Association of interleukin-10 promoter region polymorphisms with risk factors of Atherosclerosis.

Atherosclerosis is considered as an inflammatory disease, and carotid artery intima-media thickness (IMT) and carotid plaque are generally used as intermediated phenotype of atherosclerosis. The aim of this study was to investigate whether carotid IMT and plaque are associated with promoter region polymorphisms of interleukin 10 (IL-10) gene. We recruited 135 subjects from a rural area of south-eastern part of South Korea. Three polymorphisms in the promoter region of IL-10 (-1082 A/G, -819 T/C and -592 A/C) were genotyped by pyrosequencing. Carotid IMT was measured at common carotid arteries, and carotid bulbs and cardiovascular risk factors such as cholesterol, blood pressure, uric acid and homocysteine were measured using blood samples. Subjects with the minor allele (C) of -819 T/C or the minor allele (C) of -592 A/C showed lower values in carotid IMT than those with major allele homozygote of each polymorphism (P = 0.018 and P = 0.031, respectively). Subjects with carotid plaque were significantly older and showed higher values in carotid IMT, uric acid and homocysteine than those without plaque (P < 0.01, respectively). In conclusion, the promoter region polymorphisms of IL-10 gene associate with carotid IMT and plaque. Further studies with larger samples are needed to provide stronger evidence to justify anti-atheromatous properties of IL-10.

Daily skin care habits and the risk of skin eruptions and symptoms in cancer patients.

BACKGROUND: Cancer patients are at high risk for skin problems because rapidly proliferating skin cells are susceptible to anticancer therapies. However, the effects of daily skin care habits on development of skin problems in cancer patients have rarely been studied. PATIENTS AND METHODS: We conducted a survey of daily skin care habits and the presence of skin problems in 866 cancer patients. RESULTS: Hot water bath>1 h significantly increased the risk of definite eruptions [odds ratio (OR) 4.09] and the risk of itching or pain on the skin (OR 1.73). Diligent use of moisturizers did not decrease the risk of definite eruptions and symptoms, and daily bathing, scrubbing off the skin while bathing, and sun protection did not influence the risk of definite eruptions and symptoms. Subgroup analysis of 183 breast cancer patients showed results similar to the total results, including that hot water bath>1 h significantly increased the risk of definite eruptions (OR 3.41). CONCLUSIONS: Being a cross-sectional study, our study could not prove causality. However, at the present stage of knowledge, avoidance of hot water baths of protracted duration should be first emphasized in patient education to prevent skin problems in cancer patients.

Apoptosis and bcl-2 expression as predictors of survival in radiation-treated non-small-cell lung cancer.

OBJECTIVES: We assessed the role of apoptosis and the expression of bcl-2, p53, and c-myc oncoproteins in pretreatment histologic specimens as a predictor of response to radiation therapy and survival in non-small-cell lung cancer (NSCLC) patients. METHODS: Pretreatment biopsy specimens of 68 patients with NSCLC (62 squamous cell carcinoma, 6 adenocarcinoma) were stained with hematoxylin and eosin. From 5 high-powered fields, the apoptotic index (AI) was calculated as the ratio of apoptotic tumor cells to the total number of tumor cells. Bcl-2, p53, and c-myc oncoprotein expression was detected by immunohistochemical staining. RESULTS: Twenty-nine cases showed partial or complete remission, whereas 39 showed no response. AI ranged from 0.2 to 12.0% (mean +/- SD; 4.3 +/- 2.6%, median 4.0%). There was no difference in AI between responders (4.0 +/- 2.3) and nonresponders (4.5 +/- 2.8, p > 0.05). However, in the responders, AI was correlated with the degree of change in tumor volume (r = 0.41, p < 0.05). In an analysis of 53 subjects who survived more than 1 month after the completion of radiation therapy, the patients with a higher AI (n = 27, MST = 22.8 m) survived longer than those with a lower AI (n = 26, MST = 9.2, log-rank, p = 0.03). Patients expressing bcl-2 had poorer survival (n = 22, MST = 6.0 m) than patients without bcl-2 (n = 31, 22.8 m, p < 0.003). According to multivariate analysis, three variables, bcl-2 expression, AI, and response to radiation, were independent prognostic factors for survival. CONCLUSION: A low level of spontaneous apoptosis and expression of apoptosis blocking bcl-2 protein in pretreatment histology predict a poor prognosis for radiation-treated NSCLC patients.

Technetium-99m-MIBI uptake in small cell lung cancer.

UNLABELLED: Patients with small cell lung cancer (SCLC) often fail to respond to chemotherapy due to multidrug resistance (MDR). Technetium-99m-MIBI was reported to be a suitable transport substrate of P-glycoprotein, which is a cytoplasmic membrane protein encoded by the MDR gene. The purpose of this study was to evaluate whether or not the degree of MIBI uptake in SCLC or its retention on delayed imaging correlated with response to chemotherapy. METHODS: Twenty-five patients (19 men, 6 women; mean age 59 +/- 10 yr) with biopsy-proven SCLC had MIBI SPECT 3-7 days before starting chemotherapy. Imaging was acquired 1 and 4 hr after injection of 740 MBq MIBI using a single-head rotating gamma camera. Tumor-to-normal lung uptake ratio (T/NL) was measured. Percent retention (%R) was measured as: %R = 100 x (T/NL at 4 hr)/(T/NL at 1 hr). All patients received VAP chemotherapy (VP-16 100 mg/m2, adriamycin 40 mg/m2, cisplatin 25 mg/m2) every 4 wk for at least three times. Response to chemotherapy was grouped as complete remission, partial remission and no remission according to the change of tumor size on chest radiograph and CT images. Differences in T/NL and %R among the three groups were analyzed using ANOVA. RESULTS: T/NL of patients with complete remission (n = 7) and partial remission (n = 10) were significantly higher than that of no remission (n = 8) in 1 hr and 4 hr. T/NL at 1 hr in three groups were 2.75 +/- 0.78, 2.35 +/- 0.31 and 1.65 +/- 0.36, respectively. T/NL at 4 hr in three groups was 2.61 +/- 0.94, 2.48 +/- 0.50 and 1.66 +/- 0.42, respectively. However, %R was not different among three groups. Percent retention in three groups was 109.40 +/- 22.10, 96.71 +/- 14.25 and 103.59 +/- 28.43, respectively. CONCLUSION: SCLC with a higher MIBI uptake was more likely to respond to chemotherapy than that with a lower uptake. However, there was a considerable overlap of MIBI uptake among subjects. No significant correlation between the MIBI retention between 1 hr and 4 hr, and the response to chemotherapy was noted.

The interactive effect of Ras, HER2, P53 and Bcl-2 expression in predicting the survival of non-small cell lung cancer patients.

In patients with non-small cell lung cancer (NSCLC), tumor expression of P21-Ras, HER2, P53, and Bcl-2 has been reported as independent predictors of prognosis. However, the prognostic information carried by these proteins has usually been determined separately, and their potential interaction has not been taken into account. We conducted immunostaining for P21-Ras, HER2, P53 and Bcl-2 on 238 cases of NSCLC in a Korean population with 203 squamous cell carcinomas, and 35 adenocarcinomas. P21-Ras, HER2, P53 or Bcl-2 was expressed at high levels in 54.6, 42.0, 18.1 and 71.8% of the NSCLC studied, respectively. A total of 59 tumors (24.8%) expressed only one protein, while 70 (29.4%) expressed two, 59 (24.8) expressed three, and 17 tumors (7.1%) expressed all four proteins. Univariate analysis testing the association of marker expression with survival found Bcl-2 expression to be significantly associated with a poor prognosis, as well as the co-expression of Bcl-2 + HER2, Bcl-2 + HER2 + P53, and Bcl-2 + HER2 + P53 + P21-ras with an increasing hazard ratio. By multivariate analysis controlling for age, tumor stage and tumor type, only the combination of Bcl-2 + HER2 expression was an independent marker of poor prognosis (hazard ratio = 1.91, P = 0.003). Thus, a prospective analysis of the co-expression of Bcl-2 + HER2 in NSCLC patients may identify patients with a poor prognosis who may benefit from more aggressive therapy.

Different cutoff values of Cyfra 21-1 for cavitary and noncavitary lung cancers.

STUDY OBJECTIVES: Cell lysis and tumor necrosis release cytokeratin, a tumor marker of lung cancer, into the serum. The serum cytokeratin level can also be elevated in benign cavitary lung diseases. The purpose of this study was to evaluate whether Cyfra 21-1 can differentiate malignant lung diseases from benign diseases with cavitary lesions. DESIGN: This study is a retrospective review of the case records of patients with lung lesions seen during a 4-year period from January 1993 to May 1996. SETTING AND PATIENTS: Serum Cyfra 21-1 levels were measured in 306 patients with lung cancer (n = 143) or benign lung disease (n = 163). The patients were grouped according to radiologic evidence of cavitary lung lesions. Lung cancer included both non-small cell (n = 123) and small cell (n = 20) lung cancers, and the benign diseases include tuberculosis (n = 87), abscess (n = 26), pneumonia (n = 4), and others (n = 46). MEASUREMENTS AND RESULTS: Although Cyfra 21-1 clearly differentiated cavitary lung cancer (15.0, 9.1-29.8 ng/ml, median and interquartile range, n = 39) from benign cavitary disease (P < 0.001), and noncavitary lung cancer from benign noncavitary disease (1.7, 0.9-2.6 ng/ml, n = 108, P < 0.001), it could not differentiate noncavitary lung cancer (5.0, 2.1-12.4 ng/ml, n = 104) from benign cavitary diseases (3.3, 1.4-8.3 ng/ml, n = 55, P = 0.45). CONCLUSIONS: Serum Cyfra 21-1 is a useful tumor marker for differentiating benign from malignant lung diseases. However, different cutoff values are needed, depending on the presence of cavitary lesions. We recommend cutoff values of 30 ng/ml for cavitary lung diseases and 6 ng/ml for noncavitary lung diseases. If there are no radiologic data, a cutoff value of 15 ng/ml is recommended.

Comparison of Tc-99m sestamibi, serum neuron-specific enolase and lactate dehydrogenase as predictors of response to chemotherapy in small cell lung cancer.

Neuron-specific enolase (NSE) and lactate dehydrogenase (LDH) are tumor markers of small cell lung cancer (SCLC) which were reported to predict outcome of patients with SCLC. We previously reported that dipyridamole-modulated Tc-99m sestamibi (dipyridamole-MIBI) single photon emission computed tomography (SPECT) could predict the response to chemotherapy in SCLC patients. The purpose of this study was to compare dipyridamole-MIBI and pretreatment serum levels of NSE and LDH for the prediction of response to chemotherapy in SCLC. Twenty-eight SCLC patients underwent dipyridamole-MIBI SPECT 3 to 7 days before starting chemotherapy (80 mg/m2 etoposide and 80 mg/m2 cisplatin every 3 or 4 weeks for at lease two cycles). Serum levels of NSE and LDH were also measured at the same day of the imaging. Tomographic images before and after 0.84 mg/kg dipyridamole infusion were acquired 1 hour after injection of 370 (10 mCi) and 1,110 (30 mCi) MBq MIBI, respectively. The response to chemotherapy was grouped as specified as complete (CR), partial response (PR), no change (NC), and progressive disease (PD), according to the change in tumor size on chest roentgenography and CT. Patients showing CR and PR were classified as responders, and those who showed NC and PD were considered nonresponders. Among the 28 patients, 15 were responders (2 CR, 13 PR) and 13 were nonresponders (11 NC, 2 PD). The change of tumor-to-normal lung ratio (T:NL) after infusion of dipyridamole was significantly higher in responders as compared with nonresponders (0.38 +/- 0.64 vs. -0.38 +/- 0.50, respectively, p = 0.002). However, pretreatment serum NSE and LDH levels did not correlate with the response to chemotherapy. Increase of T:NL after dipyridamole infusion was a strong negative predictor of chemotherapeutic response in SCLC patients, while NSE and LDH could not predict it.

Tc-99m MIBI uptake in simultaneous thyroid and lung cancers.

The authors present a patient with simultaneous follicular thyroid and small-cell lung cancers, both of which showed Tc-99m MIBI uptake. CT scans showed two masses: one involving the right lower neck including the right supraclavicular area and the right superior mediastinum, and the other involving the peripheral portion of the right upper lobe of the lung. I-131 imaging showed increased uptake in the right neck mass only. Tc-99m MIBI imaging, which was performed for evaluation of chest pain, showed intense uptake in the neck mass (tumor to heart ratios in planar and tomographic images were 0.92 and 0.96, respectively), and less uptake in the lung mass (tumor to heart ratios in planar and tomographic images were 0.53 and 0.40, respectively). Biopsy of the right supraclavicular mass revealed a follicular carcinoma, and a bronchoscopic biopsy of the right upper lobe mass revealed a small cell carcinoma.

Dipyridamole modulated Tc-99m sestamibi lung SPECT in small cell lung cancer.

PURPOSE: In this study, the authors wanted to determine whether dipyridamole-modulated MIBI (dipyridamole-MIBI) could enhance the prediction of the response to chemotherapy in patients with small cell lung cancer. METHODS: Twenty-seven patients with biopsy-proved small cell lung cancer (25 men, 2 women; mean age, 61 +/- 7 years) underwent dipyridamole-MIBI SPECT 3 to 7 days before starting chemotherapy (80 mg/m2 etoposide and 80 mg/m2 cisplatin every 3 or 4 weeks for at least two cycles). Tomographic images before and after dipyridamole (0.84 mg/kg) were acquired 1 hour after injection of 370 (10 mCi) and 1,110 (30 mCi) MBq MIBI, respectively. The response to chemotherapy was grouped as specified as complete response (CR), partial (PR), no change (NC), or progressive disease (PD), according to the change in tumor size on chest roentgenography and CT. Patients showing CR and PR were classified as responders, and those who showed NC and PD were considered nonresponders. RESULTS: Among the 27 patients, 22 were responders (3 CR, 19 PR) and 5 were nonresponders (3 NC, 2 PD). The tumor-to-normal lung ratio (T:NL) of responders was significantly higher than that of nonresponders. The diagnostic accuracy of the T:NL ratio to differentiate responders and nonresponders was 33.3%, with a cutoff value of 2.5, which was significantly improved to 77.8% when an increased T:NL ratio after dipyridamole was assigned to a nonresponder. Furthermore, all patients with CR showed diminished T:NL ratios after dipyridamole, and all patients with NR showed an increased T:NL ratio after dipyridamole. CONCLUSION: Dipyridamole-MIBI SPECT could enhance the prediction of response to chemotherapy in patients with small cell lung cancer.

Physicochemical properties of partially oxidized corn starch from bromide-free TEMPO-mediated reaction.

This study was conducted to determine the optimal temperature and time for the regiospecific oxidation of primary alcohol groups in corn starch with 2,2,6,6-tetramethyl-1-piperidinyl oxoammonium ion (TEMPO) and sodium hyphochlorite (NaOCl). The study also elucidated the molecular structure of fully oxidized corn starch (FOCS) prepared at optimum temperature and physicochemical properties of the partially (10%, 20%, and 30%) oxidized corn starches (POCS). The reaction time rapidly decreased up to 30 degrees C, and then gradually decreased. Selectivity, yield, and viscosity were drastically reduced at temperatures higher than 35 to 40 degrees C. Optimal oxidation temperature for the production of FOCS was determined as 35 degrees C. Regiospecific oxidation of the primary alcohol group without oxidation of the secondary alcohol group was confirmed in (13)C-NMR and IR spectra. Water-binding capacity, swelling power, solubility power, and transmittance of POCS increased as the degree of oxidation increased. Hardness, gumminess, and chewiness of corn starch gel containing POCS were not significantly different from those of native corn starch gel at 1-d storage, but the values of the starch gel containing POCS were smaller than those of the native starch gel after 1-d storage. However, springiness and cohesiveness did not differ significantly among the samples regardless of storage time.

[A study on factors related to daily activities of post myocardial infarction patients].

The purpose of this study was to identify factors related to daily activities of post myocardial infarction patients. Data were collected from Aug. 1 to Aug. 31, 1988 through an interview schedule lasting for about 30-60 minutes by the investigators. Tools for this study were a daily activities scale and a subjective physical symptom scale developed by the researchers, and Zung's self rating depression scale. The subjects were 45 men 18 women post myocardial infarction patients who were receiving follow up care at SNU Hospital. The data were analyzed by percentage, mean, t-test, ANOVA, the Pearson moment Correlation Coefficient test, and Cronbach's a reliability test. The results were as follows. 1. Reliability of the daily activities scale was 0.91 by Cronbach's a. In the daily activities scale, items about transfer, exercise, and job related activities were most highly rated as meaningful to the post myocardial infarction patients. 2. The average daily activities score of these patients was 3.30 (maximum point:4) all scores were high except for exercise and job related activities. 3. There was a significant difference in daily activities according to sex; men had a higher daily activities score than women (T=2.32, P less than 0.05). 4. There was a significant difference in daily activities according to job status. Subjects having a job had a higher daily activities score. 5. The lower the depression score, the higher the daily activities score (gamma=-0.5748, P less than 0.05). 6. The lower the subjective physical symptoms score, the higher the daily activities score (gamma=-0.6015, P less than 0.05).

[Experimental study on bond strength of gold plated etched-metal surfaces of resin bonded restorations].

The purpose of this study was to compare the tensile bond strength of the resin-metal interface between etched only and etched & goldplated metal specimens. Etched only and etched & goldplated metal specimens were treated or were not treated with bonding agent and bonded to metal specimens with Comspan and MBAS. Also, electrochemically only etched metal surface and etched & goldplated metal surface was observed by SEM. The following results were obtained: 1. The tensile bond strength of the electrochemically etched only and gold-plated specimens were not significantly different in Comspan group, but the gold-plated specimens in MBAS group demonstrated slightly lower values than the etched only specimens. 2. The tensile bond strengths were not significantly different between the treated group with bonding agent and not-treated group with bonding agent. 3. The tensile bond strengths were not significantly different between the Comspan and MBAS groups. 4. The basic microretentive structures, maintained obviously in the etched and goldplated metal surfaces by SEM.

[Development or the nursing productivity conceptual framework].

This study was performed to develop the conceptual framework of the nursing productivity. The study efforts were made: (1) to define the concept the nursing productivity, (2) to identify the elements of the productivity, and (3) to determine the relationship among the elements. With the aim, the study employed a descriptive analysis by way of reviewing various references related to the subject. The nursing productivity consists of such elements as the nursing efficiency and the nursing effectiveness which are complementary to each other. The nursing efficiency is the quantitative input/output ratio, while the nursing effectiveness represents the integrated outcome of such sub-elements as the degree of accomplishing nursing goals, the quality of nursing service, consumer's satisfaction, and the degree of improvement of nurse's attitude toward the quality care. The nursing productivity can be estimated by summing up the nursing efficiency and the effectiveness. By employing the system theory model, the elements of the nursing productivity consist of three elements; the input, the process, and the output. By the process elements, the system inputs are transformed to the system outputs nursing efficiency and nursing effectiveness which are input to the system, in turn, through feedback mechanism (Figure 4).

The role of E-cadherin expression in non-small cell lung cancer.

The purpose of this study is to evaluate the clinical significance of E-cadherin expression in lung cancer. E-cadherin expression was detected by immunohistochemistry using a monoclonal antibody (HECD-1). Strongly positive (++) E-cadherin tumors were classified as a type of preserved E-cadherin expression (Pr type), while the others (+, - tumors) were classified as a type of reduced E-cadherin expression (Rd type). The frequency of Pr type in squamous cell carcinomas (59.0%) was higher than Rd type. However, in adenocarcinomas, the frequency of Rd type was higher than Pr type. E-cadherin expression pattern was significantly correlated with differentiated state (Pearson correlation coefficient 0.394, p<0.001). E-cadherin expression of well-differentiated tumors was more frequently preserved than that of poorly differentiated tumors (60.0% vs. 25.9%). With regard to the correlation between E-cadherin expression and stages of lymph node metastasis in non-small cell lung cancers, the percentage of tumors with Pr type E-cadherin expression declined from 66.3% (< or = N1) to 38.6% (> or = N2), indicating that loss of E-cadherin expression is responsible for acquisition of invasive potential of lung cancer as well as the possible role of E-cadherin in the histological differentiation of lung cancer.

Vascular endothelial growth factor in malignant and tuberculous pleural effusions.

The purpose of this study is to assess the usefulness of soluble vascular endothelial growth factor (VEGF) in the effusions of patients with malignant and tuberculous diseases. Using a sandwich enzyme-linked immunoadsorbent assay, VEGF concentration was measured in malignant (n=17) and tuberculous (n=11) pleural effusions. Pleural biopsy, cytology or microbiological methods were used to make final diagnoses. Adenosine deaminase (ADA) levels in tuberculous pleural effusions were significantly higher than those in malignant pleural effusions. The median level of VEGF in patients with malignant effusions (median, 2418 pg/mL; range, 97-62103 pg/mL) was significantly higher than tuberculous effusions (median, 994 pg/mL; range, 44-3552 pg/mL). There were no significant differences in pleural VEGF levels in patients with different histological types of lung cancer. The VEGF level was not correlated with ADA, lactate dehydrogenase and total protein levels of pleural fluid. In conclusion, pleural VEGF levels in patients with malignant effusions were significantly higher than tuberculous effusions, and the measurement of pleural VEGF is helpful in discriminating between malignant and tuberculous effusions. Further studies are needed to determine the clinical value of VEGF as a tumor marker and a prognostic factor.

Pleural empyema due to Salmonella: a case report.

Pleuropulmonary involvement of salmonella infection is very rare and only two cases of salmonella empyema have been reported in Korea. We report the case of a 70-year-old female diabetic patient who presented with right flank pain and right lower chest pain. The chest radiographs revealed fibrostreaky and hazy density at right lower lung field and blunting of right costophrenic angle. Thoracentesis revealed turbid yellowish fluid. Salmonella group B was identified from the cultures of blood and pleural fluid. After antimicrobial therapy and repeated therapeutic thoracentesis, the patient was improved.

DNA ploidy and proliferative activity in bcl-2 expressed non-small cell lung cancer.

OBJECTIVES: The expressions of bcl-2 have been reported recently in non-small cell lung carcinoma (NSCLC*). As oncogensis is believed to involve a number of genetic alterations, there can be differences in DNA ploidy or proliferative activity even in bcl-2 positive cases according to the superimposed genetic events. SUBJECTS AND METHODS: On the assumption that we might further discern the biologic behavior of bcl-2 positive NSCLC according to the status of DNA ploidy and proliferative activity, we conducted a study for bcl-2 expression with immunohistochemical staining and DNA analysis on 52 surgical specimens of NSCLC. RESULTS: The bcl-2 was positive in 52% (27/52) of specimens, According to the status of bcl-2 expression, there were no significant differences in tumor stages, performance status score and survival time. Among bcl-2 positive NSCLC, aneuploidy and high proliferative activity were noted in 40% and 44%, respectively. In cases with squamous cell carcinoma (SQC**), the proportion of aneuploidy was significantly higher in bcl-2 positive group compared to bcl-2 negative group (p < 0.01), which could not be explained with the sole effect of bcl-2. In bcl-2 positive NSCLC, there was no significant survival difference by the status of DNA analysis results. With a Coxproportional hazard model, only T stage was an independent prognostic factor. CONCLUSION: In bcl-2 expressed NSCLC, proliferative activity and DNA ploidy were not homogeneous, suggesting other genetic alterations. This may explain our results which showed no differences in survival according to the status of the bcl-2 expression.

A comparison of serum CYFRA 21-1 and SCC Ag in the diagnosis of squamous cell lung carcinoma.

To evaluate the usefulness of CYFRA 21-1 and SCC Ag in the diagnosis of squamous cell carcinoma (SQC) of the lung, we tested sera from 124 patients with lung cancers (squamous cell ca 72, adenoca 22, large cell ca 4, small cell ca 18 and undetermined 8) and 78 patients with inflammatory lung diseases (bronchitis 24, bronchiectasis 29, tuberculosis 19 and others 6) using immunoradiometric assay kit for cytokeratin fragment 19 (CYFRA 21-1) and radioimmunoassay kit for SCC Ag. The serum CYFRA 21-1 and SCC Ag were significantly higher in lung cancer patients compared with control subjects. However, the significant difference was restricted only to SQC. In patients with SQC, CYFRA 21-1 and SCC Ag showed significantly higher levels according to the advanced anatomic stages (stage I-IIIa vs. stage IIIb, IV, p < 0.05). There was a good correlation between CYFRA 21-1 and SCC Ag (r = 0.41, p < 0.001). Receiver operating characteristic (ROC) curves were generated from results of both tumor markers and areas under the curves (AUC) were calculated. AUC of CYFRA 21-1 (0.93) were significantly larger than that of SCC Ag (0.77) for the diagnosis of SQC (p < 0.05). Therefore, we conclude that CYFRA 21-1 is superior to SCC Ag in the diagnosis of squamous cell carcinoma of the lung.