Comprehensive molecular portrait using next generation sequencing of resected intestinal-type gastric cancer patients dichotomized according to prognosis.

In this study, we evaluated whether the presence of genetic alterations detected by next generation sequencing may define outcome in a prognostically-selected and histology-restricted population of resected gastric cancer (RGC). Intestinal type RGC samples from 34 patients, including 21 best and 13 worst prognostic performers, were studied. Mutations in 50 cancer-associated genes were evaluated. A significant difference between good and poor prognosis was found according to clinico-pathologic factors. The most commonly mutated genes in the whole population were PIK3CA (29.4%), KRAS (26.5%), TP53 (26.5%) MET (8.8%), SMAD4 (8.8%) and STK11 (8.8%). Multiple gene mutations were found in 14/21 (67%) patients with good prognosis, and 3/13 (23%) in the poor prognosis group. A single gene alteration was found in 5/21 (24%) good and 6/13 (46%) poor prognosis patients. No mutation was found in 2/21 (9.5%) and 4/13 (31%) of these groups, respectively. In the overall series, ß-catenin expression was the highest (82.4%), followed by E-Cadherin (76.5%) and FHIT (52.9%). The good prognosis group was characterized by a high mutation rate and microsatellite instability. Our proof-of-principle study demonstrates the feasibility of a molecular profiling approach with the aim to identify potentially druggable pathways and drive the development of customized therapies for RGC.

Somatostatin receptor imaging of small cell lung cancer (SCLC) by means of 111In-DTPA octreotide scintigraphy.

Somatostatin receptors have been described on the membrane of neoplastic cells derived from the APUD system and their expression has also been demonstrated on small cell lung cancer (SCLC) in vitro and in vivo. 21 patients with SCLC were studied using 111In-octreotide (111In-OCT) scintigraphy. Scintigraphic examinations were performed following intravenous (i.v.) injection of 111 MBq 111In-OCT with whole-body scintigraphy and planar scintigraphy of the thorax as well as the SPET technique. No short-term side effects were described following 111In-OCT administration. We studied the 111In-OCT biodistribution in 3 patients with serial scintigraphies at 1, 5 and 24 h. We used the 5 h as standard scanning time for the following 18 patients. The scintigraphic results were compared with those of other conventional diagnostic procedures. 111In-OCT detected 86% (48/56) of the lesions already known at the time of scintigraphy. It was positive in all 20 SCLC patients and negative in one lung adenocarcinoma. 111In-OCT showed high sensitivity for mediastinal metastases (94%) and good sensitivity for bone metastases (75%) and abdominal lymph node metastases (71%). 111In-OCT did not detect two liver metastases. 111In-OCT detected five unknown lesions which were confirmed by other diagnostic examinations. 111In-OCT was also effective in cancer patients with low levels of NSE. Our study shows that 111In-OCT scintigraphy is a reliable, non-invasive technique to detect primary SLCL and its locoregional or distant metastases. The clinical utility of receptor status characterisation obtained with 111In-OCT scintigraphy should be evaluated by means of an appropriate prospective study.

A summary of the Milan experience with multimodality therapies in patients with small cell lung cancer: attempts to improve long-term outcome.

From February 1985 to June 1993, 173 consecutive, previously untreated patients with small cell lung cancer received individualized treatment tailored to disease extent. Almost all patients (14 of 16) with stage I and II disease and 30 patients with operable stage III disease were submitted to surgery preceded or followed by chemotherapy. Chest irradiation and prophylactic brain radiotherapy (in complete responders) were administered at the end of treatment in 42 of 44 cases. Patients with inoperable limited disease received chemotherapy followed by radiotherapy in 67 of 71 cases, while chemotherapy alone or followed by radiotherapy in sites of either initially bulky or residual disease was administered to 58 patients with extensive disease. The overall response rate was 77% (complete response, 45%; partial response, 32%). Complete responses were documented more frequently in limited disease than in extensive disease (57% v 22%; P < .001). The 2- and 5-year freedom from progression rates (24% and 16%, respectively), as well as overall survival rates (31% and 16%, respectively) were significantly affected by disease extent. No patient with extensive disease was progression free and alive at 2 years, while more than half of stage I and II patients were disease free and alive at 5 years. This retrospective analysis performed on a large number of consecutive, nonrandomized patients suggests that, at least in patients with limited disease, it is possible to achieve favorable long-term results using treatment tailored to disease extent. Nonetheless, the disappointing results commonly achieved in the treatment of small cell lung cancer strongly support the need for either prospective, randomized studies to confirm recently reported improved results or new pilot studies with investigation of entirely innovative approaches.

Preoperative concomitant cisplatin/VP16 and radiotherapy in stage III non-small cell lung cancer.

PURPOSE: To evaluate the therapeutic effectiveness of a combined chemoradiotherapy program, followed by surgery in selected cases, in Stage III non-small cell lung cancer. METHODS AND MATERIALS: Between August 1988 and February 1990, 43 patients Staged IIIa-b (UICC 1987, 58% IIIb) have been treated with concomitant chemotherapy (cisplatin 15 mg/m2 and VP16 75 mg/m2, 5 days a week on week 1 and 5) and radiotherapy (40 Gy split course, 2 Gy/day on week 1, 2, 5, and 6), followed by attempted curative thoracotomy or more cycles of full dose chemotherapy with the same two drugs. RESULTS: Planned chemoradiotherapy has been given to 91% of patients; 13/43 patients have been operated, with 12 complete resections and three (7%) pathological complete responses. Toxicity was significant, with two postoperative deaths and two fatal radiation pneumonitis. Crude progression-free survival rate is 21% at 30 months, with nine patients (21%) alive and free from progression at follow-up times ranging from 31 to 49 months. Subset survival analysis showed a possibly greater therapeutic effect for non-squamous histology as compared to squamous carcinoma. CONCLUSION: These results are encouraging in a cohort of patients with quite advanced disease (58% Stage IIIb).

Massive infiltration of basophilic cells in inflamed tissue after injection of RANTES.

Regulated upon activation normal T expressed and secreted (RANTES) is a new inducible protein member of the human C-C branch of chemokines. RANTES is a potent monocyte and lymphocyte chemoattractant and is a mediator of inflammatory responses. In these studies we found that RANTES 10 ng/50 microl chemoattracts basophilic cells in a dose-dependent manner 4 h after an intradermal injection in rat skin sites, as revealed by optic microscopy. Moreover, in biopsy specimens from rat skin injection sites histamine release was significantly higher (P < 0.05) than in controls (PBS 50 microl) after 4 h from RANTES treatment. The presence of basophilic cells in rat skin injection sites after RANTES-treatment was also confirmed by electron microscopy studies. In addition, histidine decarboxylase (HDC) mRNA was increased in rat skin sites injected with RANTES compared to sites injected with PBS (controls). Our report describes additional biological activities for RANTES, suggesting that this human chemoattractant protein may play a fundamental role in histamine and HDC generation, along with basophilic cell recruitment.

Prognosis of resected well-differentiated neuroendocrine carcinoma of the lung.

Among lung tumors, well-differentiated neuroendocrine carcinomas are often misdiagnosed or may go unrecognized. Nineteen cases of well-differentiated neuroendocrine carcinoma (WDNC) were assessed at the National Cancer Institute of Milan over a ten-year period. There was only one woman and the age range was 50 to 77 years. Most of the patients were smokers (83 percent). All tumors were radically resected. There were 12 lobectomies, two sleeve-lobectomies, three bilobectomies, one pneumonectomy, and two segmentectomies (one patient had two synchronous WDNCs). There was neither operative mortality nor major complications. Sixteen tumors were stage 1, three were stage II, and one was stage IIIa. Five patients had adjuvant chemotherapy (cyclophosphamide, doxorubicin, and vincristine [CAV] regimen). One patient was given local or regional radiotherapy. In ten patients the tumors recurred, even though four had had adjuvant treatment. The brain was the first site of metastasis in seven cases. The pathologic stage seemed not to be closely related to the appearance of metastases (six patients with stage I disease had recurrences). Only two patients with recurrence were still alive 12 and 103 months after the procedure. The percentage of survival for patients with stage I disease after more than 100 months was 68 percent. WDNC is similar to small-cell lung carcinoma (SCLC) with regard to the neurotropism of metastases. Surgery is curative for more than one half of the patients with localized disease. Therefore, multimodal therapy, probably based on tumor behavior and investigations of tumor markers, is advisable.

Influence of interleukin-1 receptor antagonist on [3H]serotonin and histamine release by rat basophilic leukemia-2H3 cells.

Mast cells located in connective tissues are a potent source of vasoactive and inflammatory mediators, such as cytokines. They accumulate in tissues in a wide variety of diseases where their function in most cases in unclear. In this report we provide evidence that rat basophilic leukemia cells (RBLC) cultured with a natural inhibitor of IL-1, interleukin-1 receptor antagonist (IL-1RA) (500 ng/ml) for 48 h, strongly inhibited the spontaneous release of serotonin (5HT) (from 25.2 to 29.9%), and histamine (from 22.50 to 43.49%), compared to untreated cells (control). When IL-IRA-treated and -untreated RBLC were stimulated with a secretagogue (anti-IgE), no difference was found in the percent of 5HT and histamine release. The present studies describe an additional biological activity of IL-1RA, inhibiting histamine and 5HT spontaneous release from RBLC cultures.

A new polymorphism (Ser362Thr) of the L-myc gene is not associated with lung adenocarcinoma risk and prognosis.

The non-coding variation in the second intron of the L-myc gene, generating an EcoRI polymorphism, is associated with lung cancer risk and prognosis. We carried out sequence analysis of the L-myc gene in lung adenocarcinoma (ADCA) patients to identify functional polymorphisms and identified a new single nucleotide polymorphism (SNP) in the third exon of the gene causing a Ser362Thr conservative amino acid change in the C-terminus of the encoded protein. This polymorphism showed significant linkage disequilibrium with the L-myc EcoRI polymorphism located at 1751 bp distance. Genotyping of the Ser362Thr SNP in 220 Italian ADCA patients and in 230 general population controls revealed a similar low frequency (0.10-0.11) of the Thr allele in both groups. The multivariate odds ratio was 0.68 (95% confidence interval (CI) 0.38-1.22). In the ADCA patients, no significant association between the Ser/Thr polymorphism and survival was observed. Thus, the present results do not support candidacy of the L-myc Ser362Thr polymorphism for the functional polymorphism of the L-myc genomic region.

Evaluation of the soluble fragments of cytokeratin 19 (CK19) in non-small cell lung cancer (NSCLC).

This study compared the diagnostic efficacy of serum CK19 determination (Cyfra 21-1) with other tumour markers, such as CEA, SCC, NSE, TPA, in patients with resected non-small lung cancer. Tumour marker levels were tested in 90 patients with benign lung disease and at diagnosis in 72 patients with proven NSCLC, 39 squamous cell carcinoma and 33 adenocarcinoma. At presentation baseline levels of all tumor markers were significantly higher (p<0.05) in lung cancer patients than in control subjects, except for NSE. A significant increase (p<0.05) in serum concentrations was observed from stage I to stage IIIb only for Cyfra 21-1 (stage I/II, median=2.7 ng/ml; stage IIIb, median=6.3 ng/ml) and TPA (stage I/II, median=89.8 IU/ml; stage IIIb, median=170.7 IU/ml). Receiver operating characteristic (ROC) analysis was performed to evaluate the best threshold values and the global accuracy of each marker. The highest global sensitivity for NSCLC was reached by TPA (70.8%), whereas that of Cyfra 21-1 was 50%. According to tumour histology, significant difference (p<0.05) in serum levels were found only for CEA (adenocarcinomas, median=5.6 ng/ml; squamous cell carcinoma, median=3.2 ng/ml) and SCC (adenocarcinomas, median=1.0 ng/ml; squamous cell carcinoma, median=1.5 ng/ml). As regards squamous cell carcinoma histotype, the highest sensitivity was obtained by TPA (74.4% at a specificity of 62.2%) and for adenocarcinomas by CEA (78.8% at a specificity of 85.6%). Tumour marker levels were also determined during the follow-up of 10 patients. The best sensitivity in detecting relapses was shown by CEA (90%), followed by TPA (70%), SCC (50%), Cyfra 21-1 (40%) and NSE (10%), even though the CEA test displayed a high percentage of false positive results (98.1%) in patients with no evidence of disease (NED).

Pattern of mucin gene expression in normal and neoplastic lung tissues.

This work evaluates the expression in lung cancer of the most well characterized mucin genes (MUC1, MUC2, MUC3) and of the recently described MUC4 in lung tissues, to check a correlation between the expression of any particular gene and this tumor. Hybridization with synthetic oligonucleotides obtained from a part of the sequences of MUC1, MUC2, MUC3 and MUC4, was performed on blotted RNA from 18 lung cancer tissue specimens and from 10 normal tissues samples taken, when possible, from the normal lung counterpart. By means of Northern blot analysis MUC1 revealed to be the most expressed mucin gene in lung cancer, followed by MUC4; by contrast, the expression of MUC2 and MUC3 was almost undetectable in all cancer specimens. The intensity of expression of MUC1 and MUC4 was always superior in cancer tissue than in the normal counterpart. As expected, the highest reactivity for MUC1 and MUC4 expression was observed mainly in the adenocarcinoma histotype which is mucin secreting. These findings represent a contribution to the study of mucin gene pattern in lung cancer, and, in particular, indicate that MUC4, in association with the MUC1 gene, seems to be strongly expressed in this neoplastic disease.

Tumour markers CEA, NSE, SCC, TPA and CYFRA 21.1 in resectable non-small cell lung cancer.

BACKGROUND: In the last few years, several prognostic factors have been investigated in order to identify among patients with completely resected non-small cell lung cancer (NSCLC) subsets at high risk of recurrence. In this context, the actual role of serum tumour markers is still unclear. The aim of this study was to evaluate the prognostic significance of preoperative CEA, NSE, SCC, TPA and CYFRA 21.1 serum levels in 62 patients submitted to radical surgery for non-small cell lung cancer (NSCLC). The predicting ability of these tumour markers with respect to histological type and pathological stage was also assessed. PATIENTS AND METHODS: After informed consent was obtained, the preoperative serum concentrations of the tumour markers CEA, NSE, SCC, TPA and CYFRA 21.1 were measured by means of immunometric assays in 62 patients referred to our Institutions from January to December 1992. All patients had resectable, histologically proven NSCLC and were submitted to radical surgery. Overall survival (OS) was calculated as the time elapsed from surgery to the date of death or last clinical evaluation; the prognostic effect of the tumour markers was investigated by Cox multiple regression models. RESULTS: Fifty-six patients were male and 6 female; median age was 62 years. Thirty-four patients had a histological diagnosis of adenocarcinoma and 28 of squamous cell carcinomas. With regard to pathological stage, 32 patients had stage I, 4 patients had stage II and 23 patients had stage IIIA disease. In this series of patients, at a median follow-up of 55 months after surgery, we found that both TPA and CYFRA 21.1 serum levels at the time of diagnosis were reliable predictors of overall survival high values of these markers being associated with worse prognosis. CONCLUSIONS: Our findings suggest that in completely resected NSCLC, TPA and CYFRA 21.1 preoperative serum levels might provide a useful tool for stratifying subgroups of patients with different chances of disease recurrence after surgery.

Preoperative CEA, NSE, SCC, TPA and CYFRA 21.1 serum levels as prognostic indicators in resected non-small cell lung cancer.

In 62 patients affected by resectable non-small cell lung cancer (NSCLC) submitted to radical surgery we evaluated the prognostic significance of CEA, NSE, SCC, TPA, and CYFRA 21.1 serum levels at diagnosis, as well as the predictive ability of these tumor markers with respect to histological type and pathological stage. The group was composed of 56 male and 6 female patients; the median age was 62 years (range 29-73 years). Thirty-four patients had a histological diagnosis of adenocarcinoma and 28 of squamous cell carcinoma; with regard to pathological stage, 32 patients had stage 1, 4 patients stage II and 23 patients stage IIIA disease. A good predictive ability with respect to histological type was obtained with SCC serum levels; as for pathological stage, TPA and CYFRA 21.1 were found to have moderate predictive ability. In this series of patients, at a median follow-up of 55 months after surgery, we found that both TPA and CYFRA 21.1 serum levels at diagnosis were reliable predictors of overall survival, high values of these markers being associated with a worse prognosis.

A rare complication of surgical management for esophageal tumor: a non neoplastic belated fistula between stomach and main right bronchus.

The fistula between stomach and bronchus after surgery for cancer of the esophagus is a rare occurrence. We describe a gastric non neoplastic ulceration that arose late after six years from an esophagectomy, with an end-side cervical esophagogastrostomy, for a spino-cellular carcinoma. After the partial failure of surgical technique, of the endoscopic treatment and for the bad general conditions of patient we decided to treat the fistula by transluminal drainage. This technique involved a progressive resolution of the fistula, becoming, nowadays, in our division, the preferred treatment for these kinds of postoperative complications.

Clinical and pathologic predictors of survival in patients with thymic tumors.

BACKGROUND: The aim of this study is to evaluate the impact of thymectomy in patients with thymic neoplasms and to identify clinical and histopathological factors associated with improved long-term outcome of surgery. METHODS: We treated 74 patients between February 1987 and July 1993. There were 29 total and 36 simple thymectomies. These last cases, all non-myasthenic, had benign thymomas (n=30) but 6 had thymic carcinomas. Nine tumors were no-resected (5 thymomas and 4 thymic carcinomas). Minimum follow-up by Department of Thoracic Surgery Istituto Nazionale Tumori was 60 months after thymectomy. We divided the specimens according to Marino and Muller-Hermelink's classification: 54 thymomas, 18 thymic carcinomas and 2 no-diagnosis specify thymomas. There were 53 stage I, 1 stage II, 13 stage III, 5 stage IVa and 2 stage IVb according to Masaoka. RESULTS: Forty-six patients with treated thymoma were alive without disease at the end of follow-up, the remaining 8 died from recurrence in 6, a new tumor in 1 and a heart attack in the last. Of 18 thymic carcinomas 9 were alive at the end of follow-up (1 with recurrence), only 4 dead from recurrence. The actuarial survival of patients with thymomas was 88.5% at 5 years, (73.6% in cortical type, 85.7% in medullary type, 93.9% in mixed type, 100% in predominantly cortical type). Myasthenia gravis didn't influence the survival: 87.3 (no MG) vs 90%. Advanced stage thymomas significantly increased the risk of death from early stage I: 32.4 vs 100% at 5 years. In thymic carcinoma patients with well-differentiated thymic carcinoma (WDTC) died less than others: the actuarial probability of survival at 5 years was 90 vs 68%. CONCLUSIONS: Thymectomy was the best treatment to long term outcome. In our experience, survival was related to histotype and to local extension of tumor.

[Prognosis of melanoma of the vulva (author's transl)]. / Prognosi del melanoma della vulva

From 1930 to 1972, 27 cases of melanoma of the vulva were treated at the National Cancer Institute of Milan. Prognosis was evaluated in relation to the therapy, the anatomical site, the lymphnodes metastases and the classification according to Clark. The median survival was 20 months and the 4-yr survival was 19%. The authors reached the following conclusions: site and T of melanoma have no prognostic value; survival is strictly related to the lymphnodes metastases and to Clark's classification: no N+ patients survived longer than two years while 62% of N-- patients are still alive after four years. No survival after 2 years was observed in IV-V class of Clark while a 54% survival after 4 years was observed in II-III class of Clark. Surgery gives the best results while radiotherapy as single treatment is useless and its role as adjuvant postoperative therapy is still uncertain.

Five-year recurrence probabilities in 330 patients curatively resected for stage Ia bronchogenic carcinoma.

Three hundred and thirty consecutive cases of resected Stage Ia (TNM UICC classification) lung carcinomas were retrospectively reviewed with the aim of evaluating actuarial probabilities of recurrence within the 5th year from operation, according to the extent of resection, the cell type, and the T number. The probabilities of recurrence according to the pattern of failure were also assessed. Five-year overall probability of recurrence was 46.3%. Pneumonectomies showed a lower rate of relapse (37.4%) than lobectomies (49.2%), even though non significant. However, patients submitted to a lobectomy had a higher rate of 5-year survivors. Cell type had no significant impact on the probability of recurrence. 35.5% of patients with T1 carcinomas had evidence of relapse compared with 51.1% of patients with T2 tumors. This datum is explained by the presence in T1 group of a high share of squamous cell cases. Patients with T1 squamous cell carcinomas had, in fact, the best prognosis (26.5% recurred) among the subgroups obtained by stratification of T number and cell type together; loco-regional failure as exclusive modality of relapse had a 5-year rate of 19.7% and metastatic failure of 30.0%. Adenocarcinomas had a significantly higher impact on the occurrence of brain metastases.

Estrogen receptors and MPA treatment in metastatic renal carcinoma. A preliminary report.

Ten previously untreated patients with metastatic renal carcinoma underwent transperitoneal radical nephrectomy followed by high dosage MPA treatment. Estrogen receptors were determined in the specimen of all cases by the dextran-coated charcoal method: both the neoplastic tissue and the healthy parenchyma were tested. The disease progressed in 8 cases, and 2 patients are alive without any evidence of progressive disease 12 and 27 months after the operation. Very low receptor levels were detected in these 2 cases and one of them could be defined as borderline with our threshold criterion. However, receptors were undetectable in the neoplastic tissue from 4 of 8 patients who progressed. These questionable results justified the start of a prospective multicentric trial to study in a large number of cases both hormone receptors and clinical response to hormone therapy in human renal cancer.

Lobectomy with bronchoplastic procedures for lung cancer.

From April 1970 to October 1977, 19 patients with lung cancer of the upper lobar bronchus orifice underwent radical lobectomy with major bronchus resection. Sleeve lobectomy was accomplished in 11 cases and wedge lobectomy in the remaining 8. The length of the free bronchial margin in the surgical specimen was less than 1 cm in 3 cases, but limited pulmonary reserve did not allow pneumonectomy. Squamous carcinoma was diagnosed in 14 patients, adenocarcinoma in 2, oat-cell carcinoma in 2, and large cell carcinoma in one. Most cases (70%) were pathological stage I. There was one operative death due to anastomotic leakage (5%), and another patient required pneumonectomy completion. Of 13 patients with non oat-cell carcinoma and adequate bronchial resection, none had local recurrence: 3 patients developed distant metastases, and 10 are alive and disease-free after a follow-up period ranging from 16 to 104 months. The authors conclude that in selected lung cancer patients lobectomy with bronchoplastic procedures is superior to pneumonectomy for tissue sparing advantages.

Preoperative irradiation and surgery for esophageal cancer: causes of failure.

Twenty-seven patients with squamous esophageal cancer underwent small volume, low-dose, concentrated radiotherapy followed by esophageal resection whenever possible (esophagectomy for tumors of the thoracic esophagus and esophagogastrectomy for tumors of the lower esophagus). Curative resectability was 70% (19/27) with 4 operative deaths (21%). Recurrence rate was 66% after a mean period of 16 months, and the failure pathway was nodal in 53% of the cases. Historical comparison of the data suggests that preoperative irradiation increases the curative resectability rate without changing the early recurrence rate or failure pathway. Tumors with deeper invasion of the esophageal wall, which benefit by preoperative irradiation, are probably related to greater nodal diffusion, which is partly outside of the volume that may be resected or irradiated.

Late results after sleeve or wedge lobectomies for non-small-cell lung carcinoma.

From January 1971 to June 1983, 35 lobectomies with bronchoplastic procedures for invasive non-small-cell lung carcinoma were performed. Sleeve lobectomy was carried out in 21 cases, wedge lobectomy in 11, and upper sleeve bilobectomy in 3. There were 23 stage I, 10 stage II, and 2 stage IIIa tumors. Completion pneumonectomy was required in 1 case for anastomotic fistula and in 2 for atelectasis of residual lung. One of these patients died later due to empyema. The 5-year probability of death with recurrence was 31.98%. The 5-year disease-free survival was 58.57%. Metastatic relapse was observed in 8 cases and loco-regional recurrence in 5. A new primary lung tumor occurred in 2 patients.