Effectiveness and cost-effectiveness of dynamic bracing versus standard care alone in patients suffering from osteoporotic vertebral compression fractures: protocol for a multicentre, two-armed, parallel-group randomised controlled trial with 12 months of follow-up.

INTRODUCTION: Patients with osteoporosis may suffer from a fracture after minimal trauma. Osteoporotic vertebral compression fractures (OVCFs) are among the most common fractures, often leading to substantial pain. There is a need for evidence-based conservative treatment to aid in the management of OVCFs. The objective of this randomised controlled trial (RCT) is to evaluate the effectiveness and cost-effectiveness of dynamic bracing in addition to standard care for improving quality of life (QoL) in patients suffering from an OVCF. METHODS AND ANALYSIS: Ninety-eight postmenopausal women from two academic and four community hospitals with a recent symptomatic thoracolumbar OVCF will be randomised into either the standard care or dynamic bracing group. In the dynamic bracing group, the Spinova Osteo orthosis will be used in addition to standard care. Standard care comprises pain control with analgesics, physical therapy and osteoporosis medication. The primary outcome parameter is QoL 1 year after inclusion, as measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41). Secondary outcome parameters are pain, pain medication used, functional disability, sagittal spinal alignment, recurrence rate of OVCFs and physical activity in daily life. A trial-based economic evaluation consisting of both cost-effectiveness analysis and cost-utility analysis will be performed based on empirical data obtained in the RCT. A process evaluation will assess the feasibility of dynamic bracing. All outcomes will be assessed at baseline, 6 weeks, 3 months, 6 months, 9 months and 12 months. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Medical Ethics Committee, University Hospital Maastricht and Maastricht University (METC azM/UM) (NL74552.068.20/METC 20-055). Patients will be included only after verification of eligibility and obtaining written informed consent. Results will be disseminated via the Dutch National Osteoporosis Patient Society and via publications and conferences. TRIAL REGISTRATION NUMBER: NL8746.

Correlation of SHOX2 gene amplification and DNA methylation in lung cancer tumors.

BACKGROUND: DNA methylation in the SHOX2 locus was previously used to reliably detect lung cancer in a group of critical controls, including 'cytologically negative' samples with no visible tumor cell content, at a high specificity based on the analysis of bronchial lavage samples. This study aimed to investigate, if the methylation correlates with SHOX2 gene expression and/or copy number alterations. An amplification of the SHOX2 gene locus together with the observed tumor-specific hypermethylation might explain the good performance of this marker in bronchial lavage samples. METHODS: SHOX2 expression, gene copy number and DNA methylation were determined in lung tumor tissues and matched morphologically normal adjacent tissues (NAT) from 55 lung cancer patients. Quantitative HeavyMethyl (HM) real-time PCR was used to detect SHOX2 DNA methylation levels. SHOX2 expression was assayed with quantitative real-time PCR, and copy numbers alterations were measured with conventional real-time PCR and array CGH. RESULTS: A hypermethylation of the SHOX2 locus in tumor tissue as compared to the matched NAT from the same patient was detected in 96% of tumors from a group of 55 lung cancer patients. This correlated highly significantly with the frequent occurrence of copy number amplification (p < 0.0001), while the expression of the SHOX2 gene showed no difference. CONCLUSIONS: Frequent gene amplification correlated with hypermethylation of the SHOX2 gene locus. This concerted effect qualifies SHOX2 DNA methylation as a biomarker for lung cancer diagnosis, especially when sensitive detection is needed, i.e. in bronchial lavage or blood samples.

Patient-derived xenograft (PDX) models of colorectal carcinoma (CRC) as a platform for chemosensitivity and biomarker analysis in personalized medicine.

Patient-derived xenograft (PDX) tumor models represent a valuable platform for identifying new biomarkers and novel targets, to evaluate therapy response and resistance mechanisms. This study aimed at establishment, characterization and therapy testing of colorectal carcinoma-derived PDX. We generated 49 PDX and validated identity between patient tumor and corresponding PDX. Sensitivity of PDX toward conventional and targeted drugs revealed that 92% of PDX responded toward irinotecan, 45% toward 5-FU, 65% toward bevacizumab, and 61% toward cetuximab. Expression of epidermal growth factor receptor (EGFR) ligands correlated to the sensitivity toward cetuximab. Proto-oncogene B-RAF, EGFR, Kirsten rat sarcoma virus oncogene homolog gene copy number correlated positively with cetuximab and erlotinib sensitivity. The mutational analyses revealed an individual mutational profile of PDX and mainly identical profiles of PDX from primary tumor vs corresponding metastasis. Mutation in PIK3CA was a determinant of accelerated tumor doubling time. PDX with wildtype Kirsten rat sarcoma virus oncogene homolog, proto-oncogene B-RAF, and phosphatidylinositol-4,5-bisphosphate 3-kinaseM catalytic subunit alfa showed higher sensitivity toward cetuximab and erlotinib. To study the molecular mechanism of cetuximab resistance, cetuximab resistant PDX models were generated, and changes in HER2, HER3, betacellulin, transforming growth factor alfa were observed. Global proteome and phosphoproteome profiling showed a reduction in canonical EGFR-mediated signaling via PTPN11 (SHP2) and AKT1S1 (PRAS40) and an increase in anti-apoptotic signaling as a consequence of acquired cetuximab resistance. This demonstrates that PDX models provide a multitude of possibilities to identify and validate biomarkers, signaling pathways and resistance mechanisms for clinically relevant improvement in cancer therapy.

Establishment of patient-derived non-small cell lung cancer xenografts as models for the identification of predictive biomarkers.

PURPOSE: It was the aim of our study to establish an extensive panel of non-small cell lung cancer (NSCLC) xenograft models useful for the testing of novel compounds and for the identification of biomarkers. EXPERIMENTAL DESIGN: Starting from 102 surgical NSCLC specimens, which were obtained from primarily diagnosed patients with early-stage tumors (T(2)/T(3)), 25 transplantable xenografts were established and used for further investigations. RESULTS: Early passages of the NSCLC xenografts revealed a high degree of similarity with the original clinical tumor sample with regard to histology, immunohistochemistry, as well as mutation status. The chemotherapeutic responsiveness of the xenografts resembled the clinical situation in NSCLC with tumor shrinkage obtained with paclitaxel (4 of 25), gemcitabine (3 of 25), and carboplatin (3 of 25) and lower effectiveness of etoposide (1 of 25) and vinorelbine (0 of 11). Twelve of 25 NSCLC xenografts were >50% growth inhibited by the anti-epidermal growth factor receptor (EGFR) antibody cetuximab and 6 of 25 by the EGFR tyrosine kinase inhibitor erlotinib. The response to the anti-EGFR therapies did not correlate with mutations in the EGFR or p53, but there was a correlation of K-ras mutations and erlotinib resistance. Protein analysis revealed a heterogeneous pattern of expression. After treatment with cetuximab, we observed a down-regulation of EGFR in 2 of 6 sensitive xenograft models investigated but never in resistant models. CONCLUSION: An extensive panel of patient-derived NSCLC xenografts has been established. It provides appropriate models for testing marketed as well as novel drug candidates. Additional expression studies allow the identification of stratification biomarkers for targeted therapies.

Prediction of mechanical complications in adult spinal deformity surgery-the GAP score versus the Schwab classification.

BACKGROUND CONTEXT: Surgery for adult spinal deformity is a challenging and complex procedure with high reported complication (8.4%-42%) and revision rates (9%-17.6%). Failure to achieve or maintain adequate postoperative sagittal alignment has been reported to be the main cause of mechanical complications. In order to define appropriate surgical targets, the Scoliosis Research Society-Schwab classification and the Global Alignment and Proportion (GAP) score were established. In the literature, no study has yet compared these classification systems with respect to the risk of developing mechanical complications. PURPOSE: To assess and compare the ability of the Schwab classification and the GAP score to predict mechanical complications following adult spinal deformity surgery. STUDY DESIGN: Two-center, retrospective cohort study. PATIENT SAMPLE: Thirty-nine patients suffering adult spinal deformity who underwent long segment spinal fusion (≥4 levels), minimum follow-up of 2years. OUTCOME MEASURES: The ability of the Schwab classification and GAP score to predict mechanical failure was determined by computing the Area Under the receiver operating characteristic curve. METHODS: Full-spine pre- and postoperative radiographs of all patients were analyzed for mechanical complications. Subsequently, the pre- and postoperative Schwab and GAP score were determined. Logistic regression analysis was used to assess the ability of both systems to determine which was the most appropriate for the prediction of mechanical failure. Correlations between the various factors constituting the GAP score and Schwab classification were estimated using the Spearman rank order correlation coefficient. RESULTS: The results demonstrated that both classification systems are capable of predicting radiographic evidence of mechanical failure; however, the GAP score proved to be significantly better (p=.003). The relative pelvic version of the GAP score serves a similar role as the pelvic tilt modifier from the Schwab classification (ρ=-0.84, p<.01). The relative lumbar lordosis from the GAP score functions much like the PI-LL modifier from the Schwab classification (ρ=-0.94, p<.01). The GAP score is most significantly dependent on relative spinopelvic alignment, relative lumbar lordosis, and relative pelvic version (ρ=0.85, ρ=0.84, and ρ=0.84, respectively, p<.01). Correlation with the lordosis distribution index was also significant but was not as strong (ρ=0.65, p<.01). Age, on the contrary, showed poor correlation with the GAP score (ρ=0.17, p=.300). CONCLUSIONS: Both the Schwab classification and the GAP score are capable of predicting mechanical complications. The GAP score proved to be significantly more appropriate. This difference is probably attributed to the fact that in the GAP score all parameters are related to the patient's individual pelvic incidence.

Implementation of patient-reported outcome measures in appropriateness criteria of surgery for degenerative lumbar scoliosis.

BACKGROUND CONTEXT: Degenerative lumbar scoliosis (DLS) is an increasingly common spinal disorder of which current management is characterized by a substantial variety in treatment advice. To improve evidence-based clinical decision-making and increase uniformity and transparency of care, the Scoliosis Research Society established appropriateness criteria for surgery for DLS. In these criteria, however, the patient perspective was not formally incorporated. Since patient perspective is an increasingly important consideration in informed decision-making, embedding patient-reported outcome measures (PROMs) in the appropriateness criteria would allow for an objective and transparent patient-centered approach. PURPOSE: To evaluate the extent that patient perspective is integrated into the appropriateness criteria of surgery for DLS. STUDY DESIGN: Single center, retrospective, cohort study. PATIENT SAMPLE: 150 patients with symptomatic degenerative lumbar scoliosis. OUTCOME MEASURES: The association between appropriateness for surgery and various PROMs [Visual Analogue Scale for pain, Short Form 36 (SF-36), Pain Catastrophizing Scale (PCS), Hospital Anxiety Depression Scale (HADS), and Oswestry Disability Index (ODI)]. METHODS: Medical records of all patients with symptomatic DLS were reviewed and scored according to the appropriateness criteria. To assess the association between the appropriateness criteria and the validated PROMs, analysis of variance was used to test for differences in PROMS for each of the three categories resulting from the appropriateness criteria. To assess how well PROMs can discriminate between appropriate and inappropriate, we used a logistic regression analysis. Discriminative ability was subsequently determined by computing the area under the curve (AUC), resulting from the logistic regression analysis. Spearman rank analysis was used to establish a correlation pattern between the PROMs used and the appropriateness criteria. RESULTS: There was a significant association between the appropriateness of surgery and the PROMs. The discriminative ability for appropriateness of surgery for PROMs as a group was strong (AUC of 0.83). However, when considered in isolation, the predictive power of any individual PROMs was poor. The different categories of the appropriateness criteria significantly coincided with the PROMs used. CONCLUSION: There is a statistically significant association between the appropriateness criteria of surgery for DLS and PROMs. Implementation of PROMs into the appropriateness criteria may lead to more transparent, quantifiable and uniform clinical decision making for DLS.

Prognostic value of FHIT, CTNNB1, and MUC1 expression in non-small cell lung cancer.

Comprehensive expression analysis using microarrays has identified a number of differentially expressed genes in smoke-exposed bronchial epithelium and non-small cell lung cancers (NSCLCs). To evaluate the prognostic relevance of these proteins in NSCLCs, we used immunohistochemistry to investigate the expression of beta-catenin (CTNNB1), dickkopf, Xenopus, homolog of 3 (DKK3 gene), fibroblast growth factor receptor 3 (FGFR3), fragile histidine triad (FHIT), tumor protein p53 (TP53), mucin1 (MUC1), topoisomerase II alpha (TOP2A), and glutathione S-transferase-Pi (GST) in a cohort of patients (n = 125). We correlated the expression data with clinicopathologic features and clinical outcome. In addition, SNaPshot multiplex assays (Applied Biosystems, Darmstadt, Germany) and restriction fragment length polymorphism analysis were used to screen for activating point mutations at the hot spots of FGFR3 in a cohort of 30 samples of NSCLC. Using Kaplan-Meier analysis, we observed significantly better overall survival in adenocarcinomas compared with squamous cell cancers (P = .049). Loss of FHIT expression showed a strong association with shorter overall survival in both histologic types of NSCLC (squamous cell cancers, P < .001; adenocarcinomas, P = .001). In adenocarcinomas, the cytoplasmic expression of beta-catenin was associated with shorter survival (P = .012); MUC1 expression was associated with worse prognosis in patients with squamous cell cancers (P = .002). The nuclear staining of TP53 (P = .008) and TOP2A (P = .059) was associated with cancers without lymphonodal metastases. A correlation with positive staining of TOP2A (P = .03) and FGFR3 positivity (P = .057) was found in adenocarcinomas of male patients. Positive MUC1 stainings were associated with squamous cell cancers of male patients (P = .03). DKK3 expression did not show any significant association with clinical outcome or pathologic features. The screening of the FGFR3 sequence in lung cancers showed only wild-type sequences and did not detect mutations in the known hot spots for FGFR3 mutations. We conclude that the immunohistochemical loss of FHIT expression and the positivity for beta-catenin and MUC1 in NSCLC are useful prognostic markers, whereas the variable expression of TP53, TOP2A, and FGFR3 in relation to the different histologic types of NSCLC and sex of the patients is suggestive for different underlying molecular pathways.

Does video-mediastinoscopy improve the results of conventional mediastinoscopy?

OBJECTIVE: Despite new technologies, mediastinoscopy remains the gold standard for mediastinal staging of lung cancer even though the procedure is not standardised. Introduction of video-mediastinoscopy (VM) may help to overcome this problem as it better visualises the anatomy and allows a more uniform dissection than conventional mediastinoscopy (CM). Does the use of VM result in more lymph node tissue, higher accuracy and lower complication rates as compared to CM? METHODS: All mediastinoscopies from June 2003 to December 2005 were analysed. In a protocol surgeons documented location of lymph node stations, number of lymph nodes resected or biopsied and technique (VM or CM). Two groups were created for analysis: group 1 (n=366) consisting of all mediastinoscopies was reviewed for complication rates; group 2 included all patients with lung cancer who had a pN0 status by mediastinoscopy and underwent subsequent thoracotomy (n=171). This group was studied for the number of lymph nodes resected or biopsied according to the technique (VM or CM), on accuracy and negative predictive value. RESULTS: Of 366 mediastinoscopies, 132 were CM (36.1%) and 234 VM (63.9%). Complications occurred in 17 patients (4.6%): 9 recurrent laryngeal nerve palsies (VM 2.1%, CM 3.0%), 5 mediastinal enlargement on routine chest radiography interpreted as postoperative bleeding (VM 0.9%, CM 2.3%), pneumonia (1), intraoperative laceration of the pleura (1) and main bronchus (1), both corrected during the procedure (all VM 1.3%). No intraoperative haemorrhage or death occurred. VM resected more lymph nodes (mean 8.1, range 3-25) then CM (mean 6.0, range 3-11), for all mediastinoscopies the mean lymph node yield was 7.6 (range 3-25). Comparison of lymphadenectomy via thoracotomy in patients classified pN0 by mediastinoscopy (n=171) showed an accuracy of 87.9% for VM versus 83.8% for CM (85.8% for all mediastinoscopies) with a negative predictive value of 0.83 for VM and 0.81 for CM (0.82 for all mediastinoscopies). CONCLUSION: This study demonstrates that in comparison with CM, VM routinely yields more lymph nodes with fewer complications with a tendency towards better accuracy and negative predictive value. For these reasons, we believe that VM should replace CM as the method of choice. Furthermore VM would allow standardisation, thereby having an advantage in comparison to the less invasive newer staging techniques. This way mediastinoscopy could remain the gold standard despite its invasiveness.

A randomized trial of automated versus conventional protocol-driven weaning from mechanical ventilation following coronary artery bypass surgery.

OBJECTIVE: The Siemens servo 300 A ventilator has an automode function that allows automated weaning of patients from mechanical ventilation. Spontaneous breathing triggers the ventilator. After two spontaneously triggered breaths, the ventilator automatically changes from mandatory mechanical ventilation to spontaneous ventilation. If spontaneous breathing or triggering does not occur, the Siemens servo 300 A ventilator changes from spontaneous ventilation back to mandatory mechanical ventilation. We compared the effects of automated versus conventional protocol-driven weaning on the time until extubation in patients undergoing coronary artery bypass graft (CABG) surgery. In addition, we studied the effects of the mode of weaning on hemodynamic and physiologic parameters. METHODS: Twenty consecutive male patients without respiratory disease scheduled for CABG at the University Hospital of Regensburg were entered into the study. Patients were randomized to postoperative ventilation with the Siemens 300 A/automode ventilator (group A, n = 10) or with the Siemens 300 ventilator (group B, n = 10). All patients were weaned from ventilation according to a standardized protocol. RESULTS: On average, patients in group A were younger and had lower pulmonary artery pressure (PAP) and higher cardiac output compared to patients in group B. However, patients in group A had longer ischemic and bypass times compared to patients in group B. Postoperative use of analgesia and sedation were similar in both groups. Time from tracheal intubation until extubation was 2 h shorter in patients assigned to automode ventilation compared to patients assigned to conventional ventilation (mean time group A 7.9 h, group B 10.0 h; p = 0.069). Peak airway pressure was reduced by 2 cm H2O at the beginning of spontaneous ventilation in group A compared to group B. After extubation, cardiac index showed a greater increase in patients assigned to group A compared to those in group B. CONCLUSIONS: Automode ventilator weaning trended toward more rapid extubation than did conventional protocol-driven ventilation in conjunction with a standardized weaning protocol. Physiologic and hemodynamic factors were better in patients using automode ventilation compared to patients using conventional ventilation. Automode ventilation was well tolerated and did not induce significant adverse effects.

Quantitative detection of TUSC3 promoter methylation -a potential biomarker for prognosis in lung cancer.

Aberrant promoter methylation of tumor relevant genes frequently occurs in early steps of carcinogenesis and during tumor progression. Epigenetic alterations could be used as potential biomarkers for early detection and for prediction of prognosis and therapy response in lung cancer. The present study quantitatively analyzed the methylation status of known and potential gatekeeper and tumor suppressor genes [O-6-methylguanine-DNA methyltransferase (MGMT), Ras association domain family member 1A (RASSF1A), Ras protein activator like 1 (RASAL1), programmed cell death 4 (PDCD4), metastasis suppressor 1 (MTSS1) and tumor suppressor candidate 3 (TUSC3)] in 42 lung cancers and in corresponding non-malignant bronchus and lung tissue using bisulfite-conversion independent methylation-quantification of endonuclease-resistant DNA (MethyQESD). Methylation status was associated with clinical and pathological parameters. No methylation was found in the promoter regions of PDCD4 and MTSS1 of either compartment. MGMT, RASSF1A and RASAL1 showed sporadic (up to 26.2%) promoter methylation. The promoter of TUSC3, however, was frequently methylated in the tumor (59.5%), benign bronchus (67.9%) and alveolar lung (31.0%) tissues from each tumor patient. The methylation status of TUSC3 was significantly associated with smaller tumor size (P=0.008) and a longer overall survival (P=0.013). Pooled blood DNA of healthy individuals did not show any methylation of either gene. Therefore, methylation of TUSC3 shows prognostic and pathobiological relevance in lung cancer. Furthermore, quantitative detection of TUSC3 promoter methylation appears to be a promising tool for early detection and prediction of prognosis in lung cancer. However, additional studies are required to confirm this finding.

Deletions at chromosome 2q and 12p are early and frequent molecular alterations in bronchial epithelium and NSCLC of long-term smokers.

Most lung cancer is attributed to long-term smoking. In order to define chromosomal regions with an accumulation of smoking-related early molecular damage, we applied 15 microsatellite markers at 8 chromosomal regions (2q35-q36, 3p21.3, 3p14.2, 3p25, 10q11.2, 11p14-15, 12p13.1-p12.3 and 12q14) in an allelotyping study. We studied samples of 42 patients with primary non-small cell lung cancer (NSCLC) (25 squamous cell carcinomas, 13 adenocarcinomas, 2 large cell and 2 bronchioalveolar carcinomas) to compare the frequency of allelic loss in cancer tissue of smokers with matched bronchial epithelium. As a control group we used 11 samples of non-smokers. In NSCLC we found significantly higher frequencies of loss of heterozygosity (LOH) than in matched tumor free bronchial epithelium (p = 0.007). Most frequently, allelic loss was detected in NSCLC at chromosome 3p [3p25 (46%), 3p21.3 (45%), 3p14 (40%)], at 2q35 (24%), 12p12 (29%) and 12q14 (13%), but infrequently at 10q11 (7%) and 11p14-15 (5%). In corresponding histological normal bronchial epithelium, the highest percentage of LOH was found at chromosome 3p [3p21 (17%), 3p25 (12%), 3p14 (9%)] and chromosome 2q (2q35-q36) (17%) and 12p (12p12-p13) (12%). LOH in histologically normal bronchial epithelium was significantly associated with long-term smoking (p = 0.048), especially at chromosome 12p12 (p = 0.018). Our results demonstrate two further deletion hot spots at the chromosomal region 2q35-q36 and 12p12-p13 in tumor tissue of NSCLC and matched histological normal bronchial epithelium of long-term smokers, reflecting a phenomenon referred to as 'field cancerization'. These chromosomal regions represent interesting loci for potential NSCLC associated tumor suppressor genes and could be useful as screening markers for molecular risk assessment of smokers.

Multitarget FISH and LOH analyses at chromosome 3p in non-small cell lung cancer and adjacent bronchial epithelium.

Multitarget fluorescence in situ hybridization (FISH; LAVysion, Vysis, Downers Grove, IL) targeting chromosomes 6p11-q11, 7p12, 8q24, and 5p15.2 was compared with results of microsatellite studies at chromosome 3p to identify molecular changes associated with tobacco use and tumor development in non-small cell lung cancer (NSCLC). Analyses were performed on 26 NSCLCs and matched benign bronchial epithelium; samples from 10 patients without NSCLC served as control samples. Significant molecular differences between tumor tissue and corresponding benign bronchi were found using FISH (P = .001) and loss of heterozygosity (LOH) analysis (P = .031). Bronchial epithelium from patients with NSCLC was genetically different from epithelium from patients without NSCLC in FISH analysis (P = .025). Receiver operating characteristic curve analysis revealed an optimal cutoff value of 5% atypical cells for bronchial epithelium. There was no statistical correlation with the patient's smoking history, and LOH analysis of bronchi did not differentiate between patients with and without NSCLC. Multicolor FISH analysis is able to detect a tumor-associated molecular field effect in bronchi adjacent to NSCLC.

Microsatellite instability at chromosome 8p in non-small cell lung cancer is associated with lymph node metastasis and squamous differentiation.

Genetic alterations at chromosome arm 8p are associated with advanced disease and poor patient outcome in several types of malignant tumors. We studied the frequency of microsatellite instability (MSI) and loss of heterozygosity (LOH) at chromosome 8p in early stage non-small cell lung cancer (NSCLC) of 47 patients with stage I or II disease (25 squamous cell carcinomas and 22 adenocarcinomas). Microsatellite analysis was performed after laser microdissection using 5 polymorphic tetranucleotide microsatellite markers and 4 dinucleotide markers at chromosome 8p. A pentanucleotide repeat marker at the chromosomal locus 17p13.1 (TP53.Alu) was also analyzed. Expression of the mismatch repair (MMR) proteins hMSH2, hMSH6 and hMLH1 was evaluated by immunohistochemistry. Microsatellite instability (MSI) in at least 2 markers was detected in 9 of 47 patients (19.1%) and was predominantly found at tetranucleotide repeats. Sixteen of 47 (34.0%) NSCLC demonstrated LOH at chromosome 8p. All MSI-positive tumors showed normal expression of the MMR proteins. The presence of MSI at chromosome 8p was associated with lymph node metastasis (p=0.02), squamous differentiation (8/25; 32%-p=0.03), and the presence of LOH at the p53 locus (p=0.06). None of the other investigated clinical, pathologic or molecular factors correlated with MSI. Our study showed that an elevated MSI at selected tetranucleotide sequences (EMAST) on chromosome 8p is frequent in early stage squamous cell carcinomas of the lung with lymphatic spread. The tetranucleotide marker panel used in this study was able to indicate lymph node metastasis and high risk disease in patients with resectable squamous cell lung cancer.

Disseminated Cladophialophora bantiana infection in a heart transplant recipient.

Cerebral phaeohyphomycosis caused by Cladophialophora bantiana, a dematiaceous fungus, is a rare disease. The majority of cases have been reported among immunocompetent patients; only 4 cases have been published that describe transplantation patients. The overall prognosis is poor. Surgical therapy in combination with chemotherapy with itraconazole is recommended. We report the case of a heart transplant recipient with cutaneous, cerebral, and lung manifestation of Cladophialophora bantiana who died despite surgical and systemic, high-dosage itraconazole treatment.

Activation of AMP-activated protein kinase sensitizes lung cancer cells and H1299 xenografts to erlotinib.

OBJECTIVES: The therapeutic scheme for non-small cell lung cancer (NSCLC) patients can be improved if adapted to the individual response. For example, 60-70% of adenocarcinoma patients show response to EGFR-tyrosine kinase inhibitors in the presence of mutated EGFR. We searched for additional target molecules involved in the action of the EGFR-tyrosine kinase inhibitor erlotinib in the absence of EGFR mutations, which might be suitable for combinatorial therapy approaches. MATERIALS AND METHODS: Erlotinib-response associated proteins were investigated in patient-derived NSCLC mouse xenografts by reverse-phase protein array technology (RPPA) and Western blotting. A combinatorial treatment approach was carried out in NSCLC cell lines and H1299 mouse xenografts, and subsequently analyzed for consequences in cell growth and signal transduction. RESULTS: AMP-activated protein kinase (AMPK) expression was increased in erlotinib responders before and after treatment. In a combinatorial approach, activation of AMPK by A-769662 and erlotinib treatment showed a synergistic effect in cell growth reduction and apoptosis activation in H1299 cells compared to the single drugs. AMPK pathway analyses revealed an effective inhibition of mTOR signaling by drug combination. In H1299 xenografts, the tumor size was significantly decreased after combinatorial treatment. CONCLUSION: Our results suggest that AMPK activation status affects response to erlotinib in distinct lung tumor models.

Isolated Whipple's endocarditis: an underestimated diagnosis that requires molecular analysis of surgical material.

Tropheryma whipplei is known as the bacterium that causes Whipple's disease, a rare systemic illness typically affecting gastrointestinal tract, joints, and central nervous system. In addition, T whipplei infection may present as an isolated endocarditis. Although previously regarded as a rare condition, T whipplei has been recognized as a major cause of culture-negative endocarditis when integrating specific molecular analysis of surgical material into the diagnostic algorithm. Here, we report the case of a 67-year-old man undergoing mitral valve replacement due to T whipplei endocarditis, and discuss diagnostic and therapeutic implications.

Postoperative chest tube management: snapshot of German diversity.

OBJECTIVES: The management of chest tubes is one of the most critical aspects in patient care in thoracic surgery, and no consensus exists regarding the ideal chest tube management strategy. METHODS: Chest tube management protocols and their effects on chest tube therapy were compared at four German specialist thoracic surgery units. Altogether, 79 patients were stratified for underlying disease and type of surgery. A digital chest drainage system was applied to objectify the presence of air leakages. RESULTS: In our analysis, the average length of drainage therapy was 4.9 ± 2.8 days. Different chest tube management protocols resulted in a significant degree of scatter between units (P = 0.0348). Higher arbitrary postoperative suction levels (4 kPa) resulted in earlier chest tube removal than lower suction levels (2 kPa) (4.2 ± 2.4 vs 5.4 ± 3.0 days, P = 0.06). Patient discharge following chest tube removal was delayed on average by 3.2 ± 2.9 days. This delay was not correlated with the previous duration of chest tube therapy (Spearman's ρ=-0.15, P = 0.25) in contrast to the total length of hospital stay (ρ = 0.59, P < 0.001).

Reliability of a computer-aided detection system in detecting lung metastases compared to manual palpation during surgery.

For resection of lung metastases computed tomography (CT) is needed to determine the operative strategy. A computer-aided detection (CAD) system, a software tool for automated detection of lung nodules, analyses the CT scans in addition to the radiologists and clearly marks lesions. The aim of this feasibility study was to evaluate the reliability of CAD in detecting lung metastases. Preoperative CT scans of 18 patients, who underwent surgery for suspected lung metastases, were analysed with CAD (September-December 2009). During surgery all suspected lesions were traced and resected. Histological examination was performed and results compared to radiologically suspicious nodes. Radiological analysis assisted by CAD detected 64 nodules (mean 3.6, range 1-7). During surgery 91 nodules (mean 5.0, range 1-11) were resected, resulting in 27 additionally palpated nodules. Histologically all these additional nodules were benign. In contrast, all 30 nodules shown to be metastases by histological studies were correctly described by CAD. The CAD system is a sensible and useful tool for finding pulmonary lesions. It detects more and smaller lesions than conventional radiological analysis. In this feasibility study we were able to show a greater reliability of the CAD analysis. A further and prospective study to confirm these data is ongoing.

Chemoresistance in non-small-cell lung cancer: can multidrug resistance markers predict the response of xenograft lung cancer models to chemotherapy?

OBJECTIVE: In chemotherapy for non-small-cell lung cancer (NSCLC), some patients seem to exhibit an intrinsic resistance or develop an acquired resistance under treatment. Results on resistance markers for possible treatment failure as shown in studies on selected lung cancer cell lines could not be completely confirmed in clinical trials. As these conflicting data require further research, we created a model between cell culture and the clinical need to study this problem. METHODS: Our study was based on patient-derived NSCLC xenografts in a mouse model, which revealed a high coincidence with the original tumour. Protein and messenger RNA (mRNA) expression of known resistance markers (breast cancer resistance protein (BCRP), multidrug resistance P-glycoprotein (MDR), lung cancer-related protein (LRP) and multidrug resistance protein 1 (MRP1)) were analysed by real-time polymerase chain reaction (PCR) and immunoblotting in 24 xenografts. Chemosensitivity to etoposide, carboplatin, gemcitabine, paclitaxel, cetuximab and erlotinib was determined in in vivo xenograft experiments and compared with the protein and mRNA expression of the multidrug resistance markers. RESULTS: With the exception of a single correlation between chemosensitivity and mRNA expression of etoposide and bcrp (mRNA expression of BCRP), we found no significant correlation between the response rates and protein- and mRNA expression levels in our 24 xenografts. The present results indicate that in vivo expression levels of multidrug resistance proteins and their mRNAs may not play a comparable role in chemoresistance of NSCLC, as pointed out in selected tumour cell lines. CONCLUSIONS: Patient-derived xenografts allow detailed investigation of therapy-related markers and their dynamic regulation in a well-standardised and clinically related way. As a consequence of our investigations, we regard multidrug resistance to be a multifactorial phenomenon, in which more factors than the markers analysed by the present study may be involved.