The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer

Development and validation of a prognostic index for survival in non-small cell lung cancer: Results from a Tunisian cohort study

INTRODUCTION

Despite the continuous efforts made with the TNM system, the issue of heterogeneity of prognosis within the stages of non-small cell lung cancer (NSCLC) could not be resolved. Our aim was to identify prognostic factors and develop an index to predict NSCLC survival with greater accuracy.

METHODS

We conducted a survival study over 5 years on patients with NSCLC. Kaplan-Meier analysis followed by Cox regression modelling were used. Prognostic indices were derived, using either an additive or a multiplicative pattern, and were compared by their receiver operating characteristics (ROC) curves. We then proceeded to a risk stratification and validation of the index on the derivation cohort.

RESULTS

Two hundred and sixty-two NSCLC patients were included. Two models were constructed, using the following nine variables as prognostic factors: age, performance status, haemoglobin level, leucocyte count, calcium, lactate dehydrogenase, alkaline phosphatase levels, histological type and TNM stage. Four prognostic indices were derived, and the best one was picked and validated on a population of five risk groups. The higher the risk group, the shorter the survival.

CONCLUSIONS

This novel and simple prognostic tool could predict survival more accurately in patients with NSCLC.

Effect of postoperative systemic therapy on pulmonary adenocarcinoma with unexpected pleural spread detected during thoracotomy or thoracoscopy

Background

Occasionally, malignant pleural disease is only detected unexpectedly during surgery in patients with pulmonary adenocarcinoma. Previous studies mostly focused on the role of main tumor resection on patient's outcome, barely addressing the position of postoperative systemic therapy.

Methods

The medical records of 5321 non-small cell lung cancer patients who underwent thoracic surgery between January 1990 and December 2012 were reviewed. Pulmonary adenocarcinoma patients with unexpected pleural spread noted during surgery were included. The clinical and postoperative treatment variables were assessed for correlation with overall survival.

Results

In 134 patients identified, main tumor resection was performed in 87 (64.9%) patients, while 89 (66.4%) and 57 (42.5%) patients received postoperative chemotherapy and epidermal growth factor receptor- tyrosine kinase inhibitor (EGFR -TKI) therapy, respectively. Overall, the 5-year survival rate was 30.2% and median survival time was 29.3 months. Multivariate analysis showed main tumor resection and EGFR-TKI therapy were associated with better survival. Mutational status of EGFR was available in 57 patients and 43 (75.4%) had activating mutations. Resection of the main tumor conferred a better outcome in patients without EGFR mutation or with unknown EGFR mutation status and had not been treated with EGFR-TKI therapy (P = 0.003), but not in those with activating EGFR mutation and had been treated with EGFR-TKI (P = 0.857).

Conclusions

In pulmonary adenocarcinoma patients with unexpected pleural spread detected during surgery, main tumor resection and EGFR-TKI therapy correlated with better survival. Identifying EGFR mutation status before surgery can provide useful information for clinical decision during surgery.

Systematic Correlation Analyses of Circulating Tumor Cells with Clinical Variables and Tumor Markers in Lung Cancer Patients

Measurement of circulating tumor cells (CTC) offers promise as a clinical biomarker to monitor disease status, therapeutic response, and progression in cancer patients. However, its clinical value in lung cancer patients has not been fully explored. We systematically evaluate the association of CTCs with clinical variables and tumor markers in a cohort of lung cancer patients. Using the CELLSEARCH System, CTCs were detected in both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) patients prior to therapy. Univariate analysis revealed that detection of CTC was related to histology, stage, tumor size, invasiveness, and lymphatic metastasis. CTCs were associated with distant metastases in NSCLC, but not in SCLC. Using multivariate analysis, we found that CTCs were independently correlated with disease stage, SCLC, and elevated serum neuron-specific enolase (NSE). These data suggest that CTCs are more likely to be detected in patients with stage IV disease and with SCLC, and that elevated serum NSE predicts the presence of CTCs.

The Role of Thoracic Surgery in the Therapeutic Management of Metastatic Non-Small Cell Lung Cancer

INTRODUCTION

In most patients with NSCLC, the disease is diagnosed in an advanced stage, the prognosis is poor, and survival is typically measured in months. Standard therapeutic treatment regimens for patients with stage IV NSCLC typically include chemotherapy and palliative radiation. Despite newer regimens that may include molecularly targeted therapy and immunotherapy, the overall 5-year survival for stage IV disease remains low at 4% to 6%. Although therapeutic surgery is performed in a minority of cases, accumulating data suggest that thoracic surgery may play several beneficial roles for these patients.

METHODS

In this narrative review, we summarize the literature on surgical intervention in the multimodality management of stage IV NSCLC, focusing on the potential evidence for and against therapeutic or curative intent procedures to affect outcomes for patients with oligometastatic disease and pleural metastasis.

RESULTS

In selected patients, surgical resection can result in a 5-year survival rate of 30% to 50%, but this is heavily influenced by the presence of mediastinal nodal disease, which should be evaluated before therapeutic surgical procedures are undertaken. Additionally, diagnostic or palliative surgical procedures can play an important role in the personalized management of stage IV disease. These data suggest that for carefully selected patients with advanced stage NSCLC, surgical intervention can be an important component of combined modality treatment.

CONCLUSIONS

Given the advances in molecular targeted therapy and immunotherapy, further studies should focus on the possible use of surgery as a strategy of therapeutic "consolidation" for appropriately selected patients with stage IV NSCLC who are receiving combined modality care.

Application of the new 8th TNM staging system for non-small cell lung cancer: treated with curative concurrent chemoradiotherapy

BACKGROUND

The eighth tumor, node, metastasis (TNM) staging system (8-TNM) for non-small cell lung cancer (NSCLC) was newly released in 2015. This system had limitation because most patients included in the analysis were treated with surgery. Therefore, it might be difficult to reflect prognosis of patients treated with curative concurrent chemoradiotherapy (CCRT). Purpose of this study was to investigate clinical impact of the newly published 8-TNM compared to the current seventh TNM staging system (7-TNM) for locally advanced NSCLC patients treated with CCRT.

METHODS

New 8-TNM was applied to 64 patients with locally advanced NSCLC who were treated with CCRT from 2010 to 2015. Changes in T category and stage group by 8-TNM were recorded and patterns of change were evaluated. Survival was analyzed according to T category, N category, and stage group in each staging system, respectively.

RESULTS

Among the total of 64 patients, 38 (59.4%) patients showed change in T category while 22 (34.4%) patients showed change in stage group using 8-TNM compared to 7-TNM. Survival curves were significantly separated in the 8-TNM stage group (p = 0.001) than those in the 7-TNM (p > 0.05). Especially, survival of newly introduced stage IIIC by 8-TNM was significantly lower than that of others. On the other hand, there was no significant survival difference between T categories in each staging system.

CONCLUSIONS

Subdivision of stage III into IIIA, IIIB, and IIIC by 8-TNM for patients treated with CCRT better reflected prognosis than 7-TNM. However, subdivision of T category according to tumor size in 8-TNM might be less significant.

Evaluation of the 7th and 8th editions of the AJCC/UICC TNM staging systems for lung cancer in a large North American cohort

Purpose

The new 8^th American Joint Committee on Cancer (AJCC)/International Union for Cancer Control (UICC) lung cancer staging system was developed and internally validated using the International Association for the Study of Lung Cancer (IASLC) database, but external validation is needed. The goal of this study is to validate the discriminatory ability and prognostic performance of this new staging system in a larger, independent non-small cell lung cancer (NSCLC) cohort with greater emphasis on North American patients.

Methods

A total of 858,909 NSCLC cases with one malignant primary tumor collected from 2004 to 2013 in the National Cancer Database (NCDB) were analyzed. The primary coding guidelines of the Collaborative Staging Manual and Coding Instructions for the new 8^th edition AJCC/UICC lung cancer staging system was used to define the new T, M and TNM stages for all patients in the database. Kaplan-Meier curves, Cox regression models and time-dependent receiver operating characteristics were used to compare the discriminatory ability and prognostic performance of the 7^th and the revised 8^th T, M categories and overall stages.

Results

We demonstrated that the 8^th staging system provides better discriminatory ability than the 7^th staging system and predicts prognosis for NSCLC patients using the NCDB. There were significant survival differences between adjacent groups defined by both clinical staging and pathologic staging systems. These staging parameters were significantly associated with survival after adjusting for other factors.

Conclusions

The updated T, M, and overall TNM stage of the 8^th staging system show improvement compared to the 7^th edition in discriminatory ability between adjacent subgroups and are independent predictors for prognosis.

Evaluation of erlotinib for the treatment of patients with non-small cell lung cancer with epidermal growth factor receptor wild type

Erlotinib is one of the treatment choices for patients with advanced non-small cell lung cancer (NSCLC), regardless of the epidermal growth factor receptor (EGFR) mutation status. However, its efficacy for the treatment of patients with NSCLC with EGFR wild type or who are beyond the usage of gefitinib remains controversial. The present study therefore retrospectively assessed the efficacy of erlotinib in patients with wild type EGFR who had previously undergone gefitinib therapy. A total of 222 patients with NSCLC who received chemotherapeutic treatment with erlotinib between July 2007 and February 2013 were evaluated. The background variables, response rates, progression-free survival (PFS) and overall survival rates were retrospectively analyzed. The male/female ratio of patients was 103/119, and patients had a median age of 63 years (range, 33-95 years). A total of 10 of the 222 patients had clinical stages IIIB/IV, 191 had adenocarcinoma, 5 had large cell carcinoma, 10 had squamous cell carcinoma and 6 had NSCLC of a variety not otherwise specified. The EGFR mutation was positive, wild type or unknown in 95, 52 and 75 patients, respectively. In the 52 patients with EGFR wild type, there were 3 partial responders, 25 with stable disease and 24 with progressive disease, for a response rate of 6% [95% confidence interval (CI), 1.3-15%]. The median PFS of EGFR wild type and positive were 1.1 months (95% CI, 1.04-1.16 months) and 5.42 months (95% CI, 5.43-5.68 months), respectively. The results of the study demonstrated that erlotinib is not sufficiently effective for patients with NSCLC who possess the EGFR wild type status.

Ablative Therapy for Oligometastatic Non-Small Cell Lung Cancer

The oligometastatic state represents a distinct entity among those with metastatic disease and consists of patients with metastases limited in number and location, representing an intermediate state between locally confined and widely metastatic cancer. Although similar, "oligorecurrence" (limited number of metachronous metastases under conditions of a controlled primary lesion) and "oligoprogressive" (disease progression at a limited number of sites with disease controlled at other disease sites) states are distinct entities. In non-small cell lung cancer (NSCLC), the oligometastatic state is relatively common, with 20% to 50% of patients having oligometastatic disease at diagnosis. This subgroup of patients when receiving ablative therapy, such as surgery or stereotactic body radiation radiotherapy, can obtain markedly long progression-free and overall survival. The role of radical treatment for intracranial oligometastases is well established. Fewer data exist regarding radical treatment of extracranial metastases in lung cancer; however, retrospective series using surgery or stereotactic body radiotherapy for extracranial oligometastatic disease in NSCLC have shown excellent local control, with a suggestion of improvement in progression-free survival. In the present report, we have reviewed the data on the treatment of brain metastases in oligometastatic NSCLC and the results of ablative treatment of extracranial sites. Recently, the first randomized trial comparing ablative treatment versus control in oligometastatic disease was reported, and those data are reviewed in the context of smaller series. Finally, areas of controversy are discussed and a therapeutic approach for patients with oligometastatic disease is proposed.

Surgical treatment in non-small cell lung cancer with pulmonary oligometastasis

BACKGROUND

Previous studies have demonstrated survival benefits for local treatment in solitary metastatic non-small cell lung cancer (NSCLC).This study aimed to investigate the effect of local surgery for NSCLC with pulmonary oligometastasis.

METHODS

This study included 21 patients of NSCLC with pulmonary oligometastasis between January 2003 and December 2013, which were divided into two groups, group A (11 cases) for local surgery and group B (10 cases) for systematic chemotherapy, compared the median survival time (MST) and 5-year survival rate between the two groups, and analyzed the impact of the pathological types, the TNM and pN stage of primary tumor, the site, and the mode and number of oligometastatic nodule on group A.

RESULTS

The MST of group A and B were 37 and 11.6 months respectively, 5-year survival rates were 18.2 and 9.1% respectively (p < 0.05). Patients with single nodule, oligo-recurrence, primary tumor of pN0, TNM stage I or II obtained higher survival rate than those with multiple nodules, sync-oligometastases, pN1-2, stage III or IV in group A (p < 0.05). There was no significant survival time difference among pathological types of primary tumor and oligometastatic site (p > 0.05).

CONCLUSION

Local surgery significantly prolonged the overall survival time and 5-year survival rate of primary NSCLC with pulmonary oligometastasis.

[New TNM classification of non-small cell lung cancer]

Initial staging is a key part of the initial evaluation of non-small cell lung cancer. It relies on the 7th edition of the TNM classification. Proposals have been recently developed for the 8th edition of the classification, which is due to be enacted in early 2017. Among these proposals, the weight of tumor size has been increased and new N descriptors have been introduced to further describe N category depending on the number station involved. Regarding M descriptors, oligometastatic disease is distinguished from multiple distant extrathoracic metastases.

Programmed cell death-ligand 1 (PD-L1) expression and fibroblast growth factor receptor 1 (FGFR1) amplification in stage III/IV lung squamous cell carcinoma (SQC)

Background

This study was conducted to explore programmed cell death‐ligand‐1 (PD‐L1) expression and fibroblast growth factor receptor 1 (FGFR1) amplification in stage IIIB/IV lung squamous cell carcinoma (SQC). Correlations between PD‐L1 and FGFR1, and with clinicopathological characteristics, efficacy of platinum‐based chemotherapy, and prognosis were analyzed.

Methods

One hundred and twenty‐eight consecutive stage III/IV SQC patients were enrolled in this study from 2009 to 2014. Seventy‐eight patients received platinum‐based chemotherapy. Immunohistochemistry was used to assess PD‐L1 expression and fluorescence in situ hybridization was applied to detect FGFR1 amplification.

Results

PD‐L1 expression was detected in 61.7% (79/128) of lung SQC patients. Smokers had significantly higher PD‐L1 expression rates than non‐smokers (66.1% vs. 44.0%, P = 0.042, respectively). The objective response and disease control rates for platinum‐based chemotherapy were not significantly different between PD‐L1 negative and positive patients (43.3% vs. 36.2%, P = 0.434; 80.0% vs. 78.7% P = 0.840, respectively); however, overall survival in PD‐L1‐negative patients was significantly longer than in PD‐L1‐positive patients (41.5 vs. 19.3 months, P = 0.001). Twenty‐five percent (32/128) of patients displayed FGFR1 amplification, with a lower rate in stage III patients compared to stage IV (17.1% vs. 36.5%, P = 0.013, respectively). There was no significant difference in FGFR1 amplification levels between overall response, disease control or overall survival rates. No correlation was observed between PD‐L1 expression and FGFR1 amplification (P = 0.916).

Conclusion

PD‐L1 expression may function as a prognostic factor in Chinese stage III/IV SQC patients. FGFR1 amplification is more prevalent in late stage SQC patients but does not predict chemotherapy response. There is no apparent correlation between PD‐L1 expression and FGFR1 amplification.

Prognostic Impact of Newly Proposed M Descriptors in TNM Classification of Non-Small Cell Lung Cancer

INTRODUCTION

The International Association for the Study of Lung Cancer recently proposed new M descriptors for the next edition of the TNM classification for NSCLC, subdividing the current M1b category into two subcategories: M1b, which indicates a solitary extrathoracic metastasis in a single organ, and M1c, which indicates multiple extrathoracic metastasis. The purpose of this study was to validate the prognostic value of the newly proposed M descriptors in an independent cohort with multivariate and subgroup analysis.

METHODS

A total of 1024 patients in a consecutive lung cancer database who had stage IV NSCLC treated between 2011 and 2014 were analyzed. Newly proposed M staging was used for classification and comparison of survival. Adjustment for other clinical covariates and subgroup analysis was conducted.

RESULTS

According to the newly proposed M descriptors, 262 patients (25.6%), 152 patients (14.8%), and 610 patients (59.6%) were classified into the subgroups M1a, M1b, and M1c, respectively. The median overall survival times were 22.5, 17.8, and 13.6 months for the M1a, M1b, and M1c groups, respectively (p < 0.001). After adjustment for other covariates, Cox proportional hazards regression revealed statistically significantly shorter overall survival for the M1b group than for the M1a group (hazard ratio = 1.30; 95% confidence interval: 1.03-1.65, p = 0.03) and for the M1c than the M1b group (hazard ratio = 1.57; 95% confidence interval: 1.28-1.93, p < 0.001). These differences showed a consistent tendency regardless of pathologic and molecular subtypes.

CONCLUSIONS

The newly proposed M descriptors have prognostic value in patients with stage IV NSCLC.

The role of surgical intervention in lung cancer with carcinomatous pleuritis

Patients with non-small cell lung cancer (NSCLC) associated with carcinomatous pleuritis are currently classified as having stage IV disease per the 7^th edition of the tumor-node-metastasis (TNM) system, which means that the disease is deemed incurable. In fact, the 5-year survival rate of these patients was only 2% in a large global cohort collected by the International Association for the Study of Lung Cancer. However, patients with carcinomatous pleuritis have heterogeneous conditions. Some have minimal pleural effusion, which is first detected at thoracotomy; some have numerous pleural nodules without any effusion; and others have massive effusion and nodules with symptoms. Several investigators have reported the contribution of surgical intervention to favorable outcomes of patients with carcinomatous pleuritis first detected at thoracotomy. These reports show a relatively higher 5-year survival rate of 15% to 37%. The extrapleural pneumonectomy (EPP) is a radical surgical procedure that is commonly employed in the treatment of malignant pleural mesothelioma. Two authors reported that they have successfully performed EPPs for the treatment of patients with carcinomatous pleuritis. Their 5-year survival rates were estimated to be 22% and 61%, a significantly improved outcome. Although the development of chemotherapeutic agents, including molecular targeted drugs, might have the potential to prolong the survival of patients with advanced lung cancer, surgical interventions including EPP might have a role in improving the survival of patients with carcinomatous pleuritis of minimal disease and those without massive effusion or numerous pleural nodules.

The Different Effect of VEGF Polymorphisms on the Prognosis of Non-Small Cell Lung Cancer according to Tumor Histology

Vascular endothelial growth factor (VEGF) contributes to tumor angiogenesis. The role of VEGF single nucleotide polymorphisms (SNPs) in lung cancer susceptibility and its prognosis remains inconclusive and controversial. This study was performed to investigate whether VEGF polymorphisms affect survival outcomes of patients with early stage non-small cell lung cancer (NSCLC) after surgery. Three potentially functional VEGF SNPs (rs833061T>C, rs2010963G>C, and rs3025039C>T) were genotyped. A total of 782 NSCLC patients who were treated with surgical resection were enrolled. The association of the SNPs with overall survival (OS) and disease free survival (DFS) was analyzed. In overall population, none of the three polymorphisms were significantly associated with OS or DFS. However, when the patients were stratified by tumor histology, squamous cell carcinoma (SCC) and adenocarcinoma (AC) had significantly different OS (Adjusted hazard ratio [aHR] = 0.76, 95% CI = 0.56-1.03 in SCC; aHR = 1.33, 95% CI = 0.98-1.82 in AC; P for heterogeneity = 0.01) and DFS (aHR = 0.75, 95% CI = 0.58-0.97 in SCC; aHR = 1.26, 95% CI = 1.00-1.60 in AC; P for heterogeneity = 0.004) according to the rs833061T>C genotypes. Our results suggest that the prognostic role of VEGF rs833061T>C may differ depending on tumor histology.

Relationship between gene mutation and lung cancer metastasis

Cancer is a genetic disease occurring through a multi-step process. Many important genes responsible for the genesis of various cancers have been discovered, their mutations precisely identified and the pathways through which they act characterized. One question that remains unanswered is whether the development of new, more specific therapeutic agents is the best way to minimize cancer morbidity and mortality in the long-term. Metastasis is the relentless pursuit of cancer to escape its primary site and colonize distant organs. Phenotypic changes during cancer progression reflect the sequential accumulation of genetic alterations, which endow cancer cells with the ability to undergo their own divergent evolution and create distinct metastatic species. In order to understand this process, it is crucial to identify genes whose alterations accumulate during cancer progression and correlate with metastatic phenotypes of cancer cells.

Should primary tumor be resected for non-small cell lung cancer with malignant pleural disease unexpectedly found during operation?-a systemic review and meta-analysis

BACKGROUND

Non-small cell lung cancer (NSCLC) with malignant pleural disease (MPD) was considered to be contraindication for surgery, but sometimes MPD was unexpectedly found intraoperatively. There was no consensus on the role of surgical intervention on the primary tumor in patients with MPD. The object of this research was to assess whether exairesis of primary tumor could prolong survival time.

METHODS

A systemic research of literature was performed on the databases of PubMed, Embase and Web of Science. Literatures examining surgical benefit or other prognostic factors among NSCLC patients with MPD unexpectedly found during operations were included. Hazard ratio (HR) with 95% confidence interval (95% CI) as well as P value is applied for prognostic role of surgical removal or other potential factors.

RESULTS

Nine articles with a total number of 861 patients fulfilled the eligibility criteria, five of them compared the survival benefit between exploration and resection among NSCLC patients with unexpected MPD, and other studies also investigated the prognostic factors in these patients. There was a significant survival benefit in patients with primary tumor resection (HR =0.443; 95% CI: 0.344-0.571; P<0.001). This role was further detected when stratified by analysis method and ethnicity. Female was an independent favorable predicted factor (HR =0.788; 95% CI: 0.648-0.959; P=0.017) while higher N-stage was a risk factor (HR =1.879; 95% CI: 1.307-2.701; P=0.001). Among patients who received primary tumor resection, higher N-stage was also a risk factor for poorer survival (HR =2.021; 95% CI: 1.496-2.730; P<0.001).

CONCLUSIONS

Resection of primary tumor, female and lower-N stage were suggested to be beneficial prognostic factor among NSCLC patients who were detected with MPD for the first time in the operating room. And among these people who received surgical removal of primary tumor, lower N-stage also indicated a better survival.

The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M Descriptors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer

INTRODUCTION

The aim of this study is to analyze all metastatic (M) categories of the current tumor, node, and metastasis (TNM) classification of lung cancer with the objective of providing suggestions for modifications of the M component in the next edition of the TNM classification for lung cancer.

METHODS

The new International Association for the Study of Lung Cancer lung cancer database was created from 94,708 patients diagnosed as having lung cancer between 1999 and 2010. Including further patients submitted through the electronic data capture system to Cancer Research and Biostatistics until 2012, all together 1059 non-small-cell lung cancer cases were available for a detailed analysis of the clinical M categories. Overall survival was calculated using the Kaplan-Meier method, and prognosis was assessed using a Cox proportional hazards regression analysis.

RESULTS

No significant differences were found among the M1a (metastases within the chest cavity) descriptors. However, when M1b (distant metastases outside the chest cavity) were assessed according to the number of metastases, tumors with a single metastasis in a single organ had significantly better prognosis than those with multiple metastases in one or several organs.

CONCLUSIONS

In this revision of the TNM classification, cases with pleural/pericardial effusions, contralateral/bilateral lung nodules, contralateral/bilateral pleural nodules, or a combination of multiple of these parameters should continue to be grouped as M1a category. Single metastatic lesions in a single distant organ should be newly designated to the M1b category. Multiple lesions in a single organ or multiple lesions in multiple organs should be reclassified as M1c category. This new division can serve as a first step into providing rational definitions for an oligometastatic disease stage in non-small-cell lung cancer in the future.

Impact of a Contralateral Tumor Nodule on Survival in Non-Small-Cell Lung Cancer

INTRODUCTION

Contralateral lung tumors in non-small-cell lung cancer (NSCLC) are classified as stage M1a yet may represent hematogenous metastases or synchronous primary tumors. The impact of these tumors on overall survival (OS) is poorly understood. Here, we aim to determine whether NSCLC patients with M1a disease due only to a contralateral tumor nodule exhibit a favorable prognosis relative to other M1a or M1b patients.

METHODS

Retrospective evaluation of the impact of contralateral tumor nodules on OS in NSCLC stratified by primary tumor size and N stage attained from Surveillance, Epidemiology, and End Results database.

RESULTS

Of 173,640 patients, 5161 M1a-contra patients were identified. Median and 3-year OS for these patients exceeded that of patients with M1b (p < 0.0001) or other M1a disease (p < 0.0001). Primary tumor size and N stage were strongly associated with OS in M1a-contra patients. Three-year OS demonstrated a delayed convergence between M1a-contra and other M1a patients with primary tumors greater than or equal to 3 cm or mediastinal lymph node involvement. Proportional hazard modeling indicated that T1-2N0-1M1a-contra patients exhibit OS not significantly different (p = 0.258) from that predicted with comparable T and N stage disease plus a second early-stage primary.

CONCLUSIONS

Contralateral tumors in NSCLC carry a more favorable prognosis than other M1a or M1b disease. Primary tumor size and N stage may help distinguish M1a-contra patients with hematogenous metastasis from those with a synchronous, second primary.

Detecting Pulmonary Nodules in Lung Cancer Patients Using Whole Body FDG PET/CT, High-resolution Lung Reformat of FDG PET/CT, or Diagnostic Breath Hold Chest CT

RATIONALE AND OBJECTIVES

Pulmonary nodules can be missed on the non-breath hold computed tomography (CT) portion of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), and for this reason prior studies have advocated for routinely performing dedicated breath hold CT of the chest in addition to PET/CT for routine staging of malignancy. We evaluated the rate of pulmonary nodule detection on standard CT images from whole body PET/CT studies (WB-PET/CT), high-resolution lung reconstruction CT images from PET/CT studies (HR-PET/CT), and diagnostic breath hold chest CT (BH-CT).

MATERIALS AND METHODS

A cohort of 25 patients was identified who had a history of lung cancer as well as a PET/CT staging or restaging scan and BH-CT within 30 days of each other. All PET/CTs included a set of CT images using a soft tissue algorithm filter and 3.75- to 5-mm slice thickness, as well as high-resolution reformats with a sharp reconstruction filter and 2-mm slice thickness. The CT images from WB-PET/CT, HR-PET/CT, and BH-CT were reviewed by three radiologists. Significance was analyzed by two-way repeated measures analysis of variance.

RESULTS

There were 2.84 nodules found per patient with WB-PET/CT, 3.85 nodules with HR-PET/CT, and 3.91 nodules with BH-CT. When only nodules less than or equal to 8 mm in size were considered, WB-PET/CT also demonstrated significantly fewer nodules (1.98) compared to the HR-PET/CT (2.94) or a BH-CT (2.86) (P < 0.001). No difference in detection rate was noted between the two higher resolution modalities.

CONCLUSIONS

More pulmonary nodules are detected on the CT portion of PET/CT studies when high-resolution reformatted images are created and reviewed. The ability to detect nodules with the reformatted images was indistinguishable from dedicated BH-CT. Overall, high-resolution reformats of PET/CT images of the lungs can increase the sensitivity for pulmonary nodule detection, approaching that of dedicated BH-CT. These data suggest that if HR-PET/CT reformats are used, additional dedicated BH-CT is unnecessary for routine staging of lung cancer.

Does Lymph Node Metastasis Have a Negative Prognostic Impact in Patients with NSCLC and M1a Disease?

OBJECTIVES

Patients with NSCLC with M1a disease regardless of lymph node status were categorized as stage IV. This study aims to investigate whether the N descriptors in M1a patients could provide clinical information.

METHODS

Overall, 39,731 patients with NSCLC with M1a disease were identified from the Surveillance, Epidemiology, and End Results database during 2005-2012. Lung cancer-specific survival (LCSS) was compared among M1a patients stratified by N stage. A Cox proportional hazards regression model was applied to evaluate the prognostic factors. Statistical analyses were performed in all subgroups.

RESULTS

M1a patients without lymph node involvement had the best LCSS, followed by patients with N1 disease; no difference in LCSS was observed between N2 and N3 disease (N0 versus N1, p < 0.001; N1 versus N2, p < 0.001; and N2 versus N3, p = 0.478). Similarly, this trend was observed when patients were subdivided into two temporal cohorts (2005-2008 and 2009-2012) and also when M1a disease was subdivided into contralateral pulmonary nodules and pleural dissemination (malignant pleural effusion [or pericardial effusion] and pleural nodules). In addition, a difference in LCSS between N2 and N3 disease was observed in patients with malignant pleural nodules (p = 0.003). Multivariate analysis showed that lymph node involvement was an independent prognostic factor for M1a patients, and this result was also noticed in all subgroups.

CONCLUSIONS

These results provide preliminary evidence that lymph node stage may have clinical significance among patients with NSCLC with M1a disease, adding prognostic information.

[Revision of the TNM Stage Grouping in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer]

目前临床使用的肺癌分期是国际抗癌联盟（Union for International Cancer Control, UICC）于2009年1月颁布的第七版TNM分期。近年来，随着肺癌诊断技术的提高以及个体化治疗、分子靶向治疗等精准治疗模式的改变，肺癌的生存率及预后也有了明显的提高，旧的分期标准已难以适应当前的快速发展的临床需求。因此国际肺癌研究学会（International Association for the Study of Lung Cancer, IASLC）2015年对肺癌分期系统进行了更新，其修订稿发表于《Journal of Thoracic Oncology》，新版分期计划于2017年1月正式颁布实施。新分期标准采纳了来自16个国家的35个数据库，包含了自1999年-2010年间新发病的94, 708例肺癌病例。新版分期的优势在于能够更好的显示患者的预后，对临床具有更高的指导价值。

Surgical Intervention for Non-Small-Cell Lung Cancer Patients with Pleural Carcinomatosis: Results From the Japanese Lung Cancer Registry in 2004

INTRODUCTION

A subset of non-small-cell lung cancer (NSCLC) patients with malignant pleural effusion and/or malignant pleural nodules is now classified as stage IV and is generally considered a contraindication to surgery. However, several reports have demonstrated that the prognosis of patients with pleural carcinomatosis first detected at thoracotomy is relatively favorable. The aim of this study was to describe the results of surgical intervention in NSCLC patients with pleural carcinomatosis in Japan.

METHODS

In 2010, the Japanese Joint Committee of Lung Cancer Registry conducted a nationwide registration of lung cancer patients who underwent surgery in 2004. Using this database, we performed a retrospective study focused on pleural carcinomatosis. We examined the clinicopathological features, the current status of therapy, and surgical outcomes in patients with pleural carcinomatosis.

RESULTS

Among the 11,420 registered NSCLC patients, 329 (2.9%) patients had pleural carcinomatosis. The median survival time and 5-year survival rate of 313 patients without other metastatic disease were 34.0 months and 29.3%, respectively. Primary tumor resection was performed in 256 (81.8%) patients, and macroscopic complete resection was achieved in 152 (48.6%) patients, with 5-year survival rates of 33.1% and 37.1%, respectively. Multivariate analysis revealed that Eastern Cooperative Oncology Group performance status (p < 0.001), best stage nodal status (p = 0.002), and the presence or absence of gross residual tumor (p = 0.013) were independent predictors of survival.

CONCLUSION

In our surgical registry for NSCLC, patients with pleural carcinomatosis accounted for 2.9%, and macroscopic complete resection for them was associated with better survival.

Predicting distant failure in early stage NSCLC treated with SBRT using clinical parameters

PURPOSE/OBJECTIVE

The aim of this study is to predict early distant failure in early stage non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT) using clinical parameters by machine learning algorithms.

MATERIALS/METHODS

The dataset used in this work includes 81 early stage NSCLC patients with at least 6months of follow-up who underwent SBRT between 2006 and 2012 at a single institution. The clinical parameters (n=18) for each patient include demographic parameters, tumor characteristics, treatment fraction schemes, and pretreatment medications. Three predictive models were constructed based on different machine learning algorithms: (1) artificial neural network (ANN), (2) logistic regression (LR) and (3) support vector machine (SVM). Furthermore, to select an optimal clinical parameter set for the model construction, three strategies were adopted: (1) clonal selection algorithm (CSA) based selection strategy; (2) sequential forward selection (SFS) method; and (3) statistical analysis (SA) based strategy. 5-cross-validation is used to validate the performance of each predictive model. The accuracy was assessed by area under the receiver operating characteristic (ROC) curve (AUC), sensitivity and specificity of the system was also evaluated.

RESULTS

The AUCs for ANN, LR and SVM were 0.75, 0.73, and 0.80, respectively. The sensitivity values for ANN, LR and SVM were 71.2%, 72.9% and 83.1%, while the specificity values for ANN, LR and SVM were 59.1%, 63.6% and 63.6%, respectively. Meanwhile, the CSA based strategy outperformed SFS and SA in terms of AUC, sensitivity and specificity.

CONCLUSIONS

Based on clinical parameters, the SVM with the CSA optimal parameter set selection strategy achieves better performance than other strategies for predicting distant failure in lung SBRT patients.

The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer

The IASLC Staging and Prognostic Factors Committee has collected a new database of 94,708 cases donated from 35 sources in 16 countries around the globe. This has now been analysed by our statistical partners at Cancer Research And Biostatistics and, in close collaboration with the members of the committee proposals have been developed for the T, N, and M categories of the 8th edition of the TNM Classification for lung cancer due to be published late 2016. In this publication we describe the methods used to evaluate the resultant Stage groupings and the proposals put forward for the 8th edition.

Stage IV EGFR Mutation-Negative and ALK Mutation-Negative Lung Adenocarcinoma: Long-Term Survival is Possible

Lung cancer is the leading cause of cancer death in the United States with a five-year survival of 16.8% for all stages and median survival of four months for Stage IV disease. We report a case of a 54-year-old male with a seven-year survival after being diagnosed with Stage IV epidermal growth factor receptor (EGFR) mutation-negative and anaplastic lymphoma kinase (ALK) mutation-negative adenocarcinoma of the lung, demonstrating an exceptional response to treatment. 

The IASLC lung cancer staging project: the new database to inform the eighth edition of the TNM classification of lung cancer

The analyses of the retrospective database of the International Association for the Study of Lung Cancer (IASLC), consisting of more than 81,000 evaluable patients diagnosed with lung cancer between 1990 and 2000, formed the basis of recommendations to the Union for International Cancer Control and the American Joint Committee on Cancer for the revision of the sixth edition of the tumor, node, and metastasis (TNM) classification of lung cancer. However, despite the large number of patients, not all descriptors could be validated. This prompted a new collection of retrospective and prospective data to overcome the limitations of the original retrospective database. The new IASLC database has information on 94,708 new patients diagnosed of lung cancer between 1999 and 2010. They originated from 35 sources in 16 countries, and 4,667 were submitted via the online electronic data capture system. Europe contributed 46,560 patients, Asia: 41,705, North America: 4,660, Australia: 1,593, and South America: 190. After exclusions, 77,156 (70,967 with nonsmall cell lung cancer and 6,189 with small cell lung cancer) remained for analysis. This database will be analyzed according to established objectives for the T, the N, and the M components to inform the eighth edition of the TNM classification of lung cancer due to be published in 2016. The IASLC hopes for the continuing contribution of our partners around the world to improve the classification of anatomical extent of disease, but also to create prognostic groups in a parallel project of the IASLC Staging and Prognostic Factors Committee.

Relationship between tumor size and survival in non-small-cell lung cancer (NSCLC): an analysis of the surveillance, epidemiology, and end results (SEER) registry

INTRODUCTION

Tumor size is a known prognostic factor for early stage non-small-cell lung cancer (NSCLC), but its significance in node-positive and locally invasive NSCLC has not been extensively characterized. We queried the Surveillance, Epidemiology, and End Results database to evaluate the prognostic value of tumor size for early stage and node-positive and locally invasive NSCLC.

METHODS

Patients in Surveillance, Epidemiology, and End Results registry with NSCLC diagnosed between 1998 and 2003 were analyzed. Tumor size was analyzed as a continuous variable. Other demographic variables included age, gender, race, histology, primary tumor extension, node status, and primary treatment modality (surgery vs. radiation). The Kaplan-Meier method was used to estimate overall survival (OS). Cox proportional hazard model was used to evaluate whether tumor size was an independent prognostic factor.

RESULTS

In all, 52,287 eligible patients were subgrouped based on tumor extension and node status. Tumor size had a significant effect on OS in all subgroups defined by tumor extension or node status. In addition, tumor size also had statistically significant effect on OS in 15 of 16 subgroups defined by tumor extension and nodal status after adjustment for other clinical variables. Our model incorporating tumor size had significantly better predictive accuracy than our alternative model without tumor size.

CONCLUSIONS

Tumor size is an independent prognostic factor, for early stage and node-positive and locally invasive disease. Prediction tools, such as nomograms, incorporating more detailed information not captured in detail by the routine tumor, node, metastasis classification, may improve prediction accuracy of OS in NSCLC.

Accidental invisible intrathoracic disseminated pT4-M1a: a distinct lung cancer with favorable prognosis

OBJECTIVE

In the 7(th) edition of the TNM classification of malignant tumors, the prognosis for pT4-M1a stage IV lung cancer is better than for stage pIIIB. Subgroups of lung cancer patients who underwent incomplete resection (R1/R2) have a favorable prognosis. This study compares the prognosis between cases of invisible local residual disease and intrathoracic disseminated pT4-M1aIV.

METHODS

Patient characteristics and histological and molecular profiles were retrospectively collected for lung cancer patients who underwent resection intended to be curative but were accidentally incomplete. All patients were divided into either a local residual group or an intrathoracic disseminated pT4M1a group. Progression-free survival (PFS) and overall survival (OS) were evaluated by Kaplan-Meier and Cox regression models.

RESULTS

In total, 1,483 consecutive lung cancer patients receiving thoracotomies at Guangdong Lung Cancer Institute were retrospectively analyzed. Fifty-eight patients receiving incomplete resections (R1/R2) were enrolled, including 38 patients with local residual cancer (2.6% of all patients) and 20 patients with disseminated pM1a (1.3%). Patient characteristics, and histological and molecular profiles of the two groups were different. Compared to the local residual group, the disseminated pT4-M1a group contained more females (P=0.002), more patients younger than 60 years of age (P=0.028), more non-smokers (P=0.037), more adenocarcinomas (20/20 vs. 20/38, P<0.001), more adenocarcinomas with lepidic pattern (11/20 vs. 4/38, P<0.001), higher carcinoembryonic antigen (CEA) levels (P=0.06), higher epidermal growth factor receptor (EGFR) mutation rates (16/20 vs. 7/38, P<0.001), a higher R2/R1 resection ratio (P=0.013), a higher advanced stage IV/IIIB ratio (P<0.001), but fewer lymph node metastases (P=0.013). Median PFS for the local residual and disseminated pT4-M1a groups was 9.0 and 18.0 months, respectively [95% confidence interval (CI), 5.285-16.715; P =0.099]. Median OS was 15.0 and 45.0 months, respectively (95% CI, 18.972-39.028; P=0.001). Cox regression analysis revealed that group (local residual vs. disseminated pT4-M1a) was the only independent prognostic factor (P=0.044) for OS.

CONCLUSIONS

Accidental invisible intrathoracic disseminated pT4-M1a may be a distinct lung cancer subtype with a favorable prognosis. The prolonged PFS and OS might reflect the natural history of this distinct subtype, together with a favorable response to EGFR tyrosine kinase inhibitors (EGFR-TKI). For asymptomatic and slow-growing accidental pT4-M1a disease, the role of a wait-and-see strategy and the appropriate timing of systemic treatment require further investigation.

Survival Prediction Model Using Clinico-Pathologic Characteristics for Nonsmall Cell Lung Cancer Patients After Curative Resection

The current TNM staging system did not provide disease relapse information. The aim of study was try to establish a predictive survival model for disease and overall survival in nonsmall cell lung cancer patients who presented as resectable disease and to develop a reference for follow-up imaging tool selection.From January 2005 to December 2011, 442 patients who initially presented as resectable disease (stages I-IIIa) and received anatomic resection and mediastinal lymph node dissection were included in the study.Medical charts were thoroughly reviewed and clinico-pathologic factors were collected and analyzed.Visceral pleural invasion, tumor size >5 cm, and postoperative adjuvant therapy were identified as risk factors for poorer disease-free survival. The 5-year disease-free survival from score 0 to 3 was 68.7%, 46.6%, 31.9%, and 26.1%, respectively. The disease relapse percentage for scores 0 to 3 were 26.49%, 50.61%, 65.05%, and 73.81%, respectively. For analysis of overall survival, age >60 years, tumor size >3 cm, and total metastatic lymph node ratio >0.05 were correlated to worse overall survival. Because greater age may be correlated with poor general condition, we re-scored risk factors that correlated to disease severity that ranging from 0 to 2. The 5-year overall survival range from score 0 to 2 was 56.3%, 43.1%, and 13.1%, respectively.Poor prognostic factors correlated to disease-free survival were tumor size >5 cm, visceral pleural invasion, and patients needing to receive postoperative adjuvant therapy. Disease-free survival of resectable nonsmall cell lung cancer patients and disease relapse can be stratified by these 3 factors. Chest tomography may be recommended for patients with 1 or more poor disease-free survival risk factors.

Review: Cell Dynamics in Malignant Pleural Effusions

Malignant pleural effusions (MPEs) are a common manifestation found in patients with lung cancer. After cytological and histological confirmation of malignancy, talc pleurodesis still remains the treatment of choice in patients with MPEs resistant to chemotherapy. Despite this, primary challenges include reduced quality of life and life expectancy in general. Therefore, a better understanding of the cell biology of MPEs, along with improvements in treatment is greatly needed. It has recently been demonstrated that MPEs may represent an excellent source for identification of molecular mechanisms within the tumor and its environment. The present review summarizes the current understanding of MPEs cells and tumor microenvironment, and particularly focuses on dissecting the cross-talk between MPEs and epithelial to mesenchymal transition (EMT), inflammation and cancer stem cells.

Predicting the prognosis of lung cancer: the evolution of tumor, node and metastasis in the molecular age-challenges and opportunities

The tumor, node and metastasis (TNM) classification of malignant tumors was proposed by Pierre Denoit in the mid-20(th) century to code the anatomic extent of tumors. Soon after, it was accepted by the Union for International Cancer Control and by the American Joint Committee on Cancer, and published in their respective staging manuals. Till 2002, the revisions of the TNM classification were based on the analyses of a database that included over 5,000 patients, and that was managed by Clifton Mountain. These patients originated from North America and almost all of them had undergone surgical treatment. To overcome these limitations, the International Association for the Study of Lung Cancer proposed the creation of an international database of lung cancer patients treated with a wider range of therapeutic modalities. The changes introduced in the 7(th) edition of the TNM classification of lung cancer, published in 2009, derived from the analysis of an international retrospective database of 81,495 patients. The revisions for the 8(th) edition, to be published in 2016, will be based on a new retrospective and prospective international database of 77,156 patients, and will mainly concern tumor size, extrathoracic metastatic disease, and stage grouping. These revisions will improve our capacity to indicate prognosis and will make the TNM classification more robust. In the future the TNM classification will be combined with non-anatomic parameters to define prognostic groups to further refine personalized prognosis.

[New TNM classification of lung tumors]

The TNM classification of lung tumors has undergone many changes in the seventh edition published in 2010. These changes reflect current data and are based on the findings of the International Association for the Study of Lung Cancer (IASLC) from 81,495 patients and concern definitions of the T and M categories as well as stage grouping. They include a better description of regional lymph nodes of the lungs based on uniformly accepted definitions by the IASLC. The changes can lead to problems in the use of the definitions and will be discussed.

The seventh tumour-node-metastasis staging system for lung cancer: Sequel or prequel?

Anatomical cancer extent is an important predictor of prognosis and determines treatment choices. In non-small-cell lung cancer (NSCLC) the tumour–node–metastasis (TNM) classification developed by Pierre Denoix replaced in 1968 the Veterans Administration Lung cancer Group (VALG) classification, which was still in use for small-cell lung cancer (SCLC). Clifton Mountain suggested several improvements based on a database of mostly surgically treated United States (US) patients from a limited number of centres. This database was pivotal for a uniform reporting of lung cancer extent by the American Joint Committee of Cancer (AJCC) and the International Union against Cancer (IUCC), but it suffered increasingly from obsolete diagnostic and staging procedures and did not reflect new treatment modalities. Moreover, its findings were not externally validated in large Japanese and European databases, resulting in persisting controversies which could not be solved with the available database. The use of different mediastinal lymph-node maps in Japan, the (US) and Europe facilitated neither the exchange nor the comparison of treatment results.

Peter Goldstraw, a United Kingdom (UK) thoracic surgeon, started the process of updating the sixth version in 1996 and brought it to a good end 10 years later. His goals were to improve the TNM system in lung cancer by addressing the ongoing controversies, to validate the modifications and additional descriptors, to validate the TNM for use in staging SCLC and carcinoid tumours, to propose a new uniform lymph-node map and to investigate the prognostic value of non-anatomical factors. A staging committee was formed within the International Association for the Study of Lung Cancer (IASLC) – which supervised the collection of the retrospective data from >100,000 patients with lung cancer – treated throughout the world between 1990 and 2000, analyse them with the help of solid statistics and validate externally with the Surveillance, Epidemiology and End Results (SEER) database.

The ten modifications and the mediastinal lymph-node map – which were proposed in 2007 and adopted by the AJCC and IUCC in their respective seventh revision of the TNM system – were implemented as of 2010 and were rapidly adopted by the thoracic oncology community and cancer registries. As expected, not all controversies could be fully addressed, and the need for a prospective data set containing more granular information was felt early on. This data set of 25,000 consecutive incident cases will form the base for the eighth revision in 2017 and is currently being collected. Other threats are the role of stage migration and the increasing number of biological factors interfering with disease extent for prognostication. The latter issue will be addressed by the creation of a prognostic index, including several prognostic factors, of which stage will be one.

For the time being, the seventh TNM classification is considered the gold standard for the description of disease extent, initial treatment allocation and the reporting of treatment results. The uniform use of the TNM descriptors and the lymph-node map by all involved in lung cancer care is to be considered a process indicator of quality.

Pleural Photodynamic Therapy and Surgery in Lung Cancer and Thymoma Patients with Pleural Spread

Pleural spread is difficult to treat in malignancies, especially in lung cancer and thymoma. Monotherapy with surgery fails to have a better survival benefit than palliative chemotherapy, the currently accepted treatment. Photodynamic therapy utilizes a photosensitizer to target the tumor site, and the tumor is exposed to light after performing a pleurectomy and tumor resection. However, the benefits of this procedure to lung cancer or thymoma patients are unknown. We retrospectively reviewed the clinical characteristics and treatment outcomes of patients with lung cancer or thymoma with pleural seeding who underwent pleural photodynamic therapy and surgery between 2005 and 2013. Eighteen patients enrolled in this study. The mean patient age was 52.9 ± 12.2 years. Lung cancer was the inciting cancer of pleural dissemination in 10 patients (55.6%), and thymoma in 8 (44.4%). There was no procedure-related mortality. Using Kaplan-Meier survival analysis, the 3-year survival rate and the 5-year survival rate were 68.9% and 57.4%, respectively. We compared the PDT lung cancer patients with those receiving chemotherapy or target therapy (n = 51) and found that the PDT group had better survival than non-PDT patients (mean survival time: 39.0 versus 17.6 months; P = .047). With proper patient selection, radical surgical resection combined with intrapleural photodynamic therapy for pleural spread in patients with non-small cell lung cancer or thymoma is feasible and may provide a survival benefit.

The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: proposals for the T Component for the forthcoming (8th) edition of the TNM classification of malignant tumors

Despite longstanding recognition of thymic epithelial neoplasms, there is no official American Joint Committee on Cancer/Union for International Cancer Control stage classification. This article summarizes proposals for classification of the T component of stage classification for use in the 8th edition of the tumor, node, metastasis classification for malignant tumors. This represents the output of the International Association for the Study of Lung Cancer and the International Thymic Malignancies Interest Group Staging and Prognostics Factor Committee, which assembled and analyzed a worldwide database of 10,808 patients with thymic malignancies from 105 sites. The committee proposes division of the T component into four categories, representing levels of invasion. T1 includes tumors localized to the thymus and anterior mediastinal fat, regardless of capsular invasion, up to and including infiltration through the mediastinal pleura. Invasion of the pericardium is designated as T2. T3 includes tumors with direct involvement of a group of mediastinal structures either singly or in combination: lung, brachiocephalic vein, superior vena cava, chest wall, and phrenic nerve. Invasion of more central structures constitutes T4: aorta and arch vessels, intrapericardial pulmonary artery, myocardium, trachea, and esophagus. Size did not emerge as a useful descriptor for stage classification. This classification of T categories, combined with a classification of N and M categories, provides a basis for a robust tumor, node, metastasis classification system for the 8th edition of American Joint Committee on Cancer/Union for International Cancer Control stage classification.

The role of stereotactic body radiation therapy in the management of oligometastatic lung cancer

A growing body of evidence has surfaced over the past 20 years that supports the use of surgery for metastasis limited in number termed ‘oligometastases’. Local therapy for oligometastases results in long progression free survival in the absence of systemic therapy, including non-small-cell lung cancer (NSCLC). Stereotactic body radiation therapy (SBRT) allows for the delivery of anatomically precise, ablative doses of radiation therapy able to achieve local control rates of approximately 80% with minimal toxicity. In NSCLC, SBRT is emerging as an effective therapy in the management of sites resistant to targeted therapy. This review summarizes the published evidence for the use of local therapy in the management of oligometsatic cancer, with a focus on SBRT and NSCLC.

Alectinib for choroidal metastasis in a patient with crizotinib-resistant ALK rearranged positive non-small cell lung cancer

Choroidal metastasis is rare in cancer patients. Small molecules of molecular targeted agents for lung cancer with actionable mutations were reported to be palliated for symptoms caused by choroidal metastasis. Visual disturbance by choroidal metastasis significantly decreases quality of life during the patient’s remaining lifespan; therefore, radiotherapy or laser photocoagulation is proposed with consensus. However, improvement in survival with matched molecular targeted agents for oncogenic driver mutations reminds us to also be concerned with late treatment toxicities. A 30-year-old female patient previously treated with crizotinib harboring ALK rearranged non-small cell lung cancer complained of visual disturbance, fever, and bone pains undergoing anti-PD-1 antibody treatment. A decreased proportion of ALK fusion was demonstrated by fluorescence in situ hybridization in liver metastasis compared to the primary site in a chemo-naïve state. She was diagnosed with low vision, choroidal metastasis and retinal detachment. Therefore, she started alectinib treatment and both her ocular and systemic symptoms were palliated in a week. Later, she temporarily discontinued alectinib because of skin rash although the choroidal metastasis and retinal detachment resolved and she regained low vision completely at 2 weeks. She obtained partial response with alectinib for more than 5 months after recovering from skin rash.

Retrospective analysis of unknown primary cancers with malignant pleural effusion at initial diagnosis

Background

Malignant pleural effusion (MPE) can occur during the progression of various cancers. However, factors, such as the incidence of MPE associated with different types of cancers and its potential for diagnosing previously undetected cancers, are unknown. Moreover, MPE may accompany potentially curable cancers or those with a favorable survival prognosis with adequate treatment. The present study determined the types of cancers accompanied by MPE at initial diagnosis and investigated appropriate related methods for diagnosing previously unknown cancers.

Methods

We retrospectively reviewed the medical records of 35 patients with MPE at initial cancer diagnosis between 2004 and 2012. We evaluated the patient characteristics, final diagnosis, and diagnostic processes.

Results

Of the 35 patients, 10 had lung cancer, seven ovarian or peritoneal cancer, four malignant pleural mesothelioma, one breast cancer, one lymphoma, one pancreatic cancer, and 11 had cancers of unknown origin. Diagnoses of the primary lesions were confirmed using the MPE cellblock method for seven of 11 patients (63.6%), by excisional biopsy or aspiration from other sites in four of nine patients, by exploratory laparotomy in two of three patients, and by peritoneal washing cytology in five patients.

Conclusion

Lung cancer and cancer of unknown origin are major causes of MPE at initial presentation. However, these groups also contain cancers that are curable and those with good long‐term prognosis. The MPE cellblock method represents an accurate method for identifying cancer origin.

Mast cells mediate malignant pleural effusion formation

Mast cells (MCs) have been identified in various tumors; however, the role of these cells in tumorigenesis remains controversial. Here, we quantified MCs in human and murine malignant pleural effusions (MPEs) and evaluated the fate and function of these cells in MPE development. Evaluation of murine MPE-competent lung and colon adenocarcinomas revealed that these tumors actively attract and subsequently degranulate MCs in the pleural space by elaborating CCL2 and osteopontin. MCs were required for effusion development, as MPEs did not form in mice lacking MCs, and pleural infusion of MCs with MPE-incompetent cells promoted MPE formation. Once homed to the pleural space, MCs released tryptase AB1 and IL-1β, which in turn induced pleural vasculature leakiness and triggered NF-κB activation in pleural tumor cells, thereby fostering pleural fluid accumulation and tumor growth. Evaluation of human effusions revealed that MCs are elevated in MPEs compared with benign effusions. Moreover, MC abundance correlated with MPE formation in a human cancer cell-induced effusion model. Treatment of mice with the c-KIT inhibitor imatinib mesylate limited effusion precipitation by mouse and human adenocarcinoma cells. Together, the results of this study indicate that MCs are required for MPE formation and suggest that MC-dependent effusion formation is therapeutically addressable.

Staging of lung cancer

Primary lung cancer is the leading cause of cancer mortality in the world. Thorough clinical staging of patients with lung cancer is important, because therapeutic options and management are to a considerable degree dependent on stage at presentation. Radiologic imaging is an essential component of clinical staging, including chest radiography in some cases, computed tomography, MRI, and PET. Multiplanar imaging modalities allow assessment of features that are important for surgical, oncologic, and radiation therapy planning, including size of the primary tumor, location and relationship to normal anatomic structures in the thorax, and existence of nodal and/or metastatic disease.

The Clinical Use of Genomic Profiling to Distinguish Intrapulmonary Metastases From Synchronous Primaries in Non-Small-Cell Lung Cancer: A Mini-Review

The ability to reliably distinguish synchronous primary non-small-cell lung cancer (NSCLC) from intrapulmonary metastatic spread affects staging and treatment decisions in resected NSCLC. Adjuvant therapy for early-stage NSCLC is complicated and recommendations are primarily based on older data from trials that used now-outdated staging systems. Patients found to have 2 tumors with similar morphology in the same lobe are currently staged as pathologic T3 (pT3) but such cases represent a minority of patients in adjuvant lung cancer trials. Potentially more precise than tumor morphology alone, comprehensive genomic profiling technologies have the power to discriminate whether tumors in the same lobe represent 2 separate primary lesions or localized spread of a single lesion. In addition to lineage insights, tumor profiling simultaneously provides information on actionable genomic alterations. In this review we discuss the data that support the ability of molecular technologies to distinguish synchronous primary tumors from intrapulmonary metastases and discuss the use of molecular assays as an adjunct to current staging systems. Two cases are presented to highlight the potential immediate clinical implications of comprehensive genomic profiling.

New TNM classification: achievements and hurdles

The 7th edition of TNM for Lung Cancer represented a major advance from previous editions, in the process of revision, the size and breadth of the data base used, its international character, the intensity of the analysis and the critical nature of the internal and external validation undertaken before its launch in January 2010. This all came about by the involvement of the International Association for the Study of Lung Cancer (IASLC), which assumed the role previously performed by Dr. Mountain, of developing data-driven revisions for the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC). In taking on this task the IASLC made the global lung cancer community aware of the limitations of previous revisions and now stand accountable and subject to the same scrutiny. In this article we describe the achievements of the IASLC TNM and Prognostic Factors Committee, but also the short-comings of the 7th edition, as an essential step towards rectifying deficiencies and further improving the classification in future revisions.

Analysis of stage and clinical/prognostic factors for lung cancer from SEER registries: AJCC staging and collaborative stage data collection system

BACKGROUND

The American Joint Committee on Cancer (AJCC) 7th edition introduced major changes in the staging of lung cancer, including the tumor (T), node (N), metastasis (M)-TNM-system and new stage/prognostic site-specific factors (SSFs), collected under the Collaborative Stage Version 2 (CSv2) Data Collection System. The intent was to improve the stage precision that could guide treatment options and ultimately lead to better survival. This report examines stage trends, the change in stage distributions from the AJCC 6th to the 7th edition, and findings of the prognostic SSFs for 2010 lung cancer cases.

METHODS

Data were from the November 2012 submission of 18 Surveillance, Epidemiology, and End Results (SEER) Program population-based registries. A total of 344,797 cases of lung cancer, diagnosed in 2004-2010, were analyzed.

RESULTS

The percentages of small tumors and early-stage lung cancer cases increased from 2004 to 2010. The AJCC 7th edition, implemented for 2010 diagnosis year, subclassified tumor size and reclassified multiple tumor nodules, pleural effusions, and involvement of tumors in the contralateral lung, resulting in a slight decrease in stage IB and stage IIIB and a small increase in stage IIA and stage IV. Overall about 80% of cases remained the same stage group in the AJCC 6th and 7th editions. About 21% of lung cancer patients had separate tumor nodules in the ipsilateral (same) lung, and 23% of the surgically resected patients had visceral pleural invasion, both adverse prognostic factors.

CONCLUSIONS

It is feasible for high-quality population-based registries such as the SEER Program to collect more refined staging and prognostic SSFs that allows better categorization of lung cancer patients with different clinical outcomes and to assess their survival.

Lung cancer cells induce senescence and apoptosis of pleural mesothelial cells via transforming growth factor-beta1

Pleural dissemination is commonly associated with metastatic advanced lung cancer. The injury of pleural mesothelial cells (PMCs) by soluble factors, such as transforming growth factor-beta1 (TGF-β1), is a major driver of lung cancer pleural dissemination (LCPD). In this study, we examine the effects of TGF-β1 on PMC injury and the ability of TGF-β1 inhibition to alleviate this effect both in vitro and in vivo. PMCs were co-cultured with the high TGF-β1-expressing lung cancer cell line A549 and with various TGF-β1 signaling inhibitors. Expression of cleaved-caspase 3, cleaved-caspase 9, p21, and p16 were evaluated by Western blot and immunofluorescent confocal imaging. Apoptosis was measured by 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltrazoliumbromide assay and AnnexinV-propidium iodide (PI) staining. PMC senescence was assessed by staining for senescence-associated β-galactosidase (SA-β-Gal). The ability of lung cancer cells (LCCs) to adhere to injured PMCs was investigated using an LCC-PMC adhesion assay. In our mouse model, PMC injury status was monitored by hematoxylin-eosin (H&E) and Masson's trichrome staining. LCCs expressing high levels of TGF-β1 induce apoptosis and senescence of PMCs in a co-culture system. Injured PMCs adhere to LCCs, which may further promote LCPD. Importantly, PMC monolayer injury could be reversed with TGF-β1 inhibitors. This was consistent with our in vivo data showing that the TGF-β1 inhibitor SB-431542 attenuated PMC barrier injury induced by A549 culture medium in our mouse model. Our study highlights the importance of TGF-β1 signaling in LCPD and establishes this signaling pathway as a potential therapeutic target in the disease.