[Show abstract][Hide abstract] ABSTRACT: A 61-year-old female with a past medical history significant for von Hippel–Lindau (VHL) syndrome presented with multiple bilateral pulmonary lesions found on surveillance computed tomography scan. Positron emission tomography demonstrated avidity in a lesion in the right upper lobe. After an equivocal biopsy, a lobectomy via a thoracoscopic approach was performed as this lesion was concerning for a primary lung cancer. Pathology revealed a diagnosis of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma. To our knowledge, this is the first reported case of a pulmonary MALT lymphoma in a patient with VHL.
[Show abstract][Hide abstract] ABSTRACT: For patients with advanced cancers there has been a concerted effort to transition from a generic treatment paradigm to one based on tumor-specific biologic, and patient-specific clinical characteristics. This approach, known as precision therapy has been made possible owing to widespread availability and a reduction in the cost of cutting-edge technologies that are used to study the genomic, proteomic, and metabolic attributes of individual tumors. This review traces the evolution of precision therapy for lung cancer from the identification of molecular subsets of the disease to the development and approval of tyrosine kinase, as well as immune checkpoint inhibitors for lung cancer therapy. Challenges of the precision therapy era including the emergence of acquired resistance, identification of untargetable mutations, and the effect on clinical trial design are discussed. We conclude by highlighting newer applications for the concept of precision therapy.
Published by Elsevier Inc.
Seminars in Thoracic and Cardiovascular Surgery 04/2015; 27(1). DOI:10.1053/j.semtcvs.2015.04.002
[Show abstract][Hide abstract] ABSTRACT: Although microRNAs (miRs) have been implicated in the pathogenesis of various human malignancies, limited information is available regarding mechanisms by which these noncoding RNAs contribute to initiation and progression of tobacco-induced esophageal cancers. In this study, array and quantitative reverse transcriptase–PCR techniques were used to examine miR expression in immortalized esophageal epithelia (IEE) and esophageal adenocarcinoma (EAC) cells cultured in normal media with or without cigarette smoke condensate (CSC). Under relevant exposure conditions, CSC significantly decreased miR-217 expression in these cells. Endogenous levels of miR-217 expression in cultured EAC cells (EACC)/primary EACs were significantly lower than those observed in IEE/ paired normal esophageal tissues. RNA crosslink immunoprecipitation, quantitative reverse transcriptase–PCR (qRT–PCR) and immunoblot experiments demonstrated direct interaction of miR-217 with kallikrein 7 (KLK7), encoding a putative oncogene not previously implicated in EAC. Repression of miR-217 correlated with increased levels of KLK7 in primary EACs, particularly those from smokers. Chromatin and methylated DNA immunoprecipitation experiments demonstrated that CSC-mediated repression of miR-217 coincided with DNMT3b-dependent hypermethylation and decreased occupancy of nuclear factor 1 within the miR-217 genomic locus. Deoxyazacytidine induced miR-217 expression and downregulated KLK7 in EACC; deoxyazacytidine also attenuated CSC-mediated miR-217 repression and upregulation of KLK7 in IEE and EACC. Overexpression of miR-217 significantly decreased, whereas overexpression of KLK7 increased proliferation, invasion and tumorigenicity of EACC. Collectively, these data demonstrate that epigenetic repression of miR-217 contributes to the pathogenesis of EAC via upregulation of KLK7 and suggest that restoration of miR-217 expression may be a novel treatment strategy for these malignancies.
[Show abstract][Hide abstract] ABSTRACT: A 61-year-old female with a past medical history significant for von Hippel-Lindau (VHL) syndrome presented with multiple bilateral pulmonary lesions found on surveillance computed tomography scan. Positron emission tomography demonstrated avidity in a lesion in the right upper lobe. After an equivocal biopsy, a lobectomy via a thoracoscopic approach was performed as this lesion was concerning for a primary lung cancer. Pathology revealed a diagnosis of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma. To our knowledge, this is the first reported case of a pulmonary MALT lymphoma in a patient with VHL.
[Show abstract][Hide abstract] ABSTRACT: Context: Ectopic ACTH/CRH syndrome is a rare cause of Cushing syndrome (CS), especially in children. The localization, work-up, and management of ACTH/CRH secreting tumors are discussed. Setting: A retrospective study was conducted of patients under 21 years of age evaluated at the National Institutes of Health (NIH) for CS and diagnosed with ectopic ACTH/CRH secreting tumors during the period 2009-2014. Patients: Seven patients with ectopic ACTH/CRH syndrome are included in this study, median age 13.6 years (range 1-21), 3 female. Measurements: Clinical, biochemical, radiological features, treatment and histological findings are described. Results: Seven patients were found to have ACTH/CRH secreting tumors with neuroendocrine features. The site of the primary lesion varied: pancreas (3), thymus (2), liver (1), right lower pulmonary lobe (1). Patients underwent biochemical evaluation for CS, including diurnal serum cortisol and ACTH levels, urinary free cortisol levels (UFC), and CRH stimulation tests. All patients underwent radiological investigations including MRI, CT and PET scan; imaging with octreotide and 68gallium DOTA-TATE scans were performed in individual cases. Five patients underwent inferior petrosal sinus sampling; 4 patients had sampling for ACTH levels from additional sites. Three patients underwent transsphenoidal surgery (TSS), and 3 patients required bilateral adrenalectomy. 3 patients (43%) died due to metastatic disease, demonstrating the high mortality rate. One of the unique findings in these seven patients is that in each case, their neuroendocrine tumors were ultimately proven to be co-secreting ACTH and CRH. This explains the enigmatic presentation, in which 3 patients initially thought to have Cushing's disease (CD) with corresponding pituitary hyperplasia underwent TSS prior to the correct localization of the causative tumor. Conclusions: Ectopic ACTH/CRH co-secreting tumors are extremely rare in children and adolescents. Its diagnosis is frequently missed and is sometimes confused with CD due to the effect of CRH on the pituitary.
[Show abstract][Hide abstract] ABSTRACT: Mithramycin is a neoplastic antibiotic synthesized by various Streptomyces bacteria. It is under investigation as a chemotherapeutic treatment for a wide variety of cancers. Ongoing and forthcoming clinical trials will require pharmacokinetic analysis of mithramycin in humans, both to see if target concentrations are achieved and to optimize dosing and correlate outcomes (response/toxicity) with pharmacokinetics. Two published methods for mithramycin quantitation exist, but both are immunoassays that lack current bioanalytical standards of selectivity and sensitivity. To provide an upgraded and more widely applicable assay, a UPLC-MS/MS method for quantitation of mithramycin in human plasma was developed. Solid-phase extraction allowed for excellent recoveries (>90%) necessary for high throughput analyses on sensitive instrumentation. However, a ∼55% reduction in analyte signal was observed as a result of plasma matrix effects. Mithramycin and the internal standard chromomycin were separated on a Waters Acquity BEH C18 column (2.1×50mm, 1.7μm) and detected using electrospray ionization operated in the negative mode at mass transitions m/z 1083.5→268.9 and 1181.5→269.0, respectively, on an AB Sciex QTrap 5500. The assay range was 0.5-500ng/mL and proved to be linear (r(2)>0.996), accurate (≤10% deviation), and precise (CV<15%). Mithramycin was stable in plasma at room temperature for 24h, as well as through three freeze-thaw cycles. This method was subsequently used to quantitate mithramycin plasma concentrations from patients enrolled on two clinical trials at the NCI.
Journal of chromatography. B, Analytical technologies in the biomedical and life sciences 09/2014; 970C:95-101. DOI:10.1016/j.jchromb.2014.08.021 · 2.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:This phase I/II study sought to determine the safety and maximum-tolerated dose (MTD) of a novel schedule of belinostat, a histone deacetylase inhibitor administered prior to and in combination with cisplatin (P), doxorubicin (A) and cyclophosphamide (C) in thymic epithelial tumors (TET). Anti-tumor activity, pharmacokinetics, and biomarkers of response were also assessed. Experimental Design:Patients with advanced, unresectable TET received increasing doses of belinostat as a continuous intravenous infusion over 48-hours with chemotherapy in 3-week cycles. In phase II, belinostat at the MTD was used. Results:26 patients were enrolled (thymoma: 12; thymic carcinoma: 14). Dose-limiting toxicities at 2000 mg/m2 belinostat were grade 3 nausea and diarrhea and grade 4 neutropenia and thrombocytopenia, respectively, in two patients. 24 patients were treated at the MTD of 1000 mg/m2 with chemotherapy (P 50 mg/m2 on day 2; A 25 mg/m2 on days 2, 3; C 500 mg/m2 on day 3). Objective response rates in thymoma and thymic carcinoma were 64% [95% confidence interval: 30.8%-89.1%] and 21% (4.7%-50.8%) respectively. Modulation of pharmacodynamic markers of HDAC-inhibition and declines in regulatory T cell (Tregs) and exhausted CD8+ T cell populations were observed. Decline in Tregs was associated with response (p=0.0041) and progression-free survival (p=0.021). Declines in TIM-3+ CD8+T cells were larger in responders than non-responders (p=0.049). Conclusions:This study identified the MTD of belinostat in combination with PAC and indicates that the combination is active and feasible in TETs. Immunomodulatory effects on regulatory T cells and TIM3+ CD8+ T cells warrant further study.
Clinical Cancer Research 09/2014; 20(21). DOI:10.1158/1078-0432.CCR-14-0968 · 8.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Historically, extended resections for T4 non-small cell lung cancers that invade adjacent organs have been associated with significant morbidity and mortality, and poor long-term survival. However, notable improvements in imaging, surgical techniques, and perioperative care during the past several decades have resulted in an increase in survival for highly selected patients. This article provides a critical review of the existing statistical evidence regarding the utility of resections of T4 tumors invading the aorta, pulmonary artery, left atrium, and esophagus.
Published by Elsevier Inc.
Thoracic Surgery Clinics 09/2014; 24(4). DOI:10.1016/j.thorsurg.2014.07.012 · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: The incidence and patterns of metastatic disease to the central nervous system (CNS) from malignant mesothelioma is not well characterized. We describe the treatment of two cases of pleural mesotheliona with CNS metastases. We also report the results of a systematic review with pooled data analysis of CNS metastases from malignant mesothelioma.
DATA SOURCES: PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies.
STUDY SELECTION: Inclusion criteria for the pooled analysis were any clinical or autopsy study in which a) patients had a confirmed histological diagnosis of malignant mesothelioma, b) CNS metastasis was identified by autopsy, clinical pathological specimen or compelling radiographic imaging. Case reports were excluded from the pooled analysis but were incorporated into the discussion.
DATA EXTRACTION: One-hundred forty-one potentially relevant references were identified. Seven studies including 655 patients were included in the pooled analysis. Ninety-seven additional cases were identified and incorporated into the discussion.
DATA SYNTHESIS: A systematic review of the literature is provided with pooled data analysis.
CONCLUSIONS: CNS involvement of malignant mesothelioma may occur by either hematogenous spread or local extension. Some cases may represent tumor de-differentiation to a more aggressive histologic subtype. Surgery or stereotactic therapies may play a role for select patients; however, rapid recurrence has been reported. The prognostic significance of CNS disease is not well characterized. Clinicians should consider and identify CNS involvement in patients with new or evolving neurologic symptoms as early identification may allow for palliative intervention.
[Show abstract][Hide abstract] ABSTRACT: Background
Although implicated in the pathogenesis of several chronic inflammatory disorders and hematologic malignancies, telomerase mutations have not been thoroughly characterized in human cancers. The present study was performed to examine the frequency and potential clinical relevance of telomerase mutations in esophageal carcinomas.
Sequencing techniques were used to evaluate mutational status of telomerase reverse transcriptase (TERT) and telomerase RNA component (TERC) in neoplastic and adjacent normal mucosa from 143 esophageal cancer (EsC) patients. MTS, flow cytometry, time lapse microscopy, and murine xenograft techniques were used to assess proliferation, apoptosis, chemotaxis, and tumorigenicity of EsC cells expressing either wtTERT or TERT variants. Immunoprecipitation, immunoblot, immunofluorescence, promoter-reporter and qRT-PCR techniques were used to evaluate interactions of TERT and several TERT variants with BRG-1 and β-catenin, and to assess expression of cytoskeletal proteins, and cell signaling. Fluorescence in-situ hybridization and spectral karyotyping techniques were used to examine telomere length and chromosomal stability.
Sequencing analysis revealed one deletion involving TERC (TERC del 341-360), and two non-synonymous TERT variants [A279T (2 homozygous, 9 heterozygous); A1062T (4 heterozygous)]. The minor allele frequency of the A279T variant was five-fold higher in EsC patients compared to healthy blood donors (p<0.01). Relative to wtTERT, A279T decreased telomere length, destabilized TERT-BRG-1-β-catenin complex, markedly depleted β-catenin, and down-regulated canonical Wnt signaling in cancer cells; these phenomena coincided with decreased proliferation, depletion of additional cytoskeletal proteins, impaired chemotaxis, increased chemosensitivity, and significantly decreased tumorigenicity of EsC cells. A279T expression significantly increased chromosomal aberrations in mouse embryonic fibroblasts (MEFs) following Zeocin™ exposure, as well as Li Fraumeni fibroblasts in the absence of pharmacologically-induced DNA damage.
A279T induces telomere dysfunction and inhibits non-canonical telomerase activity in esophageal cancer cells. These findings warrant further analysis of A279T expression in esophageal cancers and premalignant esophageal lesions.
PLoS ONE 07/2014; 9(7):e101010. DOI:10.1371/journal.pone.0101010 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
The incidence of thoracic injuries resulting from cardiopulmonary resuscitation (CPR) is not well characterized. We describe a case in which a CPR-associated atrial rupture was identified with ultrasound and successfully managed in the intensive care unit with a bedside thoracotomy and atrial repair. We then describe a systematic review with pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries.
PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, Current Controlled Trials, and Google.
Inclusion criteria for the pooled analysis were any clinical or autopsy study in which a) patients underwent cardiopulmonary resuscitation, b) chest compressions were administered either manually or with the assistance of active compression-decompression devices, and c) autopsy or dedicated imaging assessments were conducted to identify complications. Exclusion criteria for the pooled analysis were pre-clinical studies, case reports and abstracts.
Nine-hundred twenty-eight potentially relevant references were identified. Twenty-seven references met inclusion criteria.
A systematic review of the literature is provided with pooled data analysis.
The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression-decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries.
[Show abstract][Hide abstract] ABSTRACT: Epigenetic aberrations offer dynamic and reversible targets for cancer therapy; increasingly, alteration via overexpression, mutation, or rearrangement is found in genes that control the epigenome. Such alterations suggest a fundamental role in carcinogenesis. Here, we consider three epigenetic mechanisms: DNA methylation, histone tail modification and non-coding, microRNA regulation. Evidence for each of these in lung cancer origin or progression has been gathered, along with evidence that epigenetic alterations might be useful in early detection. DNA hypermethylation of tumor suppressor promoters has been observed, along with global hypomethylation and hypoacetylation, suggesting an important role for tumor suppressor gene silencing. These features have been linked as prognostic markers with poor outcome in lung cancer. Several lines of evidence have also suggested a role for miRNA in carcinogenesis and in outcome. Cigarette smoke downregulates miR-487b, which targets both RAS and MYC; RAS is also a target of miR-let-7, again downregulated in lung cancer. Together the evidence implicates epigenetic aberration in lung cancer and suggests that targeting these aberrations should be carefully explored. To date, DNA methyltransferase and histone deacetylase inhibitors have had minimal clinical activity. Explanations include the possibility that the agents are not sufficiently potent to invoke epigenetic reversion to a more normal state; that insufficient time elapses in most clinical trials to observe true epigenetic reversion; and that doses often used may provoke off-target effects such as DNA damage that prevent epigenetic reversion. Combinations of epigenetic therapies may address those problems. When epigenetic agents are used in combination with chemotherapy or targeted therapy it is hoped that downstream biological effects will provoke synergistic cytotoxicity. This review evaluates the challenges of exploiting the epigenome in the treatment of lung cancer.
Frontiers in Oncology 10/2013; 3:261. DOI:10.3389/fonc.2013.00261