Evaluation of Musculoskeletal and Pulmonary Bacterial Infections With [124I]FIAU PET/CT.

PURPOSE: Imaging is limited in the evaluation of bacterial infection. Direct imaging of in situ bacteria holds promise for noninvasive diagnosis. We investigated the ability of a bacterial thymidine kinase inhibitor ([124I]FIAU) to image pulmonary and musculoskeletal infections. METHODS: Thirty-three patients were prospectively accrued: 16 with suspected musculoskeletal infection, 14 with suspected pulmonary infection, and 3 with known rheumatoid arthritis without infection. Thirty-one patients were imaged with [124I]FIAU PET/CT and 28 with [18F]FDG PET/CT. Patient histories were reviewed by an experienced clinician with subspecialty training in infectious diseases and were determined to be positive, equivocal, or negative for infection. RESULTS: Sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of [124I]FIAU PET/CT for diagnosing infection were estimated as 7.7% to 25.0%, 0.0%, 50%, 0.0%, and 20.0% to 71.4% for musculoskeletal infections and incalculable-100.0%, 51.7% to 72.7%, 0.0% to 50.0%, 100.0%, and 57.1% to 78.6% for pulmonary infections, respectively. The parameters for [18F]FDG PET/CT were 75.0% to 92.3%, 0.0%, 23.1% to 92.3%, 0.0%, and 21.4% to 85.7%, respectively, for musculoskeletal infections and incalculable to 100.0%, 0.0%, 0.0% to 18.2%, incalculable, and 0.0% to 18.2% for pulmonary infections, respectively. CONCLUSIONS: The high number of patients with equivocal clinical findings prevented definitive conclusions from being made regarding the diagnostic efficacy of [124I]FIAU. Future studies using microbiology to rigorously define infection in patients and PET radiotracers optimized for image quality are needed.

In Vivo Characterization of the Swine Airway Morphometry and Motion Based on Computed Tomographic Imaging During Respiration.

Swine are a commonly used model in translational pulmonary research. However, in vivo airway morphometry during respiration has not been studied in extensive detail using modern imaging tools. Chest computed tomographic was performed in swine (n = 3) at multiple stages of respiration. Morphometric parameters of each airway segment at end-expiration and end-inspiration were compared as well as among matched anatomical regions (proximal and distal; ventral, lateral, and dorsal). Analysis included segment diameter, length, ellipticity, and the bifurcation angle between daughter branches. Deformation of the airway during respiration was qualitatively visualized using a point-to-point deformation map. Comparison of airway generation showed airway diameter and length were larger at end-inspiration in the fourth and seventh generations compared to end-expiration. Bifurcation angle was larger at end-inspiration compared to end-expiration. Analysis by anatomical region showed that length and bifurcation angle were larger at inspiration in the distal airway regions only. Regardless of respiratory phase, the lateral regions had larger diameters and lengths compared to the ventral and dorsal regions at similar generations and proximal regions had larger bifurcation angles. The findings that morphological changes were more prevalent in distal airways during respiration was confirmed by analysis of a deformation map. Compared to human airway models, the relative diameter may be smaller and length may be greater in swine in similar airway generations. This morphometric description of the swine airways during respiration may guide conduct of preclinical translational studies, revealing advantages and limitations of swine models for specific evaluations. Such morphometric parameters may directly determine the suitability of the swine model for the study of lung interventions, in terms of recapitulation of human morphometry dynamics.

Pleural fluid secondary to pulmonary cryptococcal infection: a case report and review of the literature.

BACKGROUND: Pulmonary Cryptococcosis (PC) is diagnosed with increasing incidence in recent years, but it does not commonly involve the pleural space. Here, we report a HIV-negative case with advanced stage IIIB non-small cell lung cancer (NSCLC) treated with radiation therapy presented with dyspnea, a new PET-positive lung mass and bilateral pleural effusion suspecting progressive cancer. However, the patient has been diagnosed as pulmonary cryptococcal infection and successfully treated with oral fluconazole therapy. CASE PRESENTATION: A 77-year-old male with advanced stage non-small cell lung cancer treated with combined chemo-radiation therapy who presented with progressive dyspnea, a new PET-positive left lower lobe lung mass and bilateral pleural effusions. Initial diagnostic thoracentesis and bronchoscopy yielded no cancer, but instead found yeast forms consistent with cryptococcal organisms in the transbronchial biopsies of the left lower lobe lung mass. Subsequent to this, the previously collected pleural fluid culture showed growth of Cryptococcus neoformans. The same sample of pleural effusion was tested and was found to be positive for crytococcal antigen (CrAg) by a lateral flow assay (LFA). The patient has been treated with oral fluconazole therapy resulting in gradual resolution of the nodular infiltrates. CONCLUSION: PC should be considered in immunosuppressed cancer patients. Additionally, concomitant pleural involvement in pulmonary cryptococcal infections may occur. The incidence of false positive 18FDG-PET scans in granulomatous infections and the use of CrAg testing in pleural fluid to aid in diagnosis are reviewed.

Preliminary characterizations of a serum biomarker for sarcoidosis by comparative proteomic approach with tandem-mass spectrometry in ethnic Han Chinese patients.

BACKGROUND: The diagnosis of sarcoidosis is still a significant challenge in China because of the need to exclude other diseases including granulomatous infections and malignancies that may be clinically and radiographically similar. The specific aim of the study is to search for serum protein biomarkers of sarcoidosis and to validate their clinical usefulness in differential diagnosis. METHODS: Serum samples were collected from patients with sarcoidosis (n = 37), and compared to those from patients with tuberculosis (n = 20), other pulmonary diseases (n = 20), and healthy volunteers (n = 20) for determination of sarcoidosis-specific or -associated protein expression profiles. The first part of this study focused on proteomic analysis of serum from patients with sarcoidosis to identify a pattern of peptides capable of differentiating the studied populations using the ClinProt profiling technology based on mass spectrometry. Enzyme Linked Immunosorbent Assay (ELISA) was then used to verify corresponding elevation of the serum protein concentration of the potential biomarkers in the same patients sets. Receiver operating characteristic curve (ROC) analyses was performed to determine the optimal cutoff value for diagnosis. Immunohistochemistry was carried out to further confirm the protein expression patterns of the biomarkers in lung tissue. RESULTS: An unique protein peak of M/Z 3,210 Daltons (Da) was found to be differentially expressed between the sarcoidosis and control groups and was identified as the N-terminal peptide of 29 amino acids (94-122) of serum amyloid A (SAA). ELISA confirmed that the serum SAA level was significantly higher in the sarcoidosis group than that of the other 3 control groups (p < 0.05). The cutoff for serum SAA concentration determined by ROC analysis was 101.98 ng/ml, with the sensitivity and specificity of 96.3% and 52.5%, respectively. Immunohistochemical staining showed that the SAA depositions in lung tissue of the sarcoidosis patients were also significantly more intense than in non-sarcoid lung tissue (p < 0.05). CONCLUSION: This is the first study to investigate serum protein markers in Chinese subjects with sarcoidosis. This study shows that the serum SAA expression profiles were different between the sarcoidosis and non-sarcoidosis groups. SAA may be a potential serum biomarker for ruling-out the diagnosis of sarcoidosis in Chinese subjects.

Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis.

The aim of the present study was to investigate the clinical characteristics of pulmonary cryptococcosis patients in China, with analysis of immunocompetent and immunocompromised subjects. We performed a retrospective review of 76 patients diagnosed with tissue-confirmed pulmonary cryptococcosis at the Shanghai Pulmonary Hospital (Shanghai, China) during a 10-yr period (2001-2010). Of 76 patients (54 males and 22 females), 41 (53.95%) were immunocompetent and 35 out of the 41 were asymptomatic. Approximately 80% of the patients had histories suspicious of environmental fungal exposure. Radiological (computed tomography) findings showed predominantly peripheral findings (85.53%, 65 out of 76 patients) including nodular masses (55.26%, 42 out of 76), pneumonic infiltrates (23.68%, 18 out of 76) and mixed type (21.05%, 16 out of 76). 43.42% (33 out of 76) were initially misdiagnosed, often as cancer by false-positive (18)F-fluorodeoxyglucose positron emission tomography ((18)FDG-PET) (28 out of 46 cases). 51 patients received antifungal therapy, 25 patients were clinically observed without treatment. As of December 31, 2010, 71 cases showed total recovery and four cases showed improvement (efficacy rate of 98.68%, 75 out of 76). One HIV-positive case died of cryptococcal meningitis. Incidence of pulmonary cryptococcosis in China may be related to environmental fungal exposures. Most presented as asymptomatic peripheral lung lesions. False-positive (18)FDG-PET examinations often lead to initial clinical misdiagnosis of cancer. Unlike immunocompromised or clinically symptomatic patients, all immunocompetent patients had a good response, either to fluconazole monotherapy or observation, with a tendency for spontaneous remissions in the asymptomatic immunocompetent subjects.

Serum amyloid A regulates granulomatous inflammation in sarcoidosis through Toll-like receptor-2.

RATIONALE: The critical innate immune mechanisms that regulate granulomatous inflammation in sarcoidosis are unknown. Because the granuloma-inducing component of sarcoidosis tissues has physicochemical properties similar to those of amyloid fibrils, we hypothesized that host proteins capable of forming poorly soluble aggregates or amyloid regulate inflammation in sarcoidosis. OBJECTIVES: To determine the role of the amyloid precursor protein, serum amyloid A, as an innate regulator of granulomatous inflammation in sarcoidosis. METHODS: Serum amyloid A expression was determined by immunohistochemistry in sarcoidosis and control tissues and by ELISA. The effect of serum amyloid A on nuclear factor (NF)-kappaB induction, cytokine expression, and Toll-like receptor-2 stimulation was determined with transformed human cell lines and bronchoalveolar lavage cells from patients with sarcoidosis. The effects of serum amyloid A on regulating helper T cell type 1 (Th1) granulomatous inflammation were determined in experimental models of sarcoidosis, using Mycobacterium tuberculosis catalase-peroxidase. MEASUREMENTS AND MAIN RESULTS: We found that the intensity of expression and distribution of serum amyloid A within sarcoidosis granulomas was unlike that in many other granulomatous diseases. Serum amyloid A localized to macrophages and giant cells within sarcoidosis granulomas but correlated with CD3(+) lymphocytes, linking expression to local Th1 responses. Serum amyloid A activated NF-kappaB in Toll-like receptor-2-expressing human cell lines; regulated experimental Th1-mediated granulomatous inflammation through IFN-gamma, tumor necrosis factor, IL-10, and Toll-like receptor-2; and stimulated production of tumor necrosis factor, IL-10, and IL-18 in lung cells from patients with sarcoidosis, effects inhibited by blocking Toll-like receptor-2. CONCLUSIONS: Serum amyloid A is a constituent and innate regulator of granulomatous inflammation in sarcoidosis through Toll-like receptor-2, providing a mechanism for chronic disease and new therapeutic targets.

Epigenetic imprinting alterations as effective diagnostic biomarkers for early-stage lung cancer and small pulmonary nodules.

BACKGROUND: Early lung cancer detection remains a clinical challenge for standard diagnostic biopsies due to insufficient tumor morphological evidence. As epigenetic alterations precede morphological changes, expression alterations of certain imprinted genes could serve as actionable diagnostic biomarkers for malignant lung lesions. RESULTS: Using the previously established quantitative chromogenic imprinted gene in situ hybridization (QCIGISH) method, elevated aberrant allelic expression of imprinted genes GNAS, GRB10, SNRPN and HM13 was observed in lung cancers over benign lesions and normal controls, which were pathologically confirmed among histologically stained normal, paracancerous and malignant tissue sections. Based on the differential imprinting signatures, a diagnostic grading model was built on 246 formalin-fixed and paraffin-embedded (FFPE) surgically resected lung tissue specimens, tested against 30 lung cytology and small biopsy specimens, and blindly validated in an independent cohort of 155 patients. The QCIGISH diagnostic model demonstrated 99.1% sensitivity (95% CI 97.5-100.0%) and 92.1% specificity (95% CI 83.5-100.0%) in the blinded validation set. Of particular importance, QCIGISH achieved 97.1% sensitivity (95% CI 91.6-100.0%) for carcinoma in situ to stage IB cancers with 100% sensitivity and 91.7% specificity (95% CI 76.0-100.0%) noted for pulmonary nodules with diameters ≤ 2 cm. CONCLUSIONS: Our findings demonstrated the diagnostic value of epigenetic imprinting alterations as highly accurate translational biomarkers for a more definitive diagnosis of suspicious lung lesions.

T cell responses to mycobacterial catalase-peroxidase profile a pathogenic antigen in systemic sarcoidosis.

Sarcoidosis is a systemic granulomatous disease associated with local epithelioid granulomas, CD4(+) T cells, and Th1 cytokines. The tissue Ags that drive this granulomatous inflammation are uncertain. In this study, we used IFN-gamma-ELISPOT assays and flow cytometry to assess lung and blood T cell responses to the candidate pathogenic Ag, Mycobacterium tuberculosis catalase-peroxidase (mKatG) in patients with sarcoidosis from two centers. Despite differences in patient phenotypic, genetic, and prognostic characteristics, we report that T cell responses to mKatG were remarkably similar in these cohorts, with higher frequencies of mKatG-reactive, IFN-gamma-expressing T cells in the blood of sarcoidosis patients compared with nontuberculosis sensitized healthy controls, and (in a subset) in greater numbers than T cells reactive to purified protein derivative. In sarcoidosis, mKatG-reactive CD4(+) Th1 cells preferentially accumulated in the lung, indicating a compartmentalized response. Patients with or without Löfgren syndrome had similar frequencies of mKatG specific IFN-gamma-expressing blood T cells. Circulating mKatG-reactive T cells were found in chronic active sarcoidosis but not in patients with inactive disease. Together, these results demonstrate that T cell responses to mKatG in sarcoidosis fit a profile expected for a pathogenic Ag, supporting an immunotherapeutic approach to this disease.

Novel visualized quantitative epigenetic imprinted gene biomarkers diagnose the malignancy of ten cancer types.

BACKGROUND: Epigenetic alterations are involved in most cancers, but its application in cancer diagnosis is still limited. More practical and intuitive methods to detect the aberrant expressions from clinical samples using highly sensitive biomarkers are needed. In this study, we developed a novel approach in identifying, visualizing, and quantifying the biallelic and multiallelic expressions of an imprinted gene panel associated with cancer status. We evaluated the normal and aberrant expressions measured using the imprinted gene panel to formulate diagnostic models which could accurately distinguish the imprinting differences of normal and benign cases from cancerous tissues for each of the ten cancer types. RESULTS: The Quantitative Chromogenic Imprinted Gene In Situ Hybridization (QCIGISH) method developed from a 1013-case study which provides a visual and quantitative analysis of non-coding RNA allelic expressions identified the guanine nucleotide-binding protein, alpha-stimulating complex locus (GNAS), growth factor receptor-bound protein (GRB10), and small nuclear ribonucleoprotein polypeptide N (SNRPN) out of five tested imprinted genes as efficient epigenetic biomarkers for the early-stage detection of ten cancer types. A binary algorithm developed for cancer diagnosis showed that elevated biallelic expression (BAE), multiallelic expression (MAE), and total expression (TE) measurements for the imprinted gene panel were associated with cell carcinogenesis, with the formulated diagnostic models achieving consistently high sensitivities (91-98%) and specificities (86-98%) across the different cancer types. CONCLUSIONS: The QCIGISH method provides an innovative way to visually assess and quantitatively analyze individual cells for cancer potential extending from hyperplasia and dysplasia until carcinoma in situ and invasion, which effectively supplements standard clinical cytologic and histopathologic diagnosis for early cancer detection. In addition, the diagnostic models developed from the BAE, MAE, and TE measurements of the imprinted gene panel GNAS, GRB10, and SNRPN could provide important predictive information which are useful in early-stage cancer detection and personalized cancer management.

An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes.

BACKGROUND: Endoscopes, including bronchoscopes, are the medical devices most frequently associated with outbreaks of nosocomial infections. We investigated an outbreak of Pseudomonas aeruginosa infections after bronchoscopic procedures. METHODS: Microbiologic results were reviewed to determine the rates of recovery of P. aeruginosa from bronchoalveolar-lavage specimens. Environmental samples from endoscopes and the endoscopy suite were cultured. Medical records were reviewed to identify infections in the 14 days after a bronchoscopy. RESULTS: The rate of recovery of P. aeruginosa from bronchoalveolar-lavage specimens obtained with use of endoscopy-suite bronchoscopes increased from 10.4 percent at base line to 31.0 percent during the outbreak (relative risk, 2.97; 95 percent confidence interval, 2.28 to 3.90). Cultures of samples from three bronchoscopes grew P. aeruginosa, whereas cultures of samples from the environment, instrument-cleaning machines, and gastrointestinal endoscopes did not. The three bronchoscopes had been part of a nationwide recall. A total of 414 patients underwent bronchoscopy during the outbreak, and there were 48 respiratory tract and bloodstream infections among 39 of these patients (9.4 percent). In 32 infections (66.7 percent), P. aeruginosa was confirmed as a potentially causative organism. Exposure to a potentially contaminated bronchoscope may have had a role in the death of three patients. The rate of recovery of P. aeruginosa returned to base line after the instruments were removed from service. CONCLUSIONS: This large outbreak of P. aeruginosa infections related to bronchoscopy was apparently caused by a loose biopsy-port cap in the bronchoscopes. Instrument safety and surveillance methods for bronchoscopy must be improved, and better recall procedures are needed for medical devices.

Shifted focus of bronchoalveolar lavage in patients with suspected thoracic malignancy: an analysis of 224 patients.

BACKGROUND: Bronchoscopies are extensively adopted for diagnosing and staging thoracic malignancies, but studies are missing as how to keep the process streamlined and more efficient. To evaluate current role of bronchoalveolar lavage (BAL) for cancer and possible infection diagnosis when practicing comprehensive bronchoscopy for patients suspected with thoracic malignancy, and provide foundation for possible practice modification. METHODS: We retrospectively analyzed a prospectively kept database of immunocompetent patients undergoing bronchoscopy for suspected non-hematologic malignancies. Clinical, radiographic data, bronchoscopic sampling techniques and diagnostic results were recorded. Initially undiagnostic patients were followed up for 2 years for a definitive diagnosis. RESULTS: Of 224 patients included, 179 (79.9%) were confirmed with active thoracic malignancies. BAL diagnostic yield of cancer based on different radiographic characters of target lesion are as follow: isolated lymphadenopathies 0%, central lesions 45.5%, peripheral masses (diameter ≥3 cm) 21.4%, peripheral large nodules (2≤ diameter <3 cm) 15.8%, and peripheral small nodules (diameter <2 cm) 7.1%, while composite bronchoscopy achieved diagnostic yield of 93.3%, 95.5%, 91.7%, 76.9%, and 66.7% in corresponding lesion types. No cancer was diagnosed solely by BAL-cytology. Proportions of patients with positive BAL culture did not differ significantly between patients with and without pre-test suspicion for infections (P=0.199). In multivariable analysis, infections were associated with age ≥75 (OR 3.0; 95% CI: 1.29-7.06), chronic obstructive pulmonary disease (COPD) (OR 2.7; 95% CI: 1.14-6.26) and diabetes mellitus (DM) (OR 4.5; 95% CI: 1.90-10.44). CONCLUSIONS: Omitting BAL cytology in settings of comprehensive bronchoscopy may not compromise cancer diagnosis. For patients primarily suspected with thoracic malignancy, performing BAL culture only based on clinical suspicion could miss important infectious etiology.

The International Association for the Study of Lung Cancer Consensus Statement on Optimizing Management of EGFR Mutation-Positive Non-Small Cell Lung Cancer: Status in 2016.

Mutations in the epidermal growth factor receptor gene (EGFR) represent one of the most frequent "actionable" alterations in non-small cell lung cancer (NSCLC). Typified by high response rates to targeted therapies, EGFR tyrosine kinase inhibitors (TKIs) are now established first-line treatment options and have transformed the treatment paradigm for NSCLC. With the recent breakthrough designation and approval of the third-generation EGFR TKI osimertinib, available systemic and local treatment options have expanded, requiring new clinical algorithms that take into account individual patient molecular and clinical profiles. In this International Association for the Study of Lung Cancer commissioned consensus statement, key pathologic, diagnostic, and therapeutic considerations, such as optimal choice of EGFR TKI and management of brain metastasis, are discussed. In addition, recommendations are made for clinical guidelines and research priorities, such as the role of repeat biopsies and use of circulating free DNA for molecular studies. With the rapid pace of progress in treating EGFR-mutant NSCLC, this statement provides a state-of-the-art review of the contemporary issues in managing this unique subgroup of patients.

Surgical resection of limited disease small cell lung cancer in the new era of platinum chemotherapy: Its time has come.

OBJECTIVE: Although resection is not the standard of care in treating small cell lung cancer, new platinum drugs and modern staging have allowed the role of surgery to be reevaluated. METHODS: We reviewed our institutional experience of 1415 patients with small cell lung cancer from 1976 to 2002 among whom 82 (6%) underwent surgery with curative intent. RESULTS: Median age at surgery was 62 years, and small cell lung cancer of mixed morphology represented 14 of 82 (17%). Treatment consisted of surgery alone in 11% of cases (9/82), surgery with neoadjuvant therapy in 22% (18/82), and surgery with adjuvant therapy in 55% (45/82). Prophylactic cranial irradiation was given to 23% (19/82). The 5-year survival of the entire cohort was 42%. The 5-year survival of patients receiving adjuvant chemotherapy (n = 41) was significantly different according to whether patients had received platinum or nonplatinum regimens (68% vs 32.2%, P = .04). Among patients with stage I disease who received adjuvant chemotherapy (n = 24), the 5-year survivals for patients receiving platinum and nonplatinum chemotherapy were 86% and 42%, respectively ( P < .02). If patients who received either neoadjuvant or adjuvant therapy (n = 56) were considered, the 5-year survival was significantly better for platinum than for nonplatinum chemotherapy (62% vs 36%, P = .05). The 5-year survival was also better for those undergoing lobectomies (n = 52) than for those with limited resections (n = 15, 50% vs 20%, P = .03). Survival outcomes also differed by gender, with female patients having a 5-year survival advantage over male patients (60% vs 28%, P = .004). CONCLUSION: These results support a reevaluation of the role of surgery in the multimodality therapy for small cell lung cancer, which currently includes only radiotherapy and chemotherapy.

Exfoliative sputum cytology of cancers metastatic to the lung.

Although largely replaced by fine-needle aspiration (FNA) and bronchoscopy, cytological examination of sputum for exfoliated malignant cells still is considered a valuable initial diagnostic test in patients presenting with a lung mass. Thirty-five cases of secondary/metastatic tumors involving the lung and diagnosed on sputum were retrospectively reviewed from our cytopathology files for a period of 22 yr (1980-2001). Clinical history and the relevant histopathological material were examined and correlated with the cytological findings. In all cases, a history of malignancy was known. Cytological diagnoses included colonic adenocarcinoma (7 cases); non-Hodgkin's lymphoma (NHL; 5 cases); malignant melanoma (MM; 5 cases); breast carcinoma (5 cases); Hodgkin's lymphoma (HL; 3 cases); pancreatic adenocarcinoma (2 cases); prostatic adenocarcinoma (2 cases); and 1 case each of urothelial carcinoma, endometrial carcinoma, renal cell carcinoma, hepatic small-cell carcinoma, squamous-cell carcinoma (cervix), and leiomyosarcoma (LMS). Cellular preservation was optimal in all cases. The smear background was relatively clean in 25 (71%) cases and predominantly inflamed and/or necrotic in 10 (29%) cases. In non-lymphoid tumors (27 cases), isolated single malignant cells were seen in 7 (26%) cases (all cases of MM and prostatic adenocarcinoma), whereas 20 (74%) cases displayed fragments with intact tumor architecture. Overall, only 10/35 (29%) cases showed noticeable tumor-cell necrosis. In one case (LMS), cell block sections were used for immunoperoxidase (IPOX) studies with positive staining for desmin and actin. Exfoliation of cancer cells in sputum from secondary tumors in the lung is a rare phenomenon in current-day practice, with metastatic colonic adenocarcinoma seen most commonly. Intact tumor architecture was observed in exfoliated cells in 75% of the cases.

Tissue diagnosis of suspected lung cancer: selecting between bronchoscopy, transthoracic needle aspiration, and resectional biopsy.

In pursuing a tissue diagnosis of a suspected lung cancer, there is a range of procedures to choose from. The principal goals are ideally to diagnose and pathologically stage the patient's lung cancer at the same time, preferably by using the safest, least invasive, and least costly tests. If there is clinical or radiographic evidence of extrapulmonary spread of disease, including supraclavicular N3 nodal involvement or a malignant pleural effusion, then radiology-guided or open biopsy will confirm tumor cell type and stage the patient as unresectable. For patients with symptoms, such as increasing cough or hemoptysis, that are suggestive of airways involvement. with or without radiographic finding of central lesions, sputum cytology is the least invasive study with a high specificity. A positive finding of cancer is especially helpful if the patient is not a surgical candidate because of anatomic location of the lesion or severe physiologic limitations. The limited sensitivity of sputum cytology and poor NPV may improve with improved sputum induction and collection and processing techniques. Bronchoscopy with direct examination of the visible airways is most often the preferred invasive diagnostic procedure. Although the procedure should be geared toward sampling the highest staged lesion to provide an accurate tissue staging at the time of diagnosis, additional procedures can be performed in sequence to sample different nodal stations, is well as the primary lung mass. The incidental finding of an unexpected central airways lesions or a synchronous second endobronchial lung primary will also affect plans for treatment. Autofluorescence bronchoscopy can improve the sensitivity for detecting early intraepithelial neoplasia. Bronchoscopy for central and peripheral lung masses that are suspected to be lung cancer should be performed with ROSE whenever available. For visible endobronchial lesions, given the similar yield of EBBX and EBNA, EBNA may provide an immediate diagnosis, thus obviating additional, possibly morbid, procedures such as BB or EBBX. For submucosal lesions, EBNA is superior. For central cancers that are peribronchial, TBNA performed as for regional nodal sampling should have a yield that is comparable to TBNA for staging. TBBX and TBNA of peripheral nodules that are smaller than 3 cm have a lower diagnostic yield. Coming generations of thin bronchoscopes and improved radiographic guidance systems may improve our ability to biopsy these lesions with greater accuracy and safety. Under all circumstances, immediate cytology feedback with ROSE will confirm the adequacy of the retrieved specimen for a definitive tissue diagnosis, thus avoiding the need for extra biopsies, or worse yet, the need for a second invasive procedure because of insufficient diagnostic material. ROSE is educational to the clinician and fellow-in-training in getting immediate feedback on the procedural techniques and in learning pulmonary pathology, as well. The diagnostic sensitivity of TTNA is high, especially for the larger peripheral-based lung lesion, and TTNA is a relatively rapid procedure. TTNA's sensitivity falls for smaller or more central lesions, where the false negative rate can approach 25% to 30%; the risk of pneumothoraces and bleeding increases with central biopsies. Furthermore, TTNA usually does not provide information about nodal staging, unless the TTNA is initially directed toward central lymph nodes. The central airways are not examined in the same appointment to address issues of resection margins when there may be central spread of disease. TTNA should, therefore, be held in reserve for cases in which the sputum cytology and subsequent bronchoscopy are negative, and the patient is not a surgical candidate or refuses surgery, even if the cancer is potentially resectable. TTNA may then provide the tissue diagnosis to permit initiation of cytotoxic chemotherapy and radiotherapy. TTNA may also be helpful in cases where the likelihood of cancer is only intermediate, such that a specific benign diagnosis or an adequate sample without cancer will greatly reduce the likelihood ratio of missing a cancer, and justify to the patient and physician an approach of careful observation. To maximize the yield of these diagnostic procedures, there must be continued improvement in the hands-on teaching of clinical fellows and pulmonary practitioners in the use of the various techniques of TBNA and TBBX, as well as the applications of new endoscopic technology, such as EBUS. Definitive curative surgery remains the goal for patients with lung cancer, with accurate pathological staging performed intraoperatively. Complete lobectomy or pneumonectomy remains the standard resectional approach. Therefore, for patients with sufficient cardiopulmonary reserve who can be clinically staged as IA or IB, either by good quality CT with contrast or increasingly with 18-FDG PET, the initial tissue diagnosis may be at the time of surgery, when a frozen section preceding a complete lobectomy with lymph node sampling will combine diagnosis and therapy.

Ultrathin bronchoscopy in the diagnosis of peripheral cavitary lung lesions.

Ultrathin (UT) bronchoscopy has emerged as a useful tool to diagnose peripheral solid lung lesions of a malignant nature. This technology is superior to standard bronchoscopic techniques, which have low yield in identifying small lesions, especially as they extend further out along the bronchial tree. UT bronchoscopy can prevent the need to pursue more invasive open lung strategies to diagnose suspicious lesions. In this report, we present 3 distinct clinical scenarios where UT bronchoscopy was successful in diagnosing benign peripheral cavitary lesions after standard techniques failed. The use of UT bronchoscopy in each case was instrumental in allowing rapid initiation of appropriate therapy without need for more invasive surgical biopsies in the setting of a benign condition.

SH3GL2 is frequently deleted in non-small cell lung cancer and downregulates tumor growth by modulating EGFR signaling.

The purpose of this study was to identify key genetic pathways involved in non-small cell lung cancer (NSCLC) and understand their role in tumor progression. We performed a genome wide scanning using paired tumors and corresponding 16 mucosal biopsies from four follow-up lung cancer patients on Affymetrix 250K-NSpI array platform. We found that a single gene SH3GL2 located on human chromosome 9p22 was most frequently deleted in all the tumors and corresponding mucosal biopsies. We further validated the alteration pattern of SH3GL2 in a substantial number of primary NSCLC tumors at DNA and protein level. We also overexpressed wild-type SH3GL2 in three NSCLC cell lines to understand its role in NSCLC progression. Validation in 116 primary NSCLC tumors confirmed frequent loss of heterozygosity of SH3GL2 in overall 51 % (49/97) of the informative cases. We found significantly low (p = 0.0015) SH3GL2 protein expression in 71 % (43/60) primary tumors. Forced overexpression of wild-type (wt) SH3GL2 in three NSCLC cell lines resulted in a marked reduction of active epidermal growth factor receptor (EGFR) expression and an increase in EGFR internalization and degradation. Significantly decreased in vitro (p = 0.0015-0.030) and in vivo (p = 0.016) cellular growth, invasion (p = 0.029-0.049), and colony formation (p = 0.023-0.039) were also evident in the wt-SH3GL2-transfected cells accompanied by markedly low expression of activated AKT(Ser(473)), STAT3 (Tyr(705)), and PI3K. Downregulation of SH3GL2 interactor USP9X and activated ß-catenin was also evident in the SH3GL2-transfected cells. Our results indicate that SH3GL2 is frequently deleted in NSCLC and regulates cellular growth and invasion by modulating EGFR function.

Transcutaneous computed bioconductance measurement in lung cancer: a treatment enabling technology useful for adjunctive risk stratification in the evaluation of suspicious pulmonary lesions.

Lung cancer is the number one cause of cancer deaths in North America and is rapidly increasing worldwide. Although there are advances being made in the multidisciplinary management and combined-modality therapies of lung cancers, most cases are still diagnosed in later noncurable stages. Early detection has hinged on clinical risk assessment and on the future possibility of screening by low-dose computed tomography of the chest; however, this will only vastly increase the number of indeterminate pulmonary lesions (IPLs) being detected. Given that the majority of radiographically detected lung lesions are benign, and tissue confirmation by various invasive biopsy tests has increased risks and costs, a noninvasive adjunctive test that can stratify likelihood of an indeterminate lung lesion as malignant or benign will be a useful treatment-enabling technology to speed up diagnosis and treatment of lung cancers at a more curable stage and defer unnecessary invasive procedures that have potential for harm. Measurement of transcutaneous bioconductance using the differential conductivity properties of cancerous versus benign tissue has been previously demonstrated on nonlung lesions. Thus, it has the potential of being a noninvasive, simple-to-perform and repeatable test that may be valuable in assessing lung lesions. In this prospective study of subjects with known thoracic malignancies, computed bioconductance measurements discriminated between malignant lesions (29 primary lung cancers) from benign pathology (12) across a range of IPL sizes (0.8 cm and greater) with a sensitivity of 89.7% (positive predictive value 96.3%) and specificity of 91.7% (negative predictive value 78.5%). The technology seems to be effective across a range of tumor thoracic locations, cell types, and stages. Additional cohorts of subjects will be used to validate testing and for refinement of the current algorithm, which at present has a test performance with a receiver operating characteristic of 90.7%. Noninvasive transcutaneous computed bioconductance measurement can become a standard risk assessment and therapy-enabling tool in the evaluation of IPLs.