Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Current insights into the clinico-pathologic characteristics of lung cancer in women

INTRODUCTION

Lung cancer is responsible for premature cancer deaths in women and is the first cause of cancer deaths in women in many countries The problem of lung cancer in women seems to be underestimated in many aspects, including low participation in clinical trials and screening tests.

AREAS COVERED

Current research progress has contributed to a better understanding of the issue and makes it possible to describe the problem in a new light. In our paper the problem of lung cancer in women was discussed in a broad aspect, taking into account women's health, the harmful effects of smoking and the current diagnostic and treatment process. The results of treatment also differ in relation to sex. All these aspects of the diversity of women's lung cancer was presented on the basis of newest and most comprehensive literature.

EXPERT OPINION

Lung cancer in women is and will remain an important health problem worldwide, which is justified by epidemiological data, basic research and treatment results.

FAPI PET in the Management of Lung Tumors

Fibroblast activation protein (FAP), selectively expressed on activated fibroblasts in proliferating tissues, is emerging as a promising target in oncology. In lung cancer, the leading cause of cancer-related deaths worldwide, [18F]FDG PET/CT has set the bar high and earned widespread recognition in clinical guidelines for its essential role in staging and follow-up. Yet, FAP-targeted imaging agents like FAPI PET/CT have demonstrated significant potential due to their high tumor specificity, rapid tracer uptake, and low background activity. This review focuses on the role of FAPI PET/CT in lung cancer, highlighting its applications in staging, biomarker evaluation, and clinical management. FAP expression correlates with cancer associated fibroblast-driven tumorigenesis in lung cancer, showing higher expression in nonsmall cell lung cancer (NSCLC) than in small cell lung cancer (SCLC) subtypes. Studies reveal that FAPI PET/CT provides comparable or superior detection rates for primary tumors and metastases compared to [18F]FDG PET/CT, particularly in brain, pleural, and bone lesions. It also enhances accuracy in lymph node staging, influencing disease management by enabling surgical resection in cases misclassified by [18F]FDG PET/CT. Despite these advantages, several challenges remain, such as differentiating benign from malignant lesions, assessing FAPI's prognostic implications or its role in treatment response monitoring. Future directions include exploring FAPI-based theranostics, standardizing radiopharmaceuticals, and conducting well-designed, adequately powered prospective trials. FAPI PET/CT represents a transformative diagnostic tool, complementing or potentially surpassing [18F]FDG PET/CT in precision lung cancer care.

Diagnostic Accuracy of Ultrasound Guidance in Transthoracic Needle Biopsy: A Systematic Review and Meta-Analysis

PURPOSE

To perform a systematic review and meta-analysis of relevant studies to assess the diagnostic accuracy and safety outcomes of ultrasound (US)-guided transthoracic needle biopsy (TTNB) for peripheral lung and pleural lesions.

MATERIALS AND METHODS

A search was performed through Medline, Embase, Web of Science, and Cochrane Central from inception up to September 23, 2022 for diagnostic accuracy studies reporting US-guided TTNB (Prospero registration: CRD42021225168). The primary outcome was diagnostic accuracy, which was assessed by sensitivity, specificity, likelihood ratios (LR), and diagnostic odds ratio. Sensitivity and subgroup analyses were performed to evaluate inter-study heterogeneity. The secondary outcome was the frequency of complications. Random-effects models were used for the analyses. The risk of bias and the applicability of the included studies were assessed using the QUADAS-2 tool. Publication bias was assessed by testing the association between the natural logarithm of the diagnostic odds ratio and the effective sample size.

RESULTS

Of the 7841 citations identified, 83 independent cohorts (11,767 patients) were included in the analysis. The pooled sensitivity of US-TTNB was 88% (95% CI: 86%-91%, 80 studies). Pooled specificity was 100% (95% CI: 99%-100%, 72 studies), resulting in positive LR, negative LR, and diagnostic odds ratio of 946 (-743 to 2635), 0.12 (0.09 to 0.14), and 8141 (1344 to 49,321), respectively. Complications occurred in 4% (95% CI: 3%-5%) of the procedures, with pneumothorax being the most frequent (3%; 95% CI: 2%-3%, 72 studies) and resulting in chest tube placement in 0.4% (95% CI: 0.2%-0.7%, 64 studies) of the procedures.

CONCLUSIONS

US-TTNB is an effective and safe procedure for pleural lesions and peripheral lung lesions.

Evaluation of nutritional parameters that may be associated with survival in patients with locally advanced non-small cell lung carcinoma receiving definitive concurrent chemoradiotherapy: retrospective study conducted in a tertiary pulmonary hospital

Sarcopenia, defined as skeletal muscle loss, is thought to be a hallmark of cancer cachexia. It has an impact on mortality, especially in cancer patients. There are also opposing views regarding the relationship between definitive concurrent chemoradiotherapy (CRT) and sarcopenia in locally advanced lung cancer. Our aim was to investigate the prognostic effect of sarcopenia in our patients with locally advanced stage III non-small cell lung cancer (NSCLC) who received definitive concurrent CRT by using many markers, and to determine the overall survival (OS). The study was designed as a retrospective cohort. 54 patients with stage III NSCLC who received definitive concurrent CRT at the Radiation Oncology Unit of Health Sciences University Izmir Dr Suat Seren Chest Diseases and Surgery Training Hospital, between January 1, 2018 and December 31, 2019, were included in the study.92% of our patients were sarcopenic with international L3-skeletal muscle index (SMI) and Psoas muscle index (PMI) threshold values. The mean OS time was 32.4 months, and the 4-year survival rate was 38.9%. While the new threshold values specific to our patient group were 26.21 for SMI and 2.94 for PMI, SMI and PMI did not indicate OS with these values. Even with the new values, most proposed criteria for sarcopenia did not indicate OS. However, low BMI (≤21.30), low serum albumin (≤4.24 mg/dl) and low visceral fat tissue area (≤37) in univariate analysis, and low visceral fat tissue area (≤37) in multivariate analysis indicated OS. OS was poor in patients with low fat tissue area. In patients with stage III NSCLC who received definitive concurrent CRT, low visceral fat tissue area (≤37) indicated OS, rather than SMI, PMI and other sarcopenia indices.

Advancing real-world research in thoracic malignancies: learnings from the international I-O Optimise initiative

In recent years, the thoracic malignancies treatment landscape has become more complex with the emergence of novel targeted and immunotherapy-based treatments. Although beneficial to patients and physicians, this fast-paced therapeutic evolution has increased the complexity of clinical decision-making and amplified the importance of real-world evidence to support data from randomized controlled trials. The international I-O Optimise initiative was established in 2016 to provide real-world insights into the thoracic malignancies treatment landscape, and has since collaborated with 14 data sources across Europe and Canada, allowing access to data from ~ 500,000 patients with non-small-cell lung cancer, small-cell lung cancer, and malignant pleural mesothelioma. This article reviews pertinent I-O Optimise research, with discussion of the methodological/data-related learnings and expectations for future insights.

Comparison of neoadjuvant chemoimmunotherapy with planned surgery and concurrent chemoradiation followed by immunotherapy for potentially resectable stage III non-small-cell lung cancer: a retrospective study

OBJECTIVE

Despite the promising potential of neoadjuvant chemoimmunotherapy for non-small cell lung cancer (NSCLC), there is limited consensus on the optimal treatment strategy for potentially resectable NSCLC. This study aimed to evaluate the efficacy and safety of neoadjuvant chemoimmunotherapy (neoCT/IO) with planned surgery versus definitive concurrent chemoradiation followed by immunotherapy (cCRT + IO) in potentially resectable stage III NSCLC.

METHODS

This retrospective study analyzed data from patients with potentially resectable stage III NSCLC who underwent neoCT/IO with planned surgery or cCRT + IO between March 2020 and June 2023. Propensity score matching (PSM) was used to balance heterogeneity between groups. Efficacy outcomes, safety profiles and patterns of disease recurrence were assessed.

RESULTS

A total of 308 eligible patients were included in this study, of whom 195 (63.3%) underwent neoCT/IO and 113 (36.7%) received cCRT + IO. The neoCT/IO group consisted of patients who underwent neoCT/IO + Surgery and neoCT/IO + Radiotherapy. After 1:1 PSM, each group consisted of 105 patients. The median progression-free survival (PFS) was 25.9 months in the cCRT + IO group and not reached (NR) in the neoCT/IO group (hazard ratio: 2.91, 95% confidence interval: 1.77-4.78; p < 0.001). Median overall survival (OS) was NR in either group, with 3-year OS rates of 87.5% in the neoCT/IO group and 75.0% in the cCRT + IO group (p = 0.22). The incidence of grade 3/4 treatment-related adverse events was similar in both groups, except for a higher incidence of grade 3/4 hematological toxicity in the cCRT + IO group.

CONCLUSIONS

For patients with potentially resectable stage III NSCLC, neoCT/IO appears to be a safe approach and may offer better survival outcomes compared with cCRT + IO. Prospective randomized trials are needed to further validate these findings.

Clinical significance of 4 L lymphadenectomy in solid dominant clinical stage I non-small cell lung cancer in the left upper lobe

OBJECTIVES

The significance of station 4 L lymph node dissection (LND) for early-stage non-small cell lung cancer (NSCLC) is unknown.

METHODS

We evaluated 342 patients who underwent complete anatomical resection and mediastinal LND for radiologically solid dominant clinical (c)-Stage I left upper lobe NSCLC between 2008 and 2022. Solid dominant was defined as a consolidation tumor ratio >0.5, on thin-section computed tomography. After matching, postoperative complications and outcomes between the 4 L LND and non-4 L LND groups were compared. Predictors of 4 L metastasis was also identified using logistic regression analysis.

RESULTS

4LND was performed in 215 patients (63%), and 4 L metastasis was detected in 11 patients. Matching yielded 108 pairs. Recurrent nerve paralysis was more frequent in the 4LND group (P = 0.02) with no significant differences in the overall survival (OS) (5y OS: 85.2% vs. 86.3%, P = 0.66) and recurrence-free survival (RFS) (5y RFS: 78.4% vs. 78.5%, P = 0.51) between the 4 L LND and non-4 L LND groups. Logistic regression analysis determined solid component size >20 mm (P = 0.02) and pleural indentation (P = 0.02) on computed tomography findings as clinical risk factors for 4 L metastasis. The predictive criteria for 4 L metastasis were defined as solid component size ≤20 mm without pleural indentation (specificity: 100%, positive predictive value: 100%).

CONCLUSIONS

4 L LND had a higher frequency of recurrent nerve palsy, although no survival improvement was observed in solid dominant c-Stage I left upper NSCLC. 4 L LND may be omitted for solid component size ≤20 mm without pleural indentation.

The Impact of Preoperative Invasive Nodal Staging on Unexpected Mediastinal Upstaging in Early-Stage Non-small Cell Lung Cancer

INTRODUCTION

Preoperative invasive nodal staging is standard of care for early-stage non-small cell lung cancer (NSCLC). Complications and delays in care are not negligible and diagnostic accuracy varies. In our system, invasive nodal staging is performed for clear radiographic indications (node > 1.0 cm short axis or standardized uptake value > 3.0, tumor > 4.0 cm). This study assessed whether unexpected mediastinal upstaging was less common in patients receiving preoperative invasive nodal staging.

METHODS

This retrospective study evaluated nodal upstaging, defined as pathological N2 or IIIA+ disease, based on receipt or non-receipt of invasive nodal staging. Clinical stage I-II NSCLC patients who underwent resection (2009-2019) were identified from our cancer registry. Stage and preoperative nodal staging information were confirmed through chart review. Associations between patient characteristics, invasive nodal staging receipt, and clinical to pathological stage changes were analyzed.

RESULTS

Among 2576 patients, 18.7% (n = 481) underwent invasive nodal staging. After resection, 6.2% of all patients had nodal upstaging and 24.9% had TNM upstaging. Only 0.3% (n = 9) were upstaged to N2 and 0.5% (n = 13) were upstaged to IIIA+. Lack of preoperative nodal sampling was not associated with N2 or IIIA+ upstaging. Findings were consistent in subanalyses of patients with surgical specimens meeting Commission on Cancer nodal sampling criteria and with clinical IB+ disease.

CONCLUSIONS

Although most patients did not undergo invasive nodal staging, <1% had unexpected N2 on surgical pathology. There was no association between lack of preoperative invasive nodal sampling and N2 nodal upstaging. Preoperative invasive nodal staging did not increase pathologic N2 nodal upstaging in early-stage NSCLC patients in our integrated health system.

18F-FDG PET/CT in the Preoperative Diagnostic and Staging of Lung Cancer and as a Predictor of Lymph Node Involvement

Background/Objectives: The aim of this study was to evaluate the efficacy and accuracy of PET imaging and performance in defining the preoperative TNM classification, especially the intrathoracic lymph node staging, of patients with lung cancer. Methods: A retrospective, single-institution study of consecutive patients with surgical therapy of lung cancer that were undergoing preoperative PET/CT scanning at the same center was conducted. A total of 104 patients were included. All patients underwent surgical evaluation with mediastinal and hilar lymph node sampling. Five patients with preoperative suspicion of N3 nodal status who were only tested for N2 were excluded from the observations and analyses of nodal status. Results: PET/CT staged the nodal status correctly in 85 out of 99 patients (85.9%); overstaging occurred in 7 patients (7.1%) and understaging in 7 patients (7.1%). The overall prevalence of lymph node metastases was 42.3%. When preoperative T classification was compared with postoperative histopathological T classification, 75% patients were correctly staged, 13.5% were overstaged, and 11.5% were understaged by PET/CT. In univariate analysis, lymph node involvement was significantly associated (p < 0.05) with the following primary tumor characteristics: increasing diameter (>35 mm), a maximum standardized uptake value > 9.5, and higher grading. The tumor diameter and the degree of differentiation were found to be factors influencing the SUVmax of the primary tumor as well. Conclusions: Our data show that integrated PET/CT provides high accuracy in the intrathoracic nodal staging and tumor expansion of lung cancer patients and emphasizes the continued need for surgical staging.

NON-SMALL-CELL LUNG CANCER: Real-World Population-Based Cohorts' Study

INTRODUCTION

This retrospective follow-up study evaluates patient outcomes and treatment costs in two cohorts of incident NSCLC patients recorded in the population-based cancer registry of the Veneto Region in 2017 and 2019.

METHODS

This study examines two cohorts of incident NSCLC patients recorded by the Regional Veneto cancer registry in 2017 (493 patients) and 2019 (557 patients). Cancer patients were followed for three years after diagnosis to assess the disease's outcomes and analyze the overall treatment-related costs. Overall survival and cancer-specific mortality were evaluated using Cox regression models. The log-transformed overall treatment costs for the 3 years following diagnosis were analyzed using linear regression.

RESULTS

The overall mortality risk significantly lowered in the 2019 cohort (HR 0.84; 95% CI 0.72-0.98, p = 0.024). Stage III patients were not associated with a significant overall survival rate (HR 0.71; 95% CI 0.50-1.02; p = 0.065) but were associated with significantly higher cancer-specific survival (HR 0.61; 95% CI 0.41-0.91; p = 0.015). Overall, the 2019 cohort showed significantly higher costs (coefficient 0.16; 95% CI 0.02-0.30, p = 0.025), particularly as a result of increases in the costs of drug administration, outpatient services, and medical devices. However, during the same 3-year follow-up period, this cohort featured lower average costs for hospice care and hospitalizations.

CONCLUSIONS

These results revealed notable differences in clinical outcomes and patient-related costs in incident NSCLCs in 2017 and 2019. The study highlights the importance of monitoring clinical outcomes and management costs in real-world oncology practice.

Is CK7 a Prognostic Marker in Pulmonary LCNEC? Evidence from a Limited Cohort Study

Objectives: While the treatment of non-small-cell lung carcinoma has improved rapidly, the treatment of pulmonary large-cell neuroendocrine carcinoma (LCNEC) remains underdeveloped. The use of immunohistochemistry allows for accurate risk stratification. With our study, we investigated the outcome of patients with pulmonary LCNEC and analyzed whether CK7 correlates with long-term survival. Methods: We retrospectively collected the monocentric data of patients which underwent anatomical resection for lung cancer between January 2012 and December 2020. Patients that did not show pulmonary LCNEC or adenocarcinoma, had a positive resection margin, or underwent neoadjuvant therapy were excluded. The long-term survival rate of the LCNEC and adenocarcinoma groups were compared before and after propensity score matching. Furthermore, we performed survival analyses for a subgroup of LCNEC distinguished by CK7 expression, followed by Cox regression analyses. Results: A total of 466 patients were integrated for further analysis. The mean age was 65.3 ± 9.6 years. There were no significant differences between both groups regarding age, gender, or comorbidities. In terms of the UICC stage, the groups were equally distributed. Mean survival in the LCNEC group was significantly worse than in the adenocarcinoma group (LCENC: 36.4 ± 7.5 months; adenocarcinoma: 80.7 ± 8.1 months; p-value = 0.001). The mean survival rate was 19.23 ± 4.8 months in the CK7 expression group and 57.01 ± 8.5 months in the group without expression, which reached statistical significance (p-value = 0.019). Conclusions: Our study suggests that pulmonary LCNEC has a significantly worse prognosis than pulmonary adenocarcinoma. CK7 expression seems to be correlated with a worse outcome for the long-term survival rate of patients suffering from highly malignant pulmonary LCNEC.

NSCLC: Current Evidence on Its Pathogenesis, Integrated Treatment, and Future Perspectives

Non-small cell lung carcinoma (NSCLC) comprises the majority of lung cancer cases, characterized by a complex interplay of genetic alterations, environmental factors, and molecular pathways contributing to its pathogenesis. This article highlights the multifaceted pathogenesis of NSCLC and discusses screening and integrated strategies for current treatment options. NSCLC is an evolving field with various aspects including the underlying molecular alterations, oncogenic driver mutations, and immune microenvironment interactions that influence tumor progression and response to therapy. Surgical treatment remains the most applicable curative option, especially in the early stages of the disease, adjuvant chemotherapy may add benefits to previously resected patients. Combined Radio-chemotherapy can also be used for palliative purposes. There are various future perspectives and advancing horizons in NSCLC management, encompassing novel therapeutic modalities and their applications, such as CAR-T cell therapy, antibody-drug conjugates, and gene therapies. On the other hand, it's crucial to highlight the efficacy of innovative modalities of Immunotherapy and immune checkpoint inhibitors that are nowadays widely used in treatment of NSCLC. Moreover, the latest advancements in molecular profiling techniques and the development of targeted therapies designed for specific molecular alterations in NSCLC play a significant role in its treatment. In conclusion, personalized approaches are a cornerstone of successful treatment, and they are based on a patient's unique molecular profile, tumor characteristics, and host factors. Entitling the concept of individualized treatment strategies requires proper patient selection, taking into consideration mechanisms of resistance, and investigating potential combination therapies, to achieve the optimal impact on long-term survival.

Postoperative radiotherapy improves survival in completely resected non-small cell lung cancer with pathologic N2 stage IIIA and positive lymph node count greater than one: a SEER-based retrospective cohort study

Objective

Non-small cell lung cancer (NSCLC) constitutes approximately 85% of lung cancer cases, with 20%-30% of patients diagnosed at stage III. While multimodal therapy is the standard for treating locally advanced NSCLC, the role of PORT remains controversial. This study seeks to evaluate the effect of postoperative radiotherapy (PORT) on overall survival (OS) and cancer-specific survival (CSS) in patients with resected pathologic N2 (pN2) stage IIIA NSCLC.

Methods

Data from the Surveillance, Epidemiology, and End Results Program (SEER) 17 registry (2010-2019) were analyzed. The cohort included 1,471 patients aged 65 years or older, diagnosed with stage IIIA pN2 NSCLC, who had undergone lobectomy or total pneumonectomy. Patients who had received neoadjuvant chemotherapy or radiotherapy were excluded. Univariate and multivariate analyses were conducted to assess the association of PORT with OS and CSS. Kaplan-Meier survival curves were employed to estimate survival outcomes, while the COX proportional hazards model was utilized for comparative analysis. PLN counts were stratified into two categories: ≤1 and >1.

Results

Among the 1,471 patients included in the study, 613 (41.67%) received PORT, while 858 (58.33%) did not. PORT was associated with a significantly higher 1- and 3-year OS (89.96% and 68.49%, respectively) compared to the non-PORT group (87.44% and 61.88%, respectively, P = 0.03). However, no significant difference in CSS was observed between the groups (P = 0.15). Among patients with PLN counts >1, PORT significantly improved OS (HR = 1.32, 95% CI = 1.04-1.68, P = 0.0016) and CSS (HR = 1.32, 95% CI = 0.99-1.70, P = 0.026), whereas no significant differences were seen in patients with PLN counts ≤1.

Conclusions

This study underscores the potential of PORT in enhancing OS in patients with resectable pN2 stage IIIA NSCLC, particularly in those with PLN counts exceeding one. These findings suggest that PORT may offer improved outcomes in patients with extensive lymph node involvement, emphasizing the need for further prospective studies to validate and expand upon these observations.

Enhanced radiotherapy susceptibility in NSCLC through palbociclib-mediated PP5 inhibition

Radiotherapy remains a cornerstone in the treatment of non-small cell lung cancer (NSCLC), yet radioresistance often limits its efficacy. Identifying molecular targets that enhance radiosensitivity is crucial to offering both curative and palliative benefits for patients with NSCLC. Utilizing bioinformatics analysis, our study revealed significantly higher expression of PP5 in NSCLC tissues compared to normal tissues. Kaplan-Meier survival analysis also showed that high PP5 expression correlates with poorer overall survival, particularly in patients undergoing radiotherapy, suggesting a role for PP5 in radioresistance. We further demonstrated that PP5 is a critical target of palbociclib, distinct from CDK4/6, influencing radiosensitivity in NSCLC. Palbociclib enhanced radiotherapy susceptibility by inducing sustained DNA damage and AMPK activation. The subsequent cellular event is apoptosis rather than autophagy. Furthermore, the enhanced efficacy of combination therapy was counteracted by an AMPK inhibitor and PP5 activator, underscoring the importance of these pathways in mediating the response. Our findings provide compelling evidence that targeting PP5 can significantly enhance the therapeutic outcomes of radiotherapy in NSCLC. This research offers valuable insights into new combination therapy strategies, highlighting the potential of PP5 as a novel therapeutic target to overcome radioresistance.

The association of ABC proteins with multidrug resistance in cancer

Multidrug resistance (MDR) poses one of the primary challenges for cancer treatment, especially in cases of metastatic disease. Various mechanisms contribute to MDR, including the overexpression of ATP-binding cassette (ABC) proteins. In this context, we reviewed the literature to establish a correlation between the overexpression of ABC proteins and MDR in cancer, considering both in vitro and clinical studies. Initially, we presented an overview of the seven subfamilies of ABC proteins, along with the subcellular localization of each protein. Subsequently, we identified a panel of 20 ABC proteins (ABCA1-3, ABCA7, ABCB1-2, ABCB4-6, ABCC1-5, ABCC10-11, ABCE1, ABCF2, ABCG1, and ABCG2) associated with MDR. We also emphasize the significance of drug sequestration by certain ABC proteins into intracellular compartments. Among the anticancer drugs linked to MDR, 29 were definitively identified as substrates for at least one of the three most crucial ABC transporters: ABCB1, ABCC1, and ABCG2. We further discussed that the most commonly used drugs in standard regimens for mainly breast cancer, lung cancer, and acute lymphoblastic leukemia could be subject to MDR mediated by ABC transporters. Collectively, these insights will aid in conducting new studies aimed at a deeper understanding of the clinical MDR mediated by ABC proteins and in designing more effective pharmacological treatments to enhance the objective response rate in cancer patients.

Long-term survival after sleeve lobectomy versus pneumonectomy for non-small cell lung cancer

BACKGROUND

To compare short-term mortality and long-term overall survival between sleeve lobectomy and pneumonectomy for centrally located non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed patients who had been radically resected for NSCLC by sleeve lobectomy with or without pulmonary arterioplasty at our institution between 2009 and 2023. We then propensity score-matched the patients with pneumonectomy counterparts from a national registry and compared their 30- and 90-day mortality and long-term overall survival before and after matching. The mortality was compared using independence tests and the overall survival using Kaplan-Meier estimates and the log-rank test.

RESULTS

The study included 109 sleeve lobectomy patients and 315 pneumonectomy patients, of whom 60 patients from each group were matched. The 30- and 90-day mortality was similar between both the unmatched and matched groups (unmatched: 3.7 % vs 5.1 % and 5.5 % vs 9.2 %; matched: 5.0 % vs 6.7 % and 5.0 % vs 12 %. All p-values >0.05). The overall survival was longer in both the unmatched and matched sleeve lobectomy patients (unmatched: hazard ratio [HR] 0.52, 95 % confidence interval [CI] 0.37-0.73, p < 0.001; matched HR 0.55, 95 % CI 0.34-0.90, p = 0.018). The 5-year overall survival was 68 % and 49 % for the unmatched sleeve lobectomy and pneumonectomy patients, respectively, and 61 % and 42 % for the matched ones.

CONCLUSIONS

Sleeve lobectomy yields non-inferior short-term mortality and superior long-term overall survival compared with pneumonectomy and should be the resection of choice for centrally located NSCLC when feasible.

Real-world treatment patterns in patients with non-metastatic non-small cell lung cancer in Greece: the 'EVIDENCE' study

BACKGROUND

The treatment landscape of non-metastatic non-small cell lung cancer (NM-NSCLC) is rapidly evolving with recent approvals of immunotherapies and targeted therapies.

METHODS

This retrospective study included 202 adults diagnosed with NM-NSCLC between 1 January 2018 and 31 December 2020 primarily aiming to capture initial management strategies.

RESULTS

Most frequent treatment patterns among Stage I/II patients (N = 84) were surgery only (48.8%) and surgery with adjuvant chemotherapy (with/without RT; 42.9%). Among Stage III patients (N = 118), most frequent patterns were chemotherapy plus radiotherapy (44.9%) and chemotherapy only (18.6%); 58.6% of Stage IIIA patients underwent surgery (of these, 32.4% also received chemotherapy and radiotherapy).

CONCLUSION

Initial strategy was aligned with contemporary at that time European guidelines, setting a benchmark for understanding the future uptake of new therapies.

Autoplanning in the setting of stereotactic body radiation therapy for lung cancer

PURPOSE

Automatic planning (AP) has been compared to manual planning (MP) in lung stereotactic body radiation therapy (SBRT) to validate the former and to implement it in clinical practice.

METHODS

A new developing Guided Planning System (GPS) engine was used to reoptimize 20 lung SBRT plans with the RayStation™ treatment planning system (TPS). The original manual plans were optimized to deliver 60 Gy in 5 or 8 fractions to the target with constraints on organs at risk (OARs) based on an internal protocol. AP plans were compared to MP based on (i) planning target volume (PTV) and OARs dosimetric evaluation, (ii) clinician's blind plan comparison, (iii) Plan QA results, and (iv) plan quality metrics. Differences between continuous variables were explored through the Mann-Whitney test (p < 0.05).

RESULTS

Target and OARs dosimetry showed no significant difference, with the only exception of the spinal cord maximum dose that was significantly lower for AP in the 5 fractions scheme (MP: 8.93 Gy ± 3.94 Gy vs AP: 6.45 Gy ± 2.72 Gy, p = 0.034). In the blind comparison, AP was preferred in 45 % of cases while MP in 35 % of cases (no preference was expressed in 20 % of cases). A trend towards lower monitor units (MUs) was found for AP in the 5 fractions scheme (MP: 3383 ± 943 vs AP: 2662 ± 588, p = 0.059). No significant difference was found in any of the plan quality metrics.

CONCLUSIONS

AP plans were not inferior to MP plans; therefore, GPS is ready for clinical use in a pulmonary SBRT setting, reducing the planning workload and harmonizing the planning procedure.

Patients with Pulmonary Artery Reconstruction or Double Sleeve Resection Show Inferior Survival than Patients with Bronchial Sleeve Resection for Non-small Cell Lung Cancer

Sleeve lobectomy or resection with pulmonary artery reconstruction is a technique that allows for resection of locally advanced central lung carcinoma, preserving lung function, and is associated with lower morbidity and mortality than pneumonectomy. This survey aimed to assess the long-term survival comparing different types of sleeve lobectomy and identify risk factors affecting survival.All consecutive patients who underwent anatomical resection for primary non-small cell lung cancer with bronchial sleeve or pulmonary artery reconstruction in our department between September 2003 and September 2021 were included in this study. Cases with carinal sleeve pneumonectomy were excluded. Data were evaluated retrospectively.Bronchial sleeve resection was performed in 227 patients, double sleeve resection in 67 patients, and 45 cases underwent isolated lobectomy with pulmonary artery reconstruction. The mean follow-up was 33.5 months. The 5-year survival was 58.5% for patients after bronchial sleeve, 43.2% after double sleeve, and 36.8% after resection with vascular reconstruction. The difference in overall survival of these three groups was statistically significant (p = 0.012). However, the UICC stage was higher in cases with double sleeve resection or resection with vascular reconstruction (p = 0.016). Patients with lymph node metastases showed shorter overall survival (p = 0.033). The 5-year survival rate was 60.1% for patients with N0 and 47% for patients with N1 and N2 status. Induction therapy, vascular sleeve resection, and double sleeve resection were independent adverse predictors for overall survival in multivariate analysis.Sleeve lobectomy and resection with vascular reconstruction are safe procedures with good long-term survival. However, double sleeve resection and vascular sleeve resection were adverse predictors of survival, possibly due to a higher UICC stage in these patients.

Efficacy of innovative systemic treatments in combination with radiotherapy for bone metastases: a GEMO (the European Study Group of Bone Metastases) state of the art

The management of bone metastases (BoM) requires a multidisciplinary approach to prevent complications, necessitating updated knowledge in light of the rapid advancements in systemic treatments and surgical, interventional radiology or radiation techniques. This review aims to discuss efficacy of new systemic treatments on BoM, the benefits of radiotherapy adjunction, and the optimal methods for combining them. Preliminary evidence suggesting reduced efficacy of immune checkpoint inhibitors (ICI), and several multi-kinase inhibitors regarding BoM may encourage early use of radiotherapy (RT). Systemic treatment efficacy modulation by RT and ablative RT strategies are explored. Concerns for increased side effects for several kinase inhibitors and double ICI in combination with RT imply suspending those systemic treatments during RT. Various timing strategies to combine prostate hormone therapies and RT are developed. Emerging internal vectorized radiotherapy molecules necessitate developing new combination strategies with RT. Further prospective data collection and comparative trials should be encouraged.

A machine learning-based 18F-FDG PET/CT multi-modality fusion radiomics model to predict Mediastinal-Hilar lymph node metastasis in NSCLC: a multi-centre study

AIM

To develop and validate a machine learning (ML) model based on positron emission tomography/computed tomography (PET/CT) multi-modality fusion radiomics to improve the prediction efficiency of mediastinal-hilar lymph node metastasis (LNM).

MATERIALS AND METHODS

Eighty-eight non-small cell lung cancer (NSCLC) patients with 559 LNs from centre 1 were divided into training and internal validation cohorts (7:3 ratio), and 75 patients with 543 LNs from centre 2 were assigned as external validation cohorts. PET and CT images were fused by wavelet transform. Multi-modality fusion radiomics features from six images of lymph nodes were extracted. The multi-modality fusion radiomics (MFR), multi-modality fusion radiomics + metabolic parameters (MFRM), CT, PET and PET + CT models were developed based on the best one among the 11 ML algorithms. The receiver operating characteristic (ROC) curve and the Delong test were used to assess and compare the performance of the models.

RESULTS

The CatBoost algorithm was chosen, and the MFR, MFRM, CT, PET and PET + CT models were constructed. The MFR and MFRM models showed a high AUC for predicting LNM in centre 1 (AUC = 0.950 and 0.952) and centre 2 (AUC = 0.923 and 0.927), and there were significant differences in centre 2 (P=0.036). The diagnostic efficacy of MFR and MFRM models was significantly higher than CT, PET, PET + CT models and SUVmax≥3.5 (P<0.001). The MFRM prediction was statistically different from the MFR prediction in the hilar/interlobar zone.

CONCLUSION

Both the MFR and MFRM models based on multi-modality fusion radiomics showed great potential for non-invasively predicting mediastinal-hilar LNM in NSCLC.

Stereotactic Lung Re-Irradiation After a First Course of Stereotactic Radiotherapy with In-Field Relapse: A Valuable Option to Be Considered

BACKGROUND/OBJECTIVES

Stereotactic body radiation therapy (SBRT) has demonstrated high local control rates for inoperable early-stage lung cancers. However, 5-15% of patients experience local relapse within the irradiated volume after treatment, with limited curative salvage options. The aim of this review is to clarify the modalities and outcomes after a second course of SBRT in patients with local relapse after a previous lung SBRT.

METHODS

An exhaustive literature review was conducted to identify, analyse and summarise the results of 21 main studies.

RESULTS

Local repeat lung SBRT after a first course of SBRT showed a favourable local control at 1 and 2 years, ranging from 70 to 90% and 45 to 80%, respectively. Good overall survival rates were also observed at 1 and 2 years reaching up to 95% and 85%, respectively. Toxicity was rare but could be severe, with cases of Grade 4 and 5 toxicities (≈5%). An important dose relationship was observed between re-irradiation dose levels and local control, highlighting the importance of precise dosing. The cumulative doses impacting organs at risk were similarly associated with increased radiation-induced toxicity. Central lung lesions presented a higher risk for severe side effects compared to peripheral ones.

CONCLUSIONS

In conclusion, repeat lung SBRT after a first course of SBRT represents a feasible treatment option in cases of local recurrence. In order to limit severe toxicity, patients must be carefully selected, and particular attention should be given to cumulative doses to organs at risk, as well as tumour location. Thus, further investigations are still needed to refine the optimal parameters for SBRT lung re-irradiation.

Circulating Tumor DNA and [18F]FDG-PET for Early Response Assessment in Patients with Advanced NSCLC

Background/Objectives: Identifying treatment failure at earlier time points to could spare cancer patients from ineffective treatment and side effects. In this study, circulating tumor DNA (ctDNA) and [18F]FDG-PET/CT were investigated during the first cycle of anticancer therapy in patients with advanced non-small cell lung cancer (NSCLC) to explore their potential for early response evaluation. Methods: Patients with advanced NSCLC receiving first-line therapy with immune checkpoint inhibitors and/or chemotherapy were included. CtDNA and [18F]FDG-PET/CT assessments were conducted before treatment and at weeks 1 and 3 during the first cycle of therapy. ctDNA quantification was performed using a targeted next-generation sequencing (NGS) panel, and the least favorable change in any mutated allele frequency at a given time was used for analysis. [18F]FDG-PET/CT was quantified using sumSULpeak and metabolic tumor volume (MTV4.0). Early changes in ctDNA levels and [18F]FDG-PET parameters were compared with final treatment response, measured by RECIST after 12 weeks, as well as progression-free survival and overall survival. Results: Of the sixteen included patients, eight were non-responders. ctDNA mutations were detected in baseline blood samples in eight patients. Changes in ctDNA level, MTV4.0, and sumSULpeak at week 3 indicated response in 7 out of 8 patients, 13 out of 15 patients, and 9 out of 15 patients, respectively. At week 3, no false increases were seen with ctDNA and MTV4.0. Conclusions: These results suggest that early changes in ctDNA and [18F]FDG-PET/CT at 3 weeks of treatment could be used to early assess treatment response. Increased levels of ctDNA and MTV4.0 at week 3 were only observed in patients with treatment failure.

Brain Imaging in Patients with Non-Small Cell Lung Cancer-A Systematic Review

Background: Lung cancer frequently metastasizes to the brain, liver, and adrenal glands with a significant negative prognostic impact on overall survival and quality of life (QoL). To optimize treatment and prognosis, adequate staging with the detection of distant metastases is crucial. The incidence of brain metastases in potentially resectable early-stage non-small cell lung cancer (NSCLC) is as low as 3%; hence, the need for preoperative brain imaging has been a constant matter of debate, especially in stage II. In stages III and IV NSCLC, neuroimaging is an essential part of staging. Methods: A systematic literature search was performed. Publications from 1999 to 2024, focusing on preoperative brain imaging (BI) in the staging of stages I-IV NSCLC, were included. Data extraction included study population characteristics, the modality of BI, the incidence of brain metastases (BMs), and the main outcomes of the studies. The final included studies were selected according to the PRISMA criteria. In the second step, guidelines on BI in NSCLC staging of major importance were identified and compared. Results: A total of 530 articles were identified, of which 25 articles were selected. Four prospective studies and 21 retrospective investigations were included. Most of the investigations focused on BI in the early stages. The main imaging modality for BI was magnetic resonance imaging (MRI), followed by computed tomography (CT). Besides the identified 25 studies, the most important internationally applied guidelines on brain imaging in the staging of NSCLC were reviewed. While some guidelines agree on preoperative BI in NSCLC stage III (Union for International Cancer Control-UICC eighth edition) patients, other guidelines recommend earlier BI starting from clinical stage II. All mentioned guidelines homogenously recommend BI in patients with symptoms suggestive of brain pathologies. Conclusions: BI in NSCLC staging is recommended in neurologically symptomatic patients suggestive of brain metastases as well as NSCLC patients with stage III disease. Neuroimaging in stage IA patients, as well as in pure GGO (Ground-Glass Opacity) lesions, was considered unnecessary. The predominantly applied imaging modality was ce-MRI (contrast-enhanced magnetic resonance imaging). Inconsistency exists concerning BI in stage II. The identification of prognostic factors for developing BM in patients with early-stage NSCLC could help to clarify which subgroup might benefit from preoperative BI.

CT-based radiomics and cluster analysis for the prediction of local progression in stage I NSCLC patients treated with microwave ablation

To predict local progression after microwave ablation (MWA) in patients with stage I non-small cell lung cancer (NSCLC), we developed a CT-based radiomics model. Postoperative CT images were used. The intraclass correlation coefficients, two-sample t-test, least absolute shrinkage and selection operator (LASSO) regression, and Pearson correlation analysis were applied to select radiomics features and establish radiomics score. The Radiomics score was used to classify patients into new radiomics labels. The k-means cluster algorithm was employed to cluster patients into new cluster labels based on radiomics features. Logistic regression was used to build prediction models. The optimal model incorporating clinical risk factors, radiomics labels, and cluster labels achieved the best discrimination. This study proposes a radiomics model that accurately predicts local progression in patients with stage I NSCLC treated with MWA. This prediction tool may be helpful in determining MWA efficacy and individualized risk classification and treatment.

Characterization of the genomic landscape in liver oligometastatic NSCLC

OBJECTIVES

Emerging data have shown that local treatment could provide clinical benefit for non-small cell lung cancer (NSCLC) patients with oligometastasis. Liver metastases have the worst prognosis in advanced NSCLC, but the genomic characteristics of liver oligometastasis remain unclear. The aim of our study was to elucidate the molecular features of liver oligometastatic NSCLC.

METHODS

Paired liver metastatic tissue samples and peripheral blood from 32 liver oligometastatic NSCLC patients were concurrently collected for comprehensive genomic analysis using next-generation sequencing.

RESULTS

A total of 206 mutated genes in 32 patients were detected, with a median of 4 mutations per sample. The most frequent alterations (> 10%) in liver oligometastasis were TP53 (72%), EGFR (50%), RB1 (19%) and SMARCA4 (12%). The co-occurrence rate of TP53 and RB1 in our cohort was significantly higher than that in the TCGA-LUAD cohort. Age, APOBEC, homologous recombination deficiency (HRD) and deficient mismatch repair (dMMR) established the mutational signature of liver oligometastatic NSCLC. The median tumor mutation burden (TMB) was 4.8 mutations/Mb. A total of 78.12% patients harbored at least one potentially actionable molecular alteration that may guide further targeted therapy according to the OncoKB evidence.

CONCLUSIONS

Our study comprehensively delineated the genomic characteristics of liver oligometastatic NSCLC - such findings were helpful to better understand the distinct clinic-biological features of oligometastasis and optimize personalized treatment of this population.

Circulating Extracellular Vesicles as Promising Biomarkers for Precession Diagnostics: A Perspective on Lung Cancer

Extracellular vesicles (EVs) have emerged as promising biomarkers in liquid biopsy, owing to their ubiquitous presence in bodily fluids and their ability to carry disease-related cargo. Recognizing their significance in disease diagnosis and treatment, substantial efforts have been dedicated to developing efficient methods for EV isolation, detection, and analysis. EVs, heterogeneous membrane-encapsulated vesicles secreted by all cells, contain bioactive substances capable of modulating recipient cell biology upon internalization, including proteins, lipids, DNA, and various RNAs. Their prevalence across bodily fluids has positioned them as pivotal mediators in physiological and pathological processes, notably in cancer, where they hold potential as straightforward tumor biomarkers. This review offers a comprehensive examination of advanced nanotechnology-based techniques for detecting lung cancer through EV analysis. It begins by providing a brief overview of exosomes and their role in lung cancer progression. Furthermore, this review explores the evolving landscape of EV isolation and cargo analysis, highlighting the importance of characterizing specific biomolecular signatures within EVs for improved diagnostic accuracy in lung cancer patients. Innovative strategies for enhancing the sensitivity and specificity of EV isolation and detection, including the integration of microfluidic platforms and multiplexed biosensing technologies are summarized. The discussion then extends to key challenges associated with EV-based liquid biopsies, such as the standardization of isolation and detection protocols and the establishment of robust analytical platforms for clinical translation. This review highlights the transformative impact of EV-based liquid biopsy in lung cancer diagnosis, heralding a new era of personalized medicine and improved patient care.

Injecting hope: the potential of intratumoral immunotherapy for locally advanced and metastatic cancer

Despite enormous progress, advanced cancers are still one of the most serious medical problems in current society. Although various agents and therapeutic strategies with anticancer activity are known and used, they often fail to achieve satisfactory long-term patient outcomes and survival. Recently, immunotherapy has shown success in patients by harnessing important interactions between the immune system and cancer. However, many of these therapies lead to frequent side effects when administered systemically, prompting treatment modifications or discontinuation or, in severe cases, fatalities. New therapeutic approaches like intratumoral immunotherapy, characterized by reduced side effects, cost, and systemic toxicity, offer promising prospects for future applications in clinical oncology. In the context of locally advanced or metastatic cancer, combining diverse immunotherapeutic and other treatment strategies targeting multiple cancer hallmarks appears crucial. Such combination therapies hold promise for improving patient outcomes and survival and for promoting a sustained systemic response. This review aims to provide a current overview of immunotherapeutic approaches, specifically focusing on the intratumoral administration of drugs in patients with locally advanced and metastatic cancers. It also explores the integration of intratumoral administration with other modalities to maximize therapeutic response. Additionally, the review summarizes recent advances in intratumoral immunotherapy and discusses novel therapeutic approaches, outlining future directions in the field.

A New Deep Learning-Based Method for Automated Identification of Thoracic Lymph Node Stations in Endobronchial Ultrasound (EBUS): A Proof-of-Concept Study

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a cornerstone in minimally invasive thoracic lymph node sampling. In lung cancer staging, precise assessment of lymph node position is crucial for clinical decision-making. This study aimed to demonstrate a new deep learning method to classify thoracic lymph nodes based on their anatomical location using EBUS images. Bronchoscopists labeled lymph node stations in real-time according to the Mountain Dressler nomenclature. EBUS images were then used to train and test a deep neural network (DNN) model, with intraoperative labels as ground truth. In total, 28,134 EBUS images were acquired from 56 patients. The model achieved an overall classification accuracy of 59.5 ± 5.2%. The highest precision, sensitivity, and F1 score were observed in station 4L, 77.6 ± 13.1%, 77.6 ± 15.4%, and 77.6 ± 15.4%, respectively. The lowest precision, sensitivity, and F1 score were observed in station 10L. The average processing and prediction time for a sequence of ten images was 0.65 ± 0.04 s, demonstrating the feasibility of real-time applications. In conclusion, the new DNN-based model could be used to classify lymph node stations from EBUS images. The method performance was promising with a potential for clinical use.

Long-Term Oncological Outcomes Related to Lymphadenectomy in Clinical Stage I NSCLC: A Multicenter Retrospective Experience

BACKGROUND

Lymphadenectomy is considered a key part of the radical treatment of resectable lung cancer, although its appropriate extension in early stages is a debated topic due to the great heterogeneity of studies in the literature. This study aims to evaluate the impact of lymphadenectomy extent on survival and recurrence in the treatment of early-stage NSCLC patients undergoing lobectomy and lymph node dissection.

METHODS

Data from clinical stage I NSCLC patients undergoing lobectomy and hilar-mediastinal lymphadenectomy at two thoracic surgery centers from 2016 to 2019 were retrospectively evaluated. Information regarding perioperative outcomes and lymphadenectomy details was collected and analyzed, and their impact on OS, CSS, and DFS was assessed.

RESULTS

During the period under review, 323 patients with stage cI lung cancer underwent lobectomy with lymphadenectomy. Statistical analysis showed that the evaluated lymph nodal factors (mean number of lymph nodes removed and number and type of lymph node station explored) did not statistically significantly impact OS, CSS, and DFS at a median follow-up of 59 months (IQR 45-71).

CONCLUSIONS

The results of this study suggest that a less invasive procedure than systematic lymphadenectomy could be performed in early-stage cases with adequate preoperative staging.

Intratumor Heterogeneity Predicts Prognosis in Lepidic Predominant Lung Adenocarcinoma

OBJECTIVE

Among the different subtypes of invasive lung adenocarcinoma, lepidic predominant adenocarcinoma (LPA) has been recognized as the lowest-risk subtype with good prognosis. The aim of this study is to provide insight into the heterogeneity within LPA tumors and to better understand the influence of other sub-histologies on survival outcome.

METHODS

Overall, 75 consecutive patients with LPA in pathologic stage I (TNM 8th edition) who underwent resection between 2010 and 2022 were included into this retrospective, single center analysis. The proportions of different growth patterns were reported in 5% increments according to the WHO classification.

RESULTS

All tumors exhibited a predominantly lepidic growth pattern (median proportion 70%, IQR 60%-85%). The invasive component included acinar (n = 66, 88%), papillary (n = 41, 55%), micropapillary (n = 14, 19%), and solid growth patterns (n = 4, 5%), with most tumors exhibiting more than one invasive growth pattern. The presence of high-risk growth, that is, micropapillary and solid, was associated with higher T stage (r = 0.423, p = 0.0002). A classification of patients as lepidic/high-risk or lepidic/low-risk based on the presence of micropapillary and solid growth patterns resulted in a significantly worse disease-free survival (p = 0.0169, 5-year DFS: lepidic/high-risk 73% vs. lepidic/low-risk: 95%) for the lepidic/high-risk group, while the groups did not differ in age, gender, smoking status, or extent of resection.

CONCLUSION

Patients with stage I LPA exhibit considerable intratumor heterogeneity regarding growth patterns, which can be used for prognostic stratification. The occurrence of micropapillary and solid growth patterns in LPA is associated with poorer disease-free survival.

Low false-positive lymph nodes for 18 F-fibroblast activation protein inhibitors PET/computed tomography in preoperative staging of patients with nonsmall cell lung cancer

OBJECTIVE

This study aimed to evaluate the diagnostic accuracy of 18 F-fibroblast activation protein inhibitor (FAPI) PET/computed tomography (CT) in identifying primary tumors and mediastinal lymph node metastases in nonsmall cell lung cancer (NSCLC), with histopathological findings serving as the reference standard.

METHODS

Nineteen patients underwent preoperative 18 F-FAPI PET/CT and subsequent surgery; of these, 13 also underwent 18 F-fluorodeoxyglucose (FDG) PET/CT within 1 week. The diagnostic accuracy of primary tumors and lymph node metastases was evaluated for both modalities. Semiquantitative parameters, including maximum standardized uptake values (SUV max ) and target-to-background ratios (TBRs), for both primary tumors and lymph node metastases were assessed for both modalities.

RESULTS

For primary tumors, 18 of 19 (94.7%) showed positive results on 18 F-FAPI PET/CT scans. In 13 patients who also underwent 18 F-FDG PET/CT, 18 F-FAPI PET/CT demonstrated a higher detection rate compared with 18 F-FDG PET/CT (100% vs. 69.1%). The overall accuracy of lymph node assessment with 18 F-FAPI PET/CT (95.9-97.1%) was significantly higher compared to 18 F-FDG PET/CT (51.0%). Malignant lymph nodes exhibited significantly higher SUV max and TBR on 18 F-FAPI scans (SUV max : 7.0 vs. 0.9, P  < 0.001; TBR muscle : 5.0 vs. 0.8, P  < 0.001) than on 18 F-FDG scans (SUV max : 3.9 vs. 1.8, P  = 0.01), except for the liver TBR on 18 F-FDG scans (TBR liver : 1.8 vs. 1.0, P  = 0.055).

CONCLUSION

18 F-FAPI could be utilized in the preoperative staging of NSCLC to mitigate the incidence of false positives associated with 18 F-FDG, due to its higher accuracy in identifying mediastinal lymph node metastasis.

Features of late local failure of early‑stage non‑small cell lung cancer treated with stereotactic body radiotherapy

Local failure of non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT) often occurs within 2 years and delayed local failure is uncommon. In the present study, features of late local failure (LLF; >2 years after SBRT) after SBRT were investigated and compared with those of early local failure (ELF; ≤2 years after SBRT) to explore whether these two local recurrence features have different prognostic implications. Patients who underwent SBRT for stage I-IIA NSCLC between July 2006 and March 2014 were retrospectively reviewed. Overall, 173 patients underwent SBRT for NSCLC. The median follow-up times after SBRT were 50 and 31 months for survival and computed tomography (CT) follow-up, respectively. LLF and ELF occurred in 7 and 13 patients, respectively. The median times to LLF and ELF were 42 months (range, 31-61 months) and 13 months (range, 4-16 months), respectively. Local-only failure occurred in 14% (1/7) of LLF cases and 77% (10/13) of ELF cases, which was significantly different (Fisher's exact test, P=0.02). Curative-intent salvage treatment was impossible in all of the LLF cases and 69% (9/13) of the ELF cases, which was significantly different (Fisher's exact test, P<0.01). The median survival times after local failure were 9 and 25 months for patients with LLF and ELF, respectively. Additionally, the 1-year overall survival rates after local failure were 29 and 83% in the LLF and ELF groups, respectively, which was significantly different (log-rank test, P<0.01 at 1-year). In summary, the prognosis after LLF was significantly unfavorable compared with after ELF. Curative-intent salvage treatment is often difficult for LLF due to metastases. Therefore, it seems reasonable to decrease the frequency of follow-up CT for detecting tumor recurrence after the first 2 years post-SBRT.

Early, integrated palliative care for people with chronic respiratory disease: lessons learnt from lung cancer

Lung cancer and chronic non-malignant respiratory disease cause pervasive, multifactorial suffering for patients and informal carers alike. Palliative care aims to reduce suffering and improve quality of life for patients and their families. An established evidence base exists that has demonstrated the essential role of specialist palliative care for people with lung cancer. Emerging evidence supports similar benefits among people with chronic respiratory disease. Many lessons can be learnt from lung cancer care, particularly as the model of care delivery has transformed over recent decades due to major advances in the diagnostic pathway and the development of new treatments. This narrative review aims to summarize the evidence for specialist palliative care in lung cancer and chronic respiratory disease, by highlighting seven key lessons from lung cancer care that can inform the development of proactive, integrated models of palliative care among those with chronic respiratory disease. These seven lessons emphasize (1) managing challenging symptoms; (2) the efficacy of specialist palliative care; (3) the importance of providing specialist palliative care integrated with disease-directed care according to patients' needs not prognosis; (4) the need for new models of collaborative palliative care, (5) which are culturally appropriate and (6) able to evolve with changes in disease-directed care. Finally, we discuss (7) some of the critical research gaps that persist and reduce implementation in practice.

Dosimetric investigation of couch rotation angles in non-coplanar VMAT plans for lung cancer SBRT

Background

This study aimed to investigate the effect of couch rotation angles on non-coplanar volumetric modulated arc therapy (ncVMAT) plan for stereotactic body radiotherapy (SBRT) in lung cancer patients and to evaluate the feasibility of clinically applying ncVMAT for SBRT.

Methods

Twenty-four lung cancer patients with a single lesion eligible for SBRT were enrolled in the study. Seven dual partial-arc VMAT plans with varying couch angles were designed for every patient. These plans utilized two partial arcs, with the same first arc set at a fixed 0° couch angle in all plans. The second arc's couch angle varies at 15° intervals, ranging from 0° to 90°. The plans are designated as C0, NC15, NC30, NC45, NC60, NC75, and NC90, respectively. Plan evaluation included assessment of the maximum dose (Dmax), the mean dose (Dmean), homogeneity index (HI), conformity index (CI), and the ratio of the 50% isodose volume to the planning target volume (R50%). Dosimetric parameters for organs at risk such as the ipsilateral lung, contralateral lung, bilateral lungs, esophagus, trachea, chest wall, heart, and spinal cord were analyzed. Additionally, plan complexity-related metrics included modulation degree (MD), delivery time (DT), and monitor unit (MU) were assessed.

Results

As the couch rotation angle increased, parameters such as Dmax, Dmean, HI, CI, R50%, V20Gy, V25.75Gy and V30Gy of the ipsilateral lung and bilateral lungs, V10Gy of the contralateral lung and Dmean of the chest wall varied, while MD, MU, and DT increased. Compared to C0, the Dmax, Dmean, and HI of the planning target volume (PTV) decreased from 6728.35 ± 209.56cGy, 5743.04 ± 93.45cGy, and 0.281 ± 0.032 to 6500.48 ± 225.26cGy, 5654.81 ± 109.23cGy, and 0.245 ± 0.031, respectively, when the couch was rotated to 90°. The CI increased from 0.859 ± 0.031 to 0.876 ± 0.024. Decreases in R50% were 1.4%, 4.9%, 9%, 13.5%, 16.8%, and 18.4% for NC15, NC30, NC45, NC60, NC75, and NC90, respectively.

Conclusions

In the treatment of lung cancer using SBRT, ncVMAT plans demonstrate superior dose distribution and deliver lower doses to certain OARs compared to cVMAT plans. This advantage becomes more pronounced with increasing couch rotation angles. Our study offers theoretical support for the preferential use of ncVMAT plans in lung cancer SBRT and provides empirical evidence to guide the selection of optimal couch rotation angles.

The prevalence and clinical significance of EGFR mutations in non-small cell lung cancer patients in Egypt: a screening study

BACKGROUND

Lung cancer is a form of cancer that is responsible for the largest incidence of deaths attributed to cancer worldwide. Non-small cell lung cancer (NSCLC) is the most prevalent of all the subtypes of the disease. Treatment with tyrosine kinase inhibitors (TKI) may help some people who have been diagnosed with non-small cell lung cancer. The presence of actionable mutations in the epidermal growth factor receptor (EGFR) gene is a key predictor of how a patient will respond to a TKI. Thus, the frequency of identification of mutations in EGFR gene in patients with NSCLC can facilitate personalized treatment.

OBJECTIVE

The objective of this study was to screen for mutations in the EGFR gene and to investigate whether there is a correlation between the screened mutations and various clinical and pathological factors, such as gender, smoking history, and age, in tissue samples from patients with NSCLC.

METHODS

The study comprised 333 NSCLC tissue samples from 230 males and 103 females with an average age of 50 years. Exons 18-21 of the EGFR gene have been examined using real-time PCR. Using SPSS, correlations between clinical and demographic variables were examined, and EGFR mutation and clinical features associations were studied.

RESULTS

The study's findings revealed that the incidence rate of EGFR mutation was 24.32% (81/333), with partial deletion of exon 19 (19-Del) and a point mutation of L858R in exon 21 accounting for 66.67% (P < 0.001) and 28.40% (P < 0.001) of the mutant cases, respectively. Patients who had the T790M mutation represent 4.94% (P = 0.004) of total number of patients. Females harbored EGFR mutations (54.32%) with higher frequency than men (45.68%) (P < 0.001), while nonsmokers had EGFR mutations (70.37%) more frequently than current smokers (29.63%) (P < 0.001).

CONCLUSION

The screening study conducted in Egypt reported that the EGFR mutations prevalence was 24.32% among Egyptians with NSCLC. The study also found a slight gender bias, with females having an incidence rate of these mutations higher than males. Additionally, nonsmokers had higher rates of mutations in EGFR gene compared to smokers. According to the findings, somatic EGFR mutations can be employed as a diagnostic tool for non-small cell lung cancer in Egypt, and they can be implemented in conjunction with clinical criteria to identify which patients are more likely to respond favorably to TKIs.

Intraoperative patient radiation dose from cone-beam computed tomography in thoracic surgery

BACKGROUND

Several methods can be used to intraoperatively identify pulmonary lesion using radiation technology. However, little is known about patient radiation exposure during chest surgery. We aimed to measure patients' radiation exposure from cone-beam computed tomography (CBCT) used in a hybrid operating room.

METHODS

This retrospective study included patients who underwent surgical treatment in a hybrid operating room between April 2019 and December 2023 at the Teikyo University Hospital. All data was obtained prospectively, but the study was approved by the IRB as a retrospective study because of repeated extensions of study period in order to collect more cases. Skin radiation exposure was measured using five wearable dosimeters per patient. The measurements were compared to cumulative Air Kerma. Furthermore, the radiation exposure dose on the surgical side, which cannot be measured, was estimated by computer simulation.

RESULTS

Among 182 patients who underwent surgery in a hybrid operating room, radiation exposure measurements were conducted on 67 patients. The patients' mean age was 60.7 years. The average number of CBCT scans was 2.1 (1-5) and the intraoperative identification rate was 100%, with no marking-related complications. Average patient's skin radiation dose was 3.69 ± 5.48 mGy per dosimeter, and cumulative Air Kerma was 25.4 ± 19.3 mGy. The highest radiation exposure was recorded in the 5th intercostal space whereas the lowest was measured in the supraclavicular or 11th intercostal spaces. Referring to phantom and computer simulation data, the 5th and 8th intercostal spaces were significantly more exposed to radiation at not only measurement side but also the surgical field, particularly when the number of CT scans was four.

CONCLUSION

We found that the patient's 5th to 8th intercostal space was the most radiation exposed area by intraoperative CBCT imaging because the CBCT movement was restricted by the patient's arm, anesthesia machine, and operating table during chest surgery. In future, it is strongly required to research for radiation protection in this area. Furthermore, performing no more than three scans intraoperatively may be preferable in order to protect patients from radiation exposure during CBCT guided thoracic surgery.

Incidental Pulmonary Nodules: Differential Diagnosis and Clinical Management

BACKGROUND

According to data from the USA, the incidence of incidentally discovered pulmonary nodules is 5.8 per 100 000 person- years for women and 5.2 per 100 000 person-years for men. Their management as recommended in the pertinent guidelines can substantially improve clinical outcomes. More than 95% of all pulmonary nodules revealed by computerized tomography (CT) are benign, but many cases are not managed in conformity with the guidelines. In this article, we summarize the appropriate clinical approach and provide an overview of the pertinent diagnostic studies and when they should be performed.

METHODS

This review is based on relevant publications retrieved by a selective search in PubMed. The authors examined Englishlanguage recommendations issued since 2010 for the management of pulmonary nodules, supplemented by comments from the German lung cancer guideline.

RESULTS

In general, the risk that an incidentally discovered pulmonary nodule is malignant is low but rises markedly with increasing size and the presence of risk factors. When such a nodule is detected, the further recommendation, depending on size, is either for follow-up examinations with chest CT or else for an extended evaluation with positron emission tomography-CT and biopsy for histology. The diagnostic evaluation should include consideration of any earlier imaging studies that may be available as an indication of possible growth over time. Single nodules measuring less than 6 mm, in patients with few or no risk factors, do not require any follow-up. Lung cancer is diagnosed in just under 10% of patients with a nodule measuring more than 8 mm.

CONCLUSION

The recommendations of the guidelines for the management of incidentally discovered pulmonary nodules are intended to prevent both overand undertreatment. If a tumor is suspected, further care should be provided by an interdisciplinary team.

Recent Advances and Current Challenges in Stereotactic Body Radiotherapy for Ultra-Central Lung Tumors

Stereotactic body radiotherapy has been established as a viable treatment option for inoperable early-stage non-small cell lung cancer or secondary lesions mainly in oligoprogressive/oligometastatic scenarios. Treating lesions in the so-called "no flight zone" has always been challenging and conflicting data never cleared how to safely treat these lesions. This is truer considering ultra-central lesions, i.e., directly abutting or whose PTV is overlapping critical mediastinal organs. While historical retrospective data are abundant but mostly heterogenous in terms of the definition of ultra-central lesions, dosing regimens and outcomes, prospective data remain scarce, even though recently published studies have given new encouraging results for such delicate treatment scenarios. For this reason, we aimed to review and summarize current knowledge on stereotactic radiation treatment for ultra-central thoracic lesions, highlighting the most recent advances and the messages that can be taken from them. Lastly, we propose a workflow of the necessary steps to identify and treat such patients, therefore helping in elucidating the advantages and caveats of such treatment options.

Treatment of High-Risk Patients with Stage I Non-Small Cell Lung Cancer: The American Association for Thoracic Surgery Expert Consensus Document

OBJECTIVES

A significant proportion of patients with stage I non-small cell lung cancer (NSCLC) are considered at high risk for complications or mortality after lobectomy. The American Association for Thoracic Surgery (AATS) previously published important considerations in determining which patients are considered high risk. The current objective was to evaluate treatment options and important factors to consider during treatment selection for these high-risk patients.

METHODS

The AATS Clinical Practice Standards Committee assembled an expert panel to review treatment options for high-risk patients with stage I NSCLC. After a systematic search of the literature identification of lung-nodule-related factors to consider in treatment selection, the panel developed expert consensus statements and vignettes using a modified Delphi method. A 75% consensus was required for approval.

RESULTS

The expert panel identified sublobar resection, image-guided thermal ablation (IGTA), and stereotactic ablative radiotherapy (SABR), which is also known as stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS), as modalities applicable in the treatment of high-risk patients with stage I NSCLC. Fourteen statements and 5 vignettes illustrating clinical scenarios were formulated, revised, and ultimately approved.

CONCLUSION

The choice of which modality (sublobar resection, SABR, or IGTA) is optimal in high-risk patients with stage I NSCLC is complex, but a surgical approach is generally favored when deemed safe. SABR and IGTA are reasonable options in select patients, with SABR being the likely next choice in nonsurgical patients. If possible, obtaining a biopsy is very important prior non-surgical treatment. A multi-disciplinary review of patient and tumor characteristics is essential for achieving an optimal decision. The clinical treatment decision should also take patient perspectives, preferences, and quality of life into consideration.

Treatment Selection for the High-Risk Patient with Stage I Non-Small Cell Lung Cancer: Sublobar Resection, Stereotactic Ablative Radiotherapy or Image-Guided Thermal Ablation? The American Association for Thoracic Surgery Expert Consensus Document

A significant proportion of patients with stage I non-small cell lung cancer (NSCLC) are considered at high risk for complications or mortality after lobectomy. The American Association for Thoracic Surgery (AATS) previously published an expert consensus document detailing important considerations in determining who is at high risk. The current objective was to evaluate treatment options and important factors to consider during treatment selection for these high-risk patients. After systematic review of the literature, treatment options for high-risk patients with stage I NSCLC were reviewed by an AATS expert panel. Expert consensus statements and vignettes pertaining to treatment selection were then developed using discussion and a modified Delphi method. The expert panel identified sublobar resection, stereotactic ablative radiotherapy (SABR), and image-guided thermal ablation (IGTA) as modalities applicable in the treatment of high-risk patients with stage I NSCLC. The panel also identified lung-nodule-related factors that are important to consider in treatment selection. Using this information, the panel formulated 14 consensus statements and 5 vignettes illustrating clinical scenarios. This article summarizes important factors to consider in treatment selection using these modalities, which are applicable in high-risk patients with stage I NSCLC. The choice of which modality (sublobar resection, SABR, or IGTA) is optimal in high-risk patients with stage I NSCLC is complex, but a surgical approach is generally favored when deemed safe. SABR and IGTA are reasonable options in select patients. SABR is more commonly used than IGTA and is likely the next-best choice. A multi-disciplinary review of patient and tumor characteristics is essential for achieving an optimal decision. The clinical treatment decision should also take patient perspectives, preferences, and quality of life into consideration.

Long-term survival and failure patterns in inoperable early-stage non-small cell lung cancer following stereotactic body radiotherapy: a single-institution retrospective study

This study is to analyse the failure patterns and long-term survival after stereotactic body radiotherapy (SBRT) in patients with T1-3N0M0 inoperable non-small cell lung cancer (NSCLC). Early-stage NSCLC patitents who received SBRT at Zhejiang Cancer Hospital from January 2012 to September 2018 were retrospectively analyzed. The primary endpoint were the patterns of disease progression, which were divided into local recurrence, regional failure, and distant metastasis. Kaplan-Meier method survival analysis was used to calculate overall survival (OS), progression-free survival (PFS). Cox model was used for univariate analysis and multivariate analysis. A total of 215 patients with 224 lesions were enrolled. After the median follow-up time of 50.8 months (1.0-117.9 months), 76 (35.3%) patients progressed, with regional progression occurring in 4 cases (1.8%), local and local-regional progression in 17 cases (7.9%), various distant metastases developing in 55 cases (25.6%). The OS rates at 1, 3, and 5 years were 97.1%, 80.9%, and 63.8%, respectively, with a median OS of 92.2 months (95%CI, 61.5-122.9 months). The PFS rates at 1, 3, and 5 years were 87.5%, 65.9%, and 50.8%, respectively, with a median PFS of 62.2 months (95% CI, 45.0-59.4 months). There was no significant difference in OS (P = 0.832) and PFS (P = 0.672) between the two groups with or without pathology. Multivariate analysis showed that BED and patient age were independent prognostic factors affecting early-stage lung cancer survival (all P < 0.05). Distant metastasis was the main failure pattern of inoperable early-stage NSCLC after SBRT, and the high-risk population should be selected for further systemic treatment.

Advancements in lung cancer: a comprehensive perspective on diagnosis, staging, therapy and follow-up from the SAKK Working Group on Imaging in Diagnosis and Therapy Monitoring

In 2015, around 4400 individuals received a diagnosis of lung cancer, and Switzerland recorded approximately 3200 deaths related to lung cancer. Advances in detection, such as lung cancer screening and improved treatments, have led to increased identification of early-stage lung cancer and higher chances of long-term survival. This progress has introduced new considerations in imaging, emphasising non-invasive diagnosis and characterisation techniques like radiomics. Treatment aspects, such as preoperative assessment and the implementation of immune response evaluation criteria in solid tumours (iRECIST), have also seen advancements. For those undergoing curative treatment for lung cancer, guidelines propose follow-up with computed tomography (CT) scans within a specific timeframe. However, discrepancies exist in published guidelines, and there is a lack of universally accepted recommendations for follow-up procedures. This white paper aims to provide a certain standard regarding the use of imaging on the diagnosis, staging, treatment and follow-up of patients with lung cancer.

Has_circ_0002360 facilitates immune evasion by enhancing heterogeneous nuclear ribonucleoprotein A1 stability, thereby promoting malignant progression in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is marked by complex molecular aberrations including differential expression of circular RNAs (circRNAs). hsa_circ_0002360, a circRNA, has been identified as overexpressed in NSCLC. This study aimed to evaluate the expression patterns of hsa_circ_0002360 and its potential role as an oncogenic factor in NSCLC. We analyzed two GEO datasets (GSE112214 and GSE158695) using R software to identify differentially expressed circRNAs. Quantitative reverse transcription PCR (qRT-PCR) assessed the expression of hsa_circ_0002360 in NSCLC tissues and cell lines compared to controls. We used siRNA and overexpression vectors to modulate hsa_circ_0002360 levels in A549 cells, followed by assays to assess proliferation, migration, invasion, apoptosis, and epithelial-mesenchymal transition (EMT). Interactions with RNA-binding proteins, specifically HNRNPA1, were investigated using RNA-pull down and RIP assays. In GEO datasets GSE112214 and GSE158695, hsa_circ_0002360 was identified as significantly overexpressed in NSCLC, a finding supported by qRT-PCR analyses showing higher levels in NSCLC tissues and cell lines compared to controls. Functional assays demonstrated that knockdown of hsa_circ_0002360 in A549 cells decreased proliferation, migration, invasion, and altered epithelial-mesenchymal transition marker expression, while inducing apoptosis, suggesting its oncogenic role. Conversely, overexpression promoted tumor characteristics, corroborated by in vivo xenograft models showing increased tumor growth. Hsa_circ_0002360's interaction with HNRNPA1, evidenced through RNA-pull down and RIP assays, implicates it in regulatory pathways that enhance NSCLC progression. This expression was also correlated with advanced TNM stages and metastasis, highlighting its potential as a therapeutic target. hsa_circ_0002360 acts as an oncogene in NSCLC, promoting tumor progression and metastasis through regulation of cell growth, apoptosis, and EMT processes. The interaction between hsa_circ_0002360 and HNRNPA1 suggests a novel mechanism of circRNA-mediated modulation of NSCLC pathology, providing potential targets for therapeutic intervention.

Neoadjuvant therapy in early-stage non-small cell lung cancer: A real-world analysis

BACKGROUND

Phase 3 trials of neoadjuvant immunotherapy-based regimens have shown promising outcomes in patients with resectable non-small cell lung cancer (NSCLC). However, real-world data on treatment regimens with combined chemoimmunotherapy, patient profiles, and clinical outcomes in those patients are limited.

METHODS

This dual-center registry-based study describes clinical patterns and outcomes of using neoadjuvant platinum-based chemoimmunotherapy in patients with resectable NSCLC. The main objective was to evaluate the proportion of patients receiving local therapy after chemoimmunotherapy. Further objectives include pathological outcome, disease-free survival (DFS), and overall survival (OS). Histological samples underwent next-generation sequencing (NGS).

RESULTS

Seventy-two patients (median age 64.5 years (interquartile range (IQR), 59-69); 40.3 % women) were included. Prior to initiation of therapy, NGS was available in 90.3 %. Median follow-up time from date of diagnosis was 374 days (IQR, 241-605). After neoadjuvant therapy, 46 patients underwent surgery and 23 radiotherapy, resulting in 69 patients receiving local therapy. Out of 46 patients who underwent surgery, 22 had pathological complete remission (PR), 11 major PR, and 12 minor PR. DFS (95 % confidence interval (CI)) in 43 (out of 46) surgical patients with R0 resection was 98 % (93-100), 98 % (93-100) and 81 % (57-100) after 180, 360 and 720 days, respectively. OS (95 % CI) was 97 % (94-100), 90 % (82-99) and 90 % (82-99), after 180, 360 and 720 days, respectively.

CONCLUSION

Following neoadjuvant chemoimmunotherapy, the majority of resectable early-stage NSCLC patients could undergo local therapy in routine clinical practice. This was associated with favorable DFS and OS.

Predictive [18F]-FDG PET/CT-Based Radiogenomics Modelling of Driver Gene Mutations in Non-small Cell Lung Cancer

RATIONALE AND OBJECTIVES

To investigate whether [18F]-FDG PET/CT-derived radiomics may correlate with driver gene mutations in non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

In this IRB-approved retrospective study, 203 patients with surgically treated NSCLC who underwent subsequent genomic analysis of the primary tumour at our institution between December 2004 and January 2014 were identified. Of those, 128 patients (mean age 62.4 ± 10.8 years; range: 35-84) received preoperative [18F]-FDG PET/CT as part of their initial staging and thus were included in the study. PET and CT image segmentation and feature extraction were performed semi-automatically with an open-source software platform (LIFEx, Version 6.30, lifexsoft.org). Molecular profiles using different next-generation sequencing (NGS) panels were collected from a web-based resource (cBioPortal.ca for Cancer genomics). Two statistical models were then built to evaluate the predictive ability of [18F]-FDG PET/CT-derived radiomics features for driver gene mutations in NSCLC.

RESULTS

More than half (68/128, 53%) of all tumour samples harboured three or more gene mutations. Overall, 55% of tumour samples demonstrated a mutation in TP53, 26% of samples had alterations in KRAS and 17% in EGFR. Extensive statistical analysis resulted in moderate to good predictive ability. The highest Youden Index for TP53 was achieved using combined PET/CT features (0.70), for KRAS using PET features only (0.57) and for EGFR using CT features only (0.60).

CONCLUSION

Our study demonstrated a moderate to good correlation between radiomics features and driver gene mutations in NSCLC, indicating increased predictive ability of genomic profiles using combined [18F]-FDG PET/CT-derived radiomics features.

Performing High-Quality Sublobar Resections: Key Differences Between Wedge Resection and Segmentectomy

Lung cancer remains the leading cause of cancer-related deaths worldwide. The introduction of targeted treatments and immunotherapy in lung cancer has transformed patient care by offering "precision medicine" focused on the characteristics of the disease. The same concept has emerged in lung cancer surgery. This "precision surgery" aims to determine the best surgical approach based on the characteristics of the cancer, the patient's cardiorespiratory status, and technological advances in thoracic surgery. While lobectomy continues to be the gold standard for managing early-stage lung cancer, the implementation of screening programs has enabled the earlier detection of smaller tumors. In this context, sublobar resections, particularly segmentectomy, have emerged as valuable options in the treatment of early-stage lung cancer. Recent studies suggest that sublobar resections, including segmentectomy and wedge resection, provide a viable alternative to lobectomy. This review explores the various resection strategies available, tailored to patient and tumor characteristics, and highlights modern preoperative techniques aimed at advancing precision surgery.

Costs of stereotactic ablative radiotherapy compared to conventional radiotherapy in the treatment of non-small cell lung cancer - a micro-costing study using Time-Driven Activity Based Costing (TDABC)

BACKGROUND

Lung cancer is one of the leading causes of morbidity and mortality in Brazil. Radiotherapy is an important therapeutic option, but the techniques used remain subjects of discussion. In this study, we compared the costs of conventional radiotherapy (CRT) and stereotactic ablative radiotherapy (SABR) in the treatment of early-stage non-small cell lung cancer (NSCLC).

METHODS

This cost analysis study adopted a micro-costing approach, following the TDABC (Time-Driven Activity-Based Costing) methodology. The study was conducted at a specialized public cancer hospital in São Paulo, Brazil. The analysis involved seven macro-processes related to radiotherapy treatment, identifying resources, costs, and time estimates for each step.

RESULTS

The cost analysis revealed that SABR treatment for NSCLC is significantly cheaper than CRT. The direct costs of SABR treatment ranged from $2,777.25 to $3,797.49, while CRT ranged from $5,562.65 to $6,052.94. The cost related to CRT treatment constituted more than 80% of the total costs, whereas in SABR, it ranges from 59 to 68%. Planning represented 9% to 10% of the cost in CRT, increasing to 22% to 30% in SABR.

CONCLUSIONS

The results highlight that SABR treatment is a cheaper option for early-stage NSCLC patients when compared to CRT. Furthermore, the increased time required for CRT treatment limits the number of patients who can be treated. These results may influence healthcare policies and the financing of the healthcare system, directly benefiting patients and promoting the efficient allocation of resources.

The 'Liaisons dangereuses' Between Lung Cancer and Interstitial Lung Diseases: A Focus on Acute Exacerbation

Patients with interstitial lung disease (ILD) are about five times more likely to develop lung cancer than those without ILD. The presence of ILD in lung cancer patients complicates diagnosis and management, resulting in lower survival rates. Diagnostic and treatment procedures needed for cancer can increase the risk of acute exacerbation (AE), one of the most severe complications for these patients. Bronchoscopic techniques are generally considered safe, but they can trigger AE-ILD, particularly after cryoprobe biopsies. Surgical procedures for lung cancer, including lung biopsies and resections, carry an elevated risk of AE-ILD. Postoperative complications and mortality rates highlight the importance of meticulous surgical planning and postoperative care. Furthermore, cancer treatments, such as chemotherapy, are all burdened by a risk of AE-ILD occurrence. Radiotherapy is important for managing both early-stage and advanced lung cancer, but it also poses risks. Stereotactic body radiation and particle beam therapies have varying degrees of safety, with the latter potentially offering a lower risk of AE. Percutaneous ablation techniques can help patients who are not eligible for surgery. However, these procedures may complicate ILD, and their associated risks still need to be fully understood, necessitating further research for improved safety. Overall, while advancements in lung cancer treatment have improved outcomes for many patients, the complexity of managing patients with concomitant ILD needs careful consideration and multidisciplinary assessment. This review provides a detailed evaluation of these risks, emphasizing the need for personalized treatment approaches and monitoring to improve patient outcomes in this challenging population.

Intratumoral Treatment in Lung Cancer: Is It Time to Move Towards Clinical Practice?

According to a modern view, cancer no longer follows a purely mechanistic model. Rather, a tumor is conceived as a more complex structure, composed of cancer cells, the activities of which may interact and reshape the so-called tumor microenvironment (TME), leading to preservation of specific tumoral niches and promoting the survival of tumoral stem cells. Background/Objective: Therapeutic strategies must deal with this unique cancer architecture in the near future by widening their range of activities outside the cancer cells and rewiring a TME to ensure it is hostile to cancer growth. Therefore, an intratumoral therapeutic strategy may open the door to a new type of anticancer activity, one that directly injures the tumoral structure while also eliciting an influence on the TME through local and systemic immunomodulation. This review would like to assess the current situation of intratumoral strategies and their clinical implications. Methods We analyzed data from phase I, II, and III trials, comprehensive reviews and relevant clinical and preclinical research, from robust databases, like PUBMED, EMBASE, Cochrane Library, and clinicaltrials.gov. Results: Intratumoral strategies can be quite variable. It is possible the injection and inhalation of traditional antiblastic agents or immunomodulant agents, or intrapleural administration. Ablation strategy is available, both thermal and photodynamic method. Moreover, TTfields and NPs are analyzed and also brachytherapy is mentioned. Intratumoral therapy can find space in "adjuvant"/perioperative or metastatic settings. Finally, intratumoral strategies allow to synergize their activities with systemic therapies, guaranteeing better local and systemic disease control. Conclusions: Intratumoral strategies are overall promising. Antiblastic/immunomodulant injection and NPs use are especially interesting and intriguing. But, there is generally a lack of phase II and III trials, in particular NPs use need additional experimentation and clinical studies.