Validation of a Pathological Score for the Assessment of Bronchial Biopsies in Severe Uncontrolled Asthma: Beyond Blood Eosinophils.

BACKGROUND: Blood eosinophil count (BEC) is currently used as a surrogate marker of T2 inflammation in severe asthma but its relationship with tissue T2-related changes is elusive. Bronchial biopsy could add reliable information but lacks standardization. OBJECTIVES: To validate a systematic assessment of the bronchial biopsy for the evaluation of severe uncontrolled asthma (SUA) by standardizing a pathological score. METHODS: A systematic assessment of submucosal inflammation, tissue eosinophilic count/field (TEC), goblet cells hyperplasia, epithelial changes, basement membrane thickening, prominent airway smooth muscle and submucosal mucous glands was initially agreed and validated in representative bronchial biopsies of 12 patients with SUA by 8 independent pathologists. In a second phase, 62 patients with SUA who were divided according to BEC≥300cells/mm3 or less underwent bronchoscopy with bronchial biopsies and the correlations between the pathological findings and the clinical characteristics were investigated. RESULTS: The score yielded good agreement among pathologists regarding submucosal eosinophilia, TEC, goblet cells hyperplasia and mucosal glands (ICC=0.85, 0.81, 0.85 and 0.87 respectively). There was a statistically significant correlation between BEC and TEC (r=0.393, p=0.005) that disappeared after correction by oral corticosteroids (OCS) use (r=0.170, p=0.307). However, there was statistically significant correlation between FeNO and TEC (r=0.481, p=0.006) that was maintained after correction to OCS use (r=0.419, p=0.021). 82.4% of low-BEC had submucosal eosinophilia, 50% of them moderate to severe. CONCLUSION: A standardized assessment of endobronchial biopsy is feasible and could be useful for a better phenotyping of SUA especially in those receiving OCS.

Assessment of a New ROS1 Immunohistochemistry Clone (SP384) for the Identification of ROS1 Rearrangements in Patients with Non-Small Cell Lung Carcinoma: the ROSING Study.

INTRODUCTION: The ROS1 gene rearrangement has become an important biomarker in NSCLC. The College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology testing guidelines support the use of ROS1 immunohistochemistry (IHC) as a screening test, followed by confirmation with fluorescence in situ hybridization (FISH) or a molecular test in all positive results. We have evaluated a novel anti-ROS1 IHC antibody (SP384) in a large multicenter series to obtain real-world data. METHODS: A total of 43 ROS1 FISH-positive and 193 ROS1 FISH-negative NSCLC samples were studied. All specimens were screened by using two antibodies (clone D4D6 from Cell Signaling Technology and clone SP384 from Ventana Medical Systems), and the different interpretation criteria were compared with break-apart FISH (Vysis). FISH-positive samples were also analyzed with next-generation sequencing (Oncomine Dx Target Test Panel, Thermo Fisher Scientific). RESULTS: An H-score of 150 or higher or the presence of at least 70% of tumor cells with an intensity of staining of 2+ or higher by the SP384 clone was the optimal cutoff value (both with 93% sensitivity and 100% specificity). The D4D6 clone showed similar results, with an H-score of at least 100 (91% sensitivity and 100% specificity). ROS1 expression in normal lung was more frequent with use of the SP384 clone (p < 0.0001). The ezrin gene (EZR)-ROS1 variant was associated with membranous staining and an isolated green signal FISH pattern (p = 0.001 and p = 0.017, respectively). CONCLUSIONS: The new SP384 ROS1 IHC clone showed excellent sensitivity without compromising specificity, so it is another excellent analytical option for the proposed testing algorithm.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: Report of two cases.

INTRODUCTION: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare disorder characterized by a proliferation of neuroendocrine cells within the lung. It is classically described as a disease with persistent cough, dyspnea and wheezing in non-smoker middle aged females. CT of the chest reveals diffuse air trapping with mosaic pattern. PATIENTS AND METHODS: We present two cases of DIPNECH that were sent to our department to perform a lung biopsy with the diagnostic suspicion of diffuse interstitial disease. Both cases were women with a history of chronic cough and moderate effort dyspnea. RESULTS AND DISCUSSION: The aim of this paper is that physicians take into account this diagnostic entity before treating as an asthmatic a patient with these characteristics, not forgetting that they are prenoplastic lesions.

Fluorescence in situ hybridization analysis of the ALK gene in 2,045 non-small cell lung cancer patients from North-Western Spain (Galicia).

Identification of anaplastic lymphoma receptor tyrosine kinase (ALK) gene rearrangements is a standard diagnostic test in patients with advanced non-small cell lung cancer (NSCLC). The current study describes the experience of ALK rearrangement detection of a referral center in the public health care system of Galicia in North-Western Spain. The fluorescence in situ hybridization (FISH) patterns of the ALK gene and the clinical and pathological features of these patients are reported. This study is also of interest for comparative purposes due to the relative geographical isolation of the area, which could have contributed to particular genetic features. A total of 2,045 tissue samples from NSCLC patients were collected between October 2010 and July 2015 and tested for ALK rearrangements by FISH. Examination of 1,686 paraffin-embedded tissue specimens and 395 cytological samples (306 cell block preparations and 53 cytological smears) was conducted, and any associations between the FISH results and clinicopathological features were assessed. The rate of successful evaluation was marginally higher in tissue samples than in cytological samples (92.9% vs. 84.1%); this difference was not significant. ALK rearrangements were identified in 82 patients(4%): 65 (79.3%) in tissue specimens, 15 (18.3%) in cell block samples and 2 (2.4%) in cytological smears. This genetic translocation appeared to be associated with a non-smoking history, younger age, female gender, stage IV and adenocarcinoma histological type. The findings demonstrate that ALK evaluation by FISH is feasible in tissue and cytological samples. The clinical and pathological features of the ALK-positive series of patients are similar to those previously reported in the literature.

Pretreatment levels of the serum biomarkers CEA, CYFRA 21-1, SCC and the soluble EGFR and its ligands EGF, TGF-alpha, HB-EGF in the prediction of outcome in erlotinib treated non-small-cell lung cancer patients.

The aim of this study has been to investigate the potential of serum biomarkers used in clinical practice (CEA, CYFRA 21-1, SCC) together with the serum epidermal growth factor receptor (EGFR) and its associated ligands (EGF, TGF-α, HB-EGF) as outcome predictors of non-small cell lung cancer (NSCLC) patients treated with the TKI erlotinib. The pretreatment levels of these markers were evaluated through immunoassays carried out in 58 patients. The progression-free survival (PFS) and overall survival (OS) were assessed by the Kaplan-Meier method and differences between groups were compared by means of the Log-Rank test. Association of risk factors with survival was evaluated using the univariate and multivariate Cox modelling procedures. Higher CEA (>5 ng/mL) and sEGFR (>56.87 ng/mL) concentrations associated significantly with a higher overall survival. The pre-treatment sEGFR serum levels constituted an independent prognostic factor. The EGFR gene mutational status and the sEGFR level combination was the single to associate significantly with longer progression-free survival periods, in circumstances in which the EGFR gene was mutated and increased protein serum levels were detected. The overall survival as assessed through a Cox analysis revealed similar death hazards with respect to low sEGFR levels combined both with non-mutated EGFR genotypes and low CEA serum levels. Our results suggest that the pre-treatment CEA and sEGFR serum levels may provide a comparable source of information to that supplied by the EGFR gene mutational status with respect to the prognosis of erlotinib treated NSCLC patients. A combined sEGFR and CEA level appraisal could be of considerable value to select patients to undergo EGFR-TKI treatments.

Changes in clinical presentation and staging of lung cancer over two decades.

INTRODUCTION: Important clinical and epidemiological changes have been observed in lung cancer (LC) in our healthcare area compared to the previous decade. In the last 10 years, specific LC care circuits have been implemented and the active search for cases has been stepped up. The aim of this study was to analyze the progress of these changes over the last 20 years. METHODS: This is a retrospective study comparing clinical and epidemiological changes between 2 historical cohorts of LC patients (1992-1994 [group 1, 164 patients] and 2004-2006 [group 2, 250 patients]) and a current group from the period 2011-2012 (group 3, 209 patients) RESULTS: Two hundred and nine (209) LC patients were included in group 3 (2011-2012 period). After comparing groups 3 and 2, a non-significant rise in smoking was observed in women (59% vs 41%, p=.25), while the prevalence of adenocarcinoma was unchanged (45% vs 44%, p=.9). The main changes observed were the increase in cases with previous malignancies (23% vs 16%, p=.04), the rise in patients with no associated LC symptoms (33% vs 16%, p<.001), and an increased number of localized NSCLC (non-small cell LC) diagnoses (42% vs 24% in series 2, p<.001 and 14.2% in series 1, p<.001). CONCLUSIONS: The number of LC patients diagnosed in localized stages has increased significantly. Furthermore, the number of patients with no symptoms associated with LC and with a history of previous malignancy were significantly increased.

Viability of lymph node samples obtained by echobronchoscopy in the study of epigenetic alterations in patients with lung cancer.

INTRODUCTION: The diagnosis of microscopic lymph node metastasis in lung cancer is challenging despite the constant advances in tumor staging. The analysis of the methylation status of certain genes in lymph node samples could improve the diagnostic capability of conventional cyto-histological methods. The aim of this study was to demonstrate the feasibility of methylation studies using cytological lymph node samples. METHODS: Prospective study including 88 patients with a diagnosis or strong suspicion of non-small cell lung cancer, in which an echobronchoscopy was performed on mediastinal or hilar lymph nodes for diagnostic and/or staging. DNA was extracted from cytological lymph node samples and sodium bisulfite modification was performed. Methylation studies for p16/INK4a and SHOX2 were accomplished by MS-qPCR and pyrosequencing. RESULTS: The methodology used in our study yielded optimal/good DNA quality in 90% of the cases. No differences in DNA concentration were observed with respect to the lymph node biopsied and final diagnosis. Methylation analyses using MS-qPCR and pyrosequencing were not possible in a small number of samples mainly due to low DNA concentration, inadequate purity, fragmentation and/or degradation as a consequence of bisulfite conversion. CONCLUSION: Methylation quantification using MS-qPCR and pyrosequencing of cytological lymph node samples obtained using echobronchoscopy is feasible if an appropriate DNA concentration is obtained, notably contributing to the identification of epigenetic biomarkers capable of improving decision-making for the benefit of potentially curable lung cancer patients.

Thoracic ultrasound-assisted selection for pleural biopsy with Abrams needle.

BACKGROUND: Closed pleural biopsy (CPB) in patients with malignant pleural effusion is less sensitive than cytology. Ultrasound-assisted CPB allows biopsies to be performed in the lower thoracic parietal pleura, where secondary spread from pleural metastases is initially more likely to be found. We analyzed whether choosing the point of entry for CPB with thoracic ultrasound assistance influences the diagnostic yield in malignant pleural effusion. METHODS: This prospective study included patients who underwent CPB performed by an experienced pulmonologist in 2008-2010 (group A) and thoracic ultrasound was used to select the biopsy site. The results were compared with a historical series of CPB performed by the same pulmonologist without the assistance of thoracic ultrasound (group B). An Abrams needle was used in all cases. We analyzed the obtaining of pleural tissue and the diagnostic yield. RESULTS: We included 114 CPBs from group A (23% tuberculous pleural effusion, 27% malignant pleural effusion) and 67 CPBs from group B (24% tuberculous pleural effusion, 30% malignant pleural effusion) (P = .70). Pleural tissue was obtained in 96.5% of the group A CPBs and 89.6% of the group B CPBs (P = .05). The diagnostic yields of CPB for tuberculous pleural effusion and malignant pleural effusion in group A were 89.5% and 77.4%, respectively, and 91.7% and 60%, respectively, in group B (P = .80 for tuberculous pleural effusion, and P = .18 for malignant pleural effusion). CONCLUSIONS: Selecting the point of entry for CPB using thoracic ultrasound increases the likelihood of obtaining pleural tissue and the diagnostic yield, but without statistical significance. We recommend ultrasound-assisted CPB to investigate pleural effusion, since the diagnostic yield of a pleural biopsy with an Abrams needle increased by > 17% in subjects with malignant pleural effusion.

Cost-effectiveness analysis of transbronchial needle aspiration of pulmonary lesions without endobronchial affectation.

UNLABELLED: Transbronchial needle aspiration (TBNA) of pulmonary lesions without endobronchial affectation in combination with transbronchial biopsy (TBB) has been shown to increase diagnostic performance. The objective of this present study was to analyze whether the combination of TBNA with conventional TBB is a cost-effective approach. METHODOLOGY: Ours is a prospective study that included patients with lung nodules or masses with no evidence of endobronchial lesions after flexible bronchoscopy in whom both TBNA and TBB were performed. We analyzed the additional diagnostic value, the impact of TBNA on the cost of the diagnosis and the minimum level of sensitivity required in order for TBNA combined with TBB to be considered a cost-effective diagnostic approach. RESULTS: Thirty-six patients were included in the study, 25 of whom were males. TBB reached a histologic diagnosis in 39% of the cases, and its combination with TBNA diagnosed 47%. The mean diameter of the lesions was significantly greater in the positive TBNA cases compared with the negative cases (31 vs. 23mm; p=0,034). The cost analysis did not show the additional TBNA to be more cost-effective, despite demonstrating greater diagnostic sensitivity. The minimum sensitivity required for TBNA combined with TBB to be considered a cost-effective approach was 88%. CONCLUSION: The contribution of TBNA to TBB in the diagnosis of lung nodules or masses without associated endobronchial lesions does not seem to justify the additional economic cost.

Local recurrence and metastatic disease in a typical N1 carcinoid bronchial tumour.

Typical carcinoid bronchial tumour is a well-known disease that, for years, was considered benign. Currently, it is classified within the group of neuro-endocrine lung tumours. It is a low-grade malignancy tumour with a capability of local and distant recurrence. Complete resection with mediastinal lymphadenectomy is the treatment-of-choice. There are, usually, long-term survivors, even in cases of recurrence or mediastinal node invasion. These patients could benefit from removal of recurrent or metastatic disease. We present, here, a case of a 19-years-old female diagnosed as having N1-bronchial typical carcinoid tumour. She underwent radical surgery, but with mediastinal recurrence and hepatic metastases. A new radical lung resection was performed, and a liver transplant was the therapy-of-choice for the metastatic lesion.

[Local recurrence after radical prostatectomy and salvage radiotherapy]. / Recidiva local después de la prostatectomía radical y radioterapia de rescate.

OBJECTIVE: To evaluate the efficacy of radiotherapy to the prostatic bed in patients with biochemical recurrence prostate cancer after radical prostatectomy. METHODS: We analyse the outcomes of 292 patients who underwent radical prostatectomy for localized prostate cancer T1-T2 between January 1992 and June 2003, with an average follow-up of 36 months (range 6 months to 12 years). We detected biochemical recurrence (PSA > 0.20 ng/ml) in 75 (26%) patients. 75 patients with biochemical recurrence, 9 (12%) were diagnosed of local recurrence by the following criteria: a) First PSA obtained 6 weeks after radical prostatectomy < 0.20 ng/ml. b) Time to biochemical recurrence > 6 months. c) Prostate specific antigen doubling time > 6 months. d) Prostate specific antigen velocity after radical prostatectomy < 0.75 ng/ml/year. e) Prostate specific antigen level after radical prostatectomy < 2.5 ng/ml. The 9 patients diagnosed of local recurrence received an average dose of 56.42 Gy to the prostate bed. RESULTS: Of all 9 patients with local recurrence, 8(88.8%) have complete response with a mean follow-up of 30 months (12-36 months). The time between the radiotherapy and the response, in patients with complete response, was lower than 3 months in 7 patients and 12 months in 1 patient. Significant adverse effects associated to radiotherapy were not observed. CONCLUSIONS: Salvage radiotherapy may be beneficial in selected patients with local recurrence. The characteristics of prostate specific antigen elevation are useful in distinguishing men with local recurrence from those with distant metastases.

[Liposarcomas of the mediastinum in atypical locations: report of two cases]. / Liposarcomas mediastínicos de localización atípica. Aportación de 2 casos.

Liposarcomas of the mediastinum are unusual tumors characterized by compression of neighboring structures and frequent recurrence. Computed tomography and magnetic resonance imaging provide useful data for diagnosis. According to a review of the literature, surgical resection is the most effective treatment. We report two cases of mediastinal liposarcoma: the first was a liposarcoma that was a recurrence of an atypical lipoma of the neck, and the second was a giant mediastinal liposarcoma involving both hemithoraces.

[Prognostic factors of prostate cancer: usefulness of Ki-67 expression in preoperative biopsies]. / Factores pronósticos del cáncer de próstata: utilidad de la expresión del Ki67 en las biopsias preoperatorias.

OBJECTIVES: To evaluate the usefulness of Ki-67 expression in preoperative diagnostic biopsies to predict prostate cancer biochemical relapse after radical prostatectomy. METHODS: We analyze the expression of Ki-67 in ultrasound guided biopsies of 103 patients who underwent radical prostatectomy. Mean follow-up was 3.4 years (1.3-8.8 yr.). We correlated biochemical progression with traditional prognostic factors such as PSA (> 10/< or = 10), Gleason (> or = 7/< 7), pT classification (pT3/pT 0-2), and the immunohistochemical prognostic factor Ki-67 (> 3%/< or = 3%). RESULTS: 71/103 (69%) patients did not have progression and 32 (31%) had biochemical progression. Mean preoperative PSA was 10.7 ng/ml in patients without progression and 20.90 ng/ml in patients with biochemical progression (p = 0.0001). Mean Gleason score was 6.03 in patients without progression and 6.75 in patients with biochemical progression (p = 0.0001). Ki-67 expression was 3.95% in patients without progression in comparison to 5.05% of patients with biochemical progression. 12/67 (17.9%) of pT 0-2 tumors and 20/36 (55.6%) pT3 tumors progressed (p = 0.0001). Multivariate analysis indicates that there is not relationship between Ki-67 (> 3% < or = 3%) in preoperative biopsy specimens and prostate cancer biochemical progression after radical prostatectomy (p = 0.204). CONCLUSIONS: The immunohistochemical prognostic factor Ki-67 (> 3%/< or = 3%) in preoperative biopsies is less effective than classic factors, PSA (> 10/< or = 10), Gleason score (> or = 7/< 7) and pT classification (pT3/pT 0-2), to predict prostate cancer biochemical progression after radical prostatectomy.