Global and targeted metabolomics of esophageal squamous cell carcinoma discovers potential diagnostic and therapeutic biomarkers

Diagnostic and therapeutic biomarkers useful for esophageal squamous cell carcinoma (ESCC) have the ability to increase the long term survival of cancer patients. A metabolomics study, using plasma from four groups including ESCC patients before, during, and after chemoradiotherapy (CRT) and healthy controls, was originally carried out by LC-MS to determine global alterations in the metabolic profiles and find biomarkers potentially applicable to diagnosis and monitoring treatment effects. It is worth pointing out that a clear clustering and separation of metabolic data from the four groups was observed, which indicated that disease status and treatment intervention resulted in specific metabolic perturbations in the patients. A series of metabolites were found to be significantly altered in ESCC patients versus healthy controls and in pre- versus post-treatment patients based on multivariate statistical data analysis (MVDA). To further validate the reliability of these potential biomarkers, an independent validation was performed by using the selected reaction monitoring (SRM) based targeted approach. Finally, 18 most significantly altered plasma metabolites in ESCC patients, relative to healthy controls, were tentatively identified as lysophosphatidylcholines (lysoPCs), fatty acids, l-carnitine, acylcarnitines, organic acids, and a sterol metabolite. The classification performance of these metabolites were analyzed by receiver operating characteristic (ROC)(1) analysis and a biomarker panel was generated. Together, biological significance of these metabolites was discussed. Comparison between pre- and post-treatment patients generated 11 metabolites as potential therapeutic biomarkers that were tentatively identified as amino acids, acylcarnitines, and lysoPCs. Levels of three of these (octanoylcarnitine, lysoPC(16:1), and decanoylcarnitine) were closely correlated with treatment effect. Moreover, variation of these three potential biomarkers was investigated over the treatment course. The results suggest that these biomarkers may be useful in diagnosis, as well as in monitoring therapeutic responses and predicting outcomes of the ESCC.

Negative predictive value of positron emission tomography and computed tomography for stage T1-2N0 non-small-cell lung cancer: a meta-analysis

BACKGROUND

Nodal staging of non-small-cell lung cancer (NSCLC) is crucial in evaluation of prognosis and determination of therapeutic strategy. This study aimed to determine the negative predictive value (NPV) of combined positron emission tomography and computed tomography (PET-CT) in patients with stage I (T1-2N0) NSCLC and to investigate the possible risk factors for occult nodal disease.

METHODS

Studies investigating the performance of PET in conjunction with CT in the nodal staging of stage I NSCLC were identified in the MEDLINE database. The initiative of standards for reporting of diagnostic accuracy (STARD) was used to ensure study quality. Pathologic assessments through mediastinoscopy or thoracotomy were required as the reference standard for evaluation of PET-CT accuracy. Stata-based meta-analysis was applied to calculate the individual and pooled NPVs.

RESULTS

Ten studies with a total of 1122 patients with stage I (T1-2N0) NSCLC were eligible for analysis. The NPVs of combined PET and CT for mediastinal metastases were 0.94 in T1 disease and 0.89 in T2 disease. Including both T1 disease and T2 disease, the NPVs were 0.93 for mediastinal metastases and 0.87 for overall nodal metastases. Adenocarcinoma histology type (risk ratio [RR], 2.72) and high fluorine-18 (18F) fluorodeoxyglucose (FDG) uptake in the primary lesion were associated with greater risk of occult nodal metastases.

CONCLUSIONS

Although overall occult nodal metastases in clinical stage T1-2N0 NSCLC is not infrequent, combined PET and CT provide a favorable NPV for mediastinal metastases in T1N0 NSCLC, suggesting a low yield from routine invasive staging procedures for this subgroup of patients.

Risk factors for brain metastases in locally advanced non-small cell lung cancer with definitive chest radiation

PURPOSE

We intended to identify risk factors that affect brain metastases (BM) in patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving definitive radiation therapy, which may guide the choice of selective prevention strategies.

METHODS AND MATERIALS

The characteristics of 346 patients with stage III NSCLC treated with thoracic radiation therapy from January 2008 to December 2010 in our institution were retrospectively reviewed. BM rates were analyzed by the Kaplan-Meier method. Multivariate Cox regression analysis was performed to determine independent risk factors for BM.

RESULTS

The median follow-up time was 48.3 months in surviving patients. A total of 74 patients (21.4%) experienced BM at the time of analysis, and for 40 (11.7%) of them, the brain was the first site of failure. The 1-year and 3-year brain metastasis rates were 15% and 28.1%, respectively. In univariate analysis, female sex, age ≤60 years, non-squamous cell carcinoma, T3-4, N3, >3 areas of lymph node metastasis, high lactate dehydrogenase and serum levels of tumor markers (CEA, NSE, CA125) before treatment were significantly associated with BM (P<.05). In multivariate analysis, age ≤60 years (P=.004, hazard ratio [HR] = 0.491), non-squamous cell carcinoma (P=.000, HR=3.726), NSE >18 ng/mL (P=.008, HR=1.968) and CA125 ≥ 35 U/mL (P=.002, HR=2.129) were independent risk factors for BM. For patients with 0, 1, 2, and 3 to 4 risk factors, the 3-year BM rates were 7.3%, 18.9%, 35.8%, and 70.3%, respectively (P<.001).

CONCLUSIONS

Age ≤60 years, non-squamous cell carcinoma, serum NSE >18 ng/mL, and CA125 ≥ 35 U/mL were independent risk factors for brain metastasis. The possibilities of selectively using prophylactic cranial irradiation in higher-risk patients with LA-NSCLC should be further explored in the future.

Poor baseline pulmonary function may not increase the risk of radiation-induced lung toxicity

PURPOSE

Poor pulmonary function (PF) is often considered a contraindication to definitive radiation therapy for lung cancer. This study investigated whether baseline PF was associated with radiation-induced lung toxicity (RILT) in patients with non-small cell lung cancer (NSCLC) receiving conformal radiation therapy (CRT).

METHODS AND MATERIALS

NSCLC patients treated with CRT and tested for PF at baseline were eligible. Baseline predicted values of forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC), and diffusion capacity of lung for carbon monoxide (DLCO) were analyzed. Additional factors included age, gender, smoking status, Karnofsky performance status, coexisting chronic obstructive pulmonary disease (COPD), tumor location, histology, concurrent chemotherapy, radiation dose, and mean lung dose (MLD) were evaluated for RILT. The primary endpoint was symptomatic RILT (SRILT), including grade ≥2 radiation pneumonitis and fibrosis.

RESULTS

There was a total of 260 patients, and SRILT occurred in 58 (22.3%) of them. Mean FEV1 values for SRILT and non-SRILT patients were 71.7% and 65.9% (P=.077). Under univariate analysis, risk of SRILT increased with MLD (P=.008), the absence of COPD (P=.047), and FEV1 (P=.077). Age (65 split) and MLD were significantly associated with SRILT in multivariate analysis. The addition of FEV1 and age with the MLD-based model slightly improved the predictability of SRILT (area under curve from 0.63-0.70, P=.088).

CONCLUSIONS

Poor baseline PF does not increase the risk of SRILT, and combining FEV1, age, and MLD may improve the predictive ability.

Molecular predictors of brain metastasis-related microRNAs in lung adenocarcinoma

Brain metastasis (BM) is a major complication of lung adenocarcinoma (LAD). An investigation of the pathogenic mechanisms of BM, as well as the identification of appropriate molecular markers, is necessary. The aim of this study was to determine the expression patterns of microRNAs (miRNAs) in LAD with BM, and to investigate the biological role of these miRNAs during tumorigenesis. miRNA array profiles were used to identify BM-associated miRNAs. These miRNAs were independently validated in 155 LAD patients. Several in vivo and in vitro assays were performed to verify the effects of miRNAs on BM. We identified six miRNAs differentially expressed in patients with BM as compared to patients with BM. Of these, miR-4270 and miR-423-3p were further investigated. miR-4270 and miR-423-3p directly targeted MMP19 and P21, respectively, to influence cell viability, migration, and colony formation in vitro. miR-4270 downregulation and miR-423-3p upregulation was associated with an increased risk of BM in LAD patients. Thus, our results suggested that miR-4270 and miR-423-3p might play an important role in BM pathogenesis in LAD patients, and that these miRNAs might be useful prognostic and clinical treatment targets.

Radiation dose effect in locally advanced non-small cell lung cancer

Radiation is the foundation of treatment for locally advanced non-small cell lung cancer (NSCLC), and as such, optimal radiation dose is essential for successful treatment. This article will briefly review biological considerations of radiation dose and their effect in the context of three-dimensional conformal radiation therapy (3D-CRT) including intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for NSCLC. It will focus on literature review and discussions regarding radiation dose effect in locally advanced NSCLC including potential severe and lethal toxicities of high dose radiation given with concurrent chemotherapy. Potential new approaches for delivering safe and effective doses by individualizing treatment based on functional imaging are being applied in studies such as the PET boost trial and RTOG1106. The RTOG concept of delivering high dose radiation to the more resistant tumors with the use of isotoxic dose prescription and adaptive planning will also be discussed in detail.

Global metabolomics reveals potential urinary biomarkers of esophageal squamous cell carcinoma for diagnosis and staging

We performed a metabolomics study using liquid chromatography-mass spectrometry (LC-MS) combined with multivariate data analysis (MVDA) to discriminate global urine profiles in urine samples from esophageal squamous cell carcinoma (ESCC) patients and healthy controls (NC). Our work evaluated the feasibility of employing urine metabolomics for the diagnosis and staging of ESCC. The satisfactory classification between the healthy controls and ESCC patients was obtained using the MVDA model, and obvious classification of early-stage and advanced-stage patients was also observed. The results suggest that the combination of LC-MS analysis and MVDA may have potential applications for ESCC diagnosis and staging. We then conducted LC-MS/MS experiments to identify the potential biomarkers with large contributions to the discrimination. A total of 83 potential diagnostic biomarkers for ESCC were screened out, and 19 potential biomarkers were identified; the variations between the differences in staging using these potential biomarkers were further analyzed. These biomarkers may not be unique to ESCCs, but instead result from any malignant disease. To further elucidate the pathophysiology of ESCC, we studied related metabolic pathways and found that ESCC is associated with perturbations of fatty acid β-oxidation and the metabolism of amino acids, purines, and pyrimidines.

Natural growth and disease progression of non-small cell lung cancer evaluated with 18F-fluorodeoxyglucose PET/CT

PURPOSE

The aims of this study were to: (1) estimate the volumetric and metabolic growth rate of non-small cell lung cancer (NSCLC), (2) evaluate disease progression prior to treatment, and (3) explore the effects of tumor growth rate and time to treatment (TTT) on survival outcome.

METHODS

Patients with inoperable stages I-III NSCLC with serial pre-treatment PET/CT scans were eligible for this study. PET-derived metabolic tumor volumes (PET-MTV) and CT-derived gross tumor volumes (CT-GTV) were contoured using PET/CT information. Normalized standardized uptake values (NSUV) in tumors including the NSUVmean and NSUVmax were measured. Tumor growth rates expressed as doubling time (DT) were estimated using an exponential model. Pre-treatment disease progression defined as the development of any new site of disease on PET/CT and change in TNM stage (AJCC 7th ed.) were recorded. Growth rate and tumor progression were analyzed with respect to overall (OS) and progression free survival (PFS).

RESULTS

Thirty-four patients with a median inter-scan interval (ISI) of 43 days and TTT of 48 days were analyzed. Tumor volumes showed remarkable inter-scan growth while NSUV did not increase significantly. The DT for PET-MTV, CT-GTV, NSUVmean and NSUVmax were 124, 139, 597, and 333 days, respectively. Pre-treatment disease progression occurred in 20.6% patients with longer ISI being a significant risk factor (OR=1.027, p=0.02). The optimal threshold ISI to predict progression was 58 days (4.8% vs. 46.2%, p=0.007). Neither tumor growth rates nor TTT were significantly correlated to OS or PFS.

CONCLUSIONS

NSCLC displays rapid tumor volume growth whereas NSUVmean and NSUVmax are relatively stable over the same time period. Longer delays before initiation of treatment are associated with higher risk of pre-treatment disease progression.

MiR-423-5p in brain metastasis: potential role in diagnostics and molecular biology

During the last several years, a growing number of studies have shown that microRNAs (miRNAs) participate in cancer metastasis. Brain metastasis (BM) is a frequent complication of lung adenocarcinoma (LAD), and the incidence of locally advanced LAD with BM can be as high as 30-50%. This study was performed to identify the miRNA expression patterns of LAD with BM and to determine the biological role that miRNAs play in tumorigenesis. To this end, we conducted microarray and quantitative PCR analyses to evaluate BM-related miRNAs independently validated from a total of 155 patients with LAD. A series of in vivo and in vitro assays were also conducted to verify the impact of miRNAs on BM. We found significantly increased expression of miR-423-5p, and BM was predicted in non-small cell lung cancer when compared to LAD without BM. We next examined the function of miR-423-5p and discovered that it significantly promoted colony formation, cell motility, migration, and invasion in vitro. We computationally and experimentally confirmed that metastasis suppressor 1 (MTSS1) was a direct miR-423-5p target. Through a combination of image, histological, and molecular analyses, we found that miR-423-5p overexpression significantly increased tumor burden, local invasion, and distant BM. The level of MTSS1 expression was inversely correlated with miR-423-5p upregulation in the LAD specimens and was associated with survival of patients with BM. MiR-423-5p promoted BM in LAD and inhibited MTSS1 expression. Together, these results show that MiR-423-5p has the potential to be a marker of BM and/or a therapeutic target in LAD.

Intensity-Modulated Radiation Therapy May Improve Local-Regional Tumor Control for Locally Advanced Non-Small Cell Lung Cancer Compared With Three-Dimensional Conformal Radiation Therapy

BACKGROUND

Consistent results are lacking as regards the comparative effectiveness of intensity-modulated radiotherapy (IMRT) versus three-dimensional conformal radiotherapy (3DCRT) in patients with locally advanced non-small cell lung cancer (LA-NSCLC).

PATIENTS AND METHODS

Patients treated with definitive radiotherapy (RT) between 2002 and 2010 were retrospectively reviewed. Overall survival (OS), local-regional progression-free survival (LRPFS), distant metastasis-free survival (DMFS), and progression-free survival (PFS) were compared among patients irradiated with different techniques. The association between RT technique and survival indexes was assessed in a Cox proportional hazard regression model. Propensity score matching (PSM) was used to balance known confounding factors.

RESULTS

A total of 652 patients were eligible for analysis, including 206 with 3DCRT and 446 with IMRT. The median OS of the 3DCRT and IMRT groups were 19.4 and 23.3 months, with the 5-year rate of 13% and 19%, respectively (p = .043). Multivariate analysis identified IMRT as an independent favorable factor associated with LRPFS and DMFS. PSM analysis further verified the beneficial effect of IMRT on LRPFS. No difference in OS or PFS was observed between the two techniques. Subgroup analysis revealed that IMRT might be differentially more effective in both OS and LRPFS among patients who were female, nonsmokers, with adenocarcinoma, or without weight loss. There was a significant reduction of lung toxicity and similar esophagus toxicity in the IMRT group when compared with the 3DCRT group.

CONCLUSION

IMRT may confer superior LRPFS and comparable OS than can be achieved with 3DCRT in LA-NSCLC, along with the reduction of pulmonary toxicity.

IMPLICATIONS FOR PRACTICE

Based on the largest number of patients from a single institution, the present study demonstrated that intensity-modulated radiotherapy (IMRT) could provide superior local-regional progression-free survival and similar overall survival compared with the traditional three-dimensional conformal radiotherapy (3DCRT) for stage III non-small cell lung cancer (NSCLC). IMRT was also found to be associated with the significantly decreased incidence of pulmonary toxicity. These results suggest that IMRT should be considered a surrogate for 3DCRT in locally advanced NSCLC and might be the preferred option for a female nonsmoker with adenocarcinoma and a potentially high risk of pulmonary toxicity from radiotherapy.

Adding Concurrent Chemotherapy to Intensity-Modulated Radiotherapy Does Not Improve Treatment Outcomes for Stage II Nasopharyngeal Carcinoma: A Phase 2 Multicenter Clinical Trial

Purpose: To explore the efficacy of concomitant chemotherapy in intensity-modulated radiotherapy (IMRT) to treat stage II nasopharyngeal carcinoma (NPC). Methods and Materials: In this randomized phase 2 study [registered with ClinicalTrials.gov (NCT01187238)], eligible patients with stage II (2010 UICC/AJCC) NPC were randomly assigned to either IMRT alone (RT group) or IMRT combined with concurrent cisplatin (40 mg/m², weekly) (CCRT group). The primary endpoint was overall survival (OS). The second endpoints included local failure-free survival (LFFS), regional failure-free survival (RFFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and acute toxicities. Results: Between May 2010 to July 2012, 84 patients who met the criteria were randomized to the RT group (n = 43) or the CCRT group (n = 41). The median follow-up time was 75 months. The OS, LFFS, RFFS, DFS, and DMFS for the RT group and CCRT group were 100% vs. 94.0% (p = 0.25), 93.0% vs. 89.3% (p = 0.79), 97.7% vs. 95.1% (p = 0.54), 90.4% vs. 86.6% (p = 0.72), and 95.2% vs. 94.5% (p = 0.77), respectively. A total of 14 patients experienced disease failure, 7 patients in each group. The incidence of grade 2 to 4 leukopenia was higher in the CCRT group (p = 0.022). No significant differences in liver, renal, skin, or mucosal toxicity was observed between the two groups. Conclusion: For patients with stage II NPC, concomitant chemotherapy with IMRT did not improve survival or disease control but had a detrimental effect on bone marrow function.

Concurrent erlotinib and radiotherapy for chemoradiotherapy-intolerant esophageal squamous cell carcinoma patients: results of a pilot study

Concurrent chemoradiotherapy is the standard treatment for patients with locally advanced esophageal squamous cell carcinoma. However, a number of patients present intolerance to chemoradiotherapy because of advanced age or malnutrition. Erlotinib, an inhibitor of epidermal growth factor receptor tyrosine kinase, was shown to be effective in treating esophageal carcinoma, with mild toxicities. In this pilot study, we investigated the safety and efficacy of concurrent erlotinib and radiotherapy as an alternative treatment modality for esophageal carcinoma patients who are intolerant to chemoradiotherapy. Pathologically diagnosed esophageal squamous cell carcinoma patients who could not tolerate concurrent chemoradiotherapy were enrolled. All patients were treated with concurrent erlotinib and intensity-modulated radiation therapy. Erlotinib was given orally for 60 days (150 mg per day). Radiotherapy (total dose, 60 Gy) was given at dosages of 2 Gy for a total of 30 times. Immunohistochemical staining was performed to assess epidermal growth factor receptor expression. Toxicities were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 3.0). The overall survival, progression-free survival, and local-regional relapse-free survival were calculated using the Kaplan-Meier method. Between December 2007 and March 2011, 18 patients were enrolled. The median age was 71.5 years. Primary disease was stages II, III, and IV in 3, 8, and 4 patients, respectively. There were three patients with recurrent disease after radical surgery. The median follow-up time was 17.2 months. Grade 3 esophagitis and skin rash were observed in five (27.8%) and two (11.1%) patients, respectively. Radiation pneumonitis of grades 2 and 5 was observed in one patient each. No grade 3/4 impaired liver function or hematological toxicity was observed. At 1 month after radiotherapy, two (11.1%) patients achieved complete response, 11 (61.1%) patients achieved partial response, and 5 (27.8%) patients had stable disease. The median time of overall survival and progression-free survival was 21.1 and 12 months, respectively. Two-year overall survival, progression-free survival, and local-regional relapse-free survival were 44.4%, 38.9%, and 66.7%, respectively. Five of six patients examined for epidermal growth factor receptor had high expression levels (3+). The relationship between epidermal growth factor receptor expression and treatment outcomes could not be concluded. For esophageal squamous cell carcinoma patients who cannot tolerate chemoradiotherapy, concurrent erlotinib and radiotherapy are tolerable and effective. Valuable markers to predict the effect of erlotinib should be exploited in future studies.

Hepatoid adenocarcinoma of the lung: Presenting mediastinal metastasis without transfer to the liver

Hepatoid adenocarcinoma of the lung (HAL) is a rare type of lung cancer. Its diagnosis and treatment may be difficult due to the varied presentation; however, immunohistochemical analysis facilitates the diagnosis. The present study presents a case of HAL. The patient was a 48-year-old male who presented with a primary complaint of back pain. A chest computed-tomography scan revealed a lobulated soft-tissue mass that extended from the left lung apex to the middle and posterior mediastinum. The area of the largest cross-section was 7.9×10.0 cm and the lymph nodes did not demonstrate metastasis. Immunohistochemical staining of a transbronchial lung biopsy revealed that the tumor cells were α-fetoprotein (AFP)(positive) and hepatocytes(positive) and a diagnosis of hepatoid carcinoma of the left lung was established. The level of serum AFP, a tumor marker, was elevated (6,283 ng/ml). The patient presented with mediastinal metastases and was classified as stage IIIA (N2); following diagnosis, the patient received concurrent chemoradiation. Subsequent to chemoradiation, the left lung lump with the largest cross-section was 3.3×4.2 cm and the serum AFP had fallen to its lowest level (23.11 ng/ml). However, when the patient relapsed, the serum AFP level elevated markedly (57,800 ng/ml). Furthermore, the nodules of metastasis increased in number and enlarged, with the largest measuring 2.1 cm. The patient succumbed as a result of a lung infection.

Comparison of efficacy and safety between simultaneous integrated boost intensity-modulated radiotherapy and conventional intensity-modulated radiotherapy in locally advanced non-small-cell lung cancer: a retrospective study

Background

Consistent results are lacking as regards the comparative effectiveness of simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) versus conventional intensity-modulated radiotherapy in patients with locally advanced non-small-cell lung cancer (LA-NSCLC). Therefore, we conducted a retrospective analysis to demonstrate the role of SIB-IMRT for patients.

Methods

Patients who had histologically confirmed NSCLC, stage III disease and received thoracic IMRT between 2014 and 2016 were retrospectively reviewed. The survival, toxicities and dose to organs at risk (OAR) were compared among patients irradiated with different techniques. The SIB-IMRT plans were designed to deliver 45–59.4Gy (median: 50.4Gy) to PTV while simultaneously delivering 50-70Gy (median: 59.92Gy) to PGTV. As for conventional IMRT plans, a total dose of 50-70Gy (median: 60Gy) was delivered to PTV.

Results

426 patients with stage III NSCLC were eligible for analysis, including 128 with SIB-IMRT and 298 with conventional IMRT. The SIB-IMRT group had more stage IIIB disease (69.5% vs. 53%, P = 0.002), larger planning treatment volumes (median: 504 ml vs. 402 ml, P<0.001), and a larger planning treatment volume/volume of lung ratio (median, 0.18 vs. 0.12, P<0.001). The median OS of the SIB-IMRT and conventional IMRT groups were 34.5 and 31.7 months, with the 2-year rate of 60.4 and 59%, respectively (P = 0.797). No difference in PFS, LRFS or DMFS was observed between the two techniques. Patients treated with SIB-IMRT got similar lung and esophageal toxicities versus those with conventional IMRT.

Conclusions

SIB-IMRT may be an effective and safe option for patients with locally advanced NSCLC, especially for those with large mass or wide lymph node metastasis.

Increased CYFRA 21-1, CEA and NSE are Prognostic of Poor Outcome for Locally Advanced Squamous Cell Carcinoma in Lung: A Nomogram and Recursive Partitioning Risk Stratification Analysis

OBJECTIVES

This study aimed to: (1) assess the prognostic significance of serum tumor markers in locally advanced squamous cell carcinoma in lung (LA-SCCL); (2) generate a nomogram to predict the overall survival (OS) and (3) identify a prognostic stratification to assist the therapeutic decision-making.

METHODS

LA-SCCL patients receiving definitive radiotherapy and baseline tumor marker measurement were eligible for this retrospective study. Cox proportional hazards regression was used to determine independent factors associated with various survival indexes and a nomogram was created to estimate the 5-year OS probability for individual patient. The identified prognostic factors were recruited into a recursive partitioning analysis (RPA) for OS to stratify patients with distinct outcome.

RESULTS

A total of 224 patients were eligible for analysis. Increased cytokeratin-19 fragment (CYFRA 21-1) was independently associated with inferior OS, progression free survival (PFS) and a borderline decreased local-regional progression free survival (LRPFS). Elevated carcino-embryonic antigen (CEA) served as an unfavorable determinant for OS and increased neuron-specific enolase (NSE) was predictive of poor distant metastasis free survival (DMFS). A nomogram integrating KPS, TNM stage, CEA and CYFRA 21-1 was created, resulting in a c-index of 0.62. RPA identified 4 prognostic classifications, with median OS of 27.6, 19.9, 17.3 and 10.9 months for low, intermediate, high and very-high risk groups, respectively.

CONCLUSIONS

Baseline tumor marker panel including CYFRA 21-1, CEA and NSE can be prognostic of outcome for LA-SCCL receiving definitive radiotherapy. The RPA identified four prognostic subgroups, which could assist personalized therapy and clinical trial design in LA-SCCL.

Health-related quality of life in long-term survivors of unresectable locally advanced non-small cell lung cancer

BACKGROUND

Heath-related quality of life (HRQoL) among survivors with unresectable locally-advanced non-small cell lung cancer (LA-NSCLC) treated with radiotherapy and chemotherapy still is not clear. The current study were performed to determine HRQoL for long-term survivors with unresectable LA-NSCLC and to identify risk factors for poor HRQoL.

METHODS

Among patients with LA-NSCLC receiving radiotherapy and chemotherapy between January 2006 and December 2010, 82 long-term survivors beyond 5 years were identified in this cross-sectional study. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30 and the lung cancer-specific questionnaire QLQ-LC13 were employed to gather information on HRQoL. HRQoL scores were compared between different subgroups to analyze factors related to HRQoL.

RESULTS

Fifty-five out of 82 (67%) long-term survivors completed the HRQoL survey. They reported a mild reduction in global health status and physical and emotional functioning. Fatigue, dyspnea, coughing, and financial difficulties ranked the highest scores in the symptom scales. Analysis of risk factors for HRQoL showed age, exercise, smoking status, and treatment regimen were associated with global health status and functional scores, while age, gender, radiation pneumonitis, weight loss, and exercise were associated with symptom scores.

CONCLUSIONS

This study provides the first description of the HRQoL of long-term LA-NSCLC survivors receiving radiotherapy and chemotherapy who may experience a relatively high HRQoL. Factors related to poorer HRQoL are potential targets for intervention.

A deep learning method for producing ventilation images from 4DCT: First comparison with technegas SPECT ventilation

PURPOSE

The purpose of this study is to develop a deep learning (DL) method for producing four-dimensional computed tomography (4DCT) ventilation imaging and to evaluate the accuracy of the DL-based ventilation imaging against single-photon emission-computed tomography (SPECT) ventilation imaging (SPECT-VI). The performance of the DL-based method is assessed by comparing with density change- and Jacobian-based (HU and JAC) methods.

MATERIALS AND METHODS

Fifty patients with esophagus or lung cancer who underwent thoracic radiotherapy were enrolled in this study. For each patient, 4DCT scans paired with 99mTc-Technegas SPECT/CT were acquired before the first radiotherapy treatment. 4DCT and SPECT/CT were first rigidly registered using MIMvista and converted to data matrix using MATLAB, and then transferred to a DL model based on U-net for correlating 4DCT features and SPECT-VI. Two forms of 4DCT dataset [(a) ten phases and (b) two phases of peak-exhalation and peak-inhalation] as input are studied. Tenfold cross-validation procedure was used to evaluate the performance of the DL model. For comparative evaluation, HU and JAC methodologies are used to calculate specific ventilation imaging based on 4DCT (CTVI) for each patient. The voxel-wise Spearman's correlation was evaluated over the whole lung between each of CTVI and corresponding SPECT-VI. The SPECT-VI and produced CTVIs were segmented into high, median, and low functional lung (HFL, MFL, and LFL) regions. The spatial overlap of corresponding HFL, MFL, and LFL for each CTVI against SPECT-VI was also evaluated using the dice similarity coefficient (DSC). The averaged DSC of functional lung regions was calculated and statistically analyzed with a one-factor ANONA model among different methods.

RESULTS

The voxel-wise Spearman r_s values were (0.22 ± 0.31), (-0.09 ± 0.18), and (0.73 ± 0.16)/(0.71 ± 0.17) for the CTVI_HU , CTVI_JAC , and CTVI_DL(1) /CTVI_DL(2) . These results showed the DL method yielded the strongest correlation with SPECT-VI. Using the DSC as the spatial overlap metric, we found that the CTVI_HU , CTVI_JAC , and CTVI_DL(1) /CTVI_DL(2) methods achieved averaged DSC values for all patients to be (0.45 ± 0.08), (0.33 ± 0.04), and (0.73 ± 0.09)/(0.71 ± 0.09), respectively. The results demonstrated that the DL method yielded the highest similarity with SPECT-VI with the prominently significant difference (P < 10^-7 ).

CONCLUSIONS

This study developed a DL method for producing CTVI and performed a validation against SPECT-VI. The results demonstrated that DL method can derive CTVI with greatly improved accuracy in comparison to HU and JAC methods. The produced ventilation images can be more accurate and useful for lung functional avoidance radiotherapy and treatment response modeling.

A green chemometrics-assisted fluorimetric detection method for the direct and simultaneous determination of six polycyclic aromatic hydrocarbons in oil-field wastewaters

Oil-field wastewaters contain high level of polycyclic aromatic hydrocarbons (PAHs), which have to be analyzed to assess the environmental effects before discharge. In this work, a green fluorimetric detection method that combines excitation-emission matrix (EEM) fluorescence with parallel factor analysis (PARAFAC) algorithm was firstly developed to achieve the direct and simultaneous determination of six U.S. EPA PAHs in two different kinds of complex oil-field wastewaters. Due to the distinctive "second-order advantage", neither time-consuming sample pretreatments nor toxic organic reagents were involved in the determination. By using the environment-friendly "mathematical separation" of PARAFAC, satisfactory quantitative results and reasonable spectral profiles for six PAHs were successfully extracted from the total EEM signals of oil-field wastewaters without need of chromatographic separation. The limits of detection of six PAHs were in the range of 0.09-0.72ngmL^-1, and the average spiked recoveries were between (89.4±4.8)% and (109.1±5.8)%, with average relative predictive errors <2.93%. In order to further confirm the accuracy of the proposed method, the same batch oil-field wastewater samples were analyzed by the recognized GC-MS method. t-test demonstrated that no significant differences exist between the quantitative results of the two methods. Given the advantages of green, fast, low-cost and high-sensitivity, the proposed method is expected to be broadened as an appealing alternative method for multi-residue analysis of overlapped PAHs in complex wastewater samples.

Effect of Concurrent Chemoradiation With Celecoxib vs Concurrent Chemoradiation Alone on Survival Among Patients With Non-Small Cell Lung Cancer With and Without Cyclooxygenase 2 Genetic Variants: A Phase 2 Randomized Clinical Trial

IMPORTANCE

Treatment of locally advanced non-small cell lung cancer (NSCLC) remains challenging. The rationale of combining a cyclooxygenase 2 (COX-2) inhibitor with concurrent chemoradiation (CCRT) was based on results of preclinical research and prospective clinical studies; however, no randomized clinical trial has provided evidence of a direct comparison with CCRT alone.

OBJECTIVE

To determine the effect of combined selective COX-2 inhibition with standard CCRT on survival among patients with unresectable stage III NSCLC.

DESIGN, SETTING, AND PARTICIPANTS

A single-center, open-label, randomized phase 2 clinical trial was performed among 96 patients who had histologically and cytologically confirmed unresectable stage III NSCLC. Participants were enrolled from November 2011 to August 2015. Data were analyzed from February to October 2018.

INTERVENTION

Patients were randomized to receive thoracic radiation, 60 Gy, for 6 weeks concurrent with etoposide and cisplatin or the same regimen of CCRT combined with 200 mg of celecoxib, taken twice daily.

MAIN OUTCOMES AND MEASURES

The primary end point was overall survival. The secondary end points were the proportion of patients with treatment-related toxic effects, progression-free survival, and overall survival in subgroups with and without the COX-2 genotype.

RESULTS

A total of 100 patients were randomized. Following the exclusion of 4 outliers, 96 participants (96.0%) were analyzed (51 randomized to CCRT alone and 45 randomized to CCRT with celecoxib; mean [SD] age, 60.0 [8.3] years; 73.0 [76.0%] male). The median overall survival time was 32.8 (95% CI, 17.0-48.5) months in the group that received CCRT with celecoxib and 35.5 (95% CI, 25.8-45.2) months in the group that received CCRT alone (P = .88). Celecoxib with CCRT was well tolerated; the incidence of symptomatic radiation pneumonitis was 6.6% (95% CI, 1.4%-18.0%) in the group that received CCRT with celecoxib and 11.8% (95% CI, 4.4%-23.9%) in the group that received CCRT alone (P = .49). Among patients with the high-risk genotype, celecoxib plus CCRT was not associated with higher progression-free survival (hazard ratio, 0.36; 95% CI, 0.13-1.04; P = .05) or overall survival (hazard ratio, 0.50; 95% CI, 0.15-1.72; P = .26) compared with CCRT alone.

CONCLUSIONS AND RELEVANCE

In unresectable stage III NSCLC, adding celecoxib to concurrent chemoradiation did not improve survival. A smaller, not statistically significant proportion of patients in the CCRT with celecoxib group compared with the CCRT alone group developed symptomatic radiation pneumonitis. Among patients with the high-risk genotype, adding celecoxib to CCRT did not improve overall or progression-free survival.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01503385.

Consolidation chemotherapy may improve survival for patients with locally advanced non-small-cell lung cancer receiving concurrent chemoradiotherapy--retrospective analysis of 203 cases

Background

For patients with locally advanced non-small-cell lung cancer (LA-NSCLC), the role of consolidation chemotherapy (CCT) following concurrent chemoradiotherapy (CRT) is partially defined. The aim of this study was to evaluate the efficacy and toxicity of CCT.

Methods

The characteristics of LA-NSCLC patients treated with curative concurrent CRT from 2001 to 2010 were retrospectively reviewed.

Results

Among 203 patients, 113 (55.7 %) patients received CCT. The median number of delivered CCT was 3 and 89.4 % patients completed ≥2 cycles. The OS was significantly better for patients in the CCT group compared with that in the non-CCT group (median OS, 27 months vs. 16 months; 5-year OS, 30.4 % vs. 22.5 %; p = 0.012). The median PFS were 12 months in the CCT group and 9 months in the non-CCT group (p = 0.291). The survival advantages of CCT were significant for males (HR: 0.63; 95 % CI, 0.44 − 0.90), patients with age < 60 years (HR: 0.63; 95 % CI, 0.42 − 0.95), non-squamous histology (HR: 0.44; 95 % CI, 0.25 − 0.76), pretreatment KPS ≥ 80 (HR: 0.67; 95 % CI, 0.48 − 0.93), stage IIIb (HR: 0.64; 95 % CI, 0.43 − 0.95), stable disease (HR: 0.31; 95 % CI, 0.14 − 0.65) and radiotherapy dose ≥ 60 Gy (HR: 0.69; 95 % CI, 0.48 − 1.00). There was no significant difference between the CCT group and the non-CCT group regarding treatment-related toxicities.

Conclusions

CCT might further prolong survival compared with CRT alone for LA-NSCLC without increasing treatment-related toxicities, especially for males, patients with age < 60 years, non-squamous histology, pretreatment KPS ≥ 80, stage IIIb, stable disease and radiotherapy dose ≥ 60 Gy. Large size prospective investigations that incorporate patient characteristics and treatment response are warranted to validate our findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1710-2) contains supplementary material, which is available to authorized users.

The Efficacy of Upfront Intracranial Radiation with TKI Compared to TKI Alone in the NSCLC Patients Harboring EGFR Mutation and Brain Metastases

Introduction: The high intracranial efficacy of EGFR-TKI challenges the role of upfront intracranial radiation therapy (RT) in non-small cell lung cancer (NSCLC) patients with EGFR mutation and brain metastases (BM). Therefore, we conducted a retrospective analysis to demonstrate the role of upfront RT in these patients.

Materials and Methods: Patients that had histologically confirmed NSCLC with EGFR mutation, brain metastases, and received TKI or upfront RT with TKI were included in this study. Intracranial progression was estimated using the Fine-Gray competing risks model. Kaplan-Meier analysis and Log-rank test were used to evaluate and compare intracranial progression-free survival (iPFS), systemic PFS (sPFS), time to second-line systematic therapy (SST) and overall survival (OS).

Results: Among the 93 patients included, 53 patients received upfront RT and TKI, and 40 patients received TKI only. Upfront RT group showed lower intracranial progression risk with adjusted SHR 0.38 (95% CI, 0.19 to 0.75, P= 0.006) and longer median time to sPFS (15.6 vs 8.9 months, P= 0.009). There were 9 out of 36 (25%) and 16 out of 34 (47.1%) patients who had oligo-progression received salvage RT in the RT group and TKI group, respectively. After the salvage RT, upfront RT did not prolong the median time to SST (23.6 vs 18.9 months, P=0.862) and OS (median time, 35.4 vs 35.8 months, P=0.695) compared to TKI alone.

Conclusion: Compared to upfront intracranial RT, the salvage RT to oligo-progressive disease allowed patients getting TKI to have similar time on initial TKI and OS despite worse iPFS. The best timing of intracranial RT remains to be further verified.

Spatial architecture of regulatory T-cells correlates with disease progression in patients with nasopharyngeal cancer

Purpose

This study aims to investigate the prognostic value of composition and spatial architecture of tumor-infiltrating lymphocytes (TILs) as well as PDL1 expression on TILs subpopulations in nasopharyngeal carcinoma (NPC).

Methods

A total of 121 patients with NPC were included and divided into two groups: favorable (n = 68) and unfavorable (n = 53). The archived tumor tissues of the included patients were retrieved, and a tissue microarray was constructed. The density and spatial distribution of TILs infiltration were analyzed using the multiplex fluorescent immunohistochemistry staining for CD3, CD4, CD8, Foxp3, cytokeratin (CK), PDL1, and 4′,6-diamidino-2-phenylindole (DAPI). The infiltration density of TILs subpopulations and PDL1 expression were compared between the two groups. The Gcross function was calculated to quantify the relative proximity of any two types of cells. The Cox proportional hazards regression model was used to identify factors associated with overall survival (OS) and disease-free survival (DFS).

Results

The densities of regulatory T-cells (Tregs), effector T-cells (Teffs), PDL1+ Tregs, and PDL1+ Teffs were significantly higher in patients with unfavorable outcomes. PDL1 expression on tumor cells (TCs) or overall TILs was not associated with survival. Multivariate analysis revealed that higher PDL1+ Tregs infiltration density was independently associated with inferior OS and DFS, whereas Tregs infiltration density was only a prognostic marker for DFS. Spatial analysis revealed that unfavorable group had significantly stronger Tregs and PDL1+ Tregs engagement in the proximity of TCs and cytotoxic T lymphocyte (CTLs). Gcross analysis further revealed that Tregs and PDL1+ Tregs were more likely to colocalize with CTLs. Moreover, increased G_TC : _Treg (Tregs engagement surrounding TCs) and G_CTL : _{PDL1+ Treg} were identified as independent factors correlated with poor outcomes.

Conclusion

TILs have a diverse infiltrating pattern and spatial distribution in NPC. Increased infiltration of Tregs, particularly PDL1+ Tregs, as well as their proximity to TCs and CTLs, correlates with unfavorable outcomes, implying the significance of intercellular immune regulation in mediating disease progression.

MicroRNA-Related Polymorphisms in PI3K/Akt/mTOR Pathway Genes Are Predictive of Limited-Disease Small Cell Lung Cancer Treatment Outcomes

The phosphoinositide-3 kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) signaling pathway plays an important role in cancer progression and treatment, including that of small cell lung cancer (SCLC), a disease with traditionally poor prognosis. Given the regulatory role of microRNA (miRNA) in gene expression, we examined the association of single nucleotide polymorphisms (SNPs) at miRNA-binding sites of genes in the mTOR pathway with the prognosis of patients with limited-disease SCLC. A retrospective study was conducted of 146 patients with limited-disease SCLC treated with chemoradiotherapy. Nine SNPs of six mTOR pathway genes were genotyped using blood samples. Cox proportional hazard regression modeling and recursive partitioning analysis were performed to identify SNPs significantly associated with overall survival. Three SNPs, MTOR: rs2536 (T>C), PIK3R1: rs3756668 (A>G), and PIK3R1: rs12755 (A>C), were associated with longer overall survival. Recursive partitioning analysis based on unfavorable genotype combinations of the rs2536 and rs3756668 SNPs classified patients into three risk subgroups and was internally validated with 1000 bootstrap samples. These findings suggest that miRNA-related polymorphisms in the PI3K/Akt/mTOR pathway may be valuable biomarkers to complement clinicopathological variables in predicting prognosis of limited-disease SCLC and to facilitate selection of patients likely to benefit from chemoradiotherapy.

Long-term analysis of multimodality treatment outcomes and prognosis of esthesioneuroblastomas: a single center results of 138 patients

Background

The aim of this study is to evaluate the efficacy of different treatment strategies and the potential prognostic factors of esthesioneuroblastoma (ENB).

Materials and methods

Between April 1984 and December 2018, 138 patients with non-metastatic ENB were retrospectively analyzed. The treatment modalities mainly included surgery alone (n = 7), radiotherapy alone (n = 33), concurrent chemoradiotherapy (n = 17), surgery combined with current chemoradiotherapy (n = 32), and surgery plus radiotherapy (n = 49).

Results

The median follow-up time for the entire cohort was 61 months (range, 4–231 months). The 5-year overall survival (OS), locoregional failure-free survival (LRFFS), and distant metastasis-free survival (DMFS) rate were 69.6, 78.0 and 73.9%, respectively. Surgery combined with radiotherapy elicited superior survival results, and the combination of surgery and current chemoradiotherapy achieved the best prognoses for all patients, patients with advanced Kadish disease, patients receiving intensity modulated radiation therapy and those with positive surgical margin. Univariate analysis identified orbital invasion and treatment modalities were predictors for OS, LRFFS and DMFS. Lymph node metastasis was associated with OS and DMFS, but not LRFFS. Intracranial invasion, advanced Kadish stage and not receiving concurrent chemotherapy were also predictive of lower OS. Multivariate analyses indicated that lymph node metastasis was an independent prognostic factor affecting DMFS, whereas treatment modalities was independent prognostic factors for OS and LRFFS.

Conclusion

Orbital invasion, intracranial invasion, lymph node metastasis and advanced Kadish disease at initial diagnosis were significantly associated with inferior prognosis. Regarding the treatment modality, the optimal strategy remined surgery with radiotherapy-based multimodality treatment. The concurrent chemoradiotherapy may play a more beneficial role.