Prospects for population screening and diagnosis of lung cancer

Risk factors assessment and risk prediction models in lung cancer screening candidates

From February 2015, low-dose computed tomography (LDCT) screening entered the armamentarium of diagnostic tools broadly available to individuals at high-risk of developing lung cancer. While a huge number of pulmonary nodules are identified, only a small fraction turns out to be early lung cancers. The majority of them constitute a variety of benign lesions. Although it entails a burden of the diagnostic work-up, the undisputable benefit emerges from: (I) lung cancer diagnosis at earlier stages (stage shift); (II) additional findings enabling the implementation of a preventive action beyond the realm of thoracic oncology. This review presents how to utilize the risk factors from distinct categories such as epidemiology, radiology and biomarkers to target the fraction of population, which may benefit most from the introduced screening modality.

Implementation and organization of lung cancer screening

CT screening for lung cancer is now being implemented in the US and China on a widespread national scale but not in Europe so far. The review gives a status for the implementation process and the hurdles to overcome in the future. It also describes the guidelines and requirements for the structure and components of high quality CT screening programs. These are essential in order to achieve a successful program with the fewest possible harms and a possible mortality benefit like that documented in the American National Lung Screening Trial (NLST). In addition the importance of continued research in CT screening methods is described and discussed with focus on the great potential to further improve this method in the future for the benefit of patients and society.

Voxel-based comparative analysis of lung lesions in CT for therapeutic purposes

Lung cancer remains as one of the most incident types of cancer throughout the world. Temporal evaluation has become a very useful tool when one wishes to analyze some malignancy-indicating behavior. The objective of the present work is to detect changes in the local densities of lung lesions over time (follow-up analysis). From the detected changes, local information as well as extent region of changes can complement the studies regarding the malignant or benign nature of the lesion. Based on this idea, we attempt to use techniques that allow the observation of changes in the lesion over time, based on remote sensing techniques which highlight changes occurring in the environment. The techniques used were the image differencing, image rationing, median filtering, image regression and the fuzzy XOR operator. Based on the global measurement of change percentage in the density, we found density variations which were considered significant in a range from 2.22 to 36.57 % of the volume of the lesion. The results achieved are promising since, besides the visual aspects of the changes in density of the lung lesion over time, we managed to quantify these changes and compare them by volumetric analysis, a more commonly used technique for analysis of changes in lung lesions.

Dual-Energy Computed Tomography Virtual Monoenergetic Imaging of Lung Cancer: Assessment of Optimal Energy Levels

OBJECTIVE

The aim of the study was to evaluate objective and subjective image qualities of virtual monoenergetic imaging (VMI) in dual-source dual-energy computed tomography (DECT) and optimal kiloelectron-volt (keV) levels for lung cancer.

METHODS

Fifty-nine lung cancer patients underwent chest DECT. Images were reconstructed as VMI series at energy levels of 40, 60, 80, and 100 keV and standard linear blending (M_0.3) for comparison. Objective and subjective image qualities were assessed.

RESULTS

Lesion contrast peaked in 40-keV VMI reconstructions (2.5 ± 2.9) and 60 keV (1.9 ± 3.0), which was superior to M_0.3 (0.5 ± 2.7) for both comparisons (P < 0.001). Compared with M_0.3, subjective ratings were highest for 60-keV VMI series regarding general image quality (4.48 vs 4.52; P = 0.74) and increased for lesion demarcation (4.07 vs 4.84; P < 0.001), superior to all other VMI series (P < 0.001). Image sharpness was similar between both series. Image noise was rated superior in the 80-keV and M_0.3 series, followed by 60 keV.

CONCLUSIONS

Virtual monoenergetic imaging reconstructions at 60-keV provided the best combination of subjective and objective image qualities in DECT of lung cancer.

The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer

BACKGROUND

Lung cancer kills more people than any other cancer in the UK (5-year survival < 13%). Early diagnosis can save lives. The USA-based National Lung Cancer Screening Trial reported a 20% relative reduction in lung cancer mortality and 6.7% all-cause mortality in low-dose computed tomography (LDCT)-screened subjects.

OBJECTIVES

To (1) analyse LDCT lung cancer screening in a high-risk UK population, determine optimum recruitment, screening, reading and care pathway strategies; and (2) assess the psychological consequences and the health-economic implications of screening.

DESIGN

A pilot randomised controlled trial comparing intervention with usual care. A population-based risk questionnaire identified individuals who were at high risk of developing lung cancer (≥ 5% over 5 years).

SETTING

Thoracic centres with expertise in lung cancer imaging, respiratory medicine, pathology and surgery: Liverpool Heart & Chest Hospital, Merseyside, and Papworth Hospital, Cambridgeshire.

PARTICIPANTS

Individuals aged 50-75 years, at high risk of lung cancer, in the primary care trusts adjacent to the centres.

INTERVENTIONS

A thoracic LDCT scan. Follow-up computed tomography (CT) scans as per protocol. Referral to multidisciplinary team clinics was determined by nodule size criteria.

MAIN OUTCOME MEASURES

Population-based recruitment based on risk stratification; management of the trial through web-based database; optimal characteristics of CT scan readers (radiologists vs. radiographers); characterisation of CT-detected nodules utilising volumetric analysis; prevalence of lung cancer at baseline; sociodemographic factors affecting participation; psychosocial measures (cancer distress, anxiety, depression, decision satisfaction); and cost-effectiveness modelling.

RESULTS

A total of 247,354 individuals were approached to take part in the trial; 30.7% responded positively to the screening invitation. Recruitment of participants resulted in 2028 in the CT arm and 2027 in the control arm. A total of 1994 participants underwent CT scanning: 42 participants (2.1%) were diagnosed with lung cancer; 36 out of 42 (85.7%) of the screen-detected cancers were identified as stage 1 or 2, and 35 (83.3%) underwent surgical resection as their primary treatment. Lung cancer was more common in the lowest socioeconomic group. Short-term adverse psychosocial consequences were observed in participants who were randomised to the intervention arm and in those who had a major lung abnormality detected, but these differences were modest and temporary. Rollout of screening as a service or design of a full trial would need to address issues of outreach. The health-economic analysis suggests that the intervention could be cost-effective but this needs to be confirmed using data on actual lung cancer mortality.

CONCLUSIONS

The UK Lung Cancer Screening (UKLS) pilot was successfully undertaken with 4055 randomised individuals. The data from the UKLS provide evidence that adds to existing data to suggest that lung cancer screening in the UK could potentially be implemented in the 60-75 years age group, selected via the Liverpool Lung Project risk model version 2 and using CT volumetry-based management protocols.

FUTURE WORK

The UKLS data will be pooled with the NELSON (Nederlands Leuvens Longkanker Screenings Onderzoek: Dutch-Belgian Randomised Lung Cancer Screening Trial) and other European Union trials in 2017 which will provide European mortality and cost-effectiveness data. For now, there is a clear need for mortality results from other trials and further research to identify optimal methods of implementation and delivery. Strategies for increasing uptake and providing support for underserved groups will be key to implementation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78513845.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 40. See the NIHR Journals Library website for further project information.

Overexpression of PAD4 suppresses drug resistance of NSCLC cell lines to gefitinib through inhibiting Elk1-mediated epithelial-mesenchymal transition

It is reported that epithelial-to-mesenchymal transition (EMT) could induce resistance in tumor cells, and knockdown of peptidylarginine deiminase IV (PAD4) induces the activity of EMT. However, the role of PAD4 in gefitinib‑acquired resistance in non-small cell lung cancer (NSCLC) remains unclear. In this study, we aimed to investigate the role of PAD4 in the resistance of NSCLC to gefitinib. The cells resistant to gefitinib were established in accordance with the literature, and were derived from NSCLC cell lines HCC827 and H1650. Real-time quantitative PCR and western blot results showed that PAD4 was obviously downregulated in the cells resistant to gefitinib. Overexpression of PAD4 distinctly inhibited gefitinib resistance, whereas PAD4 downregulation had the opposite effect. Further data indicated that PAD4 upregulation could restrain EMT activity via controlling the expression of ETS-domain containing protein (Elk1). Conversely, inhibition of PAD4 showed the reverse function compared with PAD4 upregulation. Above all, our study showed that overexpression of PAD4 constrains the activity of EMT via suppressing Elk1 expression, and inhibits resistance of NSCLC to gefitinib.

The Clinical Dilemma of Incidental Findings on the Low-Resolution CT Images from SPECT/CT MPI Studies

Incidental findings are common in medical imaging. There is a particularly high prevalence of incidental findings within the thorax, the most frequent being pulmonary nodules. Although pulmonary nodules have the potential to be malignant, most are benign, resulting in a high number of false-positive findings. Low-resolution CT images produced for attenuation correction of SPECT images are essentially a by-product of the imaging process. The high number of false-positive incidental findings detected on these attenuation-correction images causes a reporting dilemma. Early detection of cancer can be beneficial, but false-positive findings and overdiagnosis can be detrimental to the patient. Attenuation-correction CT images are not of diagnostic quality, and further diagnostic tests are usually necessary for a definitive diagnosis to be reached. Given the high number of false-positive findings, the psychologic effect on the patient should be considered. This review recommends caution when the findings on attenuation-correction CT images are routinely reported.

The State of Lung Cancer Research: A Global Analysis

INTRODUCTION

Lung cancer is the leading cause of years of life lost because of cancer and is associated with the highest economic burden relative to other tumor types. Research remains at the cornerstone of achieving improved outcomes of lung cancer. We present the results of a comprehensive analysis of global lung cancer research between 2004 and 2013 (10 years).

METHODS

The study used bibliometrics to undertake a quantitative analysis of research output in the 24 leading countries in cancer research internationally on the basis of articles and reviews in the Web of Science (WoS) database.

RESULTS

A total of 32,161 lung cancer research articles from 2085 different journals were analyzed. Lung cancer research represented only 5.6% of overall cancer research in 2013, a 1.2% increase since 2004. The commitment to lung cancer research has fallen in most countries apart from China and shows no correlation with lung cancer burden. A review of key research types demonstrated that diagnostics, screening, and quality of life research represent 4.3%, 1.8%, and 0.3% of total lung cancer research, respectively. The leading research types were genetics (20%), systemic therapies (17%), and prognostic biomarkers (16%). Research output is increasingly basic science, with a decrease in clinical translational research output during this period.

CONCLUSIONS

Our findings have established that relative to the huge health, social, and economic burden associated with lung cancer, the level of world research output lags significantly behind that of research on other malignancies. Commitment to diagnostics, screening, and quality of life research is much lower than to basic science and medical research. The study findings are expected to provide the requisite knowledge to guide future cancer research programs in lung cancer.

High Lung Cancer Incidence in Heavy Smokers Following Hospitalization due to Pneumonia

INTRODUCTION

The rate of lung cancer incidence following pneumonia in heavy smokers is unknown. Heavy smokers hospitalized due to community-acquired pneumonia might be at high risk for subsequent lung cancer. The primary objective of this study was to determine lung cancer incidence in this high-risk population.

PATIENTS AND METHODS

This was a single-center, retrospective cohort study that included heavy smokers hospitalized due to community-acquired pneumonia between January 1, 2007 and December 31, 2011 in Beilinson hospital, a large community hospital and tertiary center. Patients were identified by International Classification of Diseases, Ninth Revision coding from the hospital's registry. Two physicians reviewed every patient's medical file for patient demographics, smoking history, lung cancer risk factors, and anatomical location of pneumonia. Data were cross-checked with the database at the national cancer registry for new diagnoses of cancer.

RESULTS

There were 381 admissions for community-acquired pneumonia included in the final analysis. Thirty-one cases (8.14%; 95% confidence interval [CI], 5.9%-11.2%) of lung cancer were diagnosed during the first year after hospitalization. Lung cancer incidence was significantly higher in patients who had upper-lobe pneumonia (23.8%; 95% CI, 14.9%-40%). Lung cancer was located within the lobe involved by the pneumonia in 75.8% of patients.

CONCLUSIONS

A high lung cancer rate was found in heavy smokers admitted due to community-acquired pneumonia. The association was especially strong for patients with upper-lobe pneumonia. Screening with chest computed tomography should be strongly considered for these patients.

miR-296-5p suppresses cell viability by directly targeting PLK1 in non-small cell lung cancer

Polo-like kinase 1 (PLK1), a critical kinase for mitotic progression, is overexpressed in a wide range of cancers. MicroRNAs (miRNAs) are a class of small non-coding RNA molecules and proposed to play important roles in the regulation of tumor progression and invasion. However, the relationship between PLK1 and miRNAs have remained unclear. In the present study, the association between PLK1 and miR-296-5p was investigated. The upregulation of PLK1 mRNA expression levels combined with the downregulation of miR-296-5p levels were detected in both non-small cell lung cancer (NSCLC) tissues and cell lines. Functional studies showed that knockdown of PLK1 by siRNA inhibited NSCLC cells proliferation. Impressively, overexpression of miR-296-5p showed the same phenocopy as the effect of PLK1 knockdown in NSCLC cells, indicating that PLK1 was a major target of miR-296-5p. Furthermore, using western blot analysis and luciferase reporter assay, PLK1 protein expression was proved to be regulated by miR-296-5p through binding to the putative binding sites in its 3'-untranslated region (3'-UTR). Taken together, the present study indicated that miR-296-5p regulated PLK1 expression and could function as a tumor suppressor in NSCLC progression, which provides a potential target for gene therapy of NSCLC.

UK Lung Cancer RCT Pilot Screening Trial: baseline findings from the screening arm provide evidence for the potential implementation of lung cancer screening

Background

Lung cancer screening using low-dose CT (LDCT) was shown to reduce lung cancer mortality by 20% in the National Lung Screening Trial.

Methods

The pilot UK Lung Cancer Screening (UKLS) is a randomised controlled trial of LDCT screening for lung cancer versus usual care. A population-based questionnaire was used to identify high-risk individuals. CT screen-detected nodules were managed by a pre-specified protocol. Cost effectiveness was modelled with reference to the National Lung Cancer Screening Trial mortality reduction.

Results

247 354 individuals aged 50–75 years were approached; 30.7% expressed an interest, 8729 (11.5%) were eligible and 4055 were randomised, 2028 into the CT arm (1994 underwent a CT). Forty-two participants (2.1%) had confirmed lung cancer, 34 (1.7%) at baseline and 8 (0.4%) at the 12-month scan. 28/42 (66.7%) had stage I disease, 36/42 (85.7%) had stage I or II disease. 35/42 (83.3%) had surgical resection. 536 subjects had nodules greater than 50 mm³ or 5 mm diameter and 41/536 were found to have lung cancer. One further cancer was detected by follow-up of nodules between 15 and 50 mm³ at 12 months. The baseline estimate for the incremental cost-effectiveness ratio of once-only CT screening, under the UKLS protocol, was £8466 per quality adjusted life year gained (CI £5542 to £12 569).

Conclusions

The UKLS pilot trial demonstrated that it is possible to detect lung cancer at an early stage and deliver potentially curative treatment in over 80% of cases. Health economic analysis suggests that the intervention would be cost effective—this needs to be confirmed using data on observed lung cancer mortality reduction.

Trial registration

ISRCTN 78513845.

Do Lung Cancer Eligibility Criteria Align with Risk among Blacks and Hispanics?

BACKGROUND

Black patients have higher lung cancer risk despite lower pack years of smoking. We assessed lung cancer risk by race, ethnicity, and sex among a nationally representative population eligible for lung cancer screening based on Medicare criteria.

METHODS

We used data from the National Health and Nutrition Examination Survey, 2007-2012 to assess lung cancer risk by sex, race and ethnicity among persons satisfying Medicare age and pack-year smoking eligibility criteria for lung cancer screening. We assessed Medicare eligibility based on age (55-77 years) and pack-years (≥ 30). We assessed 6-year lung cancer risk using a risk prediction model from Prostate, Lung, Colorectal and Ovarian Cancer Screening trial that was modified in 2012 (PLCOm2012). We compared the proportions of eligible persons by sex, race and ethnicity using Medicare criteria with a risk cut-point that was adjusted to achieve comparable total number of persons eligible for screening.

RESULTS

Among the 29.7 million persons aged 55-77 years who ever smoked, we found that 7.3 million (24.5%) were eligible for lung cancer screening under Medicare criteria. Among those eligible, Blacks had statistically significant higher (4.4%) and Hispanics lower lung cancer risk (1.2%) than non-Hispanic Whites (3.2%). At a cut-point of 2.12% risk for lung screening eligibility, the percentage of Blacks and Hispanics showed statistically significant changes. Blacks eligible rose by 48% and Hispanics eligible declined by 63%. Black men and Hispanic women were affected the most. There was little change in eligibility among Whites.

CONCLUSION

Medicare eligibility criteria for lung cancer screening do not align with estimated risk for lung cancer among Blacks and Hispanics. Data are urgently needed to determine whether use of risk-based eligibility screening improves lung cancer outcomes among minority patients.

BIONOTE e-nose technology may reduce false positives in lung cancer screening programmes†

OBJECTIVES

Breath composition may be suggestive of different conditions. E-nose technology has been used to profile volatile organic compounds (VOCs) pattern in the breath of patients compared with that of healthy individuals. BIOsensor-based multisensorial system for mimicking NOse, Tongue and Eyes (BIONOTE) technology differs from Cyranose® based on a set of separate transduction features. On the basis of our previously published experience, we investigated the discriminating ability of BIONOTE in a high-risk population enrolled in a lung cancer screening programme.

METHODS

One hundred individuals were selected for BIONOTE based on the attribution to the high-risk category (i.e. age, smoking status, chronic obstructive pulmonary disease status) of the University Campus Bio-Medico lung screening programme. We used a measure chain consisting of (i) a device named Pneumopipe (EU patent: EP2641537 (A1):2013-09-25) able to catch exhaled breath by an individual normally breathing into it and collect the exhalate onto an adsorbing cartridge; (ii) an apparatus for thermal desorption of the cartridge into the sensors chamber and (iii) a gas sensor array which is part of a sensorial platform named BIONOTE for the VOCs mixture analysis. Partial least square (PLS) has been used to build up the model, with Leave-One-Out cross-validation criterion. Each breath fingerprint analysis costs €10.

RESULTS

The overall sensitivity and specificity were 86 and 95%, respectively, delineating a substantial difference between patients and healthy individuals.

CONCLUSIONS

Our preliminary data show that BIONOTE technology may be used to reduce false-positive rates resulting from lung cancer screening with low-dose computed tomography in a cost-effective fashion. The model will be tested on a larger number of patients to confirm the reliability of these results.

Lung cancer screening: Computed tomography or chest radiographs?

Worldwide, lung cancer is the leading cause of mortality due to malignancy. The vast majority of cases of lung cancer are smoking related and the most effective way of reducing lung cancer incidence and mortality is by smoking cessation. In the Western world, smoking cessation policies have met with limited success. The other major means of reducing lung cancer deaths is to diagnose cases at an earlier more treatable stage employing screening programmes using chest radiographs or low dose computed tomography. In many countries smoking is still on the increase, and the sheer scale of the problem limits the affordability of such screening programmes. This short review article will evaluate the current evidence and potential areas of research which may benefit policy making across the world.

Lung cancer screening overdiagnosis: reports of overdiagnosis in screening for lung cancer are grossly exaggerated

The National Lung Cancer Screening Trial (NLST) demonstrated a mortality reduction benefit associated with low-dose computed tomography (LDCT) screening for lung cancer. There has been considerable debate regarding the benefits and harms of LDCT lung cancer screening, including the challenges related to its practical implementation. One of the controversies regards overdiagnosis, which conceptually denotes diagnosing a cancer that, either because of its indolent, low-aggressiveness biologic behavior or because of limited life expectancy, is unlikely to result in significant morbidity during the patient's remainder lifetime. In theory, diagnosing and treating these cancers offer no measurable benefit while incurring costs and risks. Therefore, if a screening test detects a substantial number of overdiagnosed cancers, it is less likely to be effective. It has been argued that LDCT screening for lung cancer results in an unacceptably high rate of overdiagnosis. This article aims to defend the opposite stance. Overdiagnosis does exist and to a certain extent is inherent to any cancer-screening test. Nonetheless, the concept is less dualistic and more nuanced than it has been suggested. Furthermore, the average estimates of overdiagnosis in LDCT lung cancer screening based on the totality of published data are likely much lower than the highest published estimates, if a careful definition of a positive screening test reflecting our current understanding of lung cancer biology is utilized. This article presents evidence on why reports of overdiagnosis in lung cancer screening have been exaggerated.

Significance of 18F-fluorocholine PET/CT positive pulmonary lesions in prostate cancer patients

AIM

To assess the frequency and the significance of incidental pulmonary lesions with 18F-fluorocholine (18F-FCH) PET/CT in prostate cancer (PCa) patients.

PATIENTS, METHODS

225 consecutive PCa patients referred for 18F-FCH PET/CT (median age 68 years) were retrospectively evaluated for the presence of lesions in the lungs: 173 referred for restaging and 52 for initial staging regarding their high risk of extra prostatic extension. The final diagnosis was based on histopathological or on clinical and radiological follow-up.

RESULTS

13 patients had 18F-FCH positive pulmonary and 8 patients malignant lesions: 5 patients (38%) had a primary lung cancer (2 squamous cell carcinomas, 1 papillary adenocarcinoma, 1 typical pulmonary carcinoid, 1 bronchioloalveolar carcinoma) and 3 patients (23%) PCa metastases. Benign lesions were found in 5 subjects (38%). SUVmax and maximum diameter were neither significantly different in primary and metastatic tumors nor between malignant and benign lesions.

CONCLUSIONS

Although our results suggest that incidental uptake in the lungs in PCa patients are nonspecific, their detection may have a significant impact on patient management knowing that more than 60% represent malignant disease.

The Solitary Pulmonary Nodule

Due to the high etiological diversity and the potential for malignancy, pulmonary nodules represent a clinical challenge, becoming increasingly frequent as the number of CT examinations rises. The topic gains even more importance as clear evidence for the effectiveness of CT screening was provided by the National Lung Screening Trial (NLST). Yet, the results were tempered by the high false-positive rate and the requirement of performing further diagnostic procedures. The management of those detected solitary pulmonary nodules is currently based on the individuals' risk of developing lung cancer, the pulmonary nodule characteristics and the capability of diagnostic and therapeutic approaches.

Improving selection criteria for lung cancer screening. The potential role of emphysema

RATIONALE

Lung cancer (LC) screening using low-dose chest computed tomography is now recommended in several guidelines using the National Lung Screening Trial (NLST) entry criteria (age, 55-74; ≥30 pack-years; tobacco cessation within the previous 15 yr for former smokers). Concerns exist about their lack of sensitivity.

OBJECTIVES

To evaluate the performance of NLST criteria in two different LC screening studies from Europe and the United States, and to explore the effect of using emphysema as a complementary criterion.

METHODS

Participants from the Pamplona International Early Lung Action Detection Program (P-IELCAP; n = 3,061) and the Pittsburgh Lung Screening Study (PLuSS; n = 3,638) were considered. LC cumulative frequencies, incidence densities, and annual detection rates were calculated in three hypothetical cohorts, including subjects who met NLST criteria alone, those with computed tomography-detected emphysema, and those who met NLST criteria and/or had emphysema.

MEASUREMENTS AND MAIN RESULTS

Thirty-six percent and 59% of P-IELCAP and PLuSS participants, respectively, met NLST criteria. Among these, higher LC incidence densities and detection rates were observed. However, applying NLST criteria to our original cohorts would miss as many as 39% of all LC. Annual screening of subjects meeting either NLST criteria or having emphysema detected most cancers (88% and 95% of incident LC of P-IELCAP and PLuSS, respectively) despite reducing the number of screened participants by as much as 52%.

CONCLUSIONS

LC screening based solely on NLST criteria could miss a significant number of LC cases. Combining NLST criteria and emphysema to select screening candidates results in higher LC detection rates and a lower number of cancers missed.

Lung cancer trend in England for the period of 2002 to 2011 and projections of future burden until 2020

Lung cancer is the most common cancer in the world, therefore creating a huge public health concern. The aim of this study is to determine the change in age-standardised incidence rate trend of lung cancer in England between 2002 and 2011 and use these findings to anticipate the potential burden of the disease by gender in the year 2020. Lung cancer incidence data (ICD-10 code C33-34) from 2002 and 2011 and mid-year population estimates for the same period were obtained from Office of National Statistics. Age-standardised incidence rates were calculated, by gender and region. Poisson regression analysis was used to describe the time incidence trend and projections were estimated up to year 2020. A total of 318, 417 lung cancer cases were identified. Incidence rates decreased in men by an average annual percentage change (AAPC) of -1.0% and increased in women by +1.9%. Projection analysis showed that by year 2020, provided the rates remain the same, English women will have the same lung cancer incidence rates as their male counterparts. This study demonstrated that there would be 5,848 excess lung cancer cases by 2020 with female population accounting for 85% (4,996) of the excess cases. Therefore, in addition to the development of high quality preventive intervention strategies, future public health also needs to prioritise targets at the implementation phase, in a manner that engage women living in regions that have demonstrated very high AAPC values.

Serum calprotectin, CD26 and EGF to establish a panel for the diagnosis of lung cancer

Lung cancer is the most lethal neoplasia, and an early diagnosis is the best way for improving survival. Symptomatic patients attending Pulmonary Services could be diagnosed with lung cancer earlier if high-risk individuals are promptly separated from healthy individuals and patients with benign respiratory pathologies. We searched for a convenient non-invasive serum test to define which patients should have more immediate clinical tests. Six cancer-associated molecules (HB-EGF, EGF, EGFR, sCD26, VEGF, and Calprotectin) were investigated in this study. Markers were measured in serum by specific ELISAs, in an unselected population that included 72 lung cancer patients of different histological types and 56 control subjects (healthy individuals and patients with benign pulmonary pathologies). Boosted regression and random forests analysis were conducted for the selection of the best candidate biomarkers. A remarkable discriminatory capacity was observed for EGF, sCD26, and especially for Calprotectin, these three molecules constituting a marker panel boasting a sensitivity of 83% and specificity of 87%, resulting in an associated misclassification rate of 15%. Finally, an algorithm derived by logistic regression and a nomogram allowed generating classification scores in terms of the risk of a patient of suffering lung cancer. In conclusion, we propose a non-invasive test to identify patients at high-risk for lung cancer from a non-selected population attending a Pulmonary Service. The efficacy of this three-marker panel must be tested in a larger population for lung cancer.

Implementation of lung cancer screening: promises and hurdles

Lung cancer screening is a subject of considerable interest in the medical community and the general population. Since the publication of the data from the national lung screening trial (NLST) in 2011, the interest in lung cancer screening has increased even more. Data from many sources provide evidence that low-dose computed tomography (LD-CT) lung cancer screening can be performed with even greater efficacy if inclusion criteria as well as nodule management are optimized. There are, however, also a number of potential hurdles for the implementation of lung cancer screening. Among these are, in particular, the high prevalence of screen-detected pulmonary nodules, the unknown extent of over-diagnosis, the potential harms of the cumulative radiation dose and the insufficient data on cost-efficiency of lung cancer screening. In this article, the most recent insights into some of the most imminent questions are reviewed to provide an understanding of the challenges we still face in lung cancer screening.

Long-term Oncologic and financial implications of lung cancer screening

Benefits and risks of computed tomography lung cancer screening are discussed with specific focus on oncologic and financial issues. Earlier disease stage at diagnosis implies that more patients are treated surgically, but the changes in oncologic treatment will not be dramatic. The crucial issue for implementation of screening will be that it is cost effective. Preliminary data from the National Lung Screening Trial indicate that it is cost effective and comparable to screening for other major malignancies. Some future modifications in the computed tomography screening methodology are discussed.

Effect of combined 5-aza-2'deoxycytidine and cisplatin treatment on the P15 lung adenocarcinoma cell line

Aberrant promoter hypermethylation resulting in the epigenetic silencing of apoptosis-associated genes is a key process in the chemotherapeutic treatment of cancer. The nucleoside analog, 5-aza-2'deoxycytidine (DAC), inhibits the activity of DNA methyltransferase enzymes and is able to restore the expression levels of genes that have been silenced by aberrant DNA methylation. The aim of the present study was to investigate the effect of combined treatment with DAC and cisplatin (CDDP) on the lung adenocarcinoma cell line, P15. Growth inhibition was examined using a clone formation assay and growth inhibitory activities by cell counting during treatment with DAC alone, CDDP alone or DAC followed by CDDP. In addition, changes in the mRNA expression levels of various apoptosis-associated genes following treatment with increasing concentrations of DAC were determined using reverse transcription-polymerase chain reaction. Furthermore, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) analysis was used to detect the number of apoptotic P15 tumor cells following treatment with DAC and/or CDDP. The results indicated that DAC treatment alone restored the mRNA expression levels of p73, p16^INK4a , B-cell lymphoma (Bcl)-2-associated agonist of cell death and Bcl-2-associated X protein. In addition, combined therapy with DAC and CDDP was found to significantly suppress the growth of P15 tumor cells compared with DAC or CDDP treatment alone. In conclusion, DAC may enhance the chemosensitivity of the P15 cell line to treatment with CDDP.

Analysis of MicroRNA Expression Profile Identifies Novel Biomarkers for Non-small Cell Lung Cancer

Background

Non-small cell lung cancer (NSCLC) is one of the leading causes of cancer mortality. MicroRNAs (miRNAs), small noncoding RNAs, regulate the expression of genes that play roles in human cancer via posttranscriptional inhibition.

Methods

To identify the potential miRNA biomarkers in NSCLC, we downloaded the miRNA expression profile (ID: GSE29248) of NSCLC from the Gene Expression Omnibus (GEO) database and analyzed the differentially expressed miRNAs in NSCLC tissue compared with normal control tissue. Then the targets of these differentially expressed miRNAs were screened and used in network construction and functional enrichment analysis.

Results

We identified a total of 17 miRNAs that showed a significantly differential expression in NSCLC tissue. We found that miR-34b and miR-520h might play important roles in the regulation of NSCLC, miR-22 might be a novel biomarker as an oncogene, and miR-448 might promote, while miR-654-3p prevents, NSCLC progression.

Conclusions

Our study may provide the groundwork for further clinical molecular target therapy experiments in NSCLC.

Lung cancer screening: the European perspective

European studies have contributed significantly to the understanding of lung cancer screening. Smoking within screening, quality of life, nodule management, minimally invasive treatments, cancer prevention programs, and risk models have been extensively investigated by European groups. Mortality data from European screening studies have not been encouraging so far, but long-term results of the NELSON study are eagerly awaited. Investigations on molecular markers of lung cancer are ongoing in Europe; preliminary results suggest they may become an important screening tool in the future.

Targeting LUNX inhibits non-small cell lung cancer growth and metastasis

There remains a great need for effective therapies for lung cancer, the majority of which are non-small cell lung cancers (NSCLC). Here, we report the identification of a novel candidate therapeutic target, LUNX, as a molecule overexpressed in primary NSCLC and lymph node metastases that is associated with reduced postoperative survival. Functional studies demonstrated that LUNX overexpression promoted lung cancer cell migration and proliferation by interactions with the chaperone protein 14-3-3. Conversely, LUNX silencing disrupted primary tumor growth, local invasion, and metastatic colonization. The finding that LUNX was expressed on cell membranes prompted us to generate and characterize LUNX antibodies as a candidate therapeutic. Anti-LUNX could downregulate LUNX and reduce lung cancer cell proliferation and migration in vitro. Administered in vivo to mice bearing lung cancer xenografts, anti-LUNX could slow tumor growth and metastasis and improve mouse survival. Together, our work provides a preclinical proof of concept for LUNX as a novel candidate target for immunotherapy in lung cancer.

[Lung cancer screening. What have we learnt for the practice so far?]

CLINICAL/METHODICAL ISSUE

Lung cancer is the most frequent cause of tumor-associated death and only has a good prognosis if detected at a very early tumor stage.

METHODICAL INNOVATIONS

For the first time the American National Lung Screening Trial (NLST) could prove that low-dose computed tomography (CT) screening is able to reduce lung cancer mortality by 20 %.

PERFORMANCE

To date, however, three much smaller and therefore statistically underpowered European trials could not confirm the positive results of the NLST. The results of the largest European trial NELSON are expected within the next 2 years. In addition, there are a number of open or not yet satisfactorily answered questions, such as the definition of the appropriate screening population, the management of nodules detected by screening, the effects of over-diagnosis and the risk of cumulative radiation exposure.

PRACTICAL RECOMMENDATIONS

The success of the NLST prompted several predominantly American professional societies to issue a positive recommendation about the implementation of lung cancer screening in a population at risk. However, potentially conflicting results of European studies and a number of not yet optimized issues justify caution and call for a pooled analysis of European studies in order to provide statistically sound results and to ensure a high efficiency of screening with respect to the radiation applied, mental and physical patient burden and, last but not least, the financial efforts.

The Value of Lung Cancer CT Screening: It Is All about Implementation

Hospitals have been gradually implementing new lung cancer CT screening programs following the release of the U.S. Preventive Services Task Force grade B recommendation to screen individuals at high risk for lung cancer. Policy makers have legitimately questioned whether adoption of CT screening in the community will reproduce the mortality benefits seen in the National Lung Screening Trial (NLST) and whether the benefits of screening will justify the potentially high costs. Although three annual CT screening exams proved cost-effective for the patient population enrolled in the NLST, uncertainty still exists about whether CT screening will be cost-effective in practice. The value of CT screening will depend largely on the strategies used to implement it. This manuscript reviews the current reimbursement policies for CT screening and explains the relationship between implementation strategies and screening value on the basis of the NLST cost-effectiveness analysis and other published data. A subsequent discussion ensues about the potential implementation inefficiencies that can negatively affect the value of CT screening (e.g., selection of low-risk individuals for screening, inappropriate follow-up visits for screening-detected lung nodules, failure to offer smoking cessation interventions, and overuse of medical resources for clinically irrelevant incidental findings) and the actions that can be taken to mitigate these inefficiencies and increase the value of screening.

Phase II study on dose escalating schedule of paclitaxel concurrent with radiotherapy in treating patients with locally advanced non-small cell lung cancer

OBJECTIVE

To evaluate clinical efficacy of a dose escalating schedule of paclitaxel concurrent with radiotherapy in treating patients with locally advanced non-small cell lung (NSCLC).

METHODS

Patients with locally advanced NSCLC were treated with conventional fractionated radiotherapy or three dimensional conformal radiotherapy (3 DCRT), concurrently with a dose escalating schedule of paclitaxel. All patients were divided into three groups, A with paclitaxel 30 mg/m2, B with paclitaxel 60 mg/m2 and C with paclitaxel 90 mg/m2. Paclitaxel was repeated every week for a total of 4 or 6 weeks.

RESULTS

Among 109 patients, response rates were 68.8%, 71.1% and 71.8% (p>0.05) for group A (n=32), B (n=38), and C (n=39) respectively. Accordingly, disease control rates were 81.3%, 81.6% and 82.1% (p>0.05). Progression-free survival time was 8.0 ± 5.0 months, 11.6 ± 6.1 months, and 14.8 ± 7.9 months (p<0.05), respectively. Overall survival time was 15. 4 ± 7.6 months, 18.2 ± 8.0 months, and 22.0 ± 7.6 months (p<0.05), one-year survival rates were 62.5%, 73.1% and 90.0% (p>0.05) and two-year survival rates were 31.3%, 38.5% and 50.0% (p<0.05) . Main side-effects were bone marrow suppression, radiation related esophagitis and gastrointestinal reaction.

CONCLUSION

In treating patients with NSCLC, concurrent chemoradiotherapy with paclitaxel improves early response compared with conventional fractionated radiotherapy or 3 DCRT. The survival rate was improved with the addition of paclitaxel, but there was an increase in adverse reactions when the dose of paclitaxel was increased.

(99m)Tc-3P-RGD2 micro-single-photon emission computed tomography/computed tomography provides a rational basis for integrin αvβ3-targeted therapy

PURPOSE

This study was to demonstrate the utility of (99m)Tc-3P-RGD2 micro-single-photon emission computed tomography/computed tomography (SPECT/CT) for the integrin αvβ3 expression quantification in NCI-H446 and A549 lung cancer xenografts.

MATERIALS AND METHODS

(99m)Tc-3P-RGD2 was prepared with high radiochemical purity (97%±2%) and showing high in vitro stability. The in vitro affinities of (99m)Tc-3P-RGD2 to NCI-H446 and A549 tumor cells were analyzed with γ-counter, while the in vivo uptakes in NCI-H446 and A549 xenografts were evaluated with micro-SPECT/CT. The region of interest was drawn over the tumor site and contralateral muscle on the SPECT/CT image, and the tumor to nontumor (T/NT) ratio was calculated to estimate αvβ3 expression and tumor uptake. The expressions of integrin αvβ3 in vitro and in vivo were analyzed using a flow cytometer and immunofluorescence.

RESULTS

Micro-SPECT/CT demonstrated focal uptake in the tumors. T/NT ratio in NCI-H446 xenografts was significantly higher compared with the A549 tumor model, as 5.92±0.82 and 3.62±0.91, respectively, with p<0.05. In addition, integrin αvβ3 expression in NCI-H446 cells was significantly higher compared with the A549 cells, which was consistent with the imaging data. A linear relationship was observed between (99m)Tc-3P-RGD2 uptake and αvβ3 expression (R(2)=0.7667, p<0.001).

CONCLUSION

(99m)Tc-3P-RGD2 SPECT/CT could be used to quantify integrin αvβ3 expression within tumors, providing a rational basis for integrin αvβ3-targeted cancer therapy.

Screening for lung cancer

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the current data about low-dose computed tomography (LD-CT) lung cancer screening.

RECENT FINDINGS

The National Lung Screening Trial (NLST) was the first study that provided statistical evidence that LD-CT screening for lung cancer significantly reduces lung cancer mortality by 20%. Three statistically underpowered European trials could not confirm the positive effect of LD-CT screening on lung cancer mortality. Major obstacles in lung cancer screening are overdiagnosis and the large number of false-positive results. In the NLST, more than 24% of the screens were positive, most of which (96.4%) proved to be benign in nature. Optimized protocols for the workup of detected nodules may help to reduce the number of false-positive screens.

SUMMARY

Currently, the NLST is the only sufficiently powered trial to report a lower mortality rate with LD-CT screening. Long-term follow-up data are still anticipated on the European screening trials. Furthermore, data on the extent of the potential dangers of LD-CT screening, such as overdiagnosis, false-positive results, and the effect of cumulative radiation dose, have yet to be investigated thoroughly.

Risk factors of recurrence for resected T1aN0M0 invasive lung adenocarcinoma: a clinicopathologic study of 177 patients

Background

This study aimed at identifying risk factors of recurrence for completely resected pathologic T1aN0M0 lung adenocarcinomas.

Methods

We reviewed the records of 177 T1aN0M0 invasive adenocarcinoma patients, and re-classified achieved surgical specimens according to the new International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) lung adenocarcinoma classification. Impact on recurrence-free survival (RFS) for age, gender, smoking history, lymphovascular invasion (LVI) and new classification was analyzed by log-rank test and Cox regression. Two existing prognostic grouping schemes of new classification were compared, and subsequently, the correlation of high-grade group in the better prognostic grouping model with clinical data was investigated statistically.

Results

The 5-year recurrence-free rate was 83.7%. The LVI and new adenocarcinoma classification were significantly associated with 5-year RFS (P = 0.012; P = 0.022, respectively). The designation of papillary predominant subtype in the low-grade group, along with lepidic- and acinar predominant subtype had more prognostic significance than the model of combining papillary-, solid- and micropapillary predominant subtypes as the high-grade group (P = 0.005 versus P = 0.181). This high-grade group has increased risk of recurrence in a multivariate Cox regression (adjusted HR 2.815, 95% CI: 1.239 to 6.397, P = 0.013), and is associated significantly more with male gender (adjusted OR 2.214, 95% CI: 1.050 to 4.668, P = 0.037), and, with borderline significance, the presence of LVI (adjusted OR 2.091, 95% CI: 0.938 to 4.662, P = 0.071).

Conclusions

Our results showed that the solid- and micropapillary predominant subtype of IASLC/ATS/ERS classification remains the only risk factor for post-operative recurrence of T1aN0M0 adenocarcinomas, suggesting that they can be indicators of aggressive tumor behaviors.

Transforming growth factor-β-induced miR‑143 expression in regulation of non-small cell lung cancer cell viability and invasion capacity in vitro and in vivo

Altered expression of miRNAs contributes to development and progression of non-small cell lung cancer (NSCLC), while transforming growth factor-β (TGF-β) promotes NSCLC cell epithelial-mesenchymal transition. This study aimed to investigate the effects of TGF-β-induced miR‑143 expression in regulation of NSCLC cell viability, invasion capacity in vitro, and xenograft formation and growth in nude mice. NSCLC A549 cells treated with TGF-β were subjected to miRNA microarray analysis and miR‑143 was selected for further study of tumor cell viability, wound healing, invasion capacity in vitro, and tumor growth in nude mice. TGF-β treatment upregulated expression of 16 miRNAs and downregulated expression of 42 miRNAs in A549 cells. qRT-PCR and in situ hybridization data showed that miR‑143 was significantly downregulated in 24 NSCLC and lymph node metastatic tumor tissues, but upregulated by TGF-β treatment in A549 cells. In vitro experiments showed that miR‑143 expression could significantly suppress NSCLC cell viability and invasion capacity, and nude mouse experiments confirmed the in vitro data. Bioinformatic data predicted that Smad3, CD44 and K-Ras were the targeting genes of miR‑143. TGF-β-induced miR‑143 expression was associated with suppressed expression of Smad3, CD44, and K-Ras. This study sheds light on the role of TGF-β in upregulation of miR‑143 and the role of miR‑143 in NSCLC progression, indicating that the target of miR‑143 expression could be further studied as a novel therapeutic strategy for future control of NSCLC.