Induction treatment before surgery for non-small cell lung cancer

Surgery alone is currently still accepted "standard of care" for patients with operable NSCLC, this includes stages IA and IIB, as well as selected early subsets of IIIA disease. In more advanced and inoperable stage III disease, combinations of chemotherapy and radiotherapy remain the standard treatment approach for patients with good performance status. The role of surgery following induction therapy in these advanced stage III patients is at the moment not conclusively defined. More evidence from randomized trials is clearly needed to tailor treatment for the large number of patients that present in these locally advanced stages. Enrollment of patients into ongoing prospective clinical trials should be encouraged, whenever possible, to further define prognostic factors and improve multimodality strategies in this clinical setting.

[Primary pulmonary hemangiopericytoma: 2 new cases]

We describe two new resected cases of primary pulmonary hemangiopericytoma and the review of cases published in the period 1954-2002. The first patient has a large pulmonary mass of the right apex revealed by scapular pain. The right upper lobectomy with free margins reveals hemangiopericytoma. Pelvic and pulmonary metastases appear two years after surgery, treated by two series of chemotherapy without clinical response. After acute nephrotoxicity controlled by hemodialysis, the patient dies with distant metastases three years and an half after thoracotomy. The second patient develops dry cough and thoracic pain with discovery of a cavitary mass in the right pulmonary field. Fine needle aspiration cytology suggests a mesenchymatous lesion. Three months after extended pneumonectomy, the intrathoracic tumour relapses and regresses partially under chemotherapy. Femoral and brain metastases are irradiated. The patient dies 22 months after thoracotomy. Histology and immunohistochemistry of both tumours closely related to solitary fibrous tumour confirm malignant hemangiopericytoma. Primary pulmonary hemangiopericytoma is rare and may be benign or malignant. Radical resection is the best treatment. Chemotherapy and radiotherapy may improve the prognosis. Compared with lung cancer, the tumour is a slow growing mass, often voluminous, with delayed symptoms, very few lymph node dissemination, rare brain metastasis, more frequent cutaneous or retroperitoneal dissemination, often after long-term and requiring indeed a 10 to 20 years follow-up.

Undiagnosed rupture of right hemidiaphragm--hepatothorax: a case report

A case of late diagnosis of right diaphragmatic rupture due to blunt trauma is presented. Traumatic diaphragmatic rupture is an uncommon but severe problem in a patient with multiple injuries. One third of left-sided ruptures and half of right-sided ruptures have been undetected for several days. Traumatic diaphragmatic rupture should be suspected on the basis of an abnormal chest X-ray in patients with multiple injuries. Imaging studies like computed tomography, scan and magnetic resonance imaging can be helpful for differential diagnosis. Right-sided injuries occur more commonly than previously thought and often require thoracotomy.

Increased expression of high but not low molecular weight heat shock proteins in resectable lung carcinoma

Strong expression of high-molecular-weight (HMW) heat-shock proteins (HSP) by lung carcinoma has been documented using immunohistochemistry. Far less is known about the expression of low-molecular-weight (LMW) HSP in lung cancer. We compared the quantitative expression of HMW (HSP-60, HSP-70) and LMW (HSP-27, ubiquitin) HSP in tumor and non-tumor lung tissue obtained from 47 patients undergoing surgical resection of lung carcinoma. HSP levels were determined in cell lysates from tissue samples by ELISA using streptavidin-biotin technology. Results were normalized to total protein content measured by spectrophotometry. Compared to disease-free lung tissue, tumor tissue samples showed higher levels of both HSP-60 (median value: 227 pg versus 96 pg per mg protein (P<0.001 by Wilcoxon Rank test for paired data) and HSP-70 (median value: 525 ng versus 401 ng per mg protein (P=0.01 by Wilcoxon Rank test for paired data). Tumor and tumor-free tissues show similar levels of ubiquitin and HSP-27. Neither the survival rate nor the histologic type and extent of cancer are correlated with the observed differences in HSP-60 and HSP-70 expression (P>0.1 by one way analysis of variance for repeated measures with one between subject factor). Our data confirm, on a quantitative basis, the increased expression of HSP-60 and HSP-70 in non-small-cell lung carcinoma. However, no prognostic value was found to be associated with this over-expression. In contrast, LMW stress proteins such as ubiquitin and HSP-27, although implicated in cellular processes potentially related to malignant transformation, show no increased expression in lung carcinoma.

Pulmonary sequestration-like anomaly presenting as a spontaneously resolving mass

A premature baby boy presented at birth with respiratory distress. A right lower lobe opacity was found on chest X-ray. Pulmonary sequestration was the diagnosis suggested by ultrasound. The size of the mass decreased on subsequent examinations. 4 months later X-rays and sonography failed to demonstrate any remaining mass. This case illustrates another example of involutive pathology and suggests that not all pulmonary sequestration-like anomalies should be operated on.

Lung metastases from melanoma: when is surgical treatment warranted?

Surgical treatment of lung metastases from melanoma is highly controversial as the expected outcome is much poorer than for other primary tumours and a reliable system for selecting patients is lacking. This study evaluated the long-term results of lung metastasectomy for melanoma, with the aim of defining a subset of patients with better prognosis. By reviewing the data of the International Registry of Lung Metastases (IRLM), we identified 328 patients who underwent lung metastasectomy for melanoma in the period 1945-1995. Survival was calculated by Kaplan-Meier estimate, using log-rank test and Cox regression model for statistical analysis. After complete pulmonary metastasectomy (282 patients) the 5- and 10-year survival was 22% and 16%, respectively. In this group of patients, a time to pulmonary metastases (TPM) shorter than 36 months or the presence of multiple metastases were independent unfavourable prognostic factors. There were no long-term survivors after incomplete resection (46 patients, P< 0.01). Using the IRLM grouping system, patients without risk factors (TPM > 36 months and single lesion) experienced the best survival (29% at 5 years), followed by those with one risk factor only (20% at 5 years). On the other hand, those with two risk factors or incomplete resection showed a significantly poorer survival (7% and 0% at 5 years). Surgery plays an important role in carefully selected cases of pulmonary metastatic melanoma. The prognostic grouping system proposed by the International Registry of Lung Metastases provides a simple and effective method for improving the selection of surgical candidates.

Randomized Trial of Surgery Versus Radiotherapy in Patients with Stage IIIA (N2) Non–Small-Cell Lung Cancer After a Response to Induction Chemotherapy: EORTC 08941

Combined modality treatment of patients with stage III non small-cell lung cancer (NSCLC) has recently become widely accepted. Standard combinations are neoadjuvant chemotherapy followed by radiotherapy or concurrent chemotherapy and radiotherapy. The effect of combined modality treatment on survival is dependent on both the efficacy of chemotherapy to eradicate micrometastases and optimal local control. The European Organization for Research and Treatment of Cancer (EORTC) Lung Cancer Cooperative Group has chosen to investigate in a comparative way the side effects and the effect on survival of radiotherapy versus surgery in stage IIIA (N2) NSCLC.

[Ludwig's angina]

Ludwig's angina is a rare infectious condition originating in the oropharyngeal region, most commonly from the teeth. The principal symptoms consist of cervical pain, dyspnea, dysphagia, symmetrical neck swelling and fever. Serious complications include respiratory collapses, mediastinitis, pleural empyema, pericarditis and pericardial tamponade, and may result in the death of the patient. The most useful investigations in patients with suspected Ludwig's angina are clinical assessment, a cervico-thoracic CT-scan to determine the extent of the lesions, microbiological examination and panoramic radiography to detect possible dental focuses of infection. Treatment consists of ensuring adequate ventilation by securing the upper airways, broad spectrum antibiotic therapy, eradication of the source of infection, and often early surgical decompression may be necessary. Rapid diagnosis and appropriate treatment can reduce the mortality rate to 10%.

Characterization of ligands for galectins, natural galactoside-binding immunoglobulin G subfractions and sarcolectin and also of the expression of calcyclin in thyroid lesions

The purpose of this study was to characterize ligands for galectins, natural galactoside-binding immunoglobulin G subfractions and sarcolectin and also the expression of calcyclin in various benign and malignant thyroid lesions. The extent of the binding of eight glycochemical probes was quantitatively assessed using computer-assisted microscopy on 76 thyroid lesions including 10 not-otherwise-specified multinodular goiters (S_MNG), 11 multinodular goiters with adenomatous hyperplasia (AH_MNG), 8 normomacrovesicular (NM_ADE) and 12 microvesicular (MIC_ADE) adenomas, and 9 papillary (P_CAR), 10 follicular variants of papillary (FvarP_CAR), 7 follicular (F_CAR) and 9 anaplastic (A_CAR) carcinomas. The 8 histochemical probes included 5 animal lectins (including galectins and sarcolectin), 1 polyclonal antibody (raised against calcyclin) and 2 immunoglobulin G subfractions from human serum with selectivity to alpha- and beta-galactosyl residues. The results show that multinodular goiters with adenomatous hyperplasia exhibited histochemical characteristics intermediate to those of normal multinodular goiters and microvesicular adenomas. Normomacrovesicular adenomas behaved very distinctly from microvesicular ones. Microvesicular adenomas were more closely related to differentiated thyroid carcinomas than any other type of benign thyroid lesions of epithelial origin. Papillary and follicular carcinomas seemed to represent the two extremes of the same biological entity with the follicular variant of the papillary carcinoma serving as a biological link between these two extremes. Anaplastic carcinomas behaved in a significantly different manner when compared to the differentiated forms of thyroid carcinomas. The results suggest that the patterns of expression of the glycoconjugates investigated in the present study may constitute useful tools for characterizing lesions in the human thyroid.

A pilot study for identifying at risk thyroid lesions by means of a decision tree run on clinicocytological variables

Fine-needle aspiration biopsy (FNAB) is safe, inexpensive, minimally invasive, and highly accurate in the diagnosis of nodular diseases of the thyroid. However, FNAB does not provide a reliable benign versus malignant diagnosis for 100% of the cases analysed. It is possible to increase the accuracy of the cytological diagnosis by means of information contributed by different clinical variables. In the present study we evaluate the diagnostic value of 10 variables in addition to FNAB on a series of 218 specimens for which we obtained histological diagnoses including 37 cancers (17%). The diagnostic information contributed by these variables was analyzed by means of the Decision Tree technique, an artificial intelligence-related method which forms part of the Supervised Learning algorithms. The results show that Decision Trees enable some subpopulations of patients with uncertain FNAB results to be characterized.

The influence of L-triiodothyronine, L-thyroxine, estradiol-17beta, the luteinizing-hormone-releasing hormone, the epidermal growth factor and gastrin on cell proliferation in organ cultures of 35 benign and 13 malignant human thyroid tumors

PURPOSE

To characterize the influence of six factors on human thyroid tissues at the cell-proliferation level. These six factors were the epidermal growth factor (EGF), the luteinizing-hormone-releasing hormone (LHRH), triiodothyronine, thyroxine, estradiol and gastrin.

METHODS

Forty-eight human thyroid specimens were obtained from surgical resection and maintained alive for 48 h ex vivo (in vitro) under organotypic culture conditions. These specimens comprised 35 benign cases (17 multinodular goiters and 18 adenomas) and 13 cancers. Cell proliferation in the control and treated conditions (at a 5 nM dose) was assessed by means of the thymidine labeling index, which enables the percentage of cells in the S phase of the cell cycle to be determined in accordance with autoradiographic procedures.

RESULTS

The results show that, of the six factors tested here, EGF significantly (P < 0.05 to P < 0.001) increased cell proliferation in the greatest number of cancers as compared to what happened with the remaining five. Each of these six factors significantly increased or decreased proliferative cell activity in some 10%-30% of the cases under study.

CONCLUSIONS

Triiodothyronine, thyroxine, LHRH and gastrin may increase or decrease cell proliferation in human thyroid tissues, whether benign or malignant, to the same extent as other hormones and/or growth factors such as thyrotropin, EGF, insulin-like growth factor 1, transforming growth factor beta1 and estradiol the effects of which on thyroid cell proliferation are already well documented in the literature.

[Limitations and perspectives of postoperative radiotherapy in bronchial cancer]

The role of postoperative irradiation for lung cancer remains a controversial issue. The available data suggest a reduction in local relapse in cases of positive mediastinal lymph node, but how this benefit translates into survival is not known. The current indications include tumors with positive mediastinal lymph node and incomplete resection with micro- or macroscopical residue. Nevertheless, postoperative irradiation requires a meticulous technique to avoid inducing life-threatening complications to vital organs such as the heart or the lung.

Respiratory mechanics and gas exchange during one-lung ventilation for thoracic surgery: the effects of end-inspiratory pause in stable COPD patients

OBJECTIVE

To examine the effects of end-inspiratory pause (EIP) of different durations on pulmonary mechanics and gas exchange during one-lung ventilation (OLV) for thoracic surgery.

DESIGN

A prospective clinical study.

SETTING

A university hospital.

PARTICIPANTS

Eleven patients undergoing elective pulmonary resection with pulmonary hyperinflation on their preoperative pulmonary function studies.

INTERVENTIONS

Patients were anesthetized, paralyzed, and intubated with a double-lumen endotracheal tube. Their lungs were ventilated with a Siemens 900C ventilator (Siemens; Solna, Sweden), with constant inspiratory flow. Tidal volume, respiratory rate, and inspiratory time were kept constant during the study.

MEASUREMENTS AND RESULTS

During one-lung ventilation in the lateral decubitus position, three levels of EIP (0%, 10%, and 30%) were applied to the dependent lung in random order. After 15 minutes on the given ventilatory pattern, end-inspiratory and end-expiratory occlusions of at least 5 seconds were performed to obtain respiratory mechanics data. Arterial blood gas samples were drawn to assess gas exchange. Altering the duration of end-inspiratory pause from 0% to 30% resulted in a significant increase in intrinsic positive end-expiratory pressure (PEEPi) from 4.1 cm H2O to 7.0 cm H2O. Arterial oxygenation was significantly decreased from 109.7 to 80.5 mmHg and there was a significant negative correlation between the value of partial pressure of arterial oxygen (PaO2) and PEEPi by altering the duration of end-inspiratory pause. From the preoperative pulmonary function studies, the value of functional residual capacity (FRC) (% predicted) showed a significant negative correlation with the PaO2 changes. Partial pressure of arterial carbon dioxide (PaCO2) was not altered significantly by increasing the duration of end-inspiratory pause.

CONCLUSION

During the period of OLV in the lateral position of patients with preexisting pulmonary hyperinflation, the magnitude of PEEPi increased and oxygenation decreased significantly, whereas the efficacy of ventilation was not changed by the addition of an end-inspiratory pause to the ventilatory pattern. Because arterial oxygenation is affected by the presence of pulmonary hyperinflation, the method of ventilation should take into account the magnitude of preoperative pulmonary hyperinflation.

Ectopic Cushing's syndrome and pulmonary carcinoid tumour identified by [111In-DTPA-D-Phe1]octreotide

The differential diagnosis and management of Cushing's syndrome remain difficult, particularly for ectopic adrenocorticotropin (ACTH) syndromes resulting from small bronchial carcinoids. We report the case of a 41-year-old man with ectopic ACTH-dependent Cushing's syndrome. Two computed tomography scans of the thorax were normal and magnetic resonance imaging of the chest showed a 6-mm hyperintense T1-weighted area close to the left pulmonary hilus, interpreted as probably vascular by the radiologists. An [111In-DTPA-D-Phe1]octreotide scintigraphy scan demonstrated a positive image for somatostatin receptors in exactly the same location and surgery confirmed the presence of a small ACTH-secreting carcinoid tumour in the upper left lung lobe which was resected. Surgery cured the hypercorticism of the patient. The differential diagnosis of Cushing's syndrome and the procedure for localisation of an ACTH source are discussed.

Diversity and prevalence of somatic mutations in the thyrotropin receptor and Gs alpha genes as a cause of toxic thyroid adenomas

A total of 33 different autonomous hot nodules from 31 patients, originating mainly from Belgium, were investigated for the presence of somatic mutations in the TSH receptor and Gs alpha genes. This constitutes an extension of our previous study, including the first 11 nodules of the series. The complete coding sequence of the TSH receptor gene and the segments of Gs alpha known to harbor mutations impairing guanosinetriphosphotase activity were studied by direct sequencing of genomic DNA extracted from the nodules. DNA from the juxtanodular tissue or peripheral white blood cells was analyzed in all patients to confirm that the mutations identified were somatic. Twenty-seven mutations (82%) were found in the TSH receptor gene, affecting a total of 12 different residues or locations. All these mutations but 2 (see below) have been identified previously as activating mutations. Only 2 mutations were found in Gs alpha (6%). In 4 nodules, no mutation was detected. Five residues (Ser281, Ile486, Ile568, Phe631, and Asp633) were found mutated in 3 or 4 different nodules, making them hot spots for activating mutations. Phe631 and Asp633 belong to a cluster of 5 consecutive residues (629-633) in the N-terminal half of transmembrane segment VI; which harbor together 44% of the mutations identified in this cohort. Two novel mutations were identified: a point mutation causing substitution of Phe for Leu at position 629 (L629F); and a deletion of 12 bases removing residues 658-661 at the C-terminal portion of exoloop 3 (del658-661). When tested by transfection in COS-7 cells, both mutant receptors display increase in constitutive stimulation of basal cAMP accumulation. Although it is still capable of binding TSH, the del658-661 mutant has completely lost the ability to respond to the stimulation by the hormone. Our results demonstrate that, in a cohort of patients from a moderately iodine deficient area, somatic mutations increasing the constitutive activity of the TSH receptor are the major cause of autonomous hot nodules.

Regulation and metabolic role of phospholipase D activity in human thyroid and cultured dog thyrocytes

The actions of TSH, ATP, the ionophore A23187, the endoplasmic reticulum Ca(2+)-ATPase inhibitor thapsigargin, and phorbol dibutyrate (PDBu) on 3H-cytidine-monophosphate phosphatidic acid (3H-CMP-PA) accumulation were studied in human thyroid slices to evaluate PA generation and inositol recycling towards phosphatidyl-inositol synthesis. The effects of the same agonists also were measured on phosphatidylbutanol (PtdBut) generation in 3H-palmitate or 3H-myristate prelabeled slices to assess the activity of phospholipase D (PLD). The phospholipid target of this PLD was determined on 3H-choline prelabeled human thyroid slices by measuring 3H-choline release in incubation medium and slices and 3H-choline incorporation in phospholipids. TSH (10 U/L) stimulated 3H-CMP-PA accumulation in an LiCl-and propranolol-insensitive way, as well as 2H-fatty acids incorporation into PA, diacylglycerol, and phosphatidylcholine (PtdCho) with on evidence of dose-dependent effects and had no detectable action on PLD activity. The effects of TSH were not reproduced by Bu2cAMP or forskolin. Thapsigargin and A23187 both increased CMP-PA accumulation and PtdBut generation, whereas ATP only stimulated PLD activity. The phorbol ester PDBu (5 x 10(-7) mol/L) increased PtdBut formation and 3-H-fatty acid incorporation into PtdCho, but had no effect on CMP-PA generation. Staurosporine (STSP) (5 x 10(-6) mol/L), a nonspecific inhibitor of protein kinase C, unexpectedly reproduced the effects of PDBu. The increase of 3H-choline in slices' supernatant and the decrease of 3H-choline-labeled PtdCho induced by PDBu, ATP, thapsigargin, and STSP indicate that the activated PLD hydrolyzed PtdCho. We suggest that the PA generation induced by PLD stimulation could contribute to the stimulated H2O2 formation and iodide organification observed with the agonists inducing PtdBut accumulation. Indeed, Bu2cAMP and forskolin, known to decrease iodide organification in human thyroid, inhibited the PLD stimulation induced by ATP and PDBu. In cultured dog thyrocytes, phorbol esters, and STSP induced DNA synthesis and dedifferentiation, whereas thapsigargin inhibited TSH-induced growth and killed phorbol esters stimulated cells, suggesting a positive role of PLD stimulation towards dedifferentiated growth and of simultaneously raised [Ca2+)i and stimulated protein kinase C-PLD towards growth arrest and cellular death.

CT-guided percutaneous drainage of an anterior mediastinal abscess with a 16 F catheter

We report a case of anterior mediastinal abscess treated by percutaneous drainage under computed tomography (CT) guidance. The relationships of the abscess to the adjacent organs were clearly delineated by an intravenous injection of contrast material, and the drain was inserted between the sternum and the vasa thoracica interna. Selection of this route and the choice of a large-bore catheter (16 F) are discussed.

CT-guided percutaneous drainage of an anterior mediastinal abscess with a 16 F catheter

We report a case of anterior mediastinal abscess treated by percutaneous drainage under computed tomography (CT) guidance. The relationships of the abscess to the adjacent organs were clearly delineated by an intravenous injection of contrast material, and the drain was inserted between the sternum and the vasa thoracica interna. Selection of this route and the choice of a large-bore catheter (16 F) are discussed.

Training in surgery: our constructive propositions

Several suggestions are presented in order to achieve or to maintain a level of excellence in surgical training, i.e. 1. Interuniversity theoretical teaching; 2. National evaluation; 3. Effective limitation of the number of residents; 4. Residents must be represented in critical organs; 5. A yearly evaluation of the quality of training. These requirements are fulfilled in the USA and Canada.

On-line expiratory flow-volume curves during thoracic surgery: occurrence of auto-PEEP

Flow-volume loops were monitored continuously in 39 patients undergoing thoracic surgery requiring one-lung ventilation. In 26 of the 39 patients (67%), auto-positive end-expiratory pressure (auto-PEEP) was seen on the flow-volume curves during both two-lung and one-lung ventilation. Eighty-seven percent of the patients whose trachea was intubated with a smaller size (35- and 37-French gauge) double-lumen tracheal tube exhibited auto-PEEP, compared with patients in whom the tube used was larger (39- or 41-French gauge: 54% and 50%, respectively). Before operation, mean airway resistance was significantly greater in patients who exhibited auto-PEEP during anaesthesia (2.4 cm H2O litre-1 s) than in patients without auto-PEEP (1.7 cm H2O litre-1 s).

Postoperative radiotherapy after pneumonectomy: impact of modern treatment facilities

PURPOSE

The present study was undertaken to see how modern treatment facilities, computed tomography (CT)-based treatment planning and linear accelerator, have modified the results of postoperative irradiation after a pneumonectomy for lung cancer.

METHODS AND MATERIALS

Between 1970-1985, 103 patients were treated in our department after a pneumonectomy: 50 patients with a T1T2N0 tumor and 53 patients with a T3, N1 or N2 tumor. Three groups were considered: 27 patients had only surgical resection, 51 patients were irradiated postoperatively with a Co60 source, and 25 patients were treated using those modern facilities.

RESULTS

The 5-year survival varies from 4% to 31% according to the tumor extent but also to the radiation technique. Patients treated with a Co60 source had a dismal 5-year survival rate (8%) whereas patients treated with the modern facilities had a 5-year survival rate of 30% similar to the 31% of the control surgical group including less advanced tumors.

CONCLUSION

Linear accelerator and computed tomography-based treatment planning improved the accuracy of postoperative thoracic irradiation and allow to deliver high doses to the mediastinum even after a pneumonectomy.

Ploidy level and proliferative activity measurements in a series of 407 thyroid tumors or other pathologic conditions

This study describes the ploidy level and proliferation rate in a series of 74 multinodular goiters (MNGs), 17 cases of Hashimoto's disease, 33 cases of Basedow's disease, 113 adenomas, 139 primary carcinomas, and 31 cervical lymph node metastases from 376 patients. Both ploidy level and proliferation rate were assessed by digital cell image analyses of Feulgen-stained nuclei from formalin-fixed, paraffin-embedded tissues. The ploidy level of each sample was assessed using both its DNA index and its DNA histogram type. The proliferation index assessments corresponded to the determination of the proportion of cells in the S-phase fraction. The data reveal that the proportion of aneuploid cases increases according to the following sequence: simple MNGs and normomacrovesicular adenomas-->MNGs with adenomatous hyperplasia and microvesicular adenomas and Hürthle cell adenomas-->papillary and Hürthle cell carcinomas-->follicular and medullary carcinomas-->anaplastic carcinomas. This suggests the preneoplastic nature of the microvesicular adenomas and even of MNGs with adenomatous hyperplasia. The ploidy levels of 99% of the 407 cases of the thyroid tumor series could be described using six DNA histogram types: diploid, hyperdiploid, triploid, hypertriploid, tetraploid, and polymorphic. It was possible to assess the proliferation rate of 279 samples. The results show that a significantly higher proportion of malignant compared with benign thyroid tumors (35.5% v 10.5%, respectively) exhibited a proliferation index higher than 5%, and that, whether benign or malignant, the hypertriploid thyroid tumors proliferated significantly less than the nonhypertriploid thyroid tumors.

Unlike thyrotropin, thyroid-stimulating antibodies do not activate phospholipase C in human thyroid slices

The effects of thyroid-stimulating antibodies (TSAb) and of thyrotropin (TSH) were compared, on the generation of cyclic AMP and inositol phosphates (InsP), in human thyroid slices incubated in vitro, and on the Rapoport cyclic AMP bioassay. The TSAb positive sera were obtained from 19 patients with Graves' disease. In 14 experiments with the slices system, TSH significantly increased cyclic AMP accumulation (TSH, 0.03-10 mU/ml) as well as the cyclic AMP-independent inositol trisphosphate (InsP3) generation (TSH, 1-10 mU/ml). In the same 14 experiments, TSAb (0.10-28 mg/ml) enhanced cyclic AMP intracellular levels as expected while they did not induce any InsP accumulation. Even when TSAb increased cyclic AMP levels to the same or higher values as those obtained with TSH concentrations allowing InsP3 generation. TSAb were still unable to activate the phosphatidylinositol-Ca2+ cascade. The patterns of the response curves of TSAb and TSH on cyclic AMP accumulation were different, suggesting that different mechanisms may be involved. In addition, unlike TSH, TSAb were not able to stimulate H2O2 generation, which in human tissue mainly depends on the activation of the phosphatidylinositol-Ca2+ cascade. Immunoglobulins from six additional Graves' patients lacking measurable cyclic AMP-stimulating activity in both slices and cells systems did not activate phospholipase C either. In conclusion, our results show that TSAb do not share all the metabolic actions of TSH on human thyroid tissue. The data provide support for the concept that the pathogenesis of Graves' disease can be fully accounted for by the ability of TSAb to stimulate adenylate cyclase. This work also confirms that TSH activates the cyclic AMP and the phosphatidylinositol cascade by independent pathways in the human thyroid.

[NMR evaluation of neoplastic invasion of the pulmonary artery]

Bronchial tumors that invade the mediastinum are not necessarily inoperable. Whether surgery is possible depends, among other things, on the extent of pulmonary artery invasion. The authors have studied the value of cardiac-gated MRI and compared it with CT and venous DSA for staging tumor invasion. CT demonstrated the areas of contact between tumor and mediastinum. The MRI planes were transverse and also in the main axis of the pulmonary arteries. Twenty-one patients were studied and in 16 the findings could be checked during surgery. In all cases the findings on MRI were confirmed. In eight patients MRI provided more information than CT and DSA combined and thereby showed its superiority for evaluating arterial invasion.

Resection of lung metastases from sarcomas

Between 1977 and 1987, 19 patients were candidates for resection of lung metastases from pretreated extrathoracic primary tumours. Primary tumours comprised 10 osteosarcomas, one Ewing sarcoma and eight soft tissue sarcomas. All 19 patients presented with metachronous metastases. Twenty-eight thoracotomies were performed in these 19 patients. Nine patients underwent multiple surgical explorations. All the metastases were removed by wedge resection. Seven out of 10 patients treated for osteosarcoma received pre- and postoperative chemotherapy, and three out of 10 postoperative chemotherapy only. The projected survival rate at 3 years is 33%. Seven out of 19 patients survived more than 2 years; four of them were free of disease at 33, 54, 56 and 137 months. Good prognosis appears to be long metastases-doubling time, metachronous metastases, small number of lung metastases, pathological evidence of tumour necrosis and/or fibrosis after chemotherapy and, of course, complete control of the primary tumour and no extrathoracic metastases.

[Neoplastic invasion of the pulmonary arteries. Evaluation by MRI. Preliminary experience]

Bronchial tumors invading the mediastinum are no longer systematically regarded as inoperable. Curative surgery has produced a significant survival rate and led to the adaptation of the TNM classification. The degree of invasion of the pulmonary artery is a criterion of operability. The authors are trying to assess the role of MRI with regard to CT and DSA for the measurement of invasion. Their study deals with the prospective assessment of ten patients. The MRI examinations have been carried out with a 0.5 and 1.5 T supraconductive magnet (Philips Gyroscan). Cardiac gating has been used for acquisition. The planes of section are axial, transverse or oblique along the greater axis of the pulmonary arteries. CT examinations in 9-mm thick sections with and IV contrast injection demonstrate the contact of the tumor with the mediastinum. The digital angiograms have been taken with an intravenous injection into a vein of the bend of the elbow or into a femoral vein. Six cases have been verified at surgery. In all cases, the invasion predicted with MRI proved to be correctly assessed. In three cases, MRI provides additional information to the combined findings of CT and DSA. MRI is a good complement for the preoperative assessment of patients with large tumors invading the mediastinum but for which curative surgery is indicated.

Phase II study of an intensive combination chemotherapy with cisplatin, adriamycin, etoposide and cyclophosphamide (CAVE) in small cell lung cancer

One hundred and twelve patients with small cell lung cancer (SCLC) were treated with a combination (CAVE) of cisplatin (60 mg/m2 day 1), adriamycin (45 mg/m2 day 1), etoposide (80 mg/m2 days 1-2-3) and cyclophosphamide (1 g/m2 day 1) given every 4 weeks. A total of 10 courses were given. Response evaluation was initially evaluated after the first two courses of CAVE and repeated at least after treatment completion. This regimen was associated with severe hematological toxicity, mainly leucopenia; five toxic deaths related to sepsis were observed. One hundred and one patients were evaluable for response: 63 with limited disease and 49 with extensive disease. Overall complete and partial response rates after the first two courses of chemotherapy were 16% and 63% respectively but 14 late complete responses were documented, leading to a 30% total complete response rate; 38% in patients with limited disease and 19% in those with disseminated disease. Median overall survival was 46 weeks with a 17% 2 year survival. The only significant prognostic factor for survival was the type of response. There was no survival difference between 'early' and 'late' complete responders. Complete responders had a 75 week median survival time with a 34% 2 year survival. CAVE is thus an effective regimen for SCLC, but with a considerable toxicity.

Pathogenesis of autonomous thyroid nodules: in vitro study of iodine and adenosine 3',5'-monophosphate metabolism

The in vitro characteristics of iodide and cAMP metabolism have been compared in tissues from autonomously functioning thyroid nodules and their quiescent counterpart to test the hypothesis that autonomy may result from constitutive activation of the tissue's TSH, cAMP, and protein phosphorylation regulatory axis, as in vivo nodular tissue took up more iodide. This effect was entirely due to increased transport capacity, the affinity of iodide transport, and the fractional binding of iodide to protein remaining unchanged. However, at high concentrations total iodide binding to protein was similar in quiescent and nodular tissue. In both tissues, this metabolic step was enhanced by phorbol esters and the ionophore A23187. As evaluated by autoradiography of two-dimensional gel protein electrophoregrams, no differences in the patterns of protein synthesis or phosphorylation between quiescent and nodular tissue were found. Basal cAMP levels were similar in quiescent and nodular tissue. The cAMP response to TSH was lower in nodular tissue, with no change in sensitivity or kinetics; both tissues responded to forskolin. No systematic suppression of iodide inhibition or abnormal responses to other hormones or neurotransmitters were found. Three proteins (24K-1, 24K-2, and 26K) were phosphorylated only in the presence of TSH or forskolin in both quiescent and nodular tissue. One protein substrate (20K) was phosphorylated in the presence of TSH in the quiescent, but not in the nodular, tissue. In conclusion, 1) slices from autonomous thyroid nodules reproduce the in vivo characteristics of the lesion and are, therefore, a suitable in vitro experimental model for biochemical studies; 2) taken together with data from transplantation experiments, the reproduction in vitro or its in vivo characteristics suggest an inherent defect in the nodule; 3) the homogeneity of biochemical findings within each nodule is compatible with the clonality of the lesion; 4) the autonomous nodule is a minimal deviation tumor; and 5) the characteristics of the TSH, cAMP, protein phosphorylation cascade are qualitatively normal, and autonomy does not result from constitutive activation of this system; and 6) a 20K protein, not phosphorylated in response to TSH in the nodule, could represent an absent negative controlling element.

Increased plasma motilin concentrations in small cell carcinoma of the lung

Plasma samples from 21 patients with small cell carcinoma of the lung were screened for pancreatic polypeptide, somatostatin, motilin, and vasoactive intestinal polypeptide. One patient had severe impairment of both renal and liver function. In the 20 remaining subjects vasoactive intestinal polypeptide concentrations were normal, and only two patients had increased concentrations of somatostatin. Increases in pancreatic polypeptide were detected more commonly (7/20), but these may have been non-specific age related increases. The major finding was high concentrations of motilin (greater than 496 pg/ml) in 17 of 20 patients. Plasma motilin was subsequently assayed in 16 more patients with lung cancer, including 10 patients with non-small cell carcinoma of the lung. At concentrations over 900 pg/ml plasma motilin appears to be a tumour marker for small cell carcinoma of the lung with acceptable sensitivity (59%) and specificity (78%). The origin of increased plasma motilin in small cell carcinoma of the lung was investigated. Bombesin (gastrin releasing peptide), a peptide known to stimulate the release of motilin in man, was, as in previous studies, detected in tumour but not in plasma, except in one patient out of 21. Immunohistochemical studies failed to detect motilin antigen in biopsy samples. Motilin tumour content was found to be low in tumour tissue from three patients with small cell carcinoma of the lung who had appreciable hypermotilinaemia and from three patients with non-small cell carcinoma of the lung who had either normal or slightly raised plasma motilin concentrations. The stimulus to motilin secretion in patients with small cell carcinoma of the lung remains unclear.

Subrenal capsule assay for fresh human tumors in immunocompetent mice; an inappropriate technique for non-small cell lung cancer

The subrenal capsule assay (SRA) seems to present some difficulties for the evaluation of the chemosensitivity of antineoplastic agents against fresh tumor xenografts. A study was therefore carried out to verify whether two different xenografts would behave in a similar way. Tumors such as melanoma provided adequate homogeneous material for this technique, while non-small cell lung carcinoma (NSCLC) were heterogeneous since the 1 mm3 specimen grafted under the renal capsule usually contained diffuse areas of necrosis and of infection. Furthermore, a large proportion of the grafted specimens, 257 out of 298, did not contain any tumor at all on microscopic examination even when they showed macroscopic growth. Added to these discrepancies, a random microscopic analysis of 180 adjacent fragments of NSCLC and melanomas demonstrated that the variability of heterogeneous tumors precludes any meaningful comparison between homologous tumor tissues designed to be grafted on treated and on control mice. The anti-inflammatory effect of chemotherapeutic drugs on the host's reaction to the graft is probably responsible for the differences between the macroscopic growth results observed in pieces grafted to both treated and control mice: however, it could not be simulated by hydrocortisone (HC) under our experimental conditions. This allows us to conclude that fresh tumors from NSCLC cannot be used in SRA.

A randomized study comparing a high and a standard dose of cisplatin in combination with etoposide in the treatment of advanced non-small-cell lung carcinoma

We conducted a randomized trial comparing a high (120 mg/m2 day 1) v a standard (60 mg/m2 day 1) dose of cisplatin in combination with etoposide (120 mg/m2 days 3, 5, and 7) in advanced non-small-cell lung carcinoma (NSCLC). Two hundred forty-one patients were evaluable for survival and 207 for response. We obtained a 25% objective response rate in the standard-dose arm and 29% in the high-dose arm; this difference was not statistically significant. There was no significant improvement in the overall survival or survival of responders with the high-dose regimen. However, toxicity (mainly myelosuppression) was significantly increased in the patients receiving the higher dose of cisplatin. An analysis of prognostic factors showed that disease progression, loss of body weight, performance status, and prior therapy were predictive parameters of survival.