Epidemiology of lung cancer in India: focus on the differences between non-smokers and smokers: a single-centre experience

Lived Experience among Patients Newly Diagnosed with Lung Adenocarcinoma Stage IV within One Year

BACKGROUND

lung cancer (LC) is the fifth of the 10 leading causes of death in the world. LC is in first place for cancer-related mortality for both males and females in Taiwan. It is one of the most difficult cancers to treat and is often diagnosed at a late stage. Patients with stage IV are often unprepared for the diagnosis.

MATERIALS AND METHODS

To explore lived experience among patients newly diagnosed with lung adenocarcinoma stage IV within one year.

RESULTS

Twelve participants were recruited in this study. Content analysis of the interviews revealed four themes: (1) emotional roller coaster, (2) trying to find out causes, (3) adjusting my lifestyle, and (4) cancer fighter.

CONCLUSIONS

This study provides new insight into the experiences of lung cancer patients y with newly diagnosed lung adenocarcinoma stage 4. These results will inform future supportive care service development and intervention research for patients with advanced stage cancer.

Ethnic Variation in Consumption of Traditional Tobacco Products and Lung Cancer Risk in Nepal

Lung cancer is the leading contributor to cancer deaths in the developing world. Within countries, significant variability exists in the prevalence of lung cancer risk, yet limited information is available whether some of the observed variability is associated with differences in the consumption pattern of local tobacco products with differing potency. We recruited 606 lung cancer cases and 606 controls from the B.P. Koirala Memorial Cancer Hospital in Nepal from 2009-2012. We estimated odds ratios (ORs) and 95% confidence intervals (CI) for lung cancer risk associated with different tobacco products, using unconditional logistic regression. Unfiltered cigarettes tended to be the most frequently used products across ethnic subgroup with about 53.7% of Brahmins, 60.1% of Chettris, and 52.3% of Rai/Limbu/Magar/others. In contrast, about 39.9% of Madishe/Tharu smokers reported using bidi compared with only 27.7% who smoked unfiltered cigarettes. Among those who only smoked one type of product, choor/kankat smokers had the highest lung cancer risk (OR 10.2; 95% CI 6.2-16.6), followed by bidi smokers (OR 5.6; 95% CI 3.6-8.7), unfiltered cigarettes (OR 4.9; 95% CI 3.4-7.2), and filtered cigarettes (OR 3.4; 95% CI 2.2-5.3). A clear dose-response relationship was observed between increased frequency of smoking and lung cancer risk across all ethnic subgroups. These results highlight the important role of traditional tobacco products on lung cancer risk in the low income countries.

Evaluation of epidermal growth factor receptor mutations based on mutation specific immunohistochemistry in non-small cell lung cancer: A preliminary study

BACKGROUND & OBJECTIVES

Studies have shown that immunohistochemical (IHC) staining using epidermal growth factor receptor (EGFR) mutation specific antibodies, is an easy and cost-effective, screening method compared with molecular techniques. The purpose of present study was to assess the percentage positivity of IHC using EGFR mutation specific antibodies in lung biopsy samples from patients with primary lung adenocarcinoma (ADC).

METHODS

Two hundred and six biopsies of primary lung ADC were subjected to EGFR mutation specific antibodies against del E746-A750 and L858R. Detection of EGFR mutation done by high resolution melting analysis (HRM) was used as gold standard. A concordance was established between molecular and IHC results. Frequency of IHC positivity was assessed.

RESULTS

Of the 206 patients, 129 were male and 77 were female patients, with a mean age of 54.1 yr. Fifty five (26.6%) patients (36 men; 19 women) showed positivity for IHC of del E746-A750 (33) and L858R (22). HRM results were available in 14 patients which showed EGFR mutations in correspondence with del E746-750 or L858R in 64.2 per cent cases. Positive cases on HRM were further confirmed by DNA sequencing and fragment analysis. Three patients showed exon[20] variation. Two cases were negative for mutation. The genotype of del E746-750 mutation was more common than L858R. A concordance was established between molecular mutation and IHC in 85.7 per cent cases.

INTERPRETATION & CONCLUSIONS

In this preliminary study from India mutation specific IHC was used for assessment of mutation status of EGFR. Although the number tested was small, a good concordance was observed between molecular EGFR mutation and IHC expression. IHC methodology is a potentially useful tool to guide clinicians for personalized treatment in lung ADC, especially where facilities for molecular analysis are not readily available and for use in small biopsies where material is scant for molecular tests.

Role of FNAC, fluid specimens, and cell blocks for cytological diagnosis of lung cancer in the present era

Cytoblocks prepared from residual tissue fluids and fine-needle aspirations can be useful adjuncts to smears for establishing a more definitive cytopathologic diagnosis. These paraffin embedded cytoblocks have been popular since these can be handled like any other histologic specimen. Rapid on-site evaluation (ROSE) can help in attaining adequate material in the cytoblock, which is a major concern to the cytopathologists. Ancillary studies can be done using cytoblocks including IHC and various molecular techniques. The opportunities for cytopathologists to influence therapy, and uncover strategies in the complex field of lung cancer are exciting and limitless especially in the presence of an adequate cytoblock

The utility of cytology in the diagnosis of adenocarcinoma lung: A tertiary care center study

Introduction:

Pulmonary adenocarcinoma harbors various molecular abnormalities that include epidermal growth factor mutation, anaplastic lymphoma kinase gene re-arrangement, K-RAS mutations. The availability of targeted therapy against these molecular markers has revolutionized personalized medicine. Accurate cytological diagnosis of pulmonary adenocarcinoma will aid in utilising the cytology smears for molecular testing.

Objective:

The objective of this retrospective study was to evaluate the diagnostic efficacy of various cytology samples in the diagnosis of pulmonary adenocarcinoma.

Materials and Methods:

The study included a retrospective case series of 50 patients with biopsy proven non small cell lung carcinoma of adenocarcinoma subtype. The corresponding cytology reports of all the 50 cases were analyzed for different samples including broncho-alveolar lavage (BAL), bronchial washings, bronchial brush smears, pleural fluid, sputum and guided fine needle aspiration cytology (FNAC) of lung and metastatic lymph nodes. The overall cyto-diagnosis efficacy as well that of various cytological samples were analyzed.

Results:

Multiple cytology samples were received in 14 of 50 cases. The overall diagnostic efficacy of the various cytology samples in the diagnosis of malignancy was 78% and 66.6% cases were accurately typed as non small cell lung carcinoma-adenocarcinoma. The best cytological sample for the detection of pulmonary adenocarcinoma was bronchial brush smears which had a detection rate of 70%. In fine needle aspiration cytology samples and bronchial washings the detection rate was 65.5% and 25% respectively.

Discussion and Conclusion:

In cases where the cytological diagnosis is certain the tissue biopsies can be simultaneously tested for EGRF and ALK gene mutations. Repeat biopsies are often required due to small amount of tumor tissue or necrotic biopsies. Alternate use of cytological specimen for molecular testing can be done when a diagnosis of pulmonary adenocarcinoma is established.

Prevalence and outcome of epidermal growth factor receptor mutations in non-squamous non-small cell lung cancer patients

BACKGROUND

Epidermal growth factor receptor (EGFR) mutation analysis has become an important part of the initial workup of non-squamous non-small cell lung cancer (NS-NSCLC) patients as it is now recognized both as a prognostic and predictive marker to therapy with EGFR tyrosine kinase inhibitors (TKI).

AIM

In this retrospective study conducted at a University hospital, we evaluated the prevalence of EGFR mutations in patients with NS-NSCLC, clinico-pathological correlation and outcome to treatment with EGFR TKIs.

MATERIALS AND METHODS

Case records of 147 patients of NS-NSCLC in whom EGFR mutation status was tested were screened. EGFR mutation analysis was done using DNA sequencing by real time polymerase chain reaction method from tissue and cell blocks prepared from core biopsy, fine needle aspiration cytology and pleural fluid specimens.

RESULTS

EGFR mutations were seen in 30.6% of the 111 evaluable specimens, with a significantly higher rate in females (44% vs 19.6% P = 0.0072) as compared to men and non-smokers (41% vs 12% P = 0.0013) as against smokers. Most common mutations were observed in exons 19 (71%) and 21 (25%). The estimated median progression free survival for patients with and without mutations when treated with upfront TKIs was 12 months and 3 months respectively and the estimated median overall survival for patients with and without mutations was 20 and 9 months respectively.

CONCLUSION

This study from India, further establishes the importance of upfront EGFR mutation testing in all NS-NSCLC patients, not only to prognosticate, but also to identify that subset of patients who could benefit from EGFR TKI therapy, early in the course of their disease.

Maintenance pemetrexed in nonsmall cell lung carcinoma: Outcome analysis from a tertiary care center

BACKGROUND

Maintenance pemetrexed is a standard treatment option for selected non squamous nonsmall cell lung carcinoma patients having a response to platin based doublet. We conducted a clinical audit of such selected patients and report the outcome among the Indian population.

AIM

To evaluate the outcomes with maintenance pemetrexed in the patients with locally advanced and metastatic adenocarcinoma lung.

OBJECTIVES

To calculate the progression free survival (PFS), overall survival (OS), and factors affecting the outcome.

MATERIALS AND METHODS

Data of patients with locally advanced and metastatic adenocarcinoma lung were retrieved from prospectively maintained lung cancer database registered between June 2011 and March 2014. The patients who achieved partial response (n = 87) or stable disease (n = 101) after 6 cycles of pemetrexed platin based doublet and received the maintenance pemetrexed were selected for final analysis (n = 188). Kaplan-Meir survival analysis was used for PFS and OS. Log rank test was used to evaluate the factors affecting the outcome.

RESULTS

Median follow-up is 14 months. The median number of maintenance pemetrexed cycles received is 6 (1-38). Common reason for the discontinuation are disease progression (n = 127), renal toxicity (n = 4), and social/financial (n = 7). Median PFS and OS are 8 months and 20 months, respectively. The patients with baseline pleural effusion had better PFS (9 months vs. 7 months, P = 0.02) and OS (26 months vs. 18 months, P = 0.05). The patients receiving more than 6 cycles of maintenance had improved PFS (12 vs. 7 months, P = 0.002) and OS (26 vs. 16 months, P = 0.05).

CONCLUSION

Maintenance pemetrexed is feasible and well tolerated by the majority of Indian patients who achieved the response after platin based doublet. The patients with baseline pleural effusion benefit more with maintenance pemetrexed.

Comparative study of cytology and immunocytochemistry with trucut biopsy and immunohistochemistry in diagnosis of localized lung lesions: A prospective study

Background:

Percutaneous lung biopsy is now a common procedure in pulmonary medicine, and several different techniques are in use. The most common has been the use of a fine needle under computed tomography (CT) guidance combined with the trucut needle for histology.

Aim:

To evaluate the efficacy of fine needle aspiration cytology (FNAC) and immunocytochemistry in comparison with trucut biopsy and immunohistochemistry in patients with localized intrathoracic lesions suspicious for malignancy.

Materials and Methods:

Eighty patients with localized mass lesions in the lung on imaging (chest radiograph/CT) were selected for this study over a period of 1 year. FNAC was carried out by a 22 G spinal needle after localization of the mass in the CT scan followed by guided trucut biopsy. Immunocytochemistry and immunohistochemistry were performed as and when required.

Results:

The mean age of our study population was 57.6 years and the M:F ratio was 4.2:1. Majority of the lesions were peripheral and in the right lung. Adenocarcinoma was most prevalent (49%), followed by squamous cell carcinoma and small cell carcinoma. Cyto-histopathological concordance was seen in 60 cases (75%). The highest rate of concordance was seen in small cell carcinoma (83.3%). The overall sensitivity of FNAC in distinguishing malignant lung lesions from benign lesions was 84.2% and the specificity was 100%. The sensitivity of cytology in diagnosing small cell carcinoma was 83.3% and of non-small cell carcinoma was 65.38%. Immunocytochemistry was carried out in 34 cases, all of which were followed by immunohistochemistry. Cyto-histopathological concordance was noted in 31 of these cases (91.2%). We used the standard panel of four markers (cytokeratin-7, thyroid transcription factor-1, p63 and CD56) for all selected cases.

Conclusion:

Cytology along with immunocytochemistry is highly effective in diagnosing and categorizing lung neoplasms, producing comparable results to trucut biopsy and immunohistochemistry.

Molecular spectrum of somatic EGFR and KRAS gene mutations in non small cell lung carcinoma: determination of frequency, distribution pattern and identification of novel variations in Indian patients

Somatic mutations of EGFR and KRAS gene represent the most common alterations currently known in NSCLC patients. This study explored the frequency, distribution pattern of EGFR and KRAS mutations in Indian patients. The frequencies of EGFR and KRAS mutations were 29 % (116/400) and 4.5 % (6/132) respectively. Both EGFR and KRAS mutations were prevalent in females, and a trend towards higher mutation frequency was seen in patients under ≥ 60 years age. The presence of EGFR and KRAS mutations were higher in adenocarcinomas in comparison to other histological subtype. Sequencing analysis of EGFR exon 18 revealed Inframe deletion (G709_T710 > A) and missense mutation (K713R). Among exon 19 positive cases, 49.3 % (37/75) were in-frame deletions, of which E746_A750del was frequent. Similarly, ~47 % (35/75) cases showed complex mutation involving indel. Among mutations in exon 20 (N = 9), 8 were substitutions, one showed duplication, while all exon 21 mutations were of the missense types with L858R as the most recurrent type. Sequencing analysis of KRAS exon 1 revealed three different types codon 12 substitutions resulting in c34G > T (G12C) (n = 4), c.35G > A (G12D) (n = 1), and c.35G > T (G12V) (n = 1). In conclusion, the present study is an example of molecular diversity of EGFR and KRAS gene in Indian patients and further confirms that the frequency of EGFR and KRAS mutations varies considerably globally. To the best of our knowledge, this is the first Indian study to evaluate KRAS mutation. The current study also served to identify novel variations that added new insights into the genetic heterogeneity of NSCLC.

Clinico-pathology of lung cancer in a regional cancer center in Northeastern India

BACKGROUND

Globally, there have been important changes in trends amongst gender, histology and smoking patterns of lung cancer cases.

MATERIALS AND METHODS

This retrospective study was conducted on 466 patients with lung cancer who were registered in Regional Cancer Center, Regional Institute of Medical Sciences, Manipur from January 2008 to December 2012.

RESULTS

Most were more than 60 years of age (67.8%) with a male: female ratio of 1.09:1. Some 78.8% of patients were chronic smokers with male smoker to female smoker ratio of 1.43:1. Consumption of alcohol was found in 29.4%, both smoking and alcohol in 27.5%, betel nut chewing in 37.9% and tobacco chewing in 25.3%. A history of tuberculosis was present in 16.3% of patients. The most frequent symptom was coughing (36.6%) and most common radiological presentation was a mass lesion (70%). Most of the patients had primary lung cancer in the right lung (60.3%). The most common histological subtype was squamous cell carcinoma (49.1%), also in the 40-60 year age group (45.9%), more than 60 year age group (51.6%), males (58.1%) and females (41.8%). As many as 91.9% of squamous cell carcinoma patients had a history of smoking. About 32.5% of patients had distant metastasis at presentation with brain (23.8%) and positive malignant cells in pleural effusions (23.1%) as common sites. The majority of patients were in stage III (34.4%), stage IV (32.5%) and stage II (30.2%).

CONCLUSIONS

Our analysis suggests that the gender gap has been narrowed such that about half of the patients diagnosed with lung cancer are women in this part of India. This alarming rise in female incidence is mainly attributed to an increased smoking pattern. Squamous cell carcinoma still remains the commonest histological subtype. Most of the patients were elderly aged and presented at locally or distantly advanced stages.

Diagnosis of carcinomas of extrathyroidal origin with fine needle aspiration cytology of the thyroid: An experience from a tertiary care center in South India

Intrathyroidal metastasis and direct extension of extrathyroidal malignancies can present with palpable thyroid nodules or may be detected as suspicious nodules in a thyroid scan. They can lead to diagnostic difficulty in fine needle aspiration cytology (FNAC) of the thyroid, especially in the absence of any previous history of such malignancies. Here we report an interesting case of intrathyroidal metastasis, which was initially suspected as a primary carcinoma of the thyroid; along with a short summary of a series of 11 cases of carcinomas of extrathyroidal origin, diagnosed in the FNACs of thyroid over the past three years in our institute. Knowledge of the potential diagnostic pitfalls in thyroid FNAC, a proper clinical evaluation, and judicious use of the ancillary techniques will help to attain a proper diagnosis.

Smoking cessation intervention in rural kerala, India: findings of a randomised controlled trial

BACKGROUND

Prevalence of tobacco use is higher in the rural than urban areas of India. Unlike tobacco cessation clinics located in urban areas, community-based smoking cessation intervention has the potential to reach a wider section of the community to assist in smoking cessation in the rural setting. The present study aimed to assess the effectiveness of a cessation intervention in rural Kerala state, India.

MATERIALS AND METHODS

Current daily smoking resident males in the age group 18-60 years from four community development blocks in rural Kerala were randomly allocated to intervention and control groups. The intervention group received multiple approaches in which priority was given to face-to-face interviews and telephone counselling. Initially educational materials on tobacco hazards were distributed. Further, four rounds of counselling sessions were conducted which included a group counselling with a medical camp as well as individual counselling by trained medical social workers. The control group received general awareness training on tobacco hazards along with an anti-tobacco leaflet. Self-reported smoking status was assessed after 6 and 12 months. Factors associated with tobacco cessation were estimated using binomial regression method.

RESULTS

Overall prevalence of smoking abstinence was 14.7% in the intervention and 6.8% in the control group (Relative risk: 1.85, 95% CI: 1.05, 3.25). A total of 41.3% subjects in the intervention area and 13.6% in the control area had reduced smoking by 50% or more at the end of 12 months. Lower number of cigarettes/ bidi used, low nicotine dependence and consultation with a doctor for a medical ailment were the statistically significant predictors for smoking cessation.

CONCLUSIONS

Rigorous approaches for smoking cessation programmes can enhance quit rates in smoking in rural areas of India.

[Occurrence and survival condition of lung cancer with different histologies among residents in Pudong new area]

BACKGROUND

Different histologies of lung cancer vary in occurrence and prognosis. This study aims to analyze the incidence and occurrence trend of lung cancer and investigate the survival rate and its influential factors among lung cancer patients with different histologies.

METHODS

Permanent residents were recruited between 2002 and 2009 in Pudong New Area (former Nanhui Area and former Pudong Area), Shanghai, China. Annual percent changes were estimated by a linear regression of the logarithm on the incidence rates for eight years. Survival rates were calculated and compared by using life-table analysis and Log-rank test, respectively.

RESULTS

The standardized incidence rates of lung cancer were 52.28 and 18.86 per 100,000 in males and females, respectively. The median survival time was 410.72 days for specific classified lung cancer. The incidence rates of adenocarcinoma ranked the highest and showed an upward tendency (P<0.05). Patients with small cell lung cancer showed the worst survival condition. The survival condition in males with squamous cell lung cancer living in former Nanhui Area was better compared with those living in former Pudong Area.

CONCLUSIONS

Lung cancers with different histologies demonstrated different occurrence trends and survival rates. Gender, age, and living area influence the survival rates of lung cancer with different histologies.

Frequency of EGFR mutations in 907 lung adenocarcioma patients of Indian ethnicity

BACKGROUND

During the past decade, the incidence of EGFR mutation has been shown to vary across different ethnicities. It occurs at the rate of 10-15% in North Americans and Europeans, 19% in African-Americans, 20-30% in various East Asian series including Chinese, Koreans, and Japanese. Frequency of EGFR mutations in India however remains sparsely explored.

METHODOLOGY/PRINCIPAL FINDINGS

We report 23% incidence of Epidermal growth factor receptor (EGFR) mutations in 907 Non small cell lung cancer (NSCLC) patients of Indian ethnicity, in contrast to 10-15% known in Caucasians and 27-62% among East Asians. In this study, EGFR mutations were found to be more common in never-smokers 29.4% as compared to smokers 15.3%. Consistent with other populations, mutation rates among adenocarcinoma-males were predominantly lower than females with 32% incidence. However unlike Caucasians, EGFR mutation rate among adenocarcinoma-never-smoker females were comparable to males suggesting lack of gender bias among never smokers likely to benefit from EGFR targeted therapy.

CONCLUSIONS/SIGNIFICANCE

This study has an overall implication for establishing relevance for routine EGFR mutation diagnostics for NSCLC patients in clinics and emphasizes effectiveness for adoption of EGFR inhibitors as the first line treatment among Indian population. The intermediate frequency of EGFR mutation among Indian population compared to Caucasians and East Asians is reminiscent of an ancestral admixture of genetic influence from Middle Easterners, Central Asians, and Europeans on modern- Indian population that may confer differential susceptibility to somatic mutations in EGFR.

EGFR mutations in Indian lung cancer patients: clinical correlation and outcome to EGFR targeted therapy

Screening for EGFR mutation is a key molecular test for management of lung cancer patients. Outcome of patients with mutation receiving EGFR tyrosine kinase inhibitor is known to be better across different ethnic populations. However, frequency of EGFR mutations and the clinical response in most other ethnic populations, including India, remains to be explored. We conducted a retrospective analysis of Indian lung cancer patients who were managed with oral tyrosine kinase inhibitors. Majority of the patients in the study had adenocarcinoma and were non-smokers. 39/111 patients tested positive for EGFR kinase domain mutations determined by Taqman based real time PCR. The overall response to oral TKI therapy was 30%. Patients with an activating mutation of EGFR had a response rate of 74%, while the response rate in patients with wild type EGFR was 5%, which was a statistically significant difference. Progression free survival of patients with EGFR mutations was 10 months compared to 2 months for EGFR mutation negative patients. Overall survival was 19 months for EGFR mutation patients and 13 months for mutation negative patients. This study emphasizes EGFR mutation as an important predictive marker for response to oral tyrosine kinase inhibitors in the Indian population.

Epidermal growth factor receptor mutation subtypes and geographical distribution among Indian non-small cell lung cancer patients

BACKGROUND

The Medical Oncology Department at Tata Memorial Hospital, the single largest tertiary cancer care center in Asia, receives in-house registered and referral patient samples from all parts of the country. Our recent studies establish 23% EGFR mutation frequency among Indian population. Here, we extend our study and report further analysis of distribution of different types of EGFR mutations in 1018 non small cell lung cancer patient, and its co-relation with clinical parameters and geographical variations across the country.

MATERIAL AND METHODS

This study is a retrospective analysis on all the patients who were referred for EFGR testing as a routine service over a 1.5 year period. This was part of standard care. EGFR kinase domain mutations in exon 18-21 were probed by TaqMan probe-based assays in 1018 NSCLC patients.

RESULTS AND DISCUSSION

While EGFR exon 19 mutations, the most frequent EGFR mutation, were found be higher among non smokers females, we find surprisingly higher incidence of exon 21 mutations among EGFR mutation positive male smokers of Indian ethnicity. Furthermore, as Indian population is known to be composed of a gradient admixture of Ancestral North Indian (with genetic influence from Middle Easterners, Central Asians, and Europeans harboring variant EGFR mutation frequency) and Ancestral South Indians, as a paradox our study indicates comparable EGFR mutation frequency across different geographical locations within India

CONCLUSION

Geographically there is uniform distribution in the EGFR mutation frequency within India. Further more, while exon 19 mutations are predominant among non smokers, higher incidence of exon 21 mutations exists among EGFR mutation positive male smokers of Indian ethnicity.