Hiromichi Yamane

Non–Small Cell Lung Cancer Cells Acquire Resistance to the ALK Inhibitor Alectinib by Activating Alternative Receptor Tyrosine Kinases

Crizotinib is the standard of care for advanced non-small cell lung cancer (NSCLC) patients harboring the anaplastic lymphoma kinase (ALK) fusion gene, but resistance invariably develops. Unlike crizotinib, alectinib is a selective ALK tyrosine kinase inhibitor (TKI) with more potent antitumor effects and a favorable toxicity profile, even in crizotinib-resistant cases. However, acquired resistance to alectinib, as for other TKIs, remains a limitation of its efficacy. Therefore, we investigated the mechanisms by which human NSCLC cells acquire resistance to alectinib. We established two alectinib-resistant cell lines that did not harbor the secondary ALK mutations frequently occurring in crizotinib-resistant cells. One cell line lost the EML4-ALK fusion gene, but exhibited increased activation of insulin-like growth factor-1 receptor (IGF1R) and human epidermal growth factor receptor 3 (HER3), and overexpressed the HER3 ligand neuregulin 1. Accordingly, pharmacologic inhibition of IGF1R and HER3 signaling overcame resistance to alectinib in this cell line. The second alectinib-resistant cell line displayed stimulated HGF autocrine signaling that promoted MET activation and remained sensitive to crizotinib treatment. Taken together, our findings reveal two novel mechanisms underlying alectinib resistance that are caused by the activation of alternative tyrosine kinase receptors rather than by secondary ALK mutations. These studies may guide the development of comprehensive treatment strategies that take into consideration the various approaches ALK-positive lung tumors use to withstand therapeutic insult.

Clinical outcome in patients with leptomeningeal metastasis from non-small cell lung cancer: Okayama Lung Cancer Study Group

OBJECTIVE We examined the prognosis of patients with leptomeningeal metastasis (LM) from non-small cell lung cancer (NSCLC) and that stratified by epidermal growth factor receptor (EGFR) mutation status in LM patients receiving EGFR-tyrosine kinase inhibitors (TKIs). METHODS We retrospectively analyzed a series of 91 consecutive NSCLC patients with LM between 2001 and 2010. RESULTS Most of the LM patients had adenocarcinoma histology and a poor performance status (PS). The median survival time (MST) for all patients was 3.6 months. Adenocarcinoma and TKI treatment were associated with a better prognosis. Among the patients, 51 received EGFR-TKIs. Of these, the EGFR mutation status was assessed in 30 patients; 7 (23%) showed no mutation (group 1), 10 (33%) had a mutation in exon 21 (group 2), and 13 (43%) had deletions in exon 19 (group 3). Interestingly, PS was significantly improved in groups 2 and 3 but not in group 1. The MST in these subgroups was 1.4, 7.1, and 11.0 months in groups 1, 2, and 3, respectively (p<0.001). The median time to progression or symptom deterioration was 0.9, 2.0, and 7.8 months for groups 1, 2, and 3, respectively (p<0.001). A multivariate analysis showed that EGFR-mutant tumors were associated with a better prognosis in patients receiving EGFR-TKIs. CONCLUSIONS The prognosis for patients with LM from NSCLC was still poor. Survival after the initiation of EGFR-TKI treatment differed according to the type of EGFR mutation, suggesting the potential benefit of TKIs for patients with EGFR mutations, even though they suffered from LM.

Subpopulation of small-cell lung cancer cells expressing CD133 and CD87 show resistance to chemotherapy.

Tumors are presumed to contain a small population of cancer stem cells (CSCs) that initiate tumor growth and promote tumor spreading. Multidrug resistance in CSCs is thought to allow the tumor to evade conventional therapy. This study focused on expression of CD133 and CD87 because CD133 is a putative marker of CSCs in some cancers including lung, and CD87 is associated with a stem‐cell‐like property in small‐cell lung cancer (SCLC). Six SCLC cell lines were used. The expression levels of CD133 and CD87 were analyzed by real‐time quantitative reverse transcription‐polymerase chain reaction and flow cytometry. CD133+/− and CD87+/− cells were isolated by flow cytometry. The drug sensitivities were determined using the 3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide assay. Non‐obese diabetic/severe combined immunodeficiency mice were used for the tumor formation assay. SBC‐7 cells showed the highest expression levels of both CD133 and CD87 among the cell lines. CD133−/CD87−, CD133+/CD87−, and CD133−/CD87+ cells were isolated from SBC‐7 cells; however, CD133+/CD87+ cells could not be obtained. Both CD133+/CD87− and CD133−/CD87+ subpopulations showed a higher resistance to etoposide and paclitaxel and greater re‐populating ability than the CD133−/CD87− subpopulation. CD133+/CD87− cells contained more G0 quiescent cells than CD133−/CD87− cells. By contrast, CD133−/CD87− cells showed the highest tumorigenic potential. In conclusion, both CD133 and CD87 proved to be inadequate markers for CSCs; however, they might be beneficial for predicting resistance to chemotherapy. (Cancer Sci 2013; 104: 78–84)

Human herpes virus-8-negative primary effusion lymphoma in a patient with common variable immunodeficiency

Primary effusion lymphoma (PEL) is a newly described high-grade B cell lymphoma developing in association with human herpes virus type 8 (HHV-8) in human immunodeficiency virus (HIV)-infecting individuals. Common variable immunodeficiency (CVID) is a primary immunodeficiency disease characterized by reduced serum immunoglobulin and heterogeneous clinical features. The risk of cancer in CVID patients is increased. Here, we describe a PEL that developed in the pleural and pericardial cavities of an HIV-negative and HHV-8-negative patient with CVID.

Methotrexate-Induced Lymphoproliferative Disease: Epstein-Barr Virus–Associated Lymphomatoid Granulomatosis

Case Report An asymptomatic 76-year-old woman presented with a lung mass on chest radiography. She had received methotrexate for 5.5 years (4 mg per week for 4 years and 8 mg per week for 1.5 years) for rheumatoid arthritis. Contrast-enhanced chest computed tomography revealed lung tumors with an angiogram sign in the right middle lobe (Fig 1A). An endobronchial image on flexible bronchoscopy demonstrated ulcerative erosion surrounded by pale mucosa in the right upper lobe orifice (Fig 1B; white arrowhead indicates the right upper bronchus). A biopsy of the lesions showed Epstein-Barr virus (EBV)–related lymphoproliferative disease (LPD), which was compatible with grade 2 lymphomatoid granulomatosis (LYG) according to the WHO classification on the basis of immunohistochemical findings. Serum EBV-viral capsid antigen immunoglobulin G index (12.9; normal, 0.5) and EBV nuclear antigen index (2.2; normal: 0.5) were elevated, whereasEBV-viralcapsidantigenimmunoglobulinMwasnegative.Realtime polymerase chain reaction for EBV DNA demonstrated 220 copies/mL (normal, 100 copies/mL). EBV hematoxylin and eosin staining showed the bronchus epithelium and subcutaneous infiltration of small lymphocytes, with necrosis (Fig 2A, 40 magnification; Fig 2B, 400 magnification). Figures 2C, 2D, 2E, and 2F show immunostaining using the CD20 antibody ( 40 magnification), CD79a antibody ( 40 magnification),latentmembraneprotein1antibody( 100magnification),and EBV-encoded small RNA–1 in situ hybridization ( 200 magnification), respectively. The positive results indicated EBV-induced B-cell transformation. Four weeks after discontinuation of methotrexate, chest radiography showed tumor shrinkage. Over the next 4 weeks, the disease improved remarkably (Figs 1C and 1D). The tumor has remained in this shrunken state for 1 year.

Interleukin-12 augments cytolytic activity of peripheral blood mononuclear cells against autologous lung cancer cells in combination with IL-2

The majority of patients with advanced lung cancer die within a few years. Accordingly, new therapeutic modalities need to be developed. Interleukin (IL)-12 was previously known as natural killer (NK) cell stimulatory factor or cytotoxic lymphocyte maturation factor. By virtue of its effects on T cells and NK cells, IL-12 seems to be one of the key cytokines that regulates cell-mediated anti tumor immune responses. Recently, there has been a substantial interest in the potential applications of IL-12 in the treatment of lung cancer. However, there have been no reports about the effect of IL-12 on peripheral blood mononuclear cells (PBMCs) obtained from lung cancer patients in an autologous setting. In this study, we examined the cytotoxicity of PBMC activated by IL-2, IL-12 or both against K562 or autologous lung cancer cells. In contrast to the effect of IL-2 on NK activity, IL-12 alone augmented NK activity against K562 cells, but not against autologous lung cancer cells. IL-12 augmented the IL-2 mediated cytotoxicity of PBMC against both K562 and autologous lung cancer cells. In the absence of IL-2, IL-12 alone cannot induce an autologous anti-tumor effect in vivo. In summary, our results clearly demonstrated that IL-12 can augment the cytolytic activity of PBMC against K562 and autologous lung cancer cells when combined with IL-2, although, IL-12 alone was unable to induce a marked increase in the cytotoxicity against autologous lung cancer cells. These results suggest that an administration of IL-12 in combination with IL-2 may be a useful therapeutic option for solid tumors.

Interstitial lung disease associated with gemcitabine treatment in patients with non-small-cell lung cancer and pancreatic cancer.

PurposeAlthough there are several reports concerning gemcitabine-induced interstitial lung disease (ILD), the risk factors for ILD are not well known. In addition, data comparing the incidence and pattern of ILD associated with gemcitabine treatment in patients with non-small-cell lung cancer (NSCLC) versus those with pancreatic cancer are scarce.MethodsWe reviewed clinical records of 118 patients treated with gemcitabine between November 2004 and November 2010. The radiographic findings and other relevant clinical data were reviewed to identify patients who had developed ILD associated with gemcitabine treatment.ResultsOut of these 118 patients, we identified 62 patients with NSCLC (group A) and 56 patients with pancreatic cancer (group B), which were then analysed. After gemcitabine administration, ILD was detected in 9 out of the total 118 patients (7.6%). Three patients had grade 2 ILD and 6 patients had grade 3 ILD. Multivariate analysis revealed that prior thoracic radiotherapy (odds ratio: 26.3) and pre-existing pulmonary fibrosis (PF) (odds ratio: 6.5) were correlated with ILD occurrence, but the incidence of ILD was not different between groups A and B. The median dose of gemcitabine administered till the manifestation of ILD tended to be lower in group A than in group B.ConclusionsPrior thoracic radiotherapy and pre-existing PF were correlated with higher ILD rate in gemcitabine-treated patients. ILD incidence did not differ between NSCLC and pancreatic cancer patients, which may be due to the differences in treatment strategy and tumour properties.

The effect of adding rituximab to CHOP-based therapy on clinical outcomes for Japanese patients with diffuse large B-cell lymphoma: a propensity score matching analysis.

We conducted a retrospective analysis to evaluate the impact on clinical outcomes of adding rituximab to cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) treatment for diffuse large B-cell lymphoma (DLBCL) patients in Japan. A propensity score method was used to compensate for the non-randomized study design. From January 2000 to December 2004, 378 patients who were newly diagnosed with DLBCL at 13 institutes were enrolled: 123 in the rituximab plus CHOP-based chemotherapy (R+) group, and 255 in the CHOP-based chemotherapy only (R−) group. The complete response rate was significantly higher in the R+ group than in the R− group (77.7 vs. 69.4%, P < 0.001). The progression-free survival (PFS) at 2 years was 62.4% in the R+ group and 57.0% in the R− group. The 2-year overall survival (OS) was 76.9% for the R+ group and 70.5% for the R− group. A multivariate analysis revealed that the addition of rituximab was a strong independent prognostic factor for PFS (hazard ratio 0.64, 95% CI 0.43–0.96, P = 0.031). A subgroup analysis revealed that R+ particularly benefited younger patients (hazard ratio 0.25, 95% CI 0.08–0.75, P = 0.013). IPI also showed significant impact for PFS (hazard ratio 1.82, 95% CI 1.55–2.14 for one score increase, P < 0.001) as well as OS (hazard ratio 2.10, 95% CI 1.71–2.57, P < 0.001). In summary, the addition of rituximab to CHOP-based chemotherapy results in better outcomes for Japanese DLBCL patients, particularly younger patients.

Neurogenic pulmonary edema after subarachnoid hemorrhage.

CASE REPORTA56-year-oldwomanwithamedicalhistoryofhyperten-sion suddenly fell to thegroundwhile brushing her teeth.Her family found that she had stopped breathing andchecked the pulse of the carotid artery, which could notbe palpated. Her family immediately initiated bystandercardiopulmonary resuscitation and called emergencymedical services. The patient had return of spontaneouscirculation 15 min after the onset of cardiopulmonaryarrest. On arrival at our emergency department, the pa-tient’s vital signs were the following: blood pressure102/62 mm Hg, heart rate 86 beats/min, and body tem-perature 35.9 C. Her consciousness level was E1V1M1on the Glasgow Coma Scale. She had miotic pupilswith loss of light reflex. Physical examination revealeddiffuse bilateral crackles. Despite intubation and manualventilation with oxygen administration (10 L/min), sheremained hypoxic, with a partial pressure of oxygen on39.8 mm Hg on arterial blood gas. During theintubation,pink frothy sputum was found in her trachea. A chestx-ray study showed bilateral patchy opacities withoutcardiomegaly. Due to her sudden loss of consciousnessand persistent hypoxia despite recovery from circulat-ion insufficiency, we performed a computed tomo-graphy (CT) of her brain and chest to assess for theetiology of her arrest. Diffuse subarachnoid hemorrhage(Figure 1) and acute pulmonary edema were demon-strated (Figure 2) on the CT scans.DISCUSSIONNeurogenic pulmonary edema is a rare but life-threatening complication in patients with central nervoussystem lesions and is defined as the sudden developmentof hypoxemic respiratory failure after a central nervoussystem event, which cannot be attributed to other causes

Guidelines for Long-Term Steroid Therapy in End-of-Life Palliative Care

Indicationsofshort-termsteroid therapy in oncological emergencies include bowel obstruc-tions, spinal cord compression, and superior vena cava syndrome. Inaddition, steroids can be useful for the treatment of nausea, dyspnea,anorexia, weight loss, fatigue, and in improving a patient’s generalfeeling of well-being. However, steroids have a limited effect (lastingfor up to 4 weeks) on these symptoms.