Luca Ampollini

Grading the neuroendocrine tumors of the lung: an evidence-based proposal.

Lung neuroendocrine tumors are catalogued in four categories by the World Health Organization (WHO 2004) classification. Its reproducibility and prognostic efficacy was disputed. The WHO 2010 classification of digestive neuroendocrine neoplasms is based on Ki67 proliferation assessment and proved prognostically effective. This study aims at comparing these two classifications and at defining a prognostic grading system for lung neuroendocrine tumors. The study included 399 patients who underwent surgery and with at least 1 year follow-up between 1989 and 2011. Data on 21 variables were collected, and performance of grading systems and their components was compared by Cox regression and multivariable analyses. All statistical tests were two-sided. At Cox analysis, WHO 2004 stratified patients into three major groups with statistically significant survival difference (typical carcinoid vs atypical carcinoid (AC), P=0.021; AC vs large-cell/small-cell lung neuroendocrine carcinomas, P<0.001). Optimal discrimination in three groups was observed by Ki67% (Ki67% cutoffs: G1 <4, G2 4-<25, G3 ≥25; G1 vs G2, P=0.021; and G2 vs G3, P≤0.001), mitotic count (G1 ≤2, G2 >2-47, G3 >47; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001), and presence of necrosis (G1 absent, G2 <10% of sample, G3 >10% of sample; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001) at uni and multivariable analyses. The combination of these three variables resulted in a simple and effective grading system. A three-tiers grading system based on Ki67 index, mitotic count, and necrosis with cutoffs specifically generated for lung neuroendocrine tumors is prognostically effective and accurate.

Lung metastasis resection of adenoid cystic carcinoma of salivary glands

BACKGROUND Adenoid cystic carcinoma is a rare tumour originating from the exocrine mucous glands, known for its high propensity for distant metastases. The value of lung metastasis resection from adenoid cystic carcinoma of salivary glands origin is evaluated. METHODS A retrospective study was conducted on patients undergoing surgery for primary adenoid cystic carcinoma of the salivary glands between 1982 and 2006. Patients were excluded who had primary tumour macroscopic incomplete resection or were lost at follow-up. From a database of 50 eligible patients, 27 were identified as having presented a tumour recurrence during follow-up; in 20 it was first diagnosed in the form of distant metastases, and in 7 in the form of loco-regional recurrence. Nine patients who presented isolated lung recurrence underwent complete lung metastasectomy. Demographic data, pathologic characteristics and operative and postoperative record were reviewed, as well as updated survival. RESULTS Twenty-six men and 24 women with a median age of 57 years (range 33-79) underwent radical surgery for adenoid cystic carcinoma during the study period. In 20 patients, at a median free interval time of 3 years (range 1-12), a distant metastasis relapse was observed. Nine patients with a median free interval time of 5 years (range 1-12) underwent lung metastasectomy: five had single metastasis resection, one multiple mono-pulmonary and three multiple and bilateral. In six of these patients a new disease recurrence was noted: four patients underwent further lung metastasectomy, but in all of them progression of the disease was observed. Mean survival of the population as a whole resulted as being 16 years (SE=1.4) with an actuarial survival of 77% at 5 years, 66% at 10 years and 56% at 15 years. Mean survival of patients having presented with distant metastases resulted as being 11 years (SE=2.2). Mean survival after appearance of distant metastases resulted as being 72 months (SE=15.8) in the 9 patients treated by metastasectomy, and 62 months (SE=15.1) in the 11 who did not have metastasis resection. CONCLUSIONS Patients with adenoid cystic carcinoma could be frequently encountered with disease recurrence confined to the lung. The impact of complete lung metastasis resection on the course of the disease, however, is yet to be determined.

Plasma and EBC microRNAs as early biomarkers of non-small-cell lung cancer

Abstract Lung cancer is a major cause of death in Western countries. Current screening methods are invasive and still lead to a high percentage of false positives. There is, therefore, a need to find biomarkers that increase the probability of detecting lung cancer early. MicroRNAs (miRNAs) are stable molecules in blood plasma and exhaled breath condensate (EBC). We quantified miRNA-21 and miRNA-486 expression from plasma and EBC samples from patients with a diagnosis of non-small-cell lung cancer (NSCLC) and controls. miRNA-21 was significantly higher in plasma and in EBC of the NSCLC patients and miRNA-486 was significantly lower. This difference indicates a significantly improved diagnostic value, and suggests that these miRNAs could be clinically used as a first-line screening test in high-risk subjects.

Trastuzumab emtansine is active on HER-2 overexpressing NSCLC cell lines and overcomes gefitinib resistance.

BackgroundHER-2 represents a relatively new therapeutic target for non small cell lung cancer (NSCLC) patients. The incidence for reported HER-2 overexpression/amplification/mutations ranges from 2 to 20% in NSCLC. Moreover, HER-2 amplification is a potential mechanism of resistance to tyrosine kinase inhibitors of the epidermal growth factor receptor (EGFR-TKI) (about 10% of cases). T-DM1, trastuzumab emtansine is an antibody-drug conjugate composed by the monoclonal antibody trastuzumab and the microtubule polymerization inhibitor DM1. The activity of T-DM1 has been studied in breast cancer but the role of T-DM1 in lung cancer remains unexplored.MethodsAntiproliferative and proapoptotic effects of T-DM1 have been investigated in different NSCLC cell lines by MTT, crystal violet staining, morphological study and Western blotting. HER-2 expression and cell cycle were evaluated by flow cytometry and Western blotting. Antibody dependent cell cytotoxicity (ADCC) was measured with a CytoTox assay. Xenografted mice model has been generated using a NSCLC cell line to evaluate the effect of T-DM1 on tumor growth. Moreover, a morphometric and immunohistochemical analysis of tumor xenografts was conducted.ResultsIn this study we investigated the effect of T-DM1 in a panel of NSCLC cell lines with different HER-2 expression levels, in H1781 cell line carrying HER-2 mutation and in gefitinib resistant HER-2 overexpressing PC9/HER2cl1 cell clone. T-DM1 efficiently inhibited proliferation with arrest in G2-M phase and induced cell death by apoptosis in cells with a significant level of surface expression of HER-2. Antibody-dependent cytotoxicity assay documented that T-DM1 maintained the same activity of trastuzumab. Our data also suggest that targeting HER-2 with T-DM1 potentially overcomes gefitinib resistance. In addition a correlation between cell density/tumor size with both HER-2 expression and T-DM1 activity was established in vitro and in an in vivo xenograft model.ConclusionsOur results indicate that targeting HER-2 with T-DM1 may offer a new therapeutic approach in HER-2 over-expressing lung cancers including those resistant to EGFR TKIs.

Exercise capacity assessment in patients undergoing lung resection

BACKGROUND The value is examined of preoperative functional assessment, including exercise capacity measurement by a cycloergometric maximal exercise test, in the prediction of postoperative cardio-pulmonary complication after lobar resection. METHODS In a prospective study over a 3-year period, all patients who were candidates for lung resection underwent preoperative functional evaluation by means of resting pulmonary function tests, measurement of the lung diffusing capacity for carbon monoxide and cardio-pulmonary exercise test. Patients who had had pneumonectomy or less than anatomical segmentectomy were excluded. The study population consisted of 73 patients. The postoperative morbidity and mortality record was collected. RESULTS Sixty-four patients underwent lobectomy, five bilobectomy and four segmentectomy. Indication for surgery was NSCLC in 71 cases. Two postoperative deaths were recorded (2.7%). A pulmonary (n=19) and/or cardiac (n=17) complication was scored in 30 patients (41%). Mean preoperative FEV(1) and VO(2)max of patients who developed pulmonary complications were significantly lower (p=0.013 and p=0.043 respectively) than those of patients without pulmonary complications. Logistic regression analysis found FEV(1) to be an independent factor in pulmonary complication (p=0.002). With regard to pulmonary complication occurrence, the receiver operating characteristic curve showed an area of 0.69 with VO(2)max expressed in ml/kg min and of 0.62 when VO(2)max was expressed as a percentage of the predicted value. The widest point of the curve was found at a VO(2)max value of 18.7 ml/kg min. Six out of the 14 patients (43%) with a preoperative VO(2)max equal to or lower than 15 ml/kg min had a pulmonary complication. No functional preoperative identifiers were found for the 16 patients who presented with postoperative new onset atrial fibrillation. The mean preoperative value of carbon monoxide lung diffusing capacity was significantly lower (p=0.037) in the 30 patients who had postoperative cardio-pulmonary complications than in the complication-free population. CONCLUSIONS Preoperative exercise capacity assessment helps in stratifying patients at risk for postoperative pulmonary complication. However, it does not appear to be an independent prognostic factor for postoperative outcome.

Prognostic model of survival for typical bronchial carcinoid tumours: analysis of 1109 patients on behalf of the European Association of Thoracic Surgeons (ESTS) Neuroendocrine Tumours Working Group

OBJECTIVES Typical carcinoids (TCs) are uncommon, slow-growing neoplasms, usually with high 5-year survival rates. As these are rare tumours, their management is still based on small clinical observations and no international guidelines exist. Based on the European Society of Thoracic Surgeon Neuroendocrine Tumours Working Group (NET-WG) Database, we evaluated factors that may influence TCs mortality. METHODS Using the NET-WG database, an analysis on TC survival was performed. Overall survival (OS) was calculated starting from the date of intervention. Predictors of OS were investigated using the Cox model with shared frailty (accounting for the within-centre correlation). Candidate predictors were: gender, age, smoking habit, tumour location, previous malignancy, Eastern Cooperative Oncology Group (ECOG) performance status (PS), pT, pN, TNM stage and tumour vascular invasion. The final model included predictors with P ≤ 0.15 after a backward selection. Missing data in the evaluated predictors were multiple-imputed and combined estimates were obtained from five imputed data sets. RESULTS For 58 of 1167 TC patients vital status was unavailable and analyses were therefore performed on 1109 patients from 17 institutions worldwide. During a median follow-up of 50 months, 87 patients died, with a 5-year OS rate of 93.7% (95% confidence interval: 91.7-95.3). Backward selection resulted in a prediction model for mortality containing age, gender, previous malignancies, peripheral tumour, TNM stage and ECOG PS. The final model showed a good discrimination ability with a C-statistic equal to 0.836 (bootstrap optimism-corrected 0.806). CONCLUSIONS We presented and validated a promising prognostic model for TC survival, showing good calibration and discrimination ability. Further analyses are needed and could be focused on an external validation of this model.

Predictive factors of diagnostic accuracy of CT-guided transthoracic fine-needle aspiration for solid noncalcified, subsolid and mixed pulmonary nodules

Purpose. The aim of this study was to analyse factors predicting the diagnostic accuracy of computed tomography (CT)-guided transthoracic fine-needle aspiration (TTFNA) for solid noncalcified, subsolid and mixed pulmonary nodules, with particular attention to those responsible for false negative results with a view to suggesting a method for their correction.PurposeThe aim of this study was to analyse factors predicting the diagnostic accuracy of computed tomography (CT)-guided transthoracic fine-needle aspiration (TTFNA) for solid noncalcified, subsolid and mixed pulmonary nodules, with particular attention to those responsible for false negative results with a view to suggesting a method for their correction.Materials and methodsFrom January 2007 to March 2010, we retrospectively reviewed the CT images of 198 patients of both sexes (124 males and 74 females; mean age, 70 years; range age, 44–90) used for the guidance of TTFNA of pulmonary nodules. Aspects considered were: lesion size and density, distance from the pleura, and lesion site. Multiplanar reformatted images (MPR) were retrospectively obtained in the sagittal and axial oblique planes relative to needle orientation.ResultsThe overall diagnostic accuracy of TTFNA CTguided biopsy was 86% for nodules between 0.7 and 3 cm, 83.3% for those between 0.7 and 1.5 cm, and 92% for those between 2 and 3 cm. Accuracy was 95.1% for solid pulmonary nodules, 84.6% for mixed nodules, and 66.6% for subsolid nodules. The diagnostic accuracy of CT-guided TTFNA in relation to the distance between the nodule and the pleural plane was 95.6% for lesions adhering to the pleura and 83.5% for central ones. The diagnostic accuracy was 84.2% for the pulmonary upper lobe nodules, 85.3% for the lower lobe and 90.9% for those in the lingula and middle lobe. In 75% of false negative and inadequate/insufficient cases the needle was found to lie outside the lesion, after reconstruction of the needle path by MPR.ConclusionsThe positive predictive factors of CT-guided TTFNA are related to the nodule size, density and distance from the pleural plane. The most common negative predictive factor of CT-guided TTFNA is the wrong position of the needle tip, as observed in the sagittal and axial oblique sections of the MPR reconstructions. The diagnostic accuracy of CT-guided TTFNA can therefore be improved by using the MPR technique to plan the needle path during the FNA procedure.RiassuntoObiettivoScopo del presente lavoro è stato individuare ed analizzare i fattori che predicono l’accuratezza diagnostica dell’ago-biopsia trans-toracica (TTFNA) guidata da tomografia computerizzata (TC) dei noduli polmonari solidi non calcifici, subsolidi e misti, con particolare attenzione ai fattori responsabili di falsi negativi, proponendo un metodo per la loro correzione.Materiali e metodiTra il 2007 ed il 2010 sono state analizzate retrospettivamente le immagini TC del torace di 198 pazienti di entrambi i sessi (124 maschi e 74 femmine, età media 70 anni, range età 44–90) utilizzate per l’esecuzione di TTFNA TC-guidata di noduli polmonari. I criteri analizzati sono stati: dimensione, densità, distanza dal piano pleurico e sede dei noduli polmonari. Sono state ottenute retrospettivamente immagini in ricostruzioni multiplanari (MPR) sui piani sagittali ed asssiali obliqui in relazione all’orientamento dell’ago.RisultatiL’accuratezza complessiva della TTFNA TC-guidata per noduli polmonari compresi tra 0,7 e 3 cm è stata 86%. L’accuratezza per i noduli polmonari compresi tra 7 e i 15 mm è stata del 83,3%, per quelli compresi tra 20 e 30 mm del 92%. L’accuratezza per i noduli polmonari solidi è stata del 95%, per i noduli misti 84,6% e per noduli subsolidi 66,6%. L’accuratezza per i noduli adesi al piano pleurico è stata del 95,6% e per quelli centrali 83,5%. Per i noduli dei lobi superiori è stata 84,2%, per quelli dei lobi inferiori 85,3%, per quelli della lingula e del lobo medio 90,9%. Nel 75% dei casi falsi negativi, inadeguati o insufficienti, la punta dell’ago dopo ricostruzione MPR era localizzata all’esterno o in periferia del nodulo polmonare.ConclusioniI fattori diagnostici predittivi positivi della TTFNA TC-guidata sono correlati con le dimensioni, la densità e la distanza del nodulo polmonare con il piano pleurico. Il fattore predittivo negativo ricorrente della TTFNA TC-guidata è l’errata localizzazione della punta dell’ago, mal evidente nelle scansioni assiali native, osservata retrospettivamente nelle sezioni sagittali ed assiali oblique MPR. Il ricorso alle immagini MPR sagittali e assiali oblique durante l’agoaspirazione è utile per il corretto planning della traiettoria dell’ago, quest’ultimo aspetto cruciale che influenza l’accuratezza diagnostica della procedura.

Combined use of anti-ErbB monoclonal antibodies and erlotinib enhances antibody-dependent cellular cytotoxicity of wild-type erlotinib-sensitive NSCLC cell lines

BackgroundThe epidermal growth factor receptor (EGFR) is an established target for anti-cancer treatment in different tumour types. Two different strategies have been explored to inhibit this pivotal molecule in epithelial cancer development: small molecules TKIs and monoclonal antibodies. ErbB/HER-targeting by monoclonal antibodies such as cetuximab and trastuzumab or tyrosine-kinase inhibitors as gefitinib or erlotinib has been proven effective in the treatment of advanced NSCLC.ResultsIn this study we explored the potential of combining either erlotinib with cetuximab or trastuzumab to improve the efficacy of EGFR targeted therapy in EGFR wild-type NSCLC cell lines. Erlotinib treatment was observed to increase EGFR and/or HER2 expression at the plasma membrane level only in NSCLC cell lines sensitive to the drug inducing protein stabilization. The combined treatment had marginal effect on cell proliferation but markedly increased antibody-dependent, NK mediated, cytotoxicity in vitro. Moreover, in the Calu-3 xenograft model, the combination significantly inhibited tumour growth when compared with erlotinib and cetuximab alone.ConclusionOur results indicate that erlotinib increases surface expression of EGFR and/or HER2 only in EGFR-TKI sensitive NSCLC cell lines and, in turns, leads to increased susceptibility to ADCC both in vitro and in a xenograft models. The combination of erlotinib with monoclonal antibodies represents a potential strategy to improve the treatment of wild-type EGFR NSCLC patients sensitive to erlotinib.

Diaphragmatic laceration, partial liver herniation and catamenial pneumothorax.

Catamenial pneumothorax is a recurrent pneumothorax temporally associated with menstruation. Pathogenesis remains debated however pleural endometriosis or diaphragmatic abnormalities are almost always present. We report the case of a 35-year-old woman with recurrent right catamenial pneumothorax. At thoracoscopy a large laceration of the diaphragm with partial intrathoracic liver herniation was seen. Treatment involved repair of the diaphragmatic lacerations, and pleurodesis. This report shows that large diaphragmatic defects may be observed in patients with catamenial pneumothorax.

Prophylactic Use of Helmet CPAP After Pulmonary Lobectomy: A Prospective Randomized Controlled Study

BACKGROUND: Patients undergoing pulmonary lobectomy carry a high risk of respiratory complications after surgery. The postoperative prophylactic treatment with helmet CPAP may prevent postoperative acute respiratory failure and improve the PaO2/FIO2. METHODS: We randomly allocated 50 subjects to receive continuous oxygen therapy (air-entrainment mask, FIO2 0.4) or 2 cycles of helmet CPAP for 120 min, alternating with analog oxygen therapy for 4 hours. Blood gas values were collected at admission to ICU, after 1, 3, 7, 9, 24 hours, and then in the thoracic ward after 48 hours and one week after surgery. We investigated the incidence of postoperative complications, mortality, and length of hospital stay. RESULTS: At the end of the second helmet CPAP treatment, the subjects had a significantly higher PaO2/FIO2, compared with the control group (366 ± 106 mm Hg vs 259 ± 60 mm Hg, P = .004), but the improvement in oxygenation did not continue beyond 24 hours. The postoperative preventive helmet CPAP treatment was associated with a significantly shorter hospital stay, in comparison to standard treatment (7 ± 4 d and 8 ± 13 d, respectively, P = .042). The number of minor or major postoperative complications was similar between the 2 groups. No difference in ICU readmission or mortality was observed. CONCLUSIONS: The prophylactic use of helmet CPAP improved the PaO2/FIO2, but the oxygenation benefit was not lasting. In our study, helmet CPAP was a secure and well tolerated method in subjects who underwent pulmonary lobectomy. It might be safely applied whenever necessary.