[Systemic nocardiosis with mediastinal lymph node involvement proven by endoscopic ultrasound]

INTRODUCTION

Systemic nocardiosis is an infectious disease that is rarely associated with mediastinal lymph nodes.

CASE REPORT

We report the case of a 72-year-old male patient treated with a high dose of oral corticosteroids for rheumatoid polyarthritis. This patient presented with rapid overall deterioration associated with mediastinal lymph nodes. Endobronchial ultrasound enabled us to establish a diagnosis of systemic nocardiosis. The patient recovered after having received suitable antibiotic treatment for four months.

CONCLUSION

This work reports on a rare clinical presentation of systemic nocardiosis associated with mediastinal lymphadenopathies and highlights the key role of endobronchial ultrasound in diagnosing mediastinal lymph nodes, especially in differential diagnosis for lung cancer.

Effect of industrial processing and storage procedures on oxysterols in milk and milk products

Oxysterols are products of enzymatic and/or chemical cholesterol oxidation. While some of the former possess broad antiviral activities, the latter mostly originate from the deterioration of the nutritional value of foodstuff after exposure to heat, light, radiation and oxygen, raising questions about their potential health risks. We evaluated the presence of selected oxysterols in bovine colostrum and monitored the evolution of their cholesterol ratio throughout an entire industrial-scale milk production chain and after industrially employed storage procedures of milk powders. We report here for the first time the presence of high levels of the enzymatic oxysterol 27-hydroxycholesterol (27OHC) in concentrations of antiviral interest in bovine colostrum (87.04 ng mL^-1) that decreased during the first postpartum days (56.35 ng mL^-1). Of note, this oxysterol is also observed in milk and milk products and is not negatively affected by industrial processing or storage. We further highlight an exponential increase of the non-enzymatic oxysterols 7β-hydroxycholesterol (7βOHC) and 7-ketocholesterol (7KC) in both whole (WMPs) and skimmed milk powders (SMPs) during prolonged storage, confirming their role as reliable biomarkers of cholesterol oxidation over time: after 12 months, 7βOHC reached in both SMPs and WMPs amounts that have been found to be potentially toxic in vitro (265.46 ng g^-1 and 569.83 ng g^-1, respectively). Interestingly, industrial processes appeared to affect the generation of 7βOHC and 7KC differently, depending on the presence of fat in the product: while their ratios increased significantly after skimming and processing of skimmed milk and milk products, this was not observed after processing whole milk and milk cream.

Clinical ACO phenotypes: Description of a heterogeneous entity

BACKGROUND

Because ACO (Asthma-COPD-Overlap) does not fill out asthma or COPD (Chronic Obstructive Pulmonary Disease) criteria, such patients are poorly evaluated. The aim of this study was to screen asthma and COPD for an alternative diagnosis of ACO, then to determine subgroups of patients, using cluster analysis.

MATERIAL AND METHODS

Using GINA-GOLD stepwise approach, asthmatics and COPD were screened for ACO. Clusterization was then performed employing Multiple Correspondent Analysis (MCA) model, encompassing 9 variables (age, symptoms onset, sex, BMI (Body Mass Index), smoking, FEV-1, dyspnea, exacerbation, comorbidity). Finally, clusters were compared to determine phenotypes.

RESULTS

MCA analysis was performed on 172 ACO subjects. To better distinguish clusters, the analysis was then focused on 55 subjects, having at least one cosine squared >0.3. Six clusters were identified, allowing the description of 4 phenotypes. Phenotype A represented overweighed heavy smokers, with an early onset and a severe disease (27% of ACO patients). Phenotype B gathered similar patients, with a late onset (29%). Patients from Phenotypes C-D were slighter smokers, presenting a moderate disease, with early and late onset respectively (respectively 13% and 31%).

CONCLUSIONS

By providing evidences for clusters within ACO, our study confirms its heterogeneity, allowing the identification of 4 phenotypes. Further prospective studies are mandatory to confirm these data, to determine both specific management requirements and prognostic value.

Patients with non-small-cell lung cancer harbouring a BRAF mutation: a multicentre study exploring clinical characteristics, management, and outcomes in a real-life setting: EXPLORE GFPC 02-14

Background

Mutations in BRAF are rare oncogene mutations, found in 2% of non-small-cell lung cancers (nsclcs). Little information is available about the management of patients with BRAF-mutated nsclc, except for those included in clinical trials. We undertook the present study to assess the clinical characteristics, management, and outcomes of those patients in a real-life setting.

Methods

This retrospective multicentre observational study included all patients with BRAF-mutated nsclc diagnosed between January 2012 and December 2014.

Results

Patients (n = 59) from 24 centres were included: 57.6% men; mean age: 64.5 ± 14.5 years; 82% with a performance status of 0-1 at diagnosis; smoking status: 40.3% current, 32.6% former; 93% with adenocarcinoma histology; 75% stage iv; 78% with V600E mutations; 2 with EGFR and 2 with ALK co-mutations. Of the stage iv patients, 79% received first-line therapy (14.2% anti-BRAF), and 48% received second-line treatment (23.8% anti-BRAF). Response rate and progression-free survival were, respectively, 51.7% and 8.7 months [95% confidence interval (ci): 6.4 months to 15.2 months] for first-line therapy and 35.3% and 4.1 months (95% ci: 2 months to 10.9 months) for second-line treatments. The 2-year overall survival was 58.5% (95% ci: 45.8% to 74.8%). Outcomes in patients with stage iv nsclc harbouring BRAF V600E mutations (n = 32) did not differ significantly from those of patients with other BRAF mutations.

Conclusions

In this real-world analysis, most nsclc patients with a BRAF mutation were men and current or former smokers. Survival appears to be better in these BRAF-mutated patients than in nsclc patients without an oncogenic driver.

Rapid and noninvasive quality control of anhydrous milk fat by PTR-MS: The effect of storage time and packaging

In this study, proton transfer reaction-mass spectrometry (PTR-MS), coupled with a time-of-flight mass analyzer and a multipurpose automatic sampler, was evaluated as a rapid and nondestructive tool for the quality control of anhydrous milk fat. Anhydrous milk fats packed in cardboard and bag-in-box were compared during refrigerated shelf life at 4°C for 9 months. Anhydrous milk fat samples were taken at 120, 180, and 240 days and measured by PTR-MS during storage at 50°C for 11 days. Univariate and multivariate data analysis were performed in order to classify samples according to the packaging type and compare aromatic profiles. Markers related to both packaging and storage duration were identified, and all stored samples were clearly distinguishable from reference fresh samples. Significant differences in some key butter aroma compounds such as 2-pentanone, 2-heptanone, 2/3-methylbutanal, acetoin, and butanoic acid were observed between different types of packaging. During the refrigerated storage, differences related to packaging are more evident, while during the storage at 50°C, the fat oxidation induced by the high temperature becomes the most relevant phenomenon independently of the packaging type. These results indicate the importance of avoiding anhydrous milk fat storage at 50°C for long times during industrial production processes. All together data demonstrated the viability of PTR-MS as a rapid and high-sensitivity tool in agroindustry quality control program.

[Bevacizumab in combination with first-line treatment for metastatic non-small cell lung cancer in clinical practice. Results of the EOLE study]

INTRODUCTION

The EOLE cohort aimed to describe, in routine clinical practice, the characteristics and management of patients receiving bevacizumab in combination with first-line metastatic chemotherapy for advanced metastatic or recurrent non squamous non-small cell lung cancer (nsNSCLC), as well as its efficacy and safety.

METHODS

A total of 423 patients were enrolled in this prospective, national, multicenter study. Data were collected every 3 months over an 18-month period.

RESULTS

Amongst the 407 patients analyzed (mean age 60±10 years, male 68%, ECOG-PS≤1 88%, smokers or former smokers 87%, cardiovascular comorbidities 40%), all except for 2 patients received bevacizumab (7.5 or 15mg/kg/3 weeks in 99% of patients) in combination with doublet chemotherapy. A total of 160 (60%) patients who completed induction received bevacizumab maintenance therapy. Median progression-free survival was 6.9 months (95% CI=[6.0-7.5]). Median overall survival (12.8 months [10.4-14.7]) was longer in patients with ECOG-PS≤1 (14.4 months [12.3-15.9] versus 4.9 months [3.4-8.3] if ECOG-PS=2). A total of 131 (32%) patients experienced at least one serious adverse event (SAE), and 51 (12%) at least one bevacizumab-related SAE.

CONCLUSION

EOLE confirms the efficacy and safety of bevacizumab in aNSCLC patients, in current medical practice.

Randomized open-label non-comparative multicenter phase II trial of sequential erlotinib and docetaxel versus docetaxel alone in patients with non-small-cell lung cancer after failure of first-line chemotherapy: GFPC 10.02 study

BACKGROUND

Concomitant administration of erlotinib with standard chemotherapy does not appear to improve survival among patients with non-small-cell lung cancer (NSCLC), but preliminary studies suggest that sequential administration might be effective.

OBJECTIVE

To assess the efficacy and tolerability of second-line sequential administration of erlotinib and docetaxel in advanced NSCLC.

METHODS

In an open-label phase II trial, patients with advanced NSCLC, EGFR wild-type or unknown, PS 0-2, in whom initial cisplatin-based chemotherapy had failed were randomized to sequential erlotinib 150 mg/d (day 2-16)+docetaxel (75 mg/m(2) d1) (arm ED) or docetaxel (75 mg/m(2) d1) alone (arm D) (21-day cycle). The primary endpoint was the progression-free survival rate at 15 weeks (PFS 15). Secondary endpoints included PFS, overall survival (OS), the overall response rate (ORR) and tolerability. Based on a Simon optimal two-stage design, the ED strategy was rejected if the primary endpoint was below 33/66 patients at the end of the two Simon stages.

RESULTS

147 patients were randomized (median age: 60±8 years, PS 0/1/2: 44/83/20 patients; males: 78%). The ED strategy was rejected, with only 18 of 73 patients achieving PFS15 in arm ED at the end of stage 2 and 17 of 74 patients in arm D. In arms ED and D, respectively, median PFS was 2.2 and 2.5 months and median OS was 6.5 and 8.3 months.

CONCLUSION

Sequential erlotinib and docetaxel was not more effective than docetaxel alone as second-line treatment for advanced NSCLC with wild-type or unknown EGFR status.

A multicentre phase II randomised trial of weekly docetaxel/gemcitabine followed by erlotinib on progression, vs the reverse sequence, in elderly patients with advanced non small-cell lung cancer selected with a comprehensive geriatric assessment (the GFPC 0504 study)

BACKGROUND

Elderly cancer patients form a heterogeneous population in which therapeutic decision-making is often difficult. The aim of this randomised phase II trial was to evaluate the feasibility and activity of weekly docetaxel/gemcitabine (DG) followed by erlotinib after progression (arm A) vs erlotinib followed by DG after progression (arm B) in fit elderly patients with advanced non small-cell lung cancer (NSCLC).

METHODS

Elderly chemotherapy-naive patients with stage IIIB/IV NSCLC were selected after a comprehensive geriatric assessment (socioeconomic, cognitive, depression, ADL and IADL assessments). The primary endpoint was the time to second progression (TTP2). Overall survival (OS), the time to first progression (TTP1) and safety were secondary endpoints.

RESULTS

Between July 2006 and November 2008, 22 centres enrolled 100 patients. TTP2 was 7.5 and 5.8 months in arm A and arm B, respectively; TTP1 was 4.7 and 2.7 months; and the median OS time was 9.4 and 7.1 months; the respective 1-year survival rates were 36.2 and 31.4%. There was no major unexpected toxicity.

CONCLUSION

These results suggest that weekly DG, followed by erlotinib, is a promising treatment for fit elderly patients with NSCLC; the efficacy of the reverse sequence was insufficient to recommend it for EGFR-non-selected patients.

Phase II trial of temozolomide and cisplatin followed by whole brain radiotherapy in non-small-cell lung cancer patients with brain metastases: a GLOT-GFPC study

BACKGROUND

Brain metastases (BM) considerably worsen the prognosis of non-small-cell lung cancer (NSCLC) patients. The usefulness and choice of chemotherapy remain uncertain in this indication since these patients are excluded from most clinical trials. We conducted a phase II study to determine the efficacy and tolerability of up-front chemotherapy with association of temozolomide and cisplatin in NSCLC patients with BM.

PATIENTS AND METHODS

Fifty NSCLC patients with BM received temozolomide (200 mg/m(2)/day for 5 days every 28 days) and cisplatin (75 mg/m(2) at day 1 of each cycle), up to six cycles, followed by whole brain radiotherapy (WBRT). An evaluation was carried out every two cycles and after WBRT. WBRT was performed earlier in case of progressive disease at any time or stable disease after cycle 4.

RESULTS

Eight objective responses were achieved (16%). Overall median survival was 5 months. Median time to progression was 2.3 months. Ten patients (20%) presented a grade 3/4 neutropenia and 11 patients (22%) presented a grade 3/4 thrombopenia.

CONCLUSION

This study demonstrates a lack of efficacy of up-front chemotherapy with association of temozolomide and cisplatin in these patients. Nevertheless, it supports the feasibility of chemotherapy before brain radiotherapy in NSCLC patients with BM.

Improvement in anemia management with epoietin alfa (EA) in elderly and/or poor performance status (PS) patients (pts) with advanced non-small cell lung cancer (NSCLC) (GFPC 0202)

18571

Background: EA at a starting dose of 40000 UI sc once weekly (qw) has been show to be effective in the treatment of chemotherapy (CT) induced anemia in cancer pts and early intervention with EA appears important for anemia prevention and reduce CT toxicity in elderly pts. Methods: In this multicenter phase II study, chemonaive pts with stage IIIB (pleural effusion) and IV 50 pts with mild co-morbidity (Charlson score) and good performans status (PS) received docetaxel 30 mg/m2 weekly (6 wks, 2 wks off) and gemcitabine 900 mg/m2 (only on day 1, 8, 22, 29) arm A and 50 pts with higher co-morbidity and/or poor performans status (PS) received docetaxel 30 mg/m2 weekly (6 wks, 2 wks off) arm B. Anemic pts with Hb <11.5 g/dl received EA 40000 UI/qw until a target = 13 g/dl with maintenance phase during CT and 28 days after the end of CT to maintain Hb 11.5 to 12.5 g/dl. Dose could be increased to 60000 UI/qw after 4 wks depending on Hb response. Quality of life (Qol: LCSS, Spitzer score) was assessed at baseline, 8, 16 and 24 wks. This trial assessed the effect of EA on Hb level after 4 and 8 wks, tranfusion requirements and Qol. Results: From Jun 2003 to Dec 2004 100 pts were enrolled, median age was 72,7 (66–82) arm A, 76,6 (70–84) arm B, median co-morbidity 1 (0–4) arm A; 1,9 (0–5) arm B. 59 pts received EA (58% arm A; 60% arm B), mean Hb level was 11.6 at the start of CT, and 10.42 before EA. Mean Hb increase after 4 wks was 0.77 ± 1.11 (p < 0.05), and 1.63 ± 1.36 after 8 wks (p < 0.05). Only 14.1% received transfusions. There was no significant change in global Qol and fatigue (LCSS). The main grade 3/4 CT toxicity was fatigue 25% and neutropenia in arm A and fatigue 50% in arm B. Conclusions: Weekly EA increase Hb level, early EA intervention maintain Qol and decrease red blood transfusions, and mild anemia is probably associated with significant impairment in toxicity in elderly pts with advanced NSCLC.

No significant financial relationships to disclose.

[Treatment of anemia and bone metastasis in metastatic non-small-cell lung cancer. A French survey]

Use of erythropoietin (EPO) for chemotherapy-induced anemia and biphosphonates (BP) for bone metastasis has increased steadily. However, there are no guidelines on their use in many situations such as non small cell lung carcinoma (NSCLC), which frequently alters quality of life markedly. Therefore, a multicentric survey was designed to assess the treatment of anemia and bone metastasis in chemotherapy-treated patients with non-small-cell lung carcinoma. Nine representative centers of the oncology working party of the French respiratory society (Groupe d'Oncologie de la Société de Pneumologie de Langue Française) participated. Inclusion criteria were stage IV NSCLC and at least one course of chemotherapy in the last 3 months. A total of 148 and 50 patients (pts) were included in the anemia and bone metastasis surveys, respectively. Anemia was present in 60.8% of patients, and was not treated in 75%; 15 patients received EPO (10.1%). Independent predictors of EPO use were presence of anemia-related symptoms, hemoglobin level, age and center: the rate of prescription in patients with anemia varied from 13 to 73% between centers. BP were administered in 38% of patients with bone metastasis. Independent predictors of BP use were calcium serum level, pain, and center with a rate of prescription ranging from 0 to 80% between centers. This study reveals that, in France, most patients with anemia are not treated, EPO being seldom prescribed. The use of both EPO and BP is highly variable between centers. Guidelines on the use of these supportive treatments could help improve the care for lung cancer patients receiving chemotherapy.

Prospective evaluation of early lung toxicity following three-dimensional conformal radiation therapy in non-small-cell lung cancer: preliminary results

PURPOSE

Radiation pneumonitis is the restricting complication following lung cancer irradiation. The correlation between dose-volume histograms (DVHs) and pneumonitis, with a clinical, radiological, and respiratory function evaluation was assessed. Special endpoint was the evaluation of respiratory function after three-dimensional conformal radiotherapy (3D-CRT).

METHODS AND MATERIALS

Fifty-four patients with non metastatic non-small-cell lung cancer (NSCLC) were treated with a curative intent with 3D-CRT (66 Gy). Thirty-one patients were treated postoperatively (pneumonectomy in 9 patients) for residual tumor or massive nodal involvement (N2 or N3); 23 patients were treated with exclusive radiotherapy. Clinical evaluation, CT scan, and pulmonary functional tests were performed before and 6 weeks after irradiation. The DVHs were calculated applying lung density heterogeneity.

RESULTS

Twenty patients had radiation pneumonitis. Irradiation significantly decreased total lung capacity. Volume of the PTV2 (more than 200 cm(3)) was a significant prognostic factor for lung complication.

CONCLUSION

DVHs combined with initial pulmonary functional tests can predict pulmonary toxicity and could allow us to adjust volume that received total highest dose with acceptable toxicity.