLC) was performed (the defeat of the main bronchi or lower parts of the trachea), which initially had been regarded as unresectable or inoperable (12 patients for functional reasons could not pass pneumonectomy, and in 10 patients a contraindication to primary surgery was the involvement of the distal trachea in tumor), but underwent surgery after preoperative treatment.Combination therapy included preoperative endobronchial photodynamic therapy (PDT) and chemotherapy followed by surgery and intraoperative PDT resection margins. PDT was carried out with the use of chlorine E6 (Radachlorin) and light wavelength of 662 nm. Overall response rate after neoadjuvant treatment was 82 %, endoscopic remission was observed in 21 of 22 patients (95%). 10 patients underwent pneumonectomy, 12--lobectomy. 19 surgical interventions were regarded as radical (R0--86%), 3--as microscopically non-radical (R1--14%). Degree of lymphatic metastasis spreading pN0 was detected in 6 patients (27 %), pN1--in 14 (64%) and pN2--in 2 patients (9%). Surgical lethality was 5%. In the late time of the whole observation period none of the patients developed local recurrence. One-year survival was 95%, 3-year--91%. PDT can play an important role in combination with surgical treatment for NSCLC and reduces the amount of resection in part of initially unresectable or inoperable patients.

[A case of large cell neuroendocrine carcinoma (LCNEC) of the uterine cervix successfully treated by postoperative CPT-11+CDDP chemotherapy after non-curative surgery]

A 31-year-old woman, gravida 3 para 3, visited a local clinic because of post-coital bleeding. She was diagnosed as having a uterine-cervical tumor and was referred to our hospital. Large cell neuroendocrine carcinoma (LCNEC) of the uterine cervix was pathologically shown by biopsy. The patient was initially treated by radical hysterectomy. Postoperative pathological examination revealed a direct invasion to the parametrium and the positive resection margin. Postoperatively, she was treated by CPT-11+CDDP. One course of treatment was 60mg/m² of CPT-11 administered on day 1, 8 and 15, and 60 mg/m² of CDDP on day 1, with an intermission after administration for 7 days. Six courses were carried out. This treatment resulted in complete remission. A follow-up at the outpatient clinic revealed the patient had been tumor-free for one year and three months after the first treatment. We suggest that postoperative chemotherapy with CPT-11+CDDP might be useful in the treatment of patients with LCNEC of the uterine cervix.

Biphasic large cell neuroendocrine carcinoma--pure mucinous carcinoma of the gallbladder (MANEC): a unique combination

INTRODUCTION

We report a case of primary combined large cell neuroendocrine carcinoma (LCNEC)--pure mucinous carcinoma of the gallbladder (MANEC)--which represents the first description of this entity.

METHODS

The patient is a 59-year-old Italian male who underwent cholecystectomy under a preoperative diagnosis of cholecystitis with gallstones and gallbladder tumour. During laparotomy, cholecystectomy, liver wedge resection and regional lymph node dissection were performed. The resected gallbladder showed a thickened wall, gallstones and a 4 cm gelatinous, cauliflower-like soft tissue mass.

RESULTS

Following surgery, the gallbladder tumour was diagnosed as a mixed endocrine-exocrine carcinoma. There was evidence of lymph node metastasis or direct liver invasion. The mucin-producing carcinoma was composed of poorly differentiated glandular cells with mucin lakes. The LCNEC was characterized by large cells with prominent nucleoli, coarse chromatin and a high mitotic rate. The cells showed an "organoid" growth pattern with rosette formation and frequent areas of necrosis. Chromogranin A, synaptophysin and CD56 were diffusely and strongly expressed.

DISCUSSION

This case may provide helpful insights regarding the histogenesis of this unusual combination of tumors: the concept of a collision tumor between two neoplasms that have arisen in adjacent areas may be the best explanation for its pathogenesis.

Large cell carcinoma of the lacrimal gland diagnosed by fine needle aspiration biopsy

A 67-year-old man presented with a 6-month history of a malignant appearing left lacrimal gland mass. Fine needle aspiration biopsy was performed in the office, diagnosing the mass as large cell carcinoma (LCCA) of the lacrimal gland. This represents the second reported case of LCCA of the lacrimal gland and details the potential for FNA biopsy to successfully yield the diagnosis. LCCA of the lacrimal gland is rare, but should be considered in cases of malignant lacrimal gland neoplasms.

Clinical implications of the margin cytology findings and margin/tumor size ratio in patients who underwent pulmonary excision for peripheral non-small cell lung cancer

PURPOSE

A pulmonary wedge resection is useful for the treatment of peripheral non-small cell lung cancer (NSCLC). The margin/tumor size ratio (M/T) is a predictor of positive margin cytology findings in these procedures, although the long-term clinical implications remain unclear. This relationship was investigated in this study.

METHODS

Thirty-seven cases with a high surgical risk without additional pulmonary resection were selected from those accrued in a multicenter prospective study of optimal margin distance for pulmonary excision of peripheral NSCLC and followed for more than 5 years (range 5.3-14 years).

RESULTS

Both the M/T and margin cytology findings were indicators of cancer recurrence and survival. All seven cases of surgical margin recurrence had a cytology-positive surgical margin. The 5-year survival rate was 54.2% (n = 24) for M/T < 1 and 84.6% for M/T ≥ 1 (n = 13, P = 0.05), while it was 38.5% for positive margin (n = 13) and 79.2% for negative margin (n = 24) cases (P = 0.001). In addition, the margin cytology findings were an independent prognostic factor.

CONCLUSION

A pulmonary wedge resection for peripheral NSCLC should result in a negative malignant margin, which might be obtained from a sufficient tumor margin ratio of M/T ≥ 1.

[Expression of granulocyte colony stimulating factor in patients with non-small cell lung cancer and its clinicopathological significance]

OBJECTIVE

To examine granulocyte colony stimulating factor (G-CSF) expression in human non-small cell lung cancer (NSCLC) as well as discuss its clinicopathological significance.

METHODS

Specimens were obtained from 114 cases (53 cases with granulocyte infiltration) diagnosed pathologically as NSCLC in General Hospital of PLA. Paraffin-embedded tissues from these 114 cases of NSCLC were examined for expression of G-CSF by immunohistochemical staining. Correlation between G-CSF expression and pathological features, clinical manifestation, prognosis of patients with NSCLC was analyzed statistically. All the patients were retrospectively followed-up.

RESULTS

Fifty-five of the 114 NSCLC specimens expressed G-CSF, and among these 41 (41/54, 75.9%) were large cell carcinoma, nine (9/30, 30.0%) were adenocarcinoma and five (5/30, 16.7%) were squamous cell carcinoma. The expression was significantly correlated with infiltration of tumor mass by neutrophilic granulocytes, histological type, necrosis, differentiation, lymph node metastases, distant metastases, recurrence and survival period (P < 0.01). There was no significant correlation with primary tumor size (P > 0.05). Logistic multi-factor analysis revealed that necrosis, lymph nodes metastases and distant metastases RR (risk ratio) in G-CSF positive group was 5.57, 6.28 and 5.24 times higher than those of G-CSF negative group (P < 0.05). There were remarkable difference of 5-year survival rates (0 and 12.1% respectively) and survival period (42 and 62 months respectively) between positive and negative groups (P < 0.01).

CONCLUSIONS

NSCLC with G-CSF excretion are mainly large cell lung cancer. The pathologic characteristics of these cases with G-CSF expression included poor differentiation, remarkable atypia, prominent necrosis and infiltration of tumor mass by neutrophils or emperipolesis. These tumors are usually more aggressive in biological behavior and have worse prognosis than those without G-CSF expression.

Colonic large cell neuroendocrine carcinoma obscured by an initial diagnosis of diverticulitis

Large cell neuroendocrine carcinomas are rare and aggressive colorectal malignancies that have a dismal prognosis. We present the following case of a patient who presented with signs and symptoms of diverticulitis. After failure of medical management, surgical intervention revealed a poorly differentiated adenocarcinoma with a component of large cell neuroendocrine carcinoma.

[Prognosis of surgically treated large cell neuroendocrine carcinoma]

Large cell neuroendocrine carcinoma (LCNEC) is a relatively rare tumor in malignant lung neoplasms. The prognosis of LCNEC is poor and there is no consensus on the treatment for LCNEC. We report our retrospective assessment of 11 patients of LCNEC from 1999 to 2008. Three of 11 patients had malignant exudate at thoracotomy. Seven patients received limited resection. There was a recurrence even after complete surgical resection in its early stage. Four patients received platinum-based chemotherapy for adjuvant therapy or recurrence. The response to platinum-based chemotherapy was relatively good and may be comparable to that of small cell lung cancer. The overall 5-year survival rate was 30.3%. Pulmonary LCNEC represents an aggressive tumor and multimodal treatment is required.

[Clinical characteristics and prognosis of large cell lung cancer]

OBJECTIVE

The aim of this study was to explore the clinical characteristics and analyze the prognostic factors of large cell lung cancer (LCLC).

METHODS

The clinical data of 111 LCLC cases were collected and retrospectively analyzed. The prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS

Among the 111 cases, the lesions were in the right lung of 53 patients and 26 of them were located in the superior lobe. The lesions were in the left lung of 58 cases, and 35 of them were in the superior lobe. The lesions were presented as central in 36 cases and peripheral in 75 cases, with a mean diameter of 5.3 cm. All the 111 patients were diagnosed as stage I in 38 cases, stage II in 11 cases, stage III in 45 and stage IV in 17 cases. 60 patients had lymph node metastasis and 17 cases had distant metastasis. The overall 1-, 3- and 5-year survival rates of the LCLC were 54.7%, 30.9% and 20.6%, respectively. Cox univariate analysis revealed that TNM stage (P = 0.000), lymph node metastasis (P = 0.000) and M stage (P = 0.000) are prognostic factors. Cox multivariate analysis indicated that TNM stage (P = 0.000) is an independent prognostic factor.

CONCLUSION

The prognosis of LCLC is worse than other types of non-small cell lung cancer. Complete surgical resection remains the main therapeutic approach. TNM stage is an independent prognostic factor.

Klotho is a novel biomarker for good survival in resected large cell neuroendocrine carcinoma of the lung

BACKGROUND

In terms of prognosis, large cell neuroendocrine carcinoma (LCNEC) differs distinctively from other non-small cell lung cancers, with the prognosis of LCNEC being poor, even for early-stage disease. Improvements in survival require a biomarker capable of defining a subset of patients destined to do poorly so that these patients can be targeted for additional therapies, including chemotherapy. In this study, we focused on the Klotho gene, which is an anti-aging gene known to be a potential tumor suppressor. We investigated whether the immunohistochemical expression of Klotho can predict survival patients with resected LCNEC.

METHODS

The histological characteristics of patients receiving an initial diagnosis of LCNEC (n=30) at Tokyo Medical University Hospital were retrospectively reviewed, and multiple variables including stage, lymphangioinvasion, lymph node status and the expression of Klotho as identified using an immunohistochemical analysis, were assessed.

RESULTS

Immunostaining for Klotho was mostly cytoplasmic, and Klotho expression was seen in 10 patients (33.3%) but not in 20 patients (66.7%). The expression of Klotho was significantly associated with a good outcome of resected patients with LCNEC and Klotho(-) was associated with increased LCNEC risk by multivariate analysis (hazard ratio 4.92, 95% confidence interval 1.04-23.24, p=0.044). Neither lymph node status nor lymphangioinvasion were significantly associated with a poor survival. However, among patients without lymph node metastasis or angioinvasion, the survival benefit of Klotho expression in the primary tumor was significantly higher, compared with that of patients without Klotho expression.

CONCLUSION

Klotho staining provides a new biomarker for a good outcome in patients with LCNEC, especially among patients without lymph node metastasis or lymphangioinvasion.

A randomized phase II trial of adjuvant chemotherapy with bi-weekly carboplatin plus paclitaxel versus carboplatin plus gemcitabine in patients with completely resected non-small cell lung cancer

BACKGROUND

The benefits of adjuvant chemotherapy for completely resected non-small cell lung cancer (NSCLC) have been demonstrated using mainly cisplatin (CDDP)-based chemotherapeutic regimens. However, treatment-related deaths sometimes occur. Therefore, the development of a safer regimen is necessary.

PATIENTS AND METHODS

The patients were randomized to either carboplatin (CBDCA) area under the curve (AUC) 3 and paclitaxel (PTX) 90 mg/m(2) (PCb arm) or CBDCA (AUC3) plus gemcitabine (GEM) (1000 mg/m(2)) (GCb arm) every 2 weeks for 8 cycles after surgery. The primary endpoint was the compliance with the regimen, while the secondary endpoints were safety and toxicity.

RESULTS

A total of 75 patients were enrolled in a multi-institutional study. Twenty-one out of 39 patients (54%) in the PCb arm and 25 of 36 patients (69%) in the GCb arm completed 8 cycles, and 59% in the PCb arm and 81% in the GCb arm completed ≥6 cycles. The predominant toxicity was neutropenia. Non-hematological adverse effects were infrequent and no treatment-related death was registered. The estimated disease-free survival and overall survival at 2 years were 70.8% and 66.3% in the PCb and 91.4% and 79.1% in the GCb arm, respectively.

CONCLUSION

This adjuvant bi-weekly scheduled chemotherapy resulted in good compliance in both arms, and the regimen was feasible, with acceptable levels of toxicity in completely resected Japanese NSCLC patients. Therefore, these regimens represent a new treatment option suitable for outpatients with completely resected NSCLC.

Large cell neuroendocrine carcinoma of the ampulla of vater with adenocarcinoma and squamous cell carcinoma components

A 73-year-old woman visited our hospital complaining of general fatigue and jaundice. Laboratory tests revealed an elevated total bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and γ-glutamyltransferase. Computed tomography and magnetic resonance imaging demonstrated a mass lesion at the ampulla of Vater with dilatation of the common bile duct and main pancreatic duct. Percutaneous transhepatic cholangiography revealed dilatation of the bile duct and a negative filling defect due to the tumor. Pancreatoduodenectomy was performed. The specimen included an ulcerated firm tumor of the papilla Vater. The surface of the ampulla consisted of well-differentiated papillary adenocarcinoma, whereas the deep layer, such as submucosal or muscular layer, contained large cell neuroendocrine carcinoma and squamous cell carcinoma. Immunohistochemistry revealed that the large cell neuroendocrine carcinoma component was positive for chromogranin A, synaptophysin and CD56. The patient died from multiple liver and bone metastases 13 months after surgery. This is a very rare case of a large cell neuroendocrine carcinoma accompanied by adenocarcinoma and squamous cell carcinoma components.

Cervical large cell neuroendocrine carcinoma with cytologic presentation: a case report

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) is a rare and aggressive cervical neoplasm. Few cytologic or colposcopic findings of LCNEC have been reported.

CASE

A 37-year-old woman, gravida 6, para 4, presented with vaginal bleeding for 3 months. The cervical smears showed cells dispersed as single cells or arranged as loosely cohesive sheets or glandlike aggregate and the nuclear size was almost 3-5 times larger than that of small lymphocytes. The cytologic, pathologic and immunohistochemical examinations suggested LCNEC. The patient underwent a radical hysterectomy and then received radiation and systemic chemotherapy.

CONCLUSION

Cytologic and colposcopic findings for LCNEC of the uterine cervix are reported. Patients with LCNEC have poor prognoses. Early diagnosis of the tumor is important.

Results of surgical resection for patients with large cell carcinoma of the lung

PURPOSE

The clinical features of large cell carcinoma (LCC) of the lung have remained unclear due to the low incidence of the disease. This study investigated the clinicopathological features and the surgical outcome in patients with LCC.

SUBJECTS

This study clinicopathologically evaluated 975 patients who had undergone a resection for non-small cell carcinoma between 1994 and 2007. There were 57 (5.8%) patients with LCC among them.

RESULTS

The LCC patients included 49 males and 8 females and included 9 patients with large cell neuroendocrine carcinoma. All patients excluding 1 had a smoking habit. The mean smoking pack-year index was 49.9 in the patients with LCC, 27.1 in 625 patients with adenocarcinoma, and 52.5 in 266 patients with squamous cell carcinoma, and this was significantly higher in the patients with LCC than in those with adenocarcinoma. The mean tumor diameter was 38 mm for LCC, 28 mm for adenocarcinoma, and 39 mm for squamous cell carcinoma. The pathological stage was IA in 11 patients, IB in 11, II in 12, IIIA in 16, IIIB in 5, and IV in 2. The post-operative 5-year survival rate was 60.5% for LCC, 64.3% for large cell neuroendocrine carcinoma, 67.0% for adenocarcinoma, and 50.1% for squamous cell carcinoma.

CONCLUSION

The tumor diameter was significantly larger for LCC than for adenocarcinoma at the time of diagnosis. The proportion of smokers and the smoking pack-year index in patients with LCC were significantly higher than those of adenocarcinoma. The surgical results were similar between LCC and other non-small cell lung carcinomas.

Large cell neuroendocrine carcinoma of the lung metastatic to the cauda equina

BACKGROUND CONTEXT

Large cell neuroendocrine carcinoma of the lung is an aggressive tumor with unique histopathological features. It is not known to metastasize to the spine.

PURPOSE

To report a metastatic case of this rare tumor to the cauda equina.

STUDY DESIGN

Case report.

METHODS

Retrospective case review and review of the literature.

RESULTS

The authors report a rare case of a large cell neuroendocrine lung metastasis to the lumbar spine, causing right foot drop. Magnetic resonance imaging revealed a heterogeneously enhancing intradural extramedullary mass at L2/L3 level compressing the surrounding nerve roots. During surgery, the identified nerve roots were encased by the tumor, and the dissection was tedious. Postoperatively, the patient reported significantly improved back pain and he had severe foot weakness. The functional outcome was poor because the patient lost entirely his foot function; however, his back pain improved significantly after surgery.

CONCLUSIONS

This is the first published study in which the authors described a metastasis of a rather uncommon lung cancer to the cauda equina. When a lesion of the cauda equina presents with a rapid progressive neurological deficit, leptomeningeal metastasis should be in the differential diagnosis.

Insulin-like growth factor receptor 1 (IGF1R) gene copy number is associated with survival in operable non-small-cell lung cancer: a comparison between IGF1R fluorescent in situ hybridization, protein expression, and mRNA expression

PURPOSE

The purpose of this study was to characterize insulin-like growth factor-1 receptor (IGF1R) protein expression, mRNA expression, and gene copy number in surgically resected non-small-cell lung cancers (NSCLC) in relation to epidermal growth factor receptor (EGFR) protein expression, patient characteristics, and prognosis.

PATIENTS AND METHODS

One hundred eighty-nine patients with NSCLC who underwent curative pulmonary resection were studied (median follow-up, 5.3 years). IGF1R protein expression was evaluated by immunohistochemistry (IHC) with two anti-IGF1R antibodies (n = 179). EGFR protein expression was assessed with PharmDx kit. IGF1R gene expression was evaluated using quantitative reverse transcription polymerase chain reaction (qRT-PCR) from 114 corresponding fresh-frozen samples. IGF1R gene copy number was assessed by fluorescent in situ hybridization using customized probes (n = 181).

RESULTS

IGF1R IHC score was higher in squamous cell carcinomas versus other histologies (P < .001) and associated with stage (P = .03) but not survival (P = .46). IGF1R and EGFR protein expression showed significant correlation (r = 0.30; P < .001). IGF1R gene expression by qRT-PCR was higher in squamous cell versus other histologies (P = .006) and did not associate with other clinical features nor survival (P = .73). Employing criteria previously established for EGFR copy number, patients with IGF1R amplification/high polysomy (n = 48; 27%) had 3-year survival of 58%, patients with low polysomy (n = 87; 48%) had 3-year survival of 47% and patients with trisomy/disomy (n = 46; 25%) had 3-year survival of 35%, respectively (P = .024). Prognostic value of high IGF1R gene copy number was confirmed in multivariate analysis.

CONCLUSION

IGF1R protein expression is higher in squamous cell versus other histologies and correlates with EGFR expression. IGF1R protein and gene expression does not associate with survival, whereas high IGF1R gene copy number harbors positive prognostic value.

Surgery with or without preoperative paclitaxel and carboplatin in early-stage non-small-cell lung cancer: Southwest Oncology Group Trial S9900, an intergroup, randomized, phase III trial

PURPOSE Patients with early-stage non-small-cell lung cancer (NSCLC) have a poor prognosis even after complete resection. Earlier studies of preoperative (induction) chemotherapy in resectable NSCLC demonstrated feasibility and encouraging survival data. This randomized phase III trial compared overall survival (OS) for preoperative paclitaxel and carboplatin followed by surgery with surgery alone in patients with early-stage NSCLC. PATIENTS AND METHODS Patients with clinical stage IB-IIIA NSCLC (excluding superior sulcus tumors and N2 disease) were eligible. Patients were randomly assigned to surgery alone or to three cycles of paclitaxel (225 mg/m(2)) and carboplatin (area under curve, 6) followed by surgical resection. The primary end point was OS; secondary end points were progression-free survival (PFS), chemotherapy response, and toxicity. RESULTS The trial closed early with 354 patients after reports of a survival benefit for postoperative chemotherapy in other studies. The median OS was 41 months in the surgery-only arm and 62 months in the preoperative chemotherapy arm (hazard ratio, 0.79; 95% CI, 0.60 to 1.06; P = .11.) The median PFS was 20 months for surgery alone and 33 months for preoperative chemotherapy (hazard ratio, 0.80; 95% CI, 0.61 to 1.04; P = .10.) Major response to chemotherapy was seen in 41% of patients; no unexpected toxicity was observed. CONCLUSION This trial closed prematurely after compelling evidence supporting postoperative chemotherapy emerged. Although OS and PFS were higher with preoperative chemotherapy, the differences did not reach statistical significance. At present, stronger evidence exists for postoperative chemotherapy in early-stage NSCLC.

[Solitary metachnonous jejunum and duodenum metastasis after surgical resection of lung cancer]

We report a rare case of a 58-year-old man of long-term survival after surgical treatment of solitary metachnonous jejunum and duodenum metastasis from lung cancer. He underwent right upper lobectomy with a diagnosis of lung cancer which was histologically diagnosed as large cell carcinoma (pT4-MONO, stage IIIB). One month after the operation, he suffered from ileus caused by metastasis in the jejunum. Partial resection of the jejunum and postoperative chemotherapy were performed. Two years after the 2nd surgery, another metastatic tumor was found in the duodenum, and pancreatoduodenectomy was performed. The postoperative course of the patient was uneventful without recurrence 6 years after surgical resection of lung cancer.

Optimal surgical procedure for locally curative surgery in patients with anaplastic thyroid carcinoma: importance of preoperative ultrasonography

Anaplastic thyroid carcinoma (ATC) is a very aggressive disease showing a high mortality. However, long-term survival is expected when patients do not show distant metastasis at diagnosis and undergo locally curative surgery. In this study, we investigated the optimal surgical procedure for locally curative surgery for ATC in a series of 34 patients. Twenty patients underwent total thyroidectomy but there were no detectable skip lesions of ATC in the contralateral lobe on pathological examination. Cause-specific survival (CSS) of Stage IVA or IVB patients who underwent limited thyroidectomy did not differ from that of those who underwent total thyroidectomy. Clinical node metastasis on ultrasonography was not detected in 15 patients but 11 of these patients underwent lymph node dissection. Three of these were node-positive on pathological examination but only one showed metastatic node of ATC that was involved in the primary lesion. Of 19 patients having clinical node metastasis, 10 were ATC node positive on pathological examination. Taken together, for locally curative surgery in ATC patients, 1) total thyroidectomy may not be mandatory unless patients have clinical lesions in the contralateral lobe; 2) prophylactic modified radical neck dissection may not be mandatory for patients who do not demonstrate clinical signs of lymph node metastasis; and 3) extensive and careful therapeutic node dissection may be required for patients demonstrating clinical signs of node metastasis.

[Gallbladder metastasis of large cell lung cancer]

A man, who received right upper lobectomy of the lung due to stage IIB large cell carcinoma 7 and half years ago, visited our hospital complaining of right upper abdominal pain. Computed tomography (CT) revealed gallbladder tumor and extended resection of the gallbladder was performed. Pathological diagnosis was adenosquamous cell carcinoma After 1 year and 4 months later, left adrenal gland tumor was found by CT scan, and the surgery was conducted. Pathologically, it was diagnosed as metastasis from lung cancer. By reevaluation of pathology of the gallbladder, the tumor was found to have similar component of resected lung cancer, suggesting the possibility of the tumor to be metastatic.