Sven Hillinger

Detection of extrathoracic metastases by positron emission tomography in lung cancer

BACKGROUND Accurate staging of non-small cell lung cancer is essential for treatment planning. We evaluated in a prospective study the role of whole-body 2-[18F]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in mediastinal nodal staging with a positive predictive value of 96%. The study was continued to further evaluate the value of whole-body FDG PET in detecting unexpected extrathoracic metastases (ETMs) in patients qualifying for surgical treatment by conventional staging. METHODS One hundred patients underwent clinical evaluation, chest and upper abdominal computed tomography scan, mediastinoscopy (lymph nodes greater than 1 cm on computed tomography), and routine laboratory tests. In 94 patients with stage IIIa or less and 6 with suspected N3 a whole-body FDG PET was performed. If clinical signs of ETMs were present additional diagnostic methods were applied. All findings in the FDG PET were confirmed histologically or radiologically. RESULTS Unexpected ETMs were detected in 13 (14%) of 94 patients (stage IIIa or less) at 14 sites. In addition 6 of 94 patients were restaged up to N3 after PET. The suspected N3 disease (stage IIIb) on computed tomography was confirmed by PET in all 6 patients. There was no false positive finding of ETM. Weight loss was correlated with the occurrence of ETM: more than 5 kg, 5 of 13 patients (38%); more than 10 kg, 4 of 6 patients (67%). Pathologic laboratory findings were not predictive for ETM. CONCLUSIONS Whole-body FDG PET improves detection of ETMs in patients with non-small cell lung cancer otherwise elegible for operation. In 14% of patients (stage IIIa or less), ETMs were detected, and in total, 20% of the patients were understaged.

Intratumoral Administration of Dendritic Cells Overexpressing CCL21 Generates Systemic Antitumor Responses and Confers Tumor Immunity

To achieve in situ tumor antigen uptake and presentation, intratumoral administration of ex vivo-generated, gene-modified murine bone marrow-derived dendritic cells (DC) was used in a murine lung cancer model. To attract mature host DC and activated T cells at the tumor site, the DC were transduced with an adenoviral vector expressing secondary lymphoid tissue chemokine (CCL21/SLC). Sixty percent of the mice treated with 106 DC-AdCCL21 intratumorally (7–10 ng/ml/106 cells/24 h of CCL21) at weekly intervals for 3 weeks showed complete tumor eradication, whereas only 25% of mice had complete resolution of tumors when mice were treated with fibroblasts expressing CCL21. In contrast only 12% of the mice treated with unmodified or control vector modified DC (DC-AdCV) showed complete tumor eradication. DC-AdCCL21 administration led to increases in the CD4+, CD8+, and CD3+CXCR3+ T cells, as well as DC expressing CD11c+ DEC205+. CD4+CD25+ T-regulatory cells infiltrating the tumors were markedly reduced after DC-AdCCL21 therapy. The tumor site cellular infiltrates were accompanied by the enhanced elaboration of granulocyte macrophage colony-stimulating factor, IFN-γ, MIG/CXCL9, IP-10/CXCL10, and interleukin 12, but decreases in the immunosuppressive mediators transforming growth factor β and prostaglandin E2. DC-AdCCL21-treated tumor-bearing mice showed enhanced frequency of tumor-specific T lymphocytes secreting IFN-γ, and tumor protective immunity was induced after DC-AdCCL21 therapy. In vivo depletion of IP-10/CXCL10, MIG/CXCL9, or IFN-γ significantly reduced the antitumor efficacy of DC-AdCCL21. These findings provide a strong rationale for the evaluation of DC-AdCCL21 in cancer immunotherapy.

Early and long-term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients

OBJECTIVE Minimal invasive surgical techniques have gained high acceptance in thoracic surgery during the last 10 years. However, up to now, only scant information exists on chronic postoperative pain and discomfort in patients who underwent video-assisted thoracoscopy. Therefore, a retrospective study was performed with the aid of a self-reported questionnaire. METHODS Two hundred and thirteen patients (of whom 79 females) with a mean age of 48 (range 15-88) years were operated on for a total of 225 procedures. Thoracoscopy was performed for pneumothorax (n=70), pulmonary nodules (n=44), interstitial lung diseases (n=20), pleural effusion (n=20), and empyema (n=19). Various indications included therapeutic or diagnostic procedures in bullous disease, mediastinal tumors, carcinoma, inflammatory lung disease, hyperhidrosis mani and bronchiectasis. RESULTS Mean drainage time was 6.0+/-4.7 days and hospital stay 8.4+/-6.6 days. One patient died on the ninth postoperative day after lobectomy for bronchial carcinoma due to cardiac failure, five patients needed a short period of reintubation due to acute respiratory failure. In two patients, thoracoscopic reoperation was necessary for closure of bronchopleural fistula. The self-reported questionnaire was returned by 173 (81%) of all patients within a mean follow-up of 18 (3-38) months. More than half of the patients (53%) reported no thoracic pain as early as 2 weeks after the procedure. At 2 weeks after the operation, 13% of patients suffered from localized pain and 31% from diffuse discomfort. Twelve percent needed pain medication regularly, and 3% occasionally. At 6 months postoperatively, three quarters of the patients had no complaints, 5% suffered from scar pain, and 20% had diffuse chest discomfort. One year after the procedure, 86% of the patients had no complaints, 9% suffered from minimal pain, and 5% from moderate pain. Two years after the procedure, 96% of the patients had no complaints at all. One hundred and twenty-five of the 140 patients (89%) working preoperatively went back to work within 2 weeks after the operation. Fifteen patients did not work between 3 and 16 weeks; 14 due to chest pain, one due to shoulder pain. CONCLUSION Video-assisted thoracoscopy permits very early recovery with rapid reintegration into the working process. Long-term complaints after videothoracoscopy are rare.

Pneumonectomy is a valuable treatment option after neoadjuvant therapy for stage III non-small-cell lung cancer.

OBJECTIVE The mortality of pneumonectomy after chemotherapy or chemoradiotherapy for locally advanced non-small-cell lung cancer is reported to be as high as 26%. We retrospectively reviewed the medical records of patients undergoing these procedures in 2 specialized thoracic centers to determine the outcome. METHODS Retrospective analyses were performed of all patients who underwent pneumonectomy after neoadjuvant chemotherapy or chemoradiotherapy for locally advanced non-small-cell lung cancer from 1998 to 2007. Presurgical treatment consisted of 3-4 platin-based doublets alone in 20% of patients or combined with radiotherapy (45Gy) to the tumor and mediastinum in 80% of patients. RESULTS Of 827 patients who underwent neoadjuvant therapy, 176 pneumonectomies were performed, including 138 (78%) extended resections. Post-induction pathologic stages were 0 in 36 patients (21%), I in 33 patients (19%), II in 38 patients (21%), III in 57 patients (32%), and IV in 12 patients (7%). Three patients died of pulmonary embolism, 2 patients of respiratory failure, and 1 patient of cardiac failure, resulting in a 90 postoperative day mortality rate of 3%; 23 major complications occurred in 22 patients (13%). For the overall population, 3-year survival was 43% and 5-year survival was 38%. CONCLUSION Pneumonectomy after neoadjuvant therapy for non-small-cell lung cancer can be performed with a perioperative mortality rate of 3%. Thus, the need of a pneumonectomy for complete resection alone should not be a reason to exclude patients from a potentially curative procedure if done in an experienced center. The 5-year survival of 38%, which can be achieved, justifies extended surgery within a multimodality concept for selected patients with locally advanced non-small-cell lung cancer.

SLC/CCL21-mediated anti-tumor responses require IFNγ, MIG/CXCL9 and IP-10/CXCL10

BackgroundSLC/CCL21, normally expressed in high endothelial venules and in T cell zones of spleen and lymph nodes, strongly attracts T cells and dendritic cells (DC). We have previously shown that SLC/CCL21-mediated anti-tumor responses are accompanied by significant induction of IFNγ and the CXC chemokines, monokine induced by IFNγ (MIG/CXCL9) and IFNγ-inducible protein-10 (IP-10/CXCL10).ResultsWe assessed the importance of IFNγ, IP-10/CXCL10 and MIG/CXCL9 in SLC/CCL21 therapy. In vivo depletion of IP-10/CXCL10, MIG/CXCL9 or IFNγ significantly reduced the anti-tumor efficacy of SLC/CCL21. Assessment of cytokine production at the tumor site showed an interdependence of IFNγ, MIG/CXCL9 and IP-10/CXCL10; neutralization of any one of these cytokines caused a concomitant decrease in all three cytokines. Similarly, neutralization of any one of these cytokines led to a decrease in the frequency of CXCR3+ve T cells and CD11c+ve DC at the tumor site.ConclusionThese findings indicate that the full potency of SLC/CCL21-mediated anti-tumor responses require in part the induction of IFNγ, MIG/CXCL9 and IP-10/CXCL10.

Cyclooxygenase 2 Inhibition Promotes IFN-γ-Dependent Enhancement of Antitumor Responses

In previous studies, we demonstrated an immune suppressive network in non-small cell lung cancer that is due to overexpression of tumor cyclooxygenase 2 (COX-2). In this study, we assessed the vaccination response to tumor challenge following either pharmacological or genetic inhibition of COX-2 in a murine lung cancer model. Treatment of naive mice with the COX-2 inhibitor, SC-58236, skewed splenocytes toward a type 1 cytokine response, inducing IFN-γ, IL-12, and IFN-γ-inducible protein 10, whereas the type 2 cytokines IL-4, IL-5, and IL-10 remained unaltered. Fifty percent of mice receiving SC-58236 and an irradiated tumor cell vaccine completely rejected tumors upon challenge. Those mice that did form tumors following challenge demonstrated a reduced tumor growth. In contrast, all mice either vaccinated with irradiated tumor cells alone or receiving SC-58236 alone showed progressive tumor growth. Studies performed in CD4 and CD8 knockout mice revealed a requirement for the CD4 T lymphocyte subset for the complete rejection of tumors. To determine the role of host COX-2 expression on the vaccination responses, studies were performed in COX-2 gene knockout mice. Compared with control littermates, COX-2−/− mice showed a significant tumor growth reduction, whereas heterozygous COX-2−/+ mice had an intermediate tumor growth reduction following vaccination. In vivo depletion of IFN-γ abrogated the COX-2 inhibitor-mediated enhancement of the vaccination effect. These findings provide a strong rationale for additional evaluation of the capacity of COX-2 inhibitors to enhance vaccination responses against cancer.

Airway complications after lung transplantation: risk factors, prevention and outcome

PURPOSE Anastomotic complications following lung transplantation (LuTx) have been described in up to 15% of patients. Challenging to treat, they are associated with high morbidity and a mortality rate of 2-5%. The aim of this study was to analyze the incidence of complications in a consecutive series of bronchial anastomosis after LuTx at our center and to delineate the potential risk factors. METHODS Between 1992 and 2007, 441 bronchial anastomoses were performed in 235 patients. Indications for transplantation were cystic fibrosis (35.7%) emphysema (28.1%) pulmonary fibrosis (12.8%) and pulmonary hypertension (7.7%). There were 206 sequential bilateral and 28 single transplants including lobar engraftments in 20 cases. The donor bronchus was shortened to the plane of the lobar carina including the medial wall of the intermediate bronchus. Peribronchial tissue was left untouched. Anastomosis was carried out using a continuous absorbable running suture (PDS 4/0) at the membranous and interrupted sutures at the cartilaginous part. Six elective surveillance bronchoscopies were done monthly during the first half-year post-LuTx, with detailed assessment of the pre- and post-anastomotic airways. RESULTS One-year survival since 2000 was 90.5%. In all 441 anastomoses performed, no significant dehiscence was observed. In one patient, a small fistula was detected and closed surgically on postoperative day five. Fungal membranes were found in 50% of the anastomoses at 1 month and in 14% at 6 months. Discrete narrowing of the anastomotic lumen without need for intervention was found in 4.9% of patients at 1 month and in 2.4% at 6 months. Age, cytomegalovirus status, induction therapy, immunosuppressive regimen, ischemic time, and ventilation time had no influence on bronchial healing. CONCLUSIONS Clinically relevant bronchial anastomotic complications after LuTx can be avoided by use of a simple standardized surgical technique. Aggressive antibiotic and antifungal therapy might play an important supportive role.

Apoptosis induced by ischemia and reperfusion in experimental lung transplantation.

BACKGROUND Apoptosis is a distinct form of single-cell death in response to injury. Time course of apoptosis in lung parenchymal cells during posttransplant reperfusion and the influence of oxygen content during preservation on apoptosis of parenchymal cells are studied. METHODS Orthotopic syngenic single left lung transplantation was performed in male Fischer (F344) rats after 18 hours of cold ischemia (n = 5 in all groups). Apoptotic cells were stained by the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) technique. Strictly TUNEL-positive pneumocytes were counted on anonymized slides by a pathologist on 100 fields (x400) per specimen (mean +/- SEM). RESULTS The peak of apoptotic pneumocytes occurred 2 hours after reperfusion (16.8 +/- 2.2 pneumocytes/100 fields [p/100f]; p = 0.000012 vs controls, lungs fixed after 18 hours of ischemia), whereas the lowest level of apoptotic pneumocytes was seen in lungs fixed after harvest (1.4 +/- 0.51 p/100f) and lungs not undergoing reperfusion (2.8 +/- 0.49 p/100f). Four hours after reperfusion, the number of apoptotic pneumocytes was lower than 2 hours after reperfusion (13.6 +/- 3.1 p/100f; p = 0.00032 vs controls), with a further decline at 8 hours (6.4 +/- 1.5 p/100f) and 12 hours after reperfusion (4.0 + 1.2 p/100f). Interestingly, lungs inflated with N2 before storage revealed a significantly lower level of TUNEL-positive pneumocytes 2 hours after reperfusion (8.8 2.0 p/100f) compared with lungs inflated with 100% O2 (p = 0.0052). CONCLUSIONS Apoptosis of pneumocytes after posttransplant lung reperfusion is a very early event. Prolonged hypothermic preservation without reperfusion, however, does not lead to an elevated rate of apoptotic pneumocytes in lung grafts.

Ex vivo reconditioning of marginal donor lungs injured by acid aspiration

BACKGROUND Injured lungs due to gastric acid aspiration may be rejected for transplantation because of the possibility of early graft dysfunction. We hypothesized that diluted surfactant administration during ex vivo perfusion would recondition the lungs injured by acid aspiration and permit their use as suitable grafts for transplantation. METHODS Using a pig model, lung injury was induced with 5-ml/kg administration of a betaine-HCl/pepsin mixture via a flexible bronchoscope. After injury, animals were randomly assigned to three study groups (n = 6/group): saline lavage during ex vivo perfusion (control); surfactant lavage ex vivo (SL-Exvivo); and surfactant lavage before harvest (SL-Pre); and a normal group (n = 4), with no lung injury. Cold storage time was 3 hours. A volume of 10 ml/kg (4 mg/ml, 40 mg/kg) surfactant (Curosurf) was used for lavage. Bronchoalveolar lavage (BAL) was performed before and after injury and at the end of the experiment. Protein and neutrophil percentage in BAL were assessed. Hemodynamic and aerodynamic parameters were measured every 30 minutes during a 2-hour observation period. RESULTS An approximately 50% decrease in Pao(2) was observed in all animals after injury. Ex vivo surfactant lavage resulted in lower pulmonary vascular resistance, lower oxygenation index and higher Pao(2)/Fio(2) ratio compared with the control group (p = 0.001, p = 0.0001 and p = 0.0001, respectively, according to analysis of variance for repeated measures). Wet-to-dry weight ratio was lower in the SL-Exvivo group compared with the control group (p = 0.015). BAL neutrophil percent at the end of the experiment differed significantly between control and all other groups (p < 0.05). CONCLUSION Diluted surfactant lavage during ex vivo perfusion improves graft function of lungs injured by gastric acid aspiration.

Intrapulmonary Administration of CCL21 Gene-Modified Dendritic Cells Reduces Tumor Burden in Spontaneous Murine Bronchoalveolar Cell Carcinoma

The antitumor efficiency of dendritic cells transduced with an adenovirus vector expressing secondary lymphoid chemokine (CCL21) was evaluated in a murine model of spontaneous bronchoalveolar cell carcinoma. The transgenic mice (CC-10 TAg) express the SV40 large T antigen (TAg) under the Clara cell promoter, develop bilateral, multifocal, and pulmonary adenocarcinomas, and die at 4 months as a result of progressive pulmonary tumor burden. A single intratracheal administration of CCL21 gene-modified dendritic cells (DC-AdCCL21) led to a marked reduction in tumor burden with extensive mononuclear cell infiltration of the tumors. The reduction in tumor burden was accompanied by the enhanced elaboration of type 1 cytokines [IFN-gamma, interleukin (IL)-12, and granulocyte macrophage colony-stimulating factor] and antiangiogenic chemokines (CXCL9 and CXCL10) but a concomitant decrease in the immunosuppressive molecules (IL-10, transforming growth factor-beta, prostaglandin E(2)) in the tumor microenvironment. The DC-AdCCL21 therapy group revealed a significantly greater frequency of tumor-specific T cells releasing IFN-gamma compared with the controls. Continuous therapy with weekly intranasal delivery of DC-AdCCL21 significantly prolonged median survival by >7 weeks in CC-10 TAg mice. Both innate natural killer and specific T-cell antitumor responses significantly increased following DC-AdCCL21 therapy. Significant reduction in tumor burden in a model in which tumors develop in an organ-specific manner provides a strong rationale for further evaluation of intrapulmonary-administered DC-AdCCL21 in regulation of tumor immunity and genetic immunotherapy for lung cancer.