Marius Zemaitis

Malignant Pleural and Peritoneal Mesothelioma: Incidental Diagnosis and Excellent Treatment Results

To the Editor: Patients with malignant pleural and peritoneal mesothelioma usually present with advanced symptomatic disease.1 Prognosis is poor. During our practice we had an exceptional mesothelioma case. During cholecystectomy peritoneal biopsy was done due to infiltration of omentum for 56-year-old man. The biopsy analysis showed that patient had peritoneal mesothelioma (Figure 1). The second mesothelioma marker WT-1 was positive and other markers (CEA, CD-15, and TTF-1) were negative. There were no respiratory symptoms or history of asbestos exposure. The patient (former smoker) was in good functional status. Chest computed tomography (CT) scan revealed multinodal lesions of left pleura (Figure 2). Malignant pleural and peritoneal mesothelioma was diagnosed and treatment with permetrexed 500 mg/m day 1 and cisplatin 80 mg/m day 1 (for 1 cycle) every 21 day was prescribed. The patient was assessed regularly with chest and abdomen CT (according to the modified RECIST criteria2). The pleural signs of mesothelioma disappeared completely after six cycles. No pleural or peritoneal changes were seen on CT scan 6 months after completion of chemotherapy (Figure 3). The patient is still alive with no signs of disease progression 3 years later. Early retrospective studies reported 5-year survival rates of 1% and overall median survivals of 7.6 months for patients not receiving chemotherapy. Eight randomized clinical trials concerning the mesothelioma chemotherapy have been published. Vogelzang et al.3 treated 448 eligible patients with either permetrexed and cisplatin or cisplatin alone. Response rates (41%versus 17%, p was 0.001), time to progression (5.7 versus 3.9 months, p was 0.001), and survival (median, 12.1 versus 9.3 months; hazard ratio 0.77, p was 0.020) all favored the combination treatment. In another large phase III trial,4 250 patients were randomized to receive either raltitrexed and cisplatin or cisplatin alone. Overall response rates (24% versus 14%, p was 0.056) was greater in the combination treatment arm. Now permetrexed combined with platinum compound is the only recommended treatment for extensive mesothelioma. According to the data of clinical trials the complete response during first line chemotherapy in malignant pleural mesothelioma is extremely rare. Furthermore, we could not find any reported data concerning the complete response rate in randomized clinical trials with permetrexed treatDisclosure: The authors declare no conflicts of interest. Copyright

Distribution of M1 and M2 macrophages in tumor islets and stroma in relation to prognosis of non-small cell lung cancer

BackgroundNon-small cell lung cancer (NSCLC) remains the most common cause of cancer related death worldwide. Tumor-infiltrating macrophages are believed to play an important role in growth, progression, and metastasis of tumors. In NSCLC, the role of macrophages remains controversial; therefore, we aimed to evaluate the distribution of macrophages (M1 and M2) in tumor islets and stroma and to analyze their relations to patients’ survival.MethodsLung tissue specimens from 80 NSCLC patients who underwent surgical resection for NSCLC (pathological stage I-III) and 16 control group subjects who underwent surgery because of recurrent spontaneous pneumothorax were analyzed. Immunohistochemical double staining of CD68/iNOS (markers for M1 macrophages) and CD68/CD163 (markers for M2 macrophages) was performed and evaluated in a blinded manner. The numbers of M1 and M2 macrophages in tumor islets and stroma were counted manually.ResultsPredominant infiltration of M1 and M2 macrophages was observed in the tumor stroma compared with the tumor islets. M2 macrophages predominated over M1 macrophages in the tumor tissue. Tumor islets-infiltrating M1 macrophages and the number of total tumor-infiltrating M2 macrophages were independent predictors of patients survival: high infiltration of M1 macrophages in tumor islets was associated with increased overall survival in NSCLC (P < 0.05); high infiltration of total M2 macrophages in tumor (islets and stroma) was associated with reduced overall survival in NSCLC (P < 0.05).ConclusionsThis study demonstrated that high infiltration of M1 macrophages in the tumor islets and low infiltration of total tumor-infiltrating M2 macrophages were associated with improved NSCLC patients’ survival.Trial registrationClinicalTrials.gov NCT01955343, registered on September 27, 2013

Pseudoaneurysm of brachiocephalic artery mimicking the mediastinal tumor

58 year-old male admitted to the Hospital of Lithuanian University of Health Sciences due to suspicion of mediastinal tumor for diagnostic endobronchial ultrasound procedure (EBUS). The main patients complain was progressive dyspnea. Objective investigation revealed no major findings: normal breath sounds, heart rate – 96 bpm, blood pressure – 120/80 mmHg. Chest CT scan showed the mediastinal tumor of 3.8 × 3.5 cm. During bronchoscopy smooth intratracheal nodule of 5 mm was found. Superficial biopsy showed normal airway mucosa. During EBUS procedure no clear lymph node structure or blood flow was detected. It was decided to observe the patient clinically. One month later massive hemoptysis started. Urgent bronchoscopy revealed large right-sided mass and intratracheal wall dislocation due to the possible mediastinal tumor in the same location as the polyp in the previous investigation. Repeated chest CT scan showed increasing tumor of size 4.0 × 3.2 × 4.0 cm in the mediastinum and pseudoaneurysm of brachiocephalic artery was suspected. The diagnosis was later confirmed by aortography. The patient underwent successful aneurysmectomy.