Sustained antitumor response to lenvatinib with weekend-off and alternate-day administration in chemotherapy-refractory thymic carcinoma: a case report

Lenvatinib is a multitargeted kinase inhibitor and maintaining its dose intensity has been shown to be beneficial in patients with thyroid and hepatocellular carcinomas. However, most patients require lenvatinib interruption and dose reduction due to the high incidence of adverse events (AEs). Lenvatinib was recently approved in Japan for patients with unresectable thymic carcinoma; however, real-world evidence of its clinical benefit is limited. Here, we report the case of chemotherapy-refractory thymic carcinoma in a patient who was administered a starting dose of lenvatinib using a 5-day on/2-day off (weekend-off) protocol, followed by alternate-day administration after fatigue onset derived from overt or subclinical hypothyroidism. Consequently, the patient exhibited a durable response to lenvatinib, with a 17-month progression-free survival without any severe or intolerable AEs. The present case suggests that maintaining lenvatinib dose intensity using such alternative administration regimens contributes to favorable clinical outcomes in thymic carcinoma.

Microsatellite instability detected in tumor-related genes in C57BL/6J mice with thymic lymphoma induced by N-methyl-N-nitrosourea

Microsatellite instability (MSI) has been observed within tumors and found to be closely associated with the degree of malignancy and prognosis in tumors. However, whether MSI in tumor-related genes can be induced by a chemical and whether a connection exists between MSI and tumors remain unclear. In the present study, we detected MSI in the tissues of N-methyl-N-nitrosourea (MNU) treated mice by targeting to 5, 29, 30 microsatellite loci in 3 mismatch repair (MMR) genes, 1 DNA repair gene, and 5 tumor suppressor (TS) genes, respectively. Among 26 mice survived in the MNU-group, 18 (69%) mice presented thymic lymphomas. Moreover, 61% (11/18) of the tumors metastasized to the other organs, including the liver, spleen, and kidney. We examined 104 tissues from MNU-treated mice using the 64 loci, and found 8 MSI events involved 4 loci in 4 tissues types. The MSI incidence in MMR, DNA repair, and TS genes was 67% (2/3), 0% (0/1) and 40% (2/5), respectively. MSI occurrence in tumor and non-tumor tissues was 5.6% (1/18) and 0% (0/8) and that in metastasis and non-metastasis tissues was 7.1% (1/14) and 9.4% (6/64), showing no significant difference. MSI loci in intronic regions of Atm, Msh6 and p21 and MSI in the 3'UTR of Pms2 were detected in MNU-treated mice. Specifically, we found a loss of heterozygosity in intron of Atm (ATM-8) in one metastasis mouse. Four similar events occurred in p21 gene intron (P21-1) of another non-metastasis mouse. Another MSI was a heterozygous mutation existed in an Msh6 allele (MSH6-2) in metastasis mouse. We also found a homozygous 2-bp insertion in the 3'UTR of Pms2 in two non-metastasis mice. These results imply that MNU can induce MSI in MMR and TS genes in C57BL/6J mice. MSI frequency does not seem to be associated with tumorigenesis or metastasis.

The susceptibility of inbred mice to the production of malignant thymoma by N-methyl-N-nitrosourea

The susceptibility of inbred mice to the induction of malignant thymoma by N-methyl-N-nitrosourea (MNU) has been quantified and compared. Strain differences emerged and this was also apparent in congenic lines of C57BL/10 mice, differing at the H-2 locus. However, different strains of inbred mice, with identical H-2 haplotypes, also showed varying susceptibility to MNU, indicating that the role of the MHC was not a simple one, but apparently depended on other, undefined genes. Proficiency of repair of O6-methylguanine by thymic tissue was not responsible for these strain differences and the increased resistance to induction of thymoma by MNU in older mice was due to age-dependent changes within the thymus gland. Interestingly, the thymus of older mice, grafted with neonatal thymic tissue, still provided a suitable environment for the development of thymic tumours.

Malignant thymoma in a patient with growth hormone deficiency during growth hormone therapy

Malignant thymoma was found in an 8-year-old Japanese boy with growth hormone (GH) deficiency who had received GH therapy for 3 years and 5 months. There may be a possible relationship between the occurrence of malignant thymoma and GH therapy.

Chemical induction of thymomas in AKR mice: interaction of chemical carcinogens and endogenous murine leukemia viruses. Comparison of N-methyl-N-nitrosourea and methyl methanesulphonate

The time course of development of thymic lymphoma, which occurs spontaneously in mice of the AKR strain, is accelerated by the methylating agents N-methyl-N-nitrosourea (MNU) and methyl methanesulphonate (MMS). Since MNU is a potent mutagen inducing G----A transition mutations and MMS a relatively weak mutagen, it was of interest to examine the genetic alterations associated with each class of the chemically induced tumors and to compare these alterations with those found in the spontaneous tumors. The same spectrum of genetic alterations was found for MMS-induced and spontaneous thymomas. Both showed rearrangements of c-myc and Pim-1 genes that appeared to result from integration of recombinant mink cytopathic focus-forming (MCF) proviruses but failed to reveal evidence for activation of ras oncogenes, either by DNA transfection experiments or by hybridization of DNA to specific oligonucleotide probes. Some alteration in c-myc and Pim-1 genes were also found in MNU-induced tumors, but, mainly, these involved integration of ecotropic-like rather than recombinant MCF viruses. Furthermore, MNU-induced tumors frequently (in 24% of thymomas) contained G----A transition mutations, activating the Ki-ras oncogene at codon 12 position 2. Another feature that distinguishes the MNU-induced tumors from those occurring in untreated and MMS-treated mice was the consistently high level of c-myc mRNA that occurred in the absence of c-myc gene rearrangement. Taken together, the data indicate that the mechanisms of development of tumors following treatment with MNU and MMS are distinct, and that the effect of MMS is probably to speed up the process of viral leukemogenesis.

Induction of thymic lymphomas and squamous cell carcinomas following topic application of isopropyl methanesulfonate to female Hsd:(ICR)BR mice

The goal of these experiments in female Hsd:(ICR)Br mice was to determine whether the direct-acting SN1 alkylating carcinogen isopropyl methanesulfonate (IMS) is carcinogenic and to compare its effects with those of the direct-acting SN2 methyl homologue, methyl methanesulfonate (MMS). The compounds were administered by topical application and s.c. injection. Analysis at the 288th day of mice receiving s.c. injections of IMS and MMS was the subject of a previous report (A. Segal et al., Proc. Soc. Exp. Biol. Med., 183: 132-135, 1986). The s.c. and topical application experiments were terminated at the 450th day and the final results are reported in this paper. In mice treated by s.c. injection with IMS, thymic lymphomas were observed in at least 20 of 32 mice, the first at the 40th day, and neoplasms were not observed at the injection site. Of the 30 MMS-treated mice, 11 developed sarcomas at the injection site and one thymic lymphoma was observed. In mice treated topically with IMS, thymic lymphomas were observed in 20 of 30 treated mice, the first at the 102nd day, and squamous cell carcinomas at the injection site were observed in 9 mice. Neither squamous cell carcinomas nor thymic lymphomas were observed in 30 mice following topical application of MMS. The direct-acting SN2 aklylating carcinogen beta-propiolactone was also administered by topical application. At the 450th day, at the same dose used for MMS (40 mumol/application), papillomas of the skin were observed in 25 of 30 treated mice, squamous cell carcinomas of the skin were seen in 17 mice, and one thymic lymphoma was observed. The results suggest that the rapid induction of thymomas by IMS may be related to its ability to alkylate exocyclic oxygen atoms in DNA of hemopoietic cells and also to a sensitivity of these cells to such lesions.

Induction of thymomas by N-methyl-N-nitrosourea in AKR mice: interaction between the chemical carcinogen and endogenous murine leukaemia viruses

AKR mice develop thymomas spontaneously when greater than 6 months old but when young AKR mice are treated with N-methyl-N-nitrosourea (MNU) they develop thymomas at 3-6 months of age. In this study the potential role of oncogene activation in the development of both the spontaneous and MNU-induced thymomas in AKR mice has been examined by DNA transfection into NIH3T3 mouse fibroblasts and by Southern analysis of tumour DNA. The results show that a high proportion of MNU-induced thymomas contain activated cellular rasK while no activated cellular ras genes were detected in spontaneous thymomas. Southern analysis of tumour DNA revealed that 2/30 spontaneous tumours and 2/52 MNU-induced tumours contained alterations in the c-myc gene while 5/29 spontaneous tumours and 6/56 MNU-induced tumours contained alterations in the Pim-1 gene. A more detailed analysis of the Pim-1 gene demonstrated that the alterations observed in most MNU-induced and spontaneous tumours resulted from proviral integration at the 3' end of this gene. Our analyses also demonstrated that the majority of MNU-induced tumours, including those containing rearrangements in the Pim-1 gene, lacked the somatically acquired recombinant MCF proviruses that are present in most spontaneous AKR lymphomas. These results provide evidence that the mechanisms of development of MNU-induced and spontaneous tumours in AKR mice are distinct and the development of thymomas that contain proviral integrations at the Pim-1 locus in the MNU-treated AKR mice involve cooperation between the chemical carcinogen and endogenous murine leukaemia viruses.

Thymoma associated with rheumatoid arthritis in a patient taking methotrexate

Recently many patients with rheumatoid arthritis (RA) have been effectively treated with methotrexate. Until now, there have been no treatment related neoplasms reported in patients with RA taking methotrexate. Furthermore, there have been no reports of thymoma associated with isolated RA. We describe a patient with classical RA who developed a thymoma while being treated with methotrexate.

Comparison of chemically induced and spontaneous murine thymic lymphomas in RF and AKR mice: differential expression of c-myc and c-myb

Expression of 11 cellular oncogenes was determined in normal vs. lymphomatous thymic tissues of RF and AKR mice; only c-myc and c-myb transcripts were detected in an age-inappropriate pattern in thymomas. Normal thymocytes from young RF mice contained RNA transcripts of both genes, but the transcripts were no longer detected at 9 or more weeks of age. More than 90% of RF thymomas, occurring at 20-28 weeks of age after skin painting with 3-methylcholanthrene at 12 weeks, contained c-myc transcripts, and 70% of the tumors contained c-myb transcripts. Seven cell lines derived from these 3-methylcholanthrene thymomas expressed both cellular genes, as did 2 rare spontaneous thymomas of 12-month-old RF mice. No indication of rearrangement or amplification of either gene was seen in any of the RF tumors or cell lines. In AKR mice, transcripts of the 2 genes persisted longer in the normal thymus than in RF mice, but they were no longer detected at 26 weeks of age. Of 3 thymomas in 6-month-old 3-methylcholanthrene-treated AKR mice, all expressed c-myb and 2 expressed c-myc. Among 11 spontaneous AKR thymomas, however, only 2 showed detectable levels of both genes, and 2 more expressed c-myc or c-myb but not both.

Pathology of chronic polychlorinated biphenyl (PCB) feeding in rats

The hepatocarcinogenic effect of Clophen A 30 and Clophen A 60 was tested in male weanling rats by long-term feeding over a period of 832 days. The mortality rate was investigated in 100-day intervals. In the first 800 days liver carcinoma accounted for 21% of necropsies in the Clophen A 60 group but only 2% of the necropsies in the Clophen A 30 group and none in the control animals. The tumors were first observed after 700 days. After 800 days hepatocellular carcinoma was the most common lesion observed in the Clophen A 60 animals (61%) whereas it was only observed in 3% of animals in the Clophen A 30 group and 2% in the controls. Preneoplastic lesions, such as foci of hepatocellular alterations and neoplastic nodules, were first observed after Day 500. The incidence of foci predominated in all time intervals, but an increase in neoplastic nodules and hepatocellular carcinomas was observed with increased time. There was a marked trend from foci to neoplastic nodule to hepatocellular carcinoma with time. The total mortality rate and the incidence of thymoma, inflammatory lesions of the urogenital tract, in the experiment were significantly reduced by Clophen administration. Whether this protective effect could be induced by polychlorinated biphenyls (PCBs) is discussed.

Autoimmune haemolytic disease in mice after exposure to a methylating carcinogen

N-Methyl-N-nitrosourea (MNU) but not methyl methanesulphonate (MMS) induced both autoimmune haemolytic anaemia and thymic lymphoma in susceptible strains of mice, particularly the C57BL/6. These effects could be positively correlated with the formation of O6-methylguanine in target DNA. All murine lymphoid cells showed lack of ability to remove O6-methylguanine from their DNA, therefore the variation of responses between different mouse strains indicated that other host factors, probably genetic, must be involved. The results do indicate however that a potent pre-mutagenic DNA base modification can initiate the events leading to autoimmune disease in susceptible mice.

Carcinogenesis by derivatives of 1-nitroso-3,5-dimethylpiperazine in rats

Four mononitrosopiperazines were administered to groups of 20 female Fischer 344 rats to compare their effectiveness as carcinogens. The four, 1-nitroso-3,5-dimethylpiperazine, its 4-acetyl derivative, its 4-benzoyl derivative, and 1-nitroso-3,4,5-trimethylpiperazine, were given as 0.7 mM solutions in drinking water, 100 ml to each rat per week. The length of treatment varied from 26 weeks for nitrosotrimethylpiperazine to 50 weeks for 1-nitroso-3,5-dimethyl-4-benzoylpiperazine. Dimethyl- and trimethylnitrosopiperazine gave rise to virtually 100% incidence of undifferentiated lymphomas of the thymus and leukemias within 30 weeks (in contrast to the non-C-methylated analogs which are noncarcinogenic or only weakly so). Acetyldimethylnitrosopiperazine was also a potent carcinogen, all of the rats treated with it dying within 30 weeks with tumors of the esophagus. In contrast, benzoyldimethylnitrosopiperazine was weakly carcinogenic, inducing only a small number of tumors of the forestomach and reducing the normal life span of the rats very little.

Methylnitrosourea induction of thymomas in AKR mice requires one or two "hits" only

Induction of thymomas by methylnitrosourea in many strains of mice requires 3 "hits". AKR mice develop thymomas spontaneously late in life, probably because of their large load of viral leukemia oncogenes. It was expected therefore, and so found, that methylnitrosourea induces thymomas in AKR mice with only 1 or 2 "hits". The viral oncogene therefore appears to function as a dominant "hit" gene cooperating with the chemical carcinogen.

Thymomas induced by simple alkylating agents in C57BL/Cbi mice: kinetics of the dose response

Specific-pathogen-free inbred C57BL/Cbi mice (adult virgin females) were given single sublethal doses of N-methyl-N-nitrosourea or N-ethyl-N-nitrosourea and were studied for a lifetime for the development of thymomas. A fatal lymphocytic lymphoma with a "starry sky" pattern due to the presence of macrophages was induced in the thymuses of treated mice within 250 days of treatment. Control and low-dose treatment groups had up to 70% incidence of a histiocytic lymphoma that was usually primary in mesenteric lymph nodes and nearly always occurred later than 250 days after treatment. A "one-hit" linear relationship existed between the time of appearance of induced thymic lymphomas and the log fraction of non-tumor-bearing mice. The absolute latency period of these tumors was constant and independent of dose. The effect of dose was an exponential increase of the total incidence of induced thymic lymphomas. By mathematical analysis, the best estimate of the exponent from the results was 2 or 3, indicating that the development of these induced tumors may be produced by 2 or 3 "events" in the target cell. Possible candidates for these events are premutagenic alkylation of DNA, inactivation of DNA repair, oncovirus activation, regenerative hyperplasia, development of trisomy No 15, and inhibited immunosurveillance.

Induction of duodenal-tumors and thymomas in Fischer rats by continuous oral administration of 1-propyl-1-nitrosourea

Male and female F344/DuCrj rats were given 400 ppm solution of 1-propyl-1-nitrosourea continuously in their drinking water. The incidence of digestive tract tumors was as high as 32/36 (89%) and 33/39 (85%) in male and female rats, respectively. Among these, duodenal tumors were induced most frequently, and most of them were adenocarcinoma followed by adenomas and hemangiogenic tumors. Thymomas were found in 27 (75%) males and 14 (36%) females. The lymphocytic type thymoma was the most frequent, and epithelial or mixed types were found only in 8 females. Other tumors induced were mainly in the ear ducts and lung, and the incidence was less than 13%.

Ultrastructure of spontaneous and urethan-induced thymomas in buffalo rats

Normal thymuses from Buffalo and Long-Evans rats of various ages, and spontaneous and urethan-induced thymomas in Buffalo rats, were examined by electron microscopy. Histological variabilities among thymomas of the lymphoid, mixed, and epithelial cell types were a reflection of the number of lymphoid cells within the network composed of neoplastic epithelial reticular cells. In the cytoplasm of these cells, development of tonofilaments and membrane-bound bodies and inverse development of the rough-surfaced endoplasmic reticulum were recognized in the sequential process from the lymphoid cell type to the epithelial cell type. An important role of the development of the rough-surfaced endoplasmic reticulum for thymic function was suggested. Phagocytic activity of the neoplastic epithelial reticular cells was revealed, and some of the membrane-bound bodies in these cells, especially those with moniliform structures, were regarded as remnants of damaged lymphocytes. Evidence for neoplastic epithelial reticular cell-lymphoid cell transformation could not be established from study of the thymoma tissue. No virus-like structures were observed in these thymomas.

Chromosome damage in the bone marrow of mice treated with the methylating agents methyl methanesulphonate and N-methyl-N-nitrosourea in the presence or absence of caffeine, and its relationship with thymoma induction

A single dose (0.8 mmole/kg) of N-methyl-N-nitrosourea (MNUA) causes significantly more chromosome damage in the bone marrow of mice than a dose of equal toxicity to the animals, (1.1 mmole/kg) of methyl methanesulphonate (MMS) 6, 24 and 48 h after treatment. At these doses both agents alkylate bone-marrow DNA to similar extents, but only MNUA induces thymic lymphomata. The greater chromosome-damaging effects of MNUA are ascribed to the known differences in the pattern of DNA alkylation by each agent, in particular the much higher levels of O-6 methylguanine and phosphotriesters produced by MNUA. The greater chromosome-damaging effect of MNUA may account for its higher toxicity to the bone marrow which in turn may be a significant factor in the induction of thymomata. The enhancement by caffeine of chromosome damage seen particularly 48 h after MMS-treatment suggests that post-replication repair protects cells from the effects of DNA-methylation in vivo.

Studies on thymus products. 3. Epithelial origin of the serum thymic factor

Serum thymic factor (TF) has been tested by its action on spleen rosette-forming cells from adult thymectomized mice. It has been confirmed in a blind study using coded serum samples that TF disappeared early after adult thymectomy and reappeared after grafting a thymus, either as a free graft or enclosed in cell impermeable diffusion chambers. Similar reconstitution was also obtained by grafting a non-lymphoid epithelial thymoma or pure epithelial thymus, obtained by in vivo incubation of a thymus within a diffusion chamber in an intermediate host. Conversely, TF levels were not restored in thymectomized animals treated with dispersed spleen cells or with dispersed thymic lymphocytes.

Azathioprine (Imuran) administration and the development of malignant lymphomas in NZB mice

Azathioprine in doses that made NZB mice more anaemic did not cause reversal of their positive Coombs tests. When given to young NZB mice it did not delay development of the Coombs positive state.

Azathioprine had a carcinogenic effect. Six out of eight NZB mice treated from the age of 2 months developed malignant lymphomas particularly involving the thymus.

Caution is suggested in the use of immunosuppressant agents in non-malignant conditions, especially in the young, until the risk of carcinogenesis has been evaluated.