The IASLC Mesothelioma Staging Project: Proposals for the M Descriptors and for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Mesothelioma

INTRODUCTION

The M component and TNM stage groupings for malignant pleural mesothelioma (MPM) have been empirical. The International Association for the Study of Lung Cancer developed a multinational database to propose evidence-based revisions for the eighth edition of the TNM classification of MPM.

METHODS

Data from 29 centers were submitted either electronically or by transfer of existing institutional databases. The M component as it currently stands was validated by confirming sufficient discrimination (by Kaplan-Meier analysis) with respect to overall survival (OS) between the clinical M0 (cM0) and cM1 categories. Candidate stage groups were developed by using a recursive partitioning and amalgamation algorithm applied to all cM0 cases.

RESULTS

Of 3519 submitted cases, 2414 were analyzable and 84 were cM1 cases. Median OS for cM1 cases was 9.7 months versus 13.4 months (p = 0.0013) for the locally advanced (T4 or N3) cM0 cases, supporting inclusion of only cM1 in the stage IV group. Exploratory analyses suggest a possible difference in OS for single- versus multiple-site cM1 cases. A recursive partitioning and amalgamation-generated survival tree on the OS outcomes restricted to cM0 cases with the newly proposed (eighth edition) T and N components indicates that optimal stage groupings for the eighth edition will be as follows: stage IA (T1N0), stage IB (T2-3N0), stage II (T1-2N1), stage IIIA (T3N1), stage IIIB (T1-3N2 or any T4), and stage IV (any M1).

CONCLUSIONS

This first evidence-based revision of the TNM classification for MPM leads to substantial changes in the T and N components and the stage groupings.

The IASLC Mesothelioma Staging Project: Proposals for Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma

INTRODUCTION

The current T component for malignant pleural mesothelioma (MPM) has been predominantly informed by surgical data sets and consensus. The International Association for the Study of Lung Cancer undertook revision of the seventh edition of the staging system for MPM with the goal of developing recommendations for the eighth edition.

METHODS

Data elements including detailed T descriptors were developed by consensus. Tumor thickness at three pleural levels was also recorded. An electronic data capture system was established to facilitate data submission.

RESULTS

A total of 3519 cases were submitted to the database. Of those eligible for T-component analysis, 509 cases had only clinical staging, 836 cases had only surgical staging, and 642 cases had both available. Survival was examined for T categories according to the current seventh edition staging system. There was clear separation between all clinically staged categories except T1a versus T1b (hazard ratio = 0.99, p = 0.95) and T3 versus T4 (hazard ratio = 1.22, p = 0.09), although the numbers of T4 cases were small. Pathological staging failed to demonstrate a survival difference between adjacent categories with the exception of T3 versus T4. Performance improved with collapse of T1a and T1b into a single T1 category; no current descriptors were shifted or eliminated. Tumor thickness and nodular or rindlike morphology were significantly associated with survival.

CONCLUSIONS

A recommendation to collapse both clinical and pathological T1a and T1b into a T1 classification will be made for the eighth edition staging system. Simple measurement of pleural thickness has prognostic significance and should be examined further with a view to incorporation into future staging.

The IASLC Mesothelioma Staging Project: Improving Staging of a Rare Disease Through International Participation

For nearly 40 years, there was no generally accepted staging system for malignant pleural mesothelioma. In 1994, members of the International Mesothelioma Interest Group, in collaboration with the International Association for the Study of Lung Cancer, proposed a TNM staging system based on analyses of outcomes in retrospective surgical series and small clinical trials. Subsequently accepted by the American Joint Commission on Cancer and the Union for International Cancer Control for the sixth editions of their staging manuals, this system has since been the international staging standard. However, it has significant limitations, particularly with respect to clinical staging and to the categories for lymph node staging. Here we provide an overview of the development of the International Association for the Study of Lung Cancer malignant pleural mesothelioma staging database, which was designed to address these limitations through the development of a large international data set. Analyses of this database, described in papers linked to this overview, are being used to inform revisions in the eighth editions of the American Joint Commission on Cancer and Union for International Cancer Control staging systems.

The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

Small cell lung cancer (SCLC) is commonly classified as either limited or extensive, but the Union for International Cancer Control TNM Classification of Malignant Tumours seventh edition (2009) recommended tumor, node, and metastasis (TNM) staging based on analysis of the International Association for the Study of Lung Cancer (IASLC) database.

METHODS

Survival analyses were performed for clinically and pathologically staged patients presenting with SCLC from 1999 through 2010. Prognosis was compared in relation to the TNM seventh edition staging to serve as validation and analyzed in relation to proposed changes to the T descriptors found in the eighth edition.

RESULTS

There were 5002 patients: 4848 patients with clinical and 582 with pathological stages. Among these, 428 had both. Survival differences were confirmed for T and N categories and maintained in relation to proposed revisions to T descriptors for seventh edition TNM categories and proposed changes in the eighth edition. There were also survival differences, notably at 12 months, in patients with brain-only single-site metastasis (SSM) compared to SSM at other sites, and SSM without a pleural effusion showed a better prognosis than other patients in the M1b category.

CONCLUSION

We confirm the prognostic value of clinical and pathological TNM staging in patients with SCLC, and recommend continued usage for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. However, for M descriptors, it remains uncertain whether survival differences in patients with SSM in the brain simply reflect better treatment options rather than better survival based on anatomic extent of disease.

Do we need a revised staging system for malignant pleural mesothelioma? Analysis of the IASLC database

INTRODUCTION

A number of staging systems have been proposed for malignant pleural mesothelioma (MPM) in the past, but few have utilized a TNM (tumor, node, metastasis) system. The International Association for the Study of Lung Cancer (IASLC) and the International Mesothelioma Interest Group (IMIG) previously developed a TNM-staging system which has been accepted by the International Union Against Cancer (UICC) and the American Joint Commission on Cancer (AJCC). The present study examines this staging system by analysing the updated IASLC database for patients with MPM.

METHODS

De-identified data from participating centres dated from 1995 to 2009 were submitted to the IASLC Statistical Center. Surgical procedures included those with a curative or palliative intent. Survival was measured from the date of pathologic diagnosis to the most recent contact or death. Endpoints included overall survival and analysis of potential prognostic factors.

RESULTS

Data was available for 3,101 patients from 15 centers, mostly from North America and Europe. After a median follow-up of 15 months, a number of clinicopathological and treatment-related prognostic factors were found to significantly influence overall survival. These included overall tumor stage based on the proposed TNM staging system, T category, N category, tumor histology, gender, age, and type of operation.

CONCLUSIONS

The IASLC database represents the largest, multicenter and international database on MPM to date. Analyses demonstrate that the proposed TNM staging system effectively distinguishes the T and N categories, but also highlight areas for potential revision in the future.

Sleeve pneumonectomy for lung cancer--survival and complications (single-center experience with 42 patients)

BACKGROUND

Sleeve pneumonectomy is challenging both from the technical and oncological standpoint. The benefit of induction treatment is still under investigation.

MATERIAL AND METHODS

The study included 42 patients with sleeve pneumonectomy for non-small cell lung cancer in an eight-year period. Right sleeve pneumonectomy was performed in 39 patients. Squamous cell and adenocarcinoma were found in 33 (78.5%) and 5 (11.9%) patients, respectively. Overall stage was IIIa for 25 (59.5%) and IIIb for 17 (40.5%) patients, respectively.

RESULTS

Perioperative mortality and morbidity were 16.6% and 35.7%. Leading cause of death was bronchopleural fistula. Five-year survival was 35%. The survival difference between patients with NO+N1 versus N2 lesions was statistically significant (p = 0.01). There were no two-year survivors among patients with N2 lesions. Survival difference between T3 and T4 patients was also significant (p = 0.04). In a multivariate analysis, only T and N components were found significant in terms of prognosis.

CONCLUSION

Sleeve pneumonectomy should be avoided in patients with N2 lesions confirmed preoperatively. A safe operation can be performed if the surgeon restricts airway resection to a maximum length of 4 cm.

Ontogeny of immunoreactive prostaglandin endoperoxide synthase isoforms in ovine fetal pituitary, hypothalamus and brainstem

Parturition is initiated in sheep by an increase in the activity of the fetal hypothalamus-pituitary-adrenal (HPA) axis. Prostaglandins, known to augment the activity of this endocrine axis, have long been proposed as involved in the initiation of paturition. We have previously demonstrated that endogenously produced prostanoids augment the activity of the HPA axis, and we have proposed that the increased production of prostanoids within the fetal brain or pituitary at the end of gestation might be involved in the initiation of parturition. An important regulatory step in the biosynthesis of prostanoids is the activity of prostaglandin endoperoxide synthase (PGHS). The present study was designed to test the hypothesis that the abundance of one or both isoforms of PGHS (PGHS-1 and PGHS-2) increase in brain and/or pituitary at the end of gestation. We used immunoblot analysis to measure the abundance of immunoreactive PGHS-1 and PGHS-2 in pituitary, hypothalamus and brainstem collected from fetuses of known gestational ages. We found that the abundance of PGHS-1 was weakly but significantly increased at the end of gestation in the pituitary and brainstem. The abundance of PGHS-2, on the other hand, increased exponentially in the pituitary and hypothalamus with highest concentrations found in term fetuses. We conclude that these enzymes are developmentally regulated in pituitary and in brain regions important for HPA axis control. We speculate that the increased enzyme's abundance results in increased prostanoid biosynthesis near term, and is a link in the chain of events which initiates parturition.

Treatment of poor-prognosis extensive disease small-cell lung cancer with an all-oral regimen of etoposide and cyclophosphamide - a Southwest Oncology Group clinical and pharmacokinetic study

PURPOSE

An all-oral regimen of etoposide and cyclophosphamide was developed for use in poor-prognosis extensive disease small-cell lung cancer. Limited pharmacokinetic sampling was used to derive a pharmacodynamic model predictive of myelosuppression early in the course of therapy.

PATIENTS AND METHODS

Eligible patients were chemotherapy-naive and had extensive disease small-cell lung cancer with either SWOG performance status 2 or serum albumin <3.5 g/dl. The first cohort (n = 18) received etoposide orally at 50 mg daily and cyclophosphamide orally at 50 mg daily days 1-14 every 28 days. Due to good hematologic tolerance, the second cohort (n = 39) received both agents orally at 50 mg twice daily days 1-14 every 28 days. Plasma etoposide levels were determined in samples drawn at baseline, and at 1 h, 2 h, and 23.5 h (trough) after the first dose. Linear regression analysis was used to determine pharmacokinetic and demographic parameters predictive of myelosuppression.

RESULTS

A total of 173 treatment cycles were delivered. Patients on the daily regimen had a 22% response rate (complete and partial), a 22% unconfirmed response rate, and a 5-month median survival, while patients on the twice-daily regimen had a 28% response rate (complete and partial), a 13% unconfirmed response rate, and a 7-month median survival. Granulocytopenia and alopecia were the most common toxicities seen. Significant granulocytopenia could be predicted for the twice-daily regimen according to the formula ln(AGC nadir)=7.80 - 1.88(trough), with an increased incidence of granulocytopenia if the etoposide trough value was >/=1.49 microg/ml.

CONCLUSION

Oral etoposide and oral cyclophosphamide given days 1-14 every 28 days is well tolerated and results in an acceptable response rate and median survival in poor-prognosis (poor performance status or low serum albumin) extensive disease small-cell lung cancer. A trough etoposide level obtained within 24 h of starting therapy can predict severe granulocytopenia.

Gentamicin pharmacokinetics in newborn and 42-day-old male piglets

The pharmacokinetics of gentamicin was investigated in six newborn male piglets, aged from 4 to 12 h at the time of administration of the drug, and six 42-day-old castrated male piglets, that had been weaned for 2 weeks following a single intravenous bolus of 5 mg/kg. Gentamicin was measured in serum and in urine by a fluorescence polarization immunoassay. The serum concentration-time data were best described by a three-compartment open model. A rapid initial distribution phase (pi phase) was observed in every animal. The serum beta half-life (t 1/2 beta) was significantly longer in the newborn piglets (mean +/- SEM) (5.19 +/- 0.30 h) than in the older group (3.50 +/- 0.23 h) (P < 0.05). Mean residence time was similarly longer in younger piglets (6.62 +/- 0.57 h) than in older animals (2.86 +/- 0.11 h) (P < 0.05). The steady-state volume of distribution (Vdss) was significantly larger for younger pigs (0.785 +/- 0.036 L/kg) than in elder pigs (0.474 +/- 0.029 L/kg) (P < 0.05). Urinary gamma half-life (t 1/2 gamma u) was 72.66 +/- 10.78 h in the newborn piglets and 69.20 +/- 14.77 h in the 42-day-old animals. A urinary delta phase was observed in three of the 42-day-old piglets and gave a mean t 1/2 delta u of 232.01 +/- 14.55 h. Percentages of urinary recovery of the administered dose after 144 h were 94.18 +/- 1.01 and 94.04 +/- 1.12 in the newborn and 42-day-old animals, respectively. Serum gentamicin clearance was significantly lower in younger animals (0.121 +/- 0.007 L/h.kg) than in the 42-day-old group (0.166 +/- 0.010 L/h.kg). It is suggested that in the newborn piglets, the increase of Vd(SS) could be explained by a higher proportion of extracellular water while the lower clearance could be attributed to a reduced glomerular filtration capacity. Gentamicin dosage requirement in the newborn piglets would therefore have to be adjusted, in order to take into consideration the observed differences in the man values of these latter pharmacokinetic parameters.

Renal artery aneurysm: treatment with percutaneous placement of a stent-graft

A stent-graft was placed percutaneously in the right renal artery of a 50-year-old woman with hypertension and a fibromuscular dysplastic lesion consisting of severe stenoses and a 1.5-cm saccular aneurysm with a wide neck. At 1-year follow-up with arteriography, arterial luminal diameter was normal and no aneurysm was depicted. The patient's blood pressure was normal without blood pressure medication.

Toxicological index and the presence in the workplace of chemical hazards for workers who breast-feed infants

The increasing number of women in the workplace has made it more important than ever to ensure a safe work environment, particularly with respect to mothers who choose to breast-feed their babies. The Quebec Commission de la santé et de la sécurité du travail (CSST) Toxicological Index is fully involved in the provincial program for the protective reassignment of workers who breast-feed infants. The Infotox database provides peer-reviewed information concerning chemicals identified in the workplace that may appear in the mother's milk, possibly to be ingested by the breast-fed infant. Data extracted from the CSST computer system that holds information on 5,500 substances are presented. A total of 153 chemicals (2.7%) are recognized as being involved in some milk transfer. The strength of evidence is assessed with reference to strong or weak association (excretion or detection) in humans or in animals. Such an effect provides a useful basis for administrative decision involving protective reassignment as well as evaluation of work environment. Database users must be well informed about the identification of chemicals in breast milk because this is an essential step for the evaluation of the hazards of transferring chemicals encountered in the workplace from mother to baby. Actually, the main problem is that there are very few data in the scientific literature concerning milk transfer.

Radioimmunoassay for albuterol using a monoclonal antibody: application for direct quantification in horse urine

A monoclonal antibody was synthesized in mouse against the O-(3-carboxypropionyl) derivative of albuterol linked to bovine serum albumin. Isotyping of this material revealed the IgG1 class characterized by an affinity constant of 1.03 nM-1 and a density of sites of 0.55 nM. This antibody was found specific as its cross-reactivity to structurally related molecules was less than 1% except for clenbuterol (75%). A radioimmunoassay was set up with culture supernatant (final dilution 1/1000) and [3H] albuterol. The calibration curve was characterized by a maximum binding of 28%, an ED50 of 1.15 pmol per tube, the detection limit was 28.8 fmol/tube and the linearity of the response was up to 39.8 pmol/tube. This RIA method has been used for direct quantitation of albuterol in horse urine without any clean-up or extraction step.