The prognostic significance of the 8th edition AJCC TNM staging system for non-small-cell lung cancer is not applicable to lung cancer as a second primary malignancy

BACKGROUND AND OBJECTIVES

It is unclear whether the prognostic significance of the 8th American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging system for non-small-cell lung cancer (NSCLC) is applicable to lung cancer as a second primary malignancy (LCSPM). This study used a population-based database to evaluate this relationship.

METHODS

Patients diagnosed with second primary lung cancer after a nonpulmonary malignancy were identified from the Surveillance, Epidemiology and End Results (SEER) registry from 2004 to 2015. Cumulative incidence function (CIF) and multivariable CIF regression analyses were performed to estimate the difference in disease-specific mortality (DSM) among different TNM stages.

RESULTS

Our cohort included 2687 patients from the SEER database. After CIF analysis, although rates of 1-year, 3-year, and 5-year DSM trended higher with increasing TNM stages, the DSM curves overlapped for many subcategories. In a multivariable regression analysis, hazards ratios (HRs) for subcategories of stage Ι demonstrated no significant difference compared with the reference stage ΙA1 ([ΙA2 HR = 1.120; 95% confidence interval [CI], 0.477-2.626]; [ΙA3 HR = 1.762; 95% CI, 0.752-4.126]; [ΙB HR = 2.003; 95% CI, 0.804-4.911]). The following HRs trended higher for increasing TNM stages but with overlapping CIs among adjacent stage groupings.

CONCLUSION

The 8th edition AJCC TNM staging system fails to provide accurate prognostic value for LCSPM.

Ultrasensitive DNA hypermethylation detection using plasma for early detection of NSCLC: a study in Chinese patients with very small nodules

PURPOSE

We had previously developed highly sensitive DNA methylation detection to diagnose lung cancer in patients with pulmonary nodules. To validate this approach and determine clinical utility in Chinese patients with indeterminate pulmonary nodules, we assessed the diagnostic accuracy for early stage lung cancer in plasma samples.

EXPERIMENTAL DESIGN

Patients with CT-detected small lung nodules (diameter ≤ 3.0 cm) were included. Cases (n = 163) had staged IA or IB non-small cell lung cancer (NSCLC), while controls (n = 83) had non-cancerous lesions. Promoter methylation of eight lung cancer-specific genes (CDO1, TAC1, SOX17, HOXA7, HOXA9, GATA4, GATA5, and PAX5) was detected using nanoparticle-based DNA extraction (MOB) followed by qMSP.

RESULTS

Methylation detection for CDO1, TAC1, SOX17, and HOXA7 in plasma was significantly higher in cases compared with the benign group (p < 0.001). The sensitivity and specificity for lung cancer diagnosis using individual gene was 41-69% and 49-82%. A three-gene combination of the best individual genes has sensitivity and specificity of 90% and 71%, with area under the receiver operating curve (AUC) of 0.88, (95% CI 0.84-0.93). Furthermore, three-gene combinations detected even the smallest lung nodules, with the combination of CDO1, SOX17, and HOXA7 having the overall best performance, while the combination of CDO1, TAC1, and SOX17 was best in tumor sizes less than 1.0 cm.

CONCLUSIONS

Using modified MOB-qMSP, high sensitivity and specificity, for the detection of circulating tumor DNA was obtained for early stage NSCLC. This strategy has great potential to identify patients at high risk and improve the diagnosis of lung cancer at an earlier stage.

Report on 153 sequential three-incision robotic-assisted pulmonary resections by a single surgeon: technical details and learning curve

Background

There are several techniques for robotic-assisted pulmonary resection, depending on the number and position of ports and utility incisions. We developed a technique for three-incision robotic-assisted pulmonary resection, and here we reported our initial results.

Methods

Three-incision pulmonary resection with the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was attempted in 153 patients. Robotic instruments were used for individual dissection of the hilar structures through two thoracoscopic ports and a 3-cm utility incision without rib spreading. Data on patient characteristics and perioperative results were prospectively collected.

Results

Between December 2016 and December 2018, a single surgeon performed three-incision robotic-assisted pulmonary resection on 153 consecutive patients in the Thoracic Surgery Department of the Second Xiangya Hospital. There was no emergent conversion to thoracotomy. Median operative time was 146.84 minutes (range, 40–320 minutes), and the median estimated blood loss was 62.70 mL (range, 5–200 mL). The mean postoperative days before chest tubes were removed was 3.91 (range, 2–18), and the mean postoperative days before patients were discharged was 5.34 (range, 2–20). The median number of lymph node stations dissected was 5 (range, 1–9). The mean number of nodes resected was 12 (range, 1–35), and postoperative complications were observed in 12 patients (7.84%).

Conclusions

Three-incision robotic-assisted pulmonary resection is practicable, safe, and ideal for novices experienced in video-assisted thoracic surgery (VATS) surgery. It also appears to be oncologically acceptable for lung cancer; however, more studies on a large population are necessary to confirm these conclusions.

Fate and removal of antimony in response to stringent control activities after a mine tailing spill

When tailing spill accidents occur, the risk of contamination by antimony (Sb) tailings into adjacent rivers, sediments, aquifers and soil environments is high. The Sb concentrations in water and sediment under different stringent control activities were investigated for 60 days in the Jialing River basin after a tailing spill accident. Both reservoir regulation and the construction of a temporary dam with coagulation dosing remarkably reduced the Sb levels in the river water. The increase in dissolved Sb caused by the spill was reduced from ~400 μg/L in the inflow to ~200 μg/L in the outflow by reservoir regulation. Moreover, reservoir regulation led to a high concentration of Sb in the reservoir sediment, which was difficult to remove and may cause subsequent unpredictable long-term ecological and health risks. In contrast, the Sb-enriched deposition inside the temporary dam was convenient to remove. Notably, temperature alternations between day and night in winter resulted in a large fluctuation in coagulation efficiency, which may cause the failure of stringent control projects. The results of this study suggest potential improvements to stringent control activities after mine tailing accidents to mitigate environmental impacts and prevent secondary risks.

Analysis on expression level and diagnostic value of miR-19 and miR-21 in peripheral blood of patients with undifferentiated lung cancer

OBJECTIVE

This paper aims to investigate the expression level and diagnostic value of miR-19 miR-21 in peripheral blood of patients with undifferentiated lung cancer.

PATIENTS AND METHODS

58 patients with undifferentiated lung cancer hospitalized in the oncology department of The First Affiliated Hospital of Nanchang University from September 2014 to May 2017 were selected as the experimental group, and 42 healthy volunteers in the same period as the control group at the same time. General clinical data in the two groups were collected. The expression levels of miR-19 and miR-21 in peripheral blood of the two groups were measured by Real-Time fluorescence quantitative Polymerase Chain Reaction. The expression levels of peripheral blood miR-19 and miR-21 in large and small cell lung cancer of undifferentiated lung cancer were analyzed and compared. ROC curve was used to analyze the diagnostic value of miR-19 and miR-21 in undifferentiated lung cancer.

RESULTS

The expression levels of miR-19 and miR-21 in peripheral blood of the experimental group were significantly higher than those of the control group (p<0.05). The AUC of miR-19 in the diagnosis of undifferentiated lung cancer was 0.854; the sensitivity was 98.30%; the specificity was 54.29% and the cut off was 3.54. The AUC of miR-21 in the diagnosis of undifferentiated lung cancer was 0.923; the sensitivity was 86.20%; the specificity was 76.19% and the cut off was 3.89. The AUC of combined detection in the diagnosis of undifferentiated lung cancer was 0.952; the sensitivity was 86.60%; the specificity was 97.62% and the cut off was 0.68. The specificity of combined detection was higher than that of miR-19 and miR-21 (p<0.05).

CONCLUSIONS

MiR-19 and miR-21 are highly expressed in peripheral blood of patients with undifferentiated lung cancer; miR-19 and miR-21 are expected to be used as diagnostic markers for undifferentiated lung cancer.

Ionization-induced adiabatic soliton compression in gas-filled hollow-core photonic crystal fibers

We investigate in the experiments the ionization-induced adiabatic soliton compression process in a short length of He-filled single-ring photonic crystal fiber. We observe that the plasma-driven blueshifting solitons show little residual light near the pump wavelength in a certain pulse energy region, leading to a high-efficiency frequency upconversion process. In contrast, at high pulse energy levels, we observe that the quality of the frequency upshifting process is impaired due to the existence of a dynamical loss channel induced by the coupling of the soliton to linear modes near the pump wavelength. In addition, through adjusting the input pulse energy, the central wavelength of blueshifting solitons can be continuously tuned over 300 nm. These experimental results, confirmed by numerical simulations, not only offer a deep insight into ionization-induced soliton-plasma dynamics in gas-filled hollow-core photonic crystal fibers, but also develop highly tunable ultrafast light sources at visible wavelengths, which may have many applications in ultrafast spectroscopy.

Imaging G-Ratio in Multiple Sclerosis Using High-Gradient Diffusion MRI and Macromolecular Tissue Volume

BACKGROUND AND PURPOSE

Remyelination represents an area of great therapeutic interest in multiple sclerosis but currently lacks a robust imaging marker. The purpose of this study was to use high-gradient diffusion MRI and macromolecular tissue volume imaging to obtain estimates of axonal volume fraction, myelin volume fraction, and the imaging g-ratio in patients with MS and healthy controls and to explore their relationship to neurologic disability in MS.

MATERIALS AND METHODS

Thirty individuals with MS (23 relapsing-remitting MS, 7 progressive MS) and 19 age-matched healthy controls were scanned on a 3T MRI scanner equipped with 300 mT/m maximum gradient strength using a comprehensive multishell diffusion MRI protocol. Macromolecular tissue volume imaging was performed to quantify the myelin volume fraction. Diffusion data were fitted to a 3-compartment model of white matter using a spheric mean approach to yield estimates of axonal volume fraction. The imaging g-ratio was calculated from the ratio of myelin volume fraction and axonal volume fraction. Imaging metrics were compared between groups using 2-sided t tests with a Bonferroni correction.

RESULTS

The mean g-ratio was significantly elevated in lesions compared with normal-appearing WM (0.74 vs 0.67, P < .001). Axonal volume fraction (0.17 vs 0.23, P < .001) and myelin volume fraction (0.17 vs 0.25, P < .001) were significantly lower in lesions than normal-appearing WM. Myelin volume fraction was lower in normal-appearing WM compared with that in healthy controls (0.25 vs 0.27, P = .009). Disability, as measured by the Expanded Disability Status Scale, was significantly associated with myelin volume fraction (β = -40.5, P = .001) and axonal volume fraction (β = -41.0, P = .016) in normal-appearing WM.

CONCLUSIONS

The imaging g-ratio may serve as a biomarker for the relative degree of axonal and myelin loss in MS.

Effects of curcumin on the role of MMP-2 in endometrial cancer cell proliferation and invasion

OBJECTIVE

This study aims to investigate the effect of curcumin concentrations on the proliferation and invasion of endometrial cancer cells.

MATERIALS AND METHODS

Endometrial cancer cells were cultured with 0, 15, and 30 μmol/l curcumin, and were divided into control group, low concentration group, and high concentration group. The treatment included the silencing and overexpression of MMP-2. The expression of MMP-2 and E-cadherin were detected by Western blot and the expression level changes were recorded after MMP-2 was silenced and overexpressed. Pearson's analysis was used to determine the relationship of curcumin concentration between MMP-2 mRNA. CCK-8 was used to detect the optical density of cancer cells in three groups. Transwell invasion assay was performed to analyze the invasion inhibition rate in the three groups.

RESULTS

Western blot and qPCR results: MMP-2 expression levels were lower and E-cadherin was higher in high concentration group than that in the low concentration group (p<0.01). MMP-2 protein and mRNA decreased after ShRNA and increased after overexpression (p<0.01). Pearson analysis revealed that the curcumin concentration was negatively correlated with the MMP-2 mRNA (r=-0.497, p=0.036). Cell optical density was lower with curcumin and the lowest was in high concentration group (p<0.01). After MMP-2 silencing, optical cell density decreased and this value increased after overexpression (p=0.000). Cell invasion results: Curcumin improves the rate of cell invasion (p<0.01). After silencing of MMP-2, cell invasion inhibition rate increased, while the invasion inhibition rate decreased after overexpression (p<0.01).

CONCLUSIONS

Curcumin can downregulate MMP-2, inhibit the proliferation and invasion of cancer cells.

Repair of a defect in the cervical trachea with thyroid-pericardium flap: A case report

RATIONALE

Primary end-to-end anastomosis is common in adult trachea resection. Nevertheless, considering that the utilization of grafts is still essential for restoring defect in long-segment tracheal resection surgery, long-segment tracheal resection and reconstruction still remain challenging. Herein we present a novel case in which we resected a large tracheal mass and reconstructed the long-segment defect through using a thyroid-pericardium flap, which has not been reported yet.

PATIENT CONCERNS

A 35-year old male patient was admitted due to 'Repeated dry cough for 2 years, shortness of breath after activities for 1 month'. Patient had no other obvious symptoms.

DIAGNOSES

CT revealed that a large neoplasm was located in the cervical trachea and the pedicle was in the tracheal membrane, with total length of approximately 6 cm. Positron emission tomography computed tomography demonstrated an abnormally elevated levels of glucose metabolism in the upper part of the posterior tracheal wall. Therefore, this lesion was primarily considered as a malignancy.

INTERVENTIONS

The patient was performed by a primary resection of long-segment tracheal mass followed by thyroid-pericardium composite tissue flap for reconstruction.

OUTCOME

The operation was successful, without hydrops or pneumatosis in the mediastinum. One week postoperatively, CT showed that there was no pneumomediastinum and mediastinal abscess. Three weeks postoperatively, fiber bronchoscope showed the flap with normal color and the unobstructed tracheal cavity. The patient healed without complication.

LESSONS

The thyroid-pericardium flap is a convenient, secure, and effective material for long-segment trachea mass resection and reconstruction.

Type I interferon and interferon-stimulated gene expression in oral epithelial cells

Oral epithelial cells (OEC) represent the first site of host interaction with viruses that infect the body through the oral route; however, their innate antiviral defense mechanisms yet to be defined. Previous studies have determined that OEC express pathogen-, damage-, or danger-associated molecular patterns (PAMPs or DAMPs), but their expression of key antiviral innate immune mediators, including type I interferons (type I IFN) and interferon-stimulated genes (ISGs) has not been studied extensively. We used the oral keratinocyte cell line, OKF6/TERT1, in the presence and absence of the viral mimics poly(I:C) and unmethylated CpG DNA, to define the expression of type I IFN and ISGs. We identified the basal expression of novel type I IFN genes IFNE and IFNK, while IFNB1 was induced by viral mimics, through the nuclear translocation of IRF3. Numerous ISGs were expressed at basal levels in OEC, with an apparent correlation between high expression and antiviral activity at the earlier stages of viral infection. Stimulation of OECs with poly(I:C) led to selective induction of ISGs, including MX1, BST2, PML, RSAD2, ISG15, and ZC3HAV1. Together, our results demonstrate that OECs exhibit a robust innate antiviral immune defense profile, which is primed to address a wide variety of pathogenic viruses that are transmitted orally.

Conversion therapy from N3 unresectable lung adenocarcinoma to radical surgery: a case report

Patients with N3 non-small cell lung cancer (NSCLC) have unresectable tumors. Although significant progress has been made in the past decades for such tumors, the average median survival time remains at 10 months. Equally dismal long-term survival rates were reported with the average 5-year-suvival rate at 9%. Here, we report on a case of a patient with locally advanced disease that was treated with conversion therapy using targeted anti-PD-1 immunotherapy with platinum-based chemotherapy. Following this therapeutic regimen, the tumor showed a reversion to pN0 from pN3 and the patient showed a progression free survival time of at least 33 months.

Complement alternative pathway activation associated with pulmonary hypertension in lupus nephritis patients

Pulmonary hypertension occurs in systemic lupus erythematosus (SLE) for several reasons, such as vasculopathy. Previous studies have indicated that the excessive activation of the complement alternative pathway might be involved in the pathogenesis of lupus nephritis, especially in the absence of factor H or its functional impairment. However, the clinical and pathological significance of the alternative complement activation in lupus nephritis patients with pulmonary hypertension remains elusive. The data on patients with pulmonary hypertension and non-pulmonary hypertension lupus nephritis were retrospectively analyzed in our centre. Major plasma levels of complement components were evaluated. The depositions of Bb, C3d and C5b-9 in the lung specimens of pulmonary hypertension combined with SLE patients were detected by immunofluorescence staining. Among 352 lupus nephritis cases, 24 were diagnosed with pulmonary hypertension and 328 with non-pulmonary hypertension. Higher levels of Bb and lower levels of factor H were detected in the pulmonary hypertension group in comparison with the negative group (P = 0.049, P = 0.024, respectively). Pulmonary hypertension was a risk factor for renal outcome as deduced by the log-rank and Cox test for survival analysis. C3d, C5b-9 and Bb were found to be positive in lung specimens of lupus nephritis patients with pulmonary hypertension. We concluded that activation of the complement alternative pathway may be involved in the pathogenesis of pulmonary hypertension in lupus nephritis.

LSH interacts with and stabilizes GINS4 transcript that promotes tumourigenesis in non-small cell lung cancer

Background

Elucidating mechanisms in oncogenes and epigenetic modifiers are needed to gain insights into the etiology and treatment of cancer, regulation of oncogene by chromatin modifiers at post-transcriptional level is critical and remains unclear. We have investigated the role of GINS4 in NSCLC.

Methods

The expression of chromatin modifier lymphoid-specific helicase (LSH) and GINS4 was assessed in tumor and normal tissue from 79 patients with NSCLC with clinical characteristics. HBE, A549, H358, and H522, PC9, 95C and 95D were cultured after overexpression or silencing of GIAT4RA. Cell proliferation assay, cell migration and invasion assays, plate colony formation assay, immunofluorescence assay, Operetta® high-content screening and analysis, Western blot analysis and Co-Immunoprecipitation (Co-IP) assay, RNA immunoprecipitation assay and tumor growth assay was used to address the potential interplay of between GINS4 and LSH, and the functional of GINS4.

Results

GINS4 is highly expressed in lung cancer cells and tissues, and GINS4 expression is not association with clinical risk factors, but linked with clinical stage and lymphatic metastasis status. Higher expression of GINS4 poorly linked with overall survival in lung adenocarcinomas. Furthermore, GINS4 promoted many characteristics of tumorigenesis including cell growth, clonal formation, migration and invasion, epithelial–mesenchymal transition, tumor sphere and tumor growth in vivo. Interestingly, our results demonstrated that LSH increases GINS4 expression through binding to 3’UTR region of GINS4 and stabilizing its mRNA levels. Finally, LSH overexpression rescues GINS4 knockdown-induced features.

Conclusions

GINS4 facilitates lung cancer progression by promoting key characteristics of tumor potential, and LSH epigenetically interacts with and stabilizes GINS4 transcripts.

Electronic supplementary material

The online version of this article (10.1186/s13046-019-1276-y) contains supplementary material, which is available to authorized users.

Ultrasensitive DNA hypermethylation detection using plasma for early detection of NSCLC: A validation study in Chinese patients

8522

Background: Our previous study revealed that high diagnostic accuracy for early stage lung cancer could be obtained in plasma samples with ultrasensitive DNA hypermethylation detection methods called MOB-qMSP. In this study, we sought to validate and also improve the diagnostic accuracy of lung cancer screening with modified MOB-qMSP approach in Chinese patients. We also develop a lung cancer specific gene panel for Chinese patients. Methods: We included patients with small lung nodules (less than 3cm in diameter) on CT scan screening and conducted a case-control study. Cases (n=138) had pathological confirmation of Non-Small Cell Lung Cancer (NSCLC) lesions staged IA or IB. Controls (n=65) had pathological confirmation of non-cancerous lesions. Plasma samples were obtained pre-operatively. Promoter methylation of eight lung cancer-specific genes (CDO1, TAC1, SOX17, HOXA7, HOXA9, GATA4, GATA5 and PAX5B) was detected using nanoparticle-based DNA extraction (MOB) followed by qMSP. Results: DNA methylation was detected in plasma more frequently in cases compared to controls (p<0.001) for 5 out of 8 genes. The sensitivity and specificity for lung cancer diagnosis using the best individual gene was 64-85% and 55-79% respectively. A three-gene combination of the best individual genes has sensitivity and specificity of 92% and 78%. Area under the Receiver Operating Curve (AUC) for this panel was 0.90, 95% CI (0.86-0.96). Cross validation combining gene methylation with clinical information correctly predicted lung cancer in 86% of subjects using plasma detection. Furthermore, we analyzed the sensitivity and specificity of the same three-gene combination in cases subgroups regarding the tumor size and the results are as follow: in subgroup with tumor size of 2-3cm, the sensitivity and specificity were 94% and 87%, and the AUC was 0.96, 95% CI (0.91-0.99); in subgroup with tumor size of 1-2 cm, the sensitivity and specificity were 92% and 80%, and the AUC was 0.90, 95% CI (0.84-0.96); in subgroup with tumor size less than 1cm, the sensitivity and specificity decreased to 66% and 87%, and the AUC was 0.77, 95% CI (0.64-0.88). Conclusions: This study validates our previous study but in Chinese patients that it is possible to obtain high diagnostic accuracy for early stage NSCLC using a panel of methylated promoter genes in plasma samples with ultrasensitive MOB-qMSP, especially in patients with tumor of larger size. These epigenetic biomarkers could potentially be used to identify patients with high risk of lung cancer development.

Genetic profiling of synchronous multiple primary lung carcinomas presenting as ground-glass opacities

e20034

Background: An increased incidence of synchronous multifocal pulmonary ground-glass opacities (GGOs) has been found in recent decades as a result of the advances in lung cancer screening techniques. However, little was known about the molecular mechanisms of their carcinogenesis, which may have important diagnostic, prognostic and therapeutic implications. Methods: 10 patients (pts) with clinically designated synchronous multiple primary lung cancers (sMPLC) who underwent surgical resection at our hospital were included in this study (Table). The imaging findings of all lesions were GGOs. Mutation profiles were analyzed using hybridization capture based next-generation sequencing (NGS), enabling the simultaneous detection of mutations in 1021 cancer-associated genes. Tumor mutation burden (TMB) was calculated as the number of non-synonymous SNVs and Indels per Mb in the coding region. Results: The genetic profiles of 21 tumor lesions were analyzed. No common mutations were detected between different tumors from 70% of pts (7/10). These pts had different actionable mutations, which indicate disparate even contradictory therapeutic implications. 20% of pts (2/10) shared one driver mutation of EGFR or KRAS. Only one patient had a highly consistent mutation profiles between different GGOs. Two nodules of the patient shared 55% (6/11) of mutations, including EGFR L858R, supporting the possibility of aerogenic metastasis. The median TMB difference between nodules from one individual was 2 muts/Mb. The highest TMB difference was 16 muts/Mb, which might influence the decision of immunotherapy. Conclusions: NGS reveals independent clonality of multiple GGO lesions in most sMPLC pts, which may have contradictory therapeutic implications. In addition, it could be an auxiliary tool to differentiate intrapulmonary metastasis from multiple primary lung cancers. Therefore, broader molecular profiling is strongly advised for sMPLC pts. [Table: see text]

Clinical implications of monitoring circulating tumor DNA in early- and late-stage non-small cell lung cancer patients

e20607

Background: Non-small cell lung cancer (NSCLC) accounts for about 85% of all lung cancers, and the most common types of NSCLC are squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. The development of noninvasive methods to monitor circulating tumor DNA (ctDNA) continues to be a major challenge in NSCLC. Methods: We investigated if detection of ctDNA after resection of NSCLC identifies the patients with risk of relapse, and furthermore, informs about response to management.In this cohort study, high-throughput 168 target-gene capture technology and high-sensitivity circulating single molecule amplification and re-sequencing technology (cSMART) were used to detect the somatic mutations in tissues and plasma of patients with NSCLC, respectively. Moreover, ctDNA somatic mutations were used to monitor changes in minimal residual disease during a follow-up period. Results: A total of 169 patients with lung squamous cell carcinoma and adenocarcinoma were included. Detectable levels of ctDNA were present in 60.7% of patients with stage I and 68.8% of patients with late-stage. In patients not treated with adjuvant chemotherapy, ctDNA was detected preoperatively in 46 of 81 (56.8%) patients, 14 (30.4%) of whom had recurred at follow-up of 44 months; recurrence occurred in only 2 (5.7 %) of 35 patients with negative ctDNA. Serial ctDNA status changed from positive to negative during the initial phase of post operation in four patients. Then, ctDNA became positive again after 2 weeks to 3 months, all the four patients with relapse during the follow-up of 44 months. Conclusions: Detection of ctDNA supplies evidence of residual disease and identifies patients at risk of relapse. These observations have implications for the intervention of lung squamous cell carcinoma and adenocarcinoma patients.