Pathologist-initiated reflex testing for biomarkers in non-small-cell lung cancer: expert consensus on the rationale and considerations for implementation.

Biomarker tests in lung cancer have been traditionally ordered by the treating oncologist upon confirmation of an appropriate pathological diagnosis. The delay this introduces prolongs yet further what is already a complex, multi-stage, pre-treatment pathway and delays the start of first-line systemic treatment, which is crucially informed by the results of such analysis. Reflex testing, in which the responsibility for testing for an agreed range of biomarkers lies with the pathologist, has been shown to standardise and expedite the process. Twelve experts discussed the rationale and considerations for implementing reflex testing as standard clinical practice.

Diagnostic accuracy of visual analysis versus dual time-point imaging with 18F-FDG PET/CT for the characterization of indeterminate pulmonary nodules with low uptake. / Precisión diagnóstica del análisis visual frente al protocolo de imagen tardía con 18F-FDG PET/TC para la caracterización de nódulos pulmonares indeterminados con baja captación.

OBJECTIVE: To determine the accuracy of visual analysis and the retention index (RI) with dual-time point 18F-FDG PET/CT for the characterization of indeterminate pulmonary nodules (IPN) with low FDG uptake. MATERIALS AND METHODS: A retrospective analysis was performed on 43 patients (28 men, 64 ± 11 years old, range 36-83 years) referred for IPN characterization with 18F-FDG-PET/CT and maximum standard uptake value ≤ 2.5 at 60 minutes post-injection (SUVmax1). Nodules were analyzed by size, visual score for FDG uptake on standard (OSEM 2,8) and high definition (HD) reconstructions, SUVmax1, SUVmax at 180 minutes post-injection (SUVmax2), and RI was calculated. The definitive diagnosis was based on histopathological confirmation (n = 28) or ≥ 2 years of follow-up. RESULTS: Twenty-four (56%) nodules were malignant. RI ≥ 10% on standard reconstruction detected 18 nodules that would have been considered negative using the standard SUVmax ≥ 2.5 criterion for malignancy. RI ≥ 10% had a sensitivity, specificity, PPV, NPV and accuracy of 75, 73.7, 78.3, 70, and 74.4%, respectively, while for FDG uptake > liver on HD these were 79.1, 63.2, 73.1, 70.6, and 72.1%, respectively. SUVmax1 ≥ 2, SUVmax2 > 2.5 and FDG uptake > liver on standard reconstruction had a PPV of 100%. FDG uptake > mediastinum on HD had a NPV of 100%. CONCLUSIONS: RI ≥ 10% was the most accurate criterion for malignancy, followed by FDG uptake > liver on HD reconstruction. On standard reconstruction, SUVmax1 ≥2 was highly predictive of malignancy, as well as SUVmax2 > 2.5 and FDG uptake > liver. FDG uptake < mediastinum on HD was highly predictive of benign nodules.

Surgical Outcomes in a Lung Cancer-Screening Program Using Low Dose Computed Tomography.

OBJECTIVE: Lung cancer (LC) is the leading cause of death from cancer worldwide. More than 27,000 LCs are diagnosed annually in Spain, and most are unresectable. Early detection and treatment reduce LC mortality. This study describes surgical outcomes in a longstanding LC screening cohort in Spain. METHODS: We conducted a retrospective study of surgical outcomes in a LC screening (LCS) program using low dose computed tomography (LDCT) since the year 2000. A descriptive analysis of clinical and radiological parameters, presence or absence of a preoperative diagnosis, pathological staging, morbidity, mortality, and survival was performed. RESULTS: Ninety-seven (2.5%) LC were diagnosed in 3825 screened. Twenty individuals with LC had no surgery due to advanced stage or small cell histology. Eighty-seven surgical procedures were carried out for suspected or biopsy proven LC, detected by LDCT. Most operated patients were male (57[85%]) aged 64±9.1 years. Nine patients underwent a second operation for a metachronous primary lung cancer. Mean tumor size was 15.2±7.6mm. Eight nodules were benign (9.2%). Lobectomy was performed in 56 cases (83.6%). Adenocarcinoma (n=39; 58.2%) was the most frequent histological type followed by squamous cell carcinoma (n=17; 25.4%). Fifty-nine (88%) tumors were in Stage I. Thirteen patients (15.4%) had 16 complications. The estimated survival rates at 5 and 10 years for stage I were 93% (95% CI: 79%-98%) and 83% (95% CI: 65%-92%), respectively. CONCLUSION: Lung cancer screening was associated with excellent surgical outcomes with 5 and 10-year survival rates exceeding 90 and 80%, respectively.

EUS-guided tissue acquisition in the study of the adrenal glands: Results of a nationwide multicenter study.

BACKGROUND: There are limited data about the role of endoscopic ultrasound-guided tissue acquisition (EUS-TA), by fine needle aspiration (EUS-FNA) or biopsy (EUS-FNB), in the evaluation of the adrenal glands (AG). The primary aim was to assess the diagnostic yield and safety. The secondary aims were the malignancy predictors, and to create a predictive model of malignancy. METHODS: This was a retrospective nationwide study involving all Spanish hospitals experienced in EUS-TA of AGs. Inclusion period was from April-2003 to April-2016. Inclusion criteria: all consecutive cases that underwent EUS-TA of AGs. EUS and cytopathology findings were evaluated. Statistical analyses: diagnostic accuracy of echoendoscopist's suspicion using cytology by EUS-TA, as gold standard; multivariate logistic regression model to predict tumor malignancy. RESULTS: A total of 204 EUS-TA of AGs were evaluated. Primary tumor locations were lung70%, others19%, and unknown11%. AG samples were adequate for cytological diagnosis in 91%, and confirmed malignancy in 60%. Diagnostic accuracy of the endosonographer's suspicion was 68%. The most common technique was: a 22-G (65%) and cytological needle (75%) with suction-syringe (66%). No serious adverse events were described. The variables most associated with malignancy were size>30mm (OR2.27; 95%CI, 1.16-4.05), heterogeneous echo-pattern (OR2.11; 95%CI, 1.1-3.9), variegated AG shape (OR2.46; 95%CI, 1-6.24), and endosonographer suspicion (OR17.46; 95%CI, 6.2-58.5). The best variables for a predictive multivariate logistic model of malignancy were age, sex, echo-pattern, and AG-shape. CONCLUSIONS: EUS-TA of the AGs is a safe, minimally invasive procedure, allowing an excellent diagnostic yield. These results suggest the possibility of developing a pre-EUS procedure predictive malignancy model.

Total and mutated EGFR quantification in cell-free DNA from non-small cell lung cancer patients detects tumor heterogeneity and presents prognostic value.

Mutation analysis of epidermal growth factor receptor (EGFR) gene is essential for treatment selection in non-small cell lung cancer (NSCLC). Analysis is usually performed in tumor samples. We evaluated the clinical utility of EGFR analysis in plasma cell-free DNA (cfDNA) from patients under treatment with EGFR inhibitors. We selected 36 patients with NSCLC and EGFR-activating mutations. Blood samples were collected at baseline and during treatment with EGFR inhibitors. Wild-type EGFR, L858R, delE746-A750, and T790M mutations were quantified in cfDNA by droplet digital PCR. Stage IV patients had higher total circulating EGFR copy levels than stage I (3523 vs. 1003 copies/mL; p < 0.01). There was high agreement for activating mutations between baseline cfDNA and tumor samples, especially for L858R mutation (kappa index = 0.679; p = 0.001). In 34 % of advanced NSCLC patients, we detected mutations in cfDNA not previously detected in tumor samples and double mutations in 17 %. Patients with baseline total EGFR copy levels above the median presented decreased overall survival (OS) (341 vs. 870 days, p < 0.05) and progression-free survival (PFS) (238 vs. 783 days; p < 0.05) compared with those with total EGFR copy levels below the median. Patients with baseline concentrations of activating mutations above the median (94 copies/mL) had lower OS (317 vs. 805 days; p < 0.05) and PFS (195 vs. 724 days; p < 0.05). During follow-up, T790M resistance mutation was detected in 53 % of patients. Total and mutated EGFR analysis in cfDNA seems a relevant tool to characterize the molecular profile and prognosis of NSCLC patients harboring EGFR mutations.

Guidelines for biomarker testing in metastatic melanoma: a National Consensus of the Spanish Society of Pathology and the Spanish Society of Medical Oncology.

This consensus statement, conceived as a joint initiative of the Spanish Society of Pathology (SEAP) and the Spanish Society of Medical Oncology (SEOM), makes diagnostic and treatment recommendations for the management of patients with advanced or metastatic melanoma based on the current scientific evidence on biomarker use. This document thus provides an opportunity to improve healthcare efficiency and resource use, which will benefit these patients. Based on the data available so far, this expert group recommends routinely testing patients with metastatic melanoma for BRAF mutation status, as the result affects the subsequent therapeutic management of these patients. The analysis of genetic alterations in KIT may be reasonable in patients with primary tumours in acral or mucosal sites or on chronically sun-exposed skin, in an advanced condition, but not in patients with other types of melanomas. This panel believes that testing for other genetic alterations, such as NRAS mutation status in patients not carrying BRAF mutations, GNAQ/GNA11 mutational analysis or genetic alterations in PTEN, is not currently indicated as routine clinical practice, because the results do not influence treatment planning in these patients at the present time. Other important issues addressed in this document are the organisational requirements and quality controls needed for proper testing of these biomarkers, and the legal implications to be borne in mind.

Enfermedad de Alzheimer y otras demencias

Libro que centra su atención en dar respuesta a una serie de preguntas relacionadas con el Alzheimer y otras demencias. El modo en que funciona el cerebro del paciente, cómo afecta a la actividad intelectual, cuáles con las causas o cómo se diagnostica el Alzheimer son algunas de las cuestiones resueltas en esta guía.

Walking assessment with instrumented insoles in patients with lower limb spasticity after botulinum toxin infiltration.

INTRODUCTION: Botulinum toxin A (BTA) improves the kinematic parameters of gait in patients with spasticity of lower limbs, but there are no studies in which kinetic parameters are measured with instrumented insoles. We therefore used instrumented insoles to perform a functional assessment of therapeutic results in patients with lower limb spasticity after brain injury or spinal cord infiltration indicating BTA. MATERIAL AND METHODS: Ten patients (11 lower limbs) seen in a Neurorehabilitation Unit. The tests carried out included clinical examination, gait assessment (Functional Ambulation Categories (FAC); Hospital de Sagunto Gait Scale), and biomechanical assessment (Biofoot / IBV version 5.0), before and three weeks after infiltration with BTA. STATISTICS: t-test for related samples of clinical variables, functional variables and biomechanical variables before and after infiltration. Level of significance P< .05. Qualitative method to assess whether changes in the biomechanical variables tended toward normal values. RESULTS: BTA improves muscle tone, joint arch and frequency of spasms (P<.01). The patient sample showed a high level of satisfaction with the improvement in symptoms. There were no changes in walking ability after injection. There were no statistically significant changes in biomechanical parameters, but there was improved gait cadence. The relatively small statistical significance close to P=.1 of the peak pressure in the heel after injection indicates the need for further studies with instrumented insoles in people with spasticity due to central nervous system injury. CONCLUSIONS: With the decrease in muscle tone after infiltration with BTA the clinical symptoms associated with muscle tone improved without any functional changes in gait scales. The changes in the biomechanical parameters show that larger studies using instrumented insoles should be performed in the population with spasticity after a central nervous system injury treated with BTA infiltration.

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas: clinico-pathologic results.

BACKGROUND: intraductal papillary mucinous neoplasm (IPMN) shows a series of lesions which evolve from benign lesions -adenoma- to invasive carcinoma. AIM: To analyze the clinical and pathological results of 15 patients diagnosed of IPMN, and surgically treated according to the guidelines of International Consensus Conference. MATERIAL AND METHODS: A retrospective analysis of 15 patients surgically treated between March 1993 and September 2009, according to the International Consensus recommendation. Demographic, diagnostic tools, surgical report, pathologic database and actuarial survival were analyzed with a follow-up from one and a half month through nine years. RESULTS: 6 Patients underwent pancreaticoduodenectomies, 4 total pancreatectomies, 2 body or central pancreatectomies, 2 partial pancreatectomies (enucleation) and 1 distal pancreatectomy. A morbidity of 46 and 0% hospital mortality were assessed, with a median length hospital stay of 10 days. In five cases, the IPMN was combined type (both main and branch pancreatic ducts involved) in four main duct-type and branch duct-type in the another six as well. Several atypia (IPMN carcinoma in situ) was observed in 2 patients and invasive carcinoma with negative lymph nodes was identified in 3 patients. A patient without invasive carcinoma died at 66 months of follow-up for pancreas adenocarcinoma. The actuarial survival up to recurrence or death was 105,133 months with a range of follow-up from 1 month and a half until 9 years. CONCLUSIONS: IPMN main duct or mixed type warrants complete resection due to its incidence of invasive carcinoma or precursor lesions of malignancy as well. Due to its multifocal pattern, patients should be followed in long-term surveillance. The management of asymptomatic IPMN type branch less than 3 cm is controversial.

Solid pseudopapillary tumor of the pancreas (SPPT). Still an unsolved enigma.

Solid pseudo-papillary tumor (SPPT) is a rare cystic tumor of the pancreas (1-3% of exocrine tumors of the pancreas) which shows an "enigmatic" behavior on the clinical and molecular pattern. A retrospective analysis of the cytological studies and resected specimens of pancreatic cystic tumors from May 1996 to February 2010 was carried out. Three cases of SPPT were found, which are the objective of this study. The diagnosis was established upon occasional finding in the abdominal CT, in spite of sizing between 3 and 6 cm of diameter. In the three cases the preoperative diagnosis was confirmed by cytology and specific immunohistochemical staining. Cases 2 and 3 showed strong immunoreactivity for Beta-Catenin and E-Cadherin staining. Radical resection (R0) was carried out in the three cases. A young male -21 years of age (case 1)- who had duodenal infiltration and two lymph nodes metastases died of hepatic and peritoneal recurrence 20 months following surgery. The other two cases are free of disease. The current review of the literature reports roughly 800 cases since the first report in 1959, and shows the enigmatic character of this tumor regarding the cellular origin, molecular pathways, prognostic factors and clinical behavior.

EUELC project: a multi-centre, multipurpose study to investigate early stage NSCLC, and to establish a biobank for ongoing collaboration.

The European Early Lung Cancer (EUELC) project aims to determine if specific genetic alterations occurring in lung carcinogenesis are detectable in the respiratory epithelium. In order to pursue this objective, nonsmall cell lung cancer (NSCLC) patients with a very high risk of developing progressive lung cancer were recruited from 12 centres in eight European countries: France, Germany, southern Ireland, Italy, the Netherlands, Poland, Spain and the UK. In addition, NSCLC patients were followed up every 6 months for 36 months. A European Bronchial Tissue Bank was set up at the University of Liverpool (Liverpool, UK) to optimise the use of biological specimens. The molecular-pathological investigations were subdivided into specific work packages that were delivered by EUELC Partners. The work packages encompassed mutational analysis, genetic instability, methylation profiling, expression profiling utilising immunohistochemistry and chip-based technologies, as well as in-depth analysis of FHIT and RARbeta genes, the telomerase catalytic subunit hTERT and genotyping of susceptibility genes in specific pathways. The EUELC project engendered a tremendous collaborative effort, and it enabled the EUELC Partners to establish protocols for assessing molecular biomarkers in early lung cancer with the view to using such biomarkers for early diagnosis and as intermediate end-points in future chemopreventive programmes.

Molecular characterization of small peripheral lung tumors based on the analysis of fine needle aspirates.

The computed tomography (CT)-based early lung cancer diagnostic technologies allow the detection of very small stage I lung tumors. As part of these screening protocols any suspicious nodule has to be diagnosed morphologically, which requires CT-guided Fine Needle Aspiration, open biopsy or surgery. Fine Needle Aspiration (FNA) cytology is a well-recognised method for a rapid and accurate diagnosis of small lung tumors. Molecular analysis of the FNA specimens could complement cytology diagnosis by the characterization of the biological traits at the preoperative stage. In this study, we aimed to characterize the biological profile of 33 paraffin-embedded transthoracic FNA samples obtained from three groups of lung cancer patients: two groups of small early-detected lung adenocarcinomas (radiologically subsolid and solid nodules) and a third group of small metastatic adenocarcinomas. Genetic analysis was performed by fluorescence in situ hybridization using the four-color LAVysion probe. p53 and Ki-67 protein expression was also evaluated by immunocytochemistry. The samples showed gains for all targets analyzed; two cases had EGFR gene amplification and two cases had MYC amplification. There were no significant differences in the percentage of genetically malignant cells and the expression of Ki-67 among the three groups. However, p53 accumulation was significantly higher in the metastatic group compared to the subsolid early-detected group (P = 0.001). In conclusion, molecular analysis of FNA specimens may provide useful information at preoperative stages. In our series, a good prognostic profile in subsolid early detected adenocarcinomas is suggested.

[Solitary focal tracheal lesions. A case report]. / Lesiones traqueales focales. A propósito de un caso.

We present a case of adenoid cystic tracheal carcinoma detected by computerized tomography (64-MDCT) with cyto-histological correlation in a patient with hemoptysis. In this article we review the differential diagnosis of solitary focal tracheal lesions as they appear in computerized tomography (CT). In this case, image methods suggested the diagnosis but underestimated the tracheal wall invasion, which was established by histologycal examination of the resected tumor.

ERK1/2 is activated in non-small-cell lung cancer and associated with advanced tumours.

Activation of the ERK1/2 pathway is involved in malignant transformation both in vitro and in vivo. Little is known about the role of activated ERK1/2 in non-small cell lung cancer (NSCLC). The purpose of this study was to characterise the extent of the activation of ERK1/2 by immunohistochemistry in patients with NSCLC, and to determine the relationship of ERK1/2 activation with clinicopathological variables. Specimens from 111 patients with NSCLC (stages I-IV) were stained for P-ERK. Staining for epidermal growth factor receptor (EGFR) and Ki-67 was also performed. In all, 34% of the tumour specimens showed activation for ERK1/2, while normal lung epithelial tissue was consistently negative. There was a strong statistical correlation between nuclear and cytoplasmic P-ERK staining and advanced stages (P<0.05 and P<0.001, respectively), metastatic hilar or mediastinal lymph nodes (P<0.01, P<0.001), and higher T stages (P<0.01, P<0.001). We did not find correlation of nuclear or cytoplasmic P-ERK staining with either EGFR expression or Ki-67 expression. Total ERK1/2 expression was evaluated with a specific ERK1/2 antibody and showed that P-ERK staining was not due to ERK overexpression but rather to hyperactivation of ERK1/2. Patients with a positive P-ERK cytoplasmic staining had a significant lower survival (P<0.05). However, multivariate analysis did not show significant survival difference. Our study indicates that nuclear and cytoplasmic ERK1/2 activation positively correlates with stage, T and lymph node metastases, and thus, is associated with advanced and aggressive NSCLC tumours.

[Memory evaluation using functional magnetic resonance: applications in preoperative patients and in Alzheimer s disease]. / Evaluacion de la memoria mediante resonancia magnetica funcional: aplicaciones en pacientes prequirurgicos y en la enfermedad de Alzheimer.

The assessment of memory functions related to medial temporal lobe has become one of the most important issues on current neuropsychology. On this communication, we review the results which our research group has achieved using two functional magnetic resonance Image procedures to assess memory function: Hometown walking task and an encoding/retrieval task using complex images. Nine patients with tumoural temporal lesions performed the hometown walking task. The results of these patients showed either a bilateral or contralesional representation of memory function. These results confirm those obtained by Jokeit, Okujava y Woermann (2001), and they seem to prove that this protocol is useful to determine the preservation of memory function in the non damaged hemisphere. On the other hand, the images encoding/retrieval task has been run by two groups of four patients diagnosed as Alzheimer disease and mild cognitive impairment, and another group of five patients who participated as a control group. According to our hypothesis, the results have shown a lower activation at the left parahippocampal gyrus in mild cognitive impairment and Alzheimer disease patients than controls, just as a lower bilateral activation in the same structure for the Alzheimer group than the control group. As a whole, our results show how important may become functional magnetic resonance image for neuropsychological assessment of memory, and as a diagnostic tool for CNS diseases.

PTEN protein expression correlates with PTEN gene molecular changes but not with VEGF expression in astrocytomas.

PTEN gene (10q23) is a relevant tumor suppressor gene whose protein is a phosphatase involved in the control of angiogenesis of some tumors including astrocytomas. There are no studies correlating molecular changes of PTEN and the immunohistochemical expression of its protein (pPTEN) with the expression of vascular endothelial growth factor (VEGF) in astrocytomas. Fifty-six surgically resected brain gliomas, 10 grade 2, 16 grade 3, and 30 grade 4, were studied by a combined approach, consisting of (1) PCR analysis using four microsatellite markers against the PTEN gene region (10q23), (2) the FISH technique to test chromosome 10 using a pericentromeric probe, and (3) immunohistochemical evaluation of pPTEN and VEGF. Loss of heterozygosity (LOH) of PTEN was observed in 10% of fibrillary grade 2 astrocytomas and all gemistocytic ones. In high-grade tumors, LOH was more frequent in grade 4 than in grade 3 (> or =2 loci deleted, 83% and 56%, respectively). Monosomy for chromosome 10 was observed especially in high-grade tumors (6% of grade 3 and 50% of grade 4) and in 20% of grade 2 tumors, corresponding to gemistocytic astrocytomas. Results with both antibodies against PTEN were concordant: loss of cytoplasmic immunoreactivity was frequently observed according to homogeneous or heterogeneous patterns in 70% and 50% of grades 4 and 3, respectively, but not in grade 2. Immunonegativity of pPTEN was associated with PTEN gene deletion (> or =2 loci deleted) (P = 0.04) but not with monosomy. Cytoplasmic immunoreactivity against VEGF was observed in high-grade and in gemistocytic astrocytomas, but not in conventional grade 2 tumors. Tumor expression of pPTEN was not associated with immunoreactivity against VEGF when the same areas were considered. In conclusion, loss of PTEN expression is frequent in high-grade astrocytomas, but not in grade 2 tumors, and correlates with PTEN deletion and loss of chromosome 10. PTEN immunoreactivity does not correlate with VEGF expression in astrocytomas when similar areas are considered.

[FICTION as a new tool to early lung cancer diagnosis]. / Desarrollo de la técnica de FICTION como nueva herramienta para el diagnóstico precoz de cáncer de pulmón.

Lung cancer is one of the most frequent causes of cancer death in Western countries. Overall 5-year survival rate is lower than 15% mainly due to the late diagnosis of the disease. Primary prevention (reduction of tobacco consumption) and more effective methods for early detection are needed. Some studies have recently shown that low-dose spiral computed tomography (CT) is a useful technique to the detection of pulmonary malignant nodules in early stages. Studies are developing to evaluate its efficacy in series of high-risk patients. A new cytogenetic technique has been developed: the FICTION technique (Fluorescence Immunophenotyping and Interphase Cytogenetics as a Tool for the Investigation of Neoplasms). This technique allows the simultaneous study of immunophenotypic markers and genetic abnormalities present in tumour cells. The goal of our project is optimise this technique in sputum and bronchoalveolar lavage specimens from lung cancer patients. The overall goal of this project is evaluate the usefulness of this technique, together with the new radiological techniques, in early detection programs of lung cancer in high-risk patients. In the present study we review the cytogenetic studies on lung cancer carried out in the recent years. We also introduce the basic methodological aspects that will be developed in our project.

[Streptococcus suis meningitis]. / Meningitis por Streptococcus suis.

Human infection by Streptococcus suis (S. suis) is a zoonosis, with a known occupational risk and clinical presentation mainly as a purulent meningitis with low mortality and frequent hearing loss and ataxia sequela. Less than 150 human cases have been reported since original one thirty years ago. There is a geographical distribution most patients living in northern Europe and south Asia. S. suis disease in human has been reported in two patients in Spain the last years. We present two patients with S. suis meningitis, both were men with occupation related by pork meet, and good outcome. They come at our hospital in a lapse of one month. Both had neurosensorial hearing loss and walking ataxia. One patient had peripheral facial paralysis and diplopia because of paresia of contralateral sixth nerve, with complete resolution at three months. The rare presentation of S. suis meningitis in our country must not forget us to record the working risk at anamnesis.