Combination effect between bortezomib and tumor necrosis factor alpha on gefitinib-resistant non-small cell lung cancer cell lines.

Tumor cells that have acquired resistance to gefitinib may complicate the future treatment of patients with non-small cell lung cancer (NSCLC). To investigate the mechanisms of acquired resistance, an acquired gefitinib-resistant cell line, PC-9/ZD2001, has been established using a gefitinib-sensitive NSCLC cell line, PC-9. PC-9/ZD2001 showed collateral sensitivity to tumor necrosis factor (TNF)-alpha. Bortezomib is a proteasome inhibitor and enhances TNF-alpha-induced cell death. These observations suggest that the combination of bortezomib and TNF-alpha might have effects against gefitinib-resistant cells. To verify this hypothesis, a combination effect between these drugs was examined using MTT assay and immunoblotting. This combination showed synergistic cytotoxic effect in NSCLC cell lines with either acquired or intrinsic gefitinib resistance. However, this combination effect was not observed in gefitinib-sensitive cells. On the other hand, bortezomib inhibited TNF-alpha-induced IkappaB degradation in all cell lines. From these observations, it is concluded that the combination of bortezomib and TNF-alpha could be used to overcome gefitinib-resistance.

[Two cases with recurrent non-small cell lung cancer successfully treated with cisplatin and S-1].

We report two cases with recurrent non-small cell lung cancer (NSCLC) successfully treated with cisplatin and S-1 after multiple chemotherapy. A 64-year-old woman was diagnosed with adenocarcinoma, yield-T4N2M1, stage IV. She was treated with cisplatin 60 mg/m(2) (day 8) and S-1 80 mg/m(2) (days 1-21) as sixth-line chemotherapy after treatment with paclitaxel and irinotecan, cisplatin and gemcitabine, docetaxel, gefitinib, and vinorelbine. Chest computed tomography (CT) showed partial response of recurrent tumors. Another woman (56 years old) was diagnosed with adenocarcinoma, yield-T0N1M1, stage IV. She was also treated with cisplatin and S-1 as fourth-line chemotherapy after treatment with nedaplatin and gemcitabine, docetaxel and irinotecan, and gefitinib. Chest CT showed a partial response of recurrent tumors. Additionally, we retrospectively reviewed 10 cases with recurrent NSCLC treated with cisplatin and S-1 during the same period. Grade 3 to 4 hematologic toxicity included neutropenia in 30% of these 10 patients, thrombocytopenia in 20%, and anemia in 60%. Grade 3 non-hematologic toxicity included hyperglycemia and hyponatremia in 20% of the 10 patients. All side effects were manageable and there was no case of treatment-related death. Cisplatin combined with S-1 could be an option for recurrent NSCLC.

Effectiveness of intensive follow-up after response in patients with small cell lung cancer.

We investigated whether intensive follow-up leads to earlier diagnosis of recurrence, more effective treatment, and longer survival in patients with small cell lung cancer (SCLC) who had shown a complete or partial response to first-line chemotherapy. The subjects of this retrospective study were 94 patients with SCLC who had shown a complete or partial response to first-line chemotherapy. The patients were separated into two arms: an intensive follow-up arm in which patients underwent regular blood tests, chest radiography, computed tomography of the chest and upper abdomen, magnetic resonance or computed tomography of the brain, and bone scintigraphy bimonthly for 6 months and then quarterly for 1.5 years; and a nonintensive follow-up arm in which these examinations were performed at the physician's discretion. All patients also underwent interviews and physical examinations monthly for 2 years and bimonthly for a further 3 years. Patient characteristics did not differ significantly between the arms. Disease recurred in 55 of 62 patients of the intensive arm and 29 of 32 patients of the nonintensive arm. Asymptomatic recurrences were detected more frequently in the intensive arm than in the nonintensive arm. The response rate to salvage therapy among all patients with recurrent disease was significantly higher in the intensive arm (61.8%) than in the nonintensive arm (37.9%; p=0.04). Both median postrelapse survival and overall median survival were significantly longer in the intensive arm (9 and 20 months, respectively, p=0.04 and p=0.001) than in the nonintensive arm (4 and 13 months, respectively). Intensive follow-up helps detect recurrence earlier, enhances the effectiveness of treatment, and lengthens survival in patients with SCLC. Well-designed prospective, randomized trials including a cost-benefit analysis are needed to compare intensive and nonintensive follow-up regimens.

Mutant epidermal growth factor receptor undergoes less protein degradation due to diminished binding to c-Cbl.

Gefitinib (Iressa) sensitivity in non-small cell lung cancer (NSCLC) is associated with activating mutations in epidermal growth factor receptor (EGFR). It was reported that autophosphorylation of the mutant EGFR is prolonged compared with wild-type EGFR. To explore the mechanism of sustained autophosphorylation, the mutant and wild-type EGFR degradation activities were examined in NSCLC cell lines. EGFR degradation activity was measured by 125I-EGF. The degradation rate of EGFR was lower in the PC-9 NSCLC cell line, which expressed 15-bp deletion mutant EGFR, compared with that in the PC-14 NSCLC (wild-type EGFR). To clarify the mechanism, the stable transfected cell lines, 293_pEGFR and 293_pdelta15, expressing wild-type and mutant EGFR, respectively, were used. In 293_pdelta15, EGFR degradation and binding of c-Cbl ubiquitin ligase to this receptor were reduced compared with 293_pEGFR. Based on these results, we conclude that the mutant EGFR underwent less protein degradation due to diminished binding to c-Cbl.

[Two cases of successfully treated invasive pulmonary aspergillosis following influenza virus infection].

While invasive pulmonary aspergillosis usually occurs in immunocompromised hosts, it has been described after influenza virus infection in healthy individuals. The first case was a 76-year-old previously healthy woman admitted because of chest pain, cough, sputum, fever, and a chest radiograph abnormality. A transbronchial biopsy specimen showed fungal hyphae. Amphotericin B (AMPH) and Itraconazole (ITCZ) were given, and she improved gradually. A viral test showed a titre of 1/128 to influenza A. Case 2 was a 72-year-old previously healthy man admitted because of cough, fever, chest pain and a consolidation and cavitation on the chest radiograph. Antibiotics were ineffective. Cavitation with a halo sign appeared on the contralateral lung. Because his daughter was infected with Influenza B, we suspected he had been infected with IPA following influenza infection. AMPH and ITCZ and Micafungin sodium were given. His respiratory failure worsened, and on the tenth hospital day he required artificial ventilation; his condition improved gradually, (extubation after 40 days.) A viral test showed a titre of 1/128 to influenza B. IPA must be considered for the differential diagnosis of complications of influenza virus infection.

Phase II study of biweekly administration of docetaxel and irinotecan in patients with refractory or relapsed advanced non-small cell lung cancer.

We examined the safety and efficacy of the combination of docetaxel and irinotecan administered biweekly in patients with refractory or relapsed advanced non-small cell lung cancer (NSCLC). Patients with previously treated NSCLC of stage III or IV were eligible if they had a performance status of 2 or less, were 75 years or younger, and had adequate organ function. From May 2003 through February 2006, 35 patients (27 men and 8 women; median age 64 years; age range 41-75 years) were enrolled. Patients were treated every 4 weeks with docetaxel (33 mg/m(2) on days 2 and 16) plus irinotecan (50 mg/m(2) on days 1 and 15). None of the 35 patients achieved a complete response, but five achieved a partial response, for an overall response rate of 14.3% (95% confidence interval, 4.8-30.3%). The median survival time was 8 months (range 2-29 months). The median time to progression was 3 months (range 1-12 months). Grade 3 to 4 hematologic toxicities included leukopenia in 48.6% of patients, neutropenia in 54.3%, and anemia in 25.7%. No patients had grade 3 to 4 diarrhea or nausea and vomiting. Although one patient had grade 3 drug-induced interstitial pneumonia, all side effects were manageable, and there were no treatment-related deaths. In conclusion, the combination of docetaxel and irinotecan administered biweekly is a safe and effective treatment for refractory or relapsed NSCLC. However, the search for even more active regimens should be continued.

Phase II study of the combination of gemcitabine and nedaplatin for advanced non-small-cell lung cancer.

We examined the efficacy and safety of the combination of gemcitabine and nedaplatin in patients with untreated advanced non-small-cell lung cancer. Thirty-four patients (24 men and 10 women) with a mean age of 69 years (range, 39-75 years) were treated every 3 weeks with gemcitabine (1,000 mg/m(2) on days 1 and 8) and nedaplatin (100 mg/m(2) on day 1). Four patients had stage IIIB disease and 30 patients had stage IV disease. None of the 33 patients achieved a complete response, but 10 achieved a partial response, for a response rate of 30.3% (95% confidence interval, 15.6-48.7%). One patient could not be evaluated for response because only one course of chemotherapy had been administered due to grade 3 eruption. The median survival time was 9.0 months (range, 1-17 months). Grades 3-4 hematological toxicities included leukopenia in 47% of patients, neutropenia in 62%, thrombocytopenia in 56%, and anemia in 44%. Grades 3-4 nonhematological toxicities included nausea and vomiting in 6% of patients, diarrhea in 3%, and hepatic dysfunction in 9%. There were no treatment-related deaths. The dose intensities were 89.6% and 86.7%, respectively, of the planned doses of gemcitabine and nedaplatin. Our results suggest that the combination of gemcitabine and nedaplatin is an acceptable treatment for patients with previously untreated advanced non-small-cell lung cancer.

The combination of cisplatin and vinorelbine with concurrent thoracic radiation therapy for locally advanced stage IIIA or IIIB non-small-cell lung cancer.

AIMS: The aims of this study were to assess the efficacy and toxicity of concurrent chemoradiotherapy with divided schedule of cisplatin and vinorelbine in patients with locally advanced non-small-cell lung cancer (NSCLC). METHODS: Patients with previously untreated, unresectable, and stage IIIA or IIIB NSCLC were eligible if they had a performance status of 0 or 1, were 75 years or younger, and had adequate organ function. Twenty-six patients (24 men and 2 women; median age, 66 years; age range, 42-75 years) were enrolled. Both cisplatin (40 mg/m(2)) and vinorelbine (20 mg/m(2)) were given on days 1 and 8 every 3 weeks. Beginning on day 2 of chemotherapy, thoracic radiotherapy was given for approximately 6 weeks (2 Gy per fraction; total dose, 60 Gy). RESULTS: Five of the 26 patients achieved a complete response, and 16 achieved a partial response for an overall response rate of 80.8% (95% confidence interval, 60.6-93.4%). The median survival time was 23 months (range, 4-43 months). Overall survival rates at 1 and 2 years were 80 and 56%, respectively. Hematologic toxicities included grade 3-4 neutropenia in 84.6% of patients, grade 3-4 thrombocytopenia in 3.8%, and grade 3-4 anemia in 61.5%. Two patients (7.7%) had grade 3 radiation esophagitis that resolved completely without dilation. Grade 3-4 radiation pneumonitis occurred in two patients (7.7%) and was treated with corticosteroids. Both patients had a good partial resolution of symptoms and radiographic abnormalities. There were no treatment-related deaths. The actual delivered dose intensities for both cisplatin and vinorelbine were 79.5%. Radiotherapy was completed in 96% of patients. CONCLUSION: Concurrent chemoradiotherapy with cisplatin and vinorelbine administered on a divided schedule is effective and well tolerated in patients with locally advanced NSCLC.

Enhancement of sensitivity to tumor necrosis factor alpha in non-small cell lung cancer cells with acquired resistance to gefitinib.

Tumor cells that have acquired resistance to gefitinib through continuous drug administration may complicate future treatment. To investigate the mechanisms of acquired resistance, we established PC-9/ZD2001, a non-small-cell lung cancer cell line resistant to gefitinib, by continuous exposure of the parental cell line PC-9 to gefitinib. After 6 months of culture in gefitinib-free conditions, PC-9/ZD2001 cells reacquired sensitivity to gefitinib and were established as a revertant cell line, PC-9/ZD2001R. PC-9/ZD2001 cells showed collateral sensitivity to several anticancer drugs (vinorelbine, paclitaxel, camptothecin, and 5-fluorouracil) and to tumor necrosis factor alpha (TNF-alpha). Compared with PC-9 cells, PC-9/ZD2001 cells were 67-fold more sensitive to TNF-alpha and PC-9/ZD2001R cells were 1.3-fold more sensitive. Therefore, collateral sensitivity to TNF-alpha was correlated with gefitinib resistance. PC-9/ZD2001 cells expressed a lower level of epidermal growth factor receptor (EGFR) than did PC-9 cells; this down-regulation was partially reversed in PC-9/ZD2001R cells. TNF-alpha-induced autophosphorylation of EGFR (cross-talk signaling) was detected in all three cell lines. However, TNF-alpha-induced Akt phosphorylation and IkappaB degradation were observed much less often in PC-9/ZD2001 cells than in PC-9 cells or PC-9/ZD2001R cells. Expression of the inhibitor of apoptosis proteins c-IAP1 and c-IAP2 was induced by TNF-alpha in PC-9 and PC-9/ZD2001R cells but not in PC-9/ZD2001 cells. This weak effect of EGFR on Akt pathway might contribute to the TNF-alpha sensitivity of PC-9/ZD2001 cells. These results suggest that therapy with TNF-alpha would be effective in some cases of non-small-cell lung cancer that have acquired resistance to gefitinib.

[Infection control in a teaching hospital without a tuberculosis ward].

Approximately 30 cases of tuberculosis are diagnosed in our hospital each year. Because three of our nurses contracted tuberculosis in 1998, we implemented the following control measures for tuberculosis : (1) immediate examination, diagnosis, and treatment in suspected cases; (2) screening of all health-care workers with a two-step tuberculin skin test (TST); (3) examination of all persons exposed to tuberculosis-infected persons; and (4) greater awareness of tuberculosis. We offered prophylactic medications to all exposed persons with a TST reaction greater than 20 mm. These control measures increased the numbers of outpatients who were examined and treated, and decreased the prevalence of tuberculosis among long-term inpatients. High-risk indices also decreased over a 2-year period. Forty-seven staff members showed TST reactions, and 5 of them received prophylactic medication. No cases of tuberculosis developed in staff members exposed to tuberculosis-infected persons. However, tuberculosis developed in one staff member who had a strong TST reaction at the start of employment. In this case, results of TSTs previously administered to all health-care workers was useful for estimating the prevalence of infection. We used a new method for diagnosing tuberculosis in 27 persons believed to be infected. Of these 27 persons, 5 (19%) showed reactions greater than pseudopositive reactions and were given prophylactic medication. Early diagnosis of infected persons, examination of persons exposed to tuberculosis, and greater disease awareness are important measures for monitoring tuberculosis and controlling its spread.

Phase II study of irinotecan and carboplatin in patients with the refractory or relapsed small cell lung cancer.

We examined the safety and efficacy of the combination of irinotecan plus carboplatin in patients with refractory or relapsed small cell lung cancer (SCLC). Patients with previously treated SCLC were eligible. Patients were treated every 3 weeks with carboplatin (with a target area under the concentration versus time curve of 5 mg min/ml using the Calvert formula on day 1) plus irinotecan (50 mg/m(2) on days 1 and 8). From May 2000 to January 2002, 24 patients were eligible. None of the 22 patients achieved a complete response, but 15 achieved a partial response with an overall response rate of 68.2% (95% confidence interval, 45.1-86.1%). In 13 patients with sensitive disease, the response rate was 92.3% (95% confidence interval, 64.0-99.8%). The median survival time (MST) was 194 days (range 27-605 days). The MST did not differ significantly between patients with sensitive disease (245 days) and those with refractory disease (194 days, P=0.88). One patient died of treatment-related sepsis. Grade 3-4 hematologic toxicities included leukopenia in 58% of patients, neutropenia in 63%, thrombocytopenia in 58%, and anemia in 67%. Grade 3 diarrhea developed in 21% of patients and grade 3-4 infection in 13%. No patients had grade 4 diarrhea or grade 3-4 nausea and vomiting. This regimen is effective and well tolerated in patients with relapsed or refractory SCLC. However, the search for even more active regimens should be continued.