Long-term results of the international adjuvant lung cancer trial evaluating adjuvant Cisplatin-based chemotherapy in resected lung cancer

Overall Survival Analyses following Adjuvant Chemotherapy or Nonadjuvant Chemotherapy in Patients with Stage IB Non-Small-Cell Lung Cancer

Background

Adjuvant chemotherapy (ACT) can improve prognosis for stages II-IIIA patients with non-small-cell lung cancer (NSCLC), but its implication in stage I patients is still an intractable puzzle. This study aims to seek ACT candidates for stage IB NSCLC and establish a nomogram to predict overall survival (OS) of specific patient for clinician's decision.

Method

We performed a retrospective study on 16,765 patients (ACT group: n = 2,187; non-ACT group: n = 14,578) from the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival was assessed in two groups. We performed propensity-score matching for risk adjustment. The risk factors were identified and used to create nomogram. Concordance index (C-index), Hosmer–Lemeshow test, and calibration were applied to evaluate model performance. To further evaluate the influence of tumor size on the selection of potential ACT candidates for patients with stage IB NSCLC, subgroup analyses were executed.

Result

Survival analysis for the entire study cohort showed that ACT had better OS than non-ACT (HR = 0.800, CI: (0.751–0.851), P < 0.0001). In matched cohort, ACT also presented better OS than non-ACT (HR = 0.775, CI: (0.704–0.853), P < 0.0001). Univariate and multivariate Cox regression analysis revealed that eight prognostic factors, including gender, age, grade, pathological subtype, tumor size, visceral pleural invasion, surgical procedure, and the number of removed lymph nodes, were significantly correlated with OS. The nomogram was further constructed based on these prognostic factors. The C-index of nomogram was 0.639 (95%CI: 0.632–0.646). The Hosmer–Lemeshow test, and calibration presented good congruence between the predictions and actual observations. Subgroup analyses of tumor size group showed that ACT shared similar OS to non-ACT in NSCLC patients with tumor size ≤20 mm (P > 0.05). However, for NSCLC patients with 20 mm < size ≤30 mm (HR = 0.845, 95%CI (0.724–0.986), P=0.032) and 30 mm < size ≤40 mm (HR = 0.912, 95%CI (0.833–1.000), P=0.049), ACT associated with better OS.

Conclusion

In this study, we found that ACT had better OS than non-ACT in patients with stage IB NSCLC. The nomogram provided an individual prediction of OS for patients after surgical resection. Patients with tumor size >20 mm and ≤40 mm may be potential candidates for ACT.

A prognostic and predictive computational pathology image signature for added benefit of adjuvant chemotherapy in early stage non-small-cell lung cancer

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Poster presentation at the USCAP 108th Annual Meeting, March 16–21, 2019.

Background

We developed and validated a prognostic and predictive computational pathology risk score (CoRiS) using H&E stained tissue images from patients with early-stage non-small cell lung cancer (ES-NSCLC).

Methods

1330 patients with ES-NSCLC were acquired from 3 independent sources and divided into four cohorts D_1-4. D₁ comprised 100 surgery treated patients and was used to identify prognostic features via an elastic-net Cox model to predict overall and disease-free survival. CoRiS was constructed using the Cox model coefficients for the top features. The prognostic performance of CoRiS was evaluated on D₂ (N=331), D₃ (N=657) and D₄ (N=242). Patients from D₂ and D₃ which comprised surgery + chemotherapy were used to validate CoRiS as predictive of added benefit to adjuvant chemotherapy (ACT) by comparing survival between different CoRiS defined risk groups.

Findings

CoRiS was found to be prognostic on univariable analysis, D₂ (hazard ratio (HR) = 1.41, adjusted (adj.) P = .01) and D₃ (HR = 1.35, adj. P < .001). Multivariable analysis showed CoRiS was independently prognostic, D₂ (HR = 1.41, adj. P < .001) and D₃ (HR = 1.35, adj. P < .001), after adjusting for clinico-pathologic factors. CoRiS was also able to identify high-risk patients who derived survival benefit from ACT D₂ (HR = 0.42, adj. P = .006) and D₃ (HR = 0.46, adj. P = .08).

Interpretation

CoRiS is a tissue non-destructive, quantitative and low-cost tool that could potentially help guide management of ES-NSCLC patients.

Molecular Mechanisms of Antiproliferative and Apoptosis Activity by 1,5-Bis(4-Hydroxy-3-Methoxyphenyl)1,4-Pentadiene-3-one (MS13) on Human Non-Small Cell Lung Cancer Cells

Diarylpentanoid (DAP), an analog that was structurally modified from a naturally occurring curcumin, has shown to enhance anticancer efficacy compared to its parent compound in various cancers. This study aims to determine the cytotoxicity, antiproliferative, and apoptotic activity of diarylpentanoid MS13 on two subtypes of non-small cell lung cancer (NSCLC) cells: squamous cell carcinoma (NCI-H520) and adenocarcinoma (NCI-H23). Gene expression analysis was performed using Nanostring PanCancer Pathways Panel to determine significant signaling pathways and targeted genes in these treated cells. Cytotoxicity screening revealed that MS13 exhibited greater inhibitory effect in NCI-H520 and NCI-H23 cells compared to curcumin. MS13 induced anti-proliferative activity in both cells in a dose- and time-dependent manner. Morphological analysis revealed that a significant number of MS13-treated cells exhibited apoptosis. A significant increase in caspase-3 activity and decrease in Bcl-2 protein concentration was noted in both MS13-treated cells in a time- and dose-dependent manner. A total of 77 and 47 differential expressed genes (DEGs) were regulated in MS13 treated-NCI-H520 and NCI-H23 cells, respectively. Among the DEGs, 22 were mutually expressed in both NCI-H520 and NCI-H23 cells in response to MS13 treatment. The top DEGs modulated by MS13 in NCI-H520—DUSP4, CDKN1A, GADD45G, NGFR, and EPHA2—and NCI-H23 cells—HGF, MET, COL5A2, MCM7, and GNG4—were highly associated with PI3K, cell cycle-apoptosis, and MAPK signaling pathways. In conclusion, MS13 may induce antiproliferation and apoptosis activity in squamous cell carcinoma and adenocarcinoma of NSCLC cells by modulating DEGs associated with PI3K-AKT, cell cycle-apoptosis, and MAPK pathways. Therefore, our present findings could provide an insight into the anticancer activity of MS13 and merits further investigation as a potential anticancer agent for NSCLC cancer therapy.

Association of postoperative recurrence with radiological and clinicopathological features in patients with stage IA-IIA lung adenocarcinoma

OBJECTIVES

To retrospectively investigate whether radiological and clinicopathological characteristics were associated with the presence of stage IA-IIA lung adenocarcinoma in patients at high risk for a postoperative recurrence.

MATERIALS AND METHODS

Three hundred twelve patients with biopsy-proven node-negative early-stage (IA-IIA) lung adenocarcinoma met the inclusion criteria for this study. Demographics data and histopathological findings were collected from medical records. Computed tomography (CT) performed approximately 1 month before surgery was manually scored using 23 CT descriptors. Univariate analyses were applied to demonstrate an association between clinicopathological and radiological features and 2-/5-year recurrences. Multivariate logistic regression was performed to assess the ability of radiological and clinicopathological features to discriminate low and high-risk factors for recurrence. A ROC curve was used to evaluate prediction performance.

RESULTS

Univariate analysis revealed that the 2-year recurrence was associated with six radiological features and two clinicopathological features, while 5-year recurrence was associated with five radiological features and two clinicopathological features. A multivariate logistic regression model of combined clinicopathological and radiological features showed that stage IIA (OR = 2.87), solid texture (solid part > 50 %: OR = 4.81; solid part = 100 %: OR = 3.61), pleural attachment (OR = 3.97) and bronchovascular bundle thickening (OR = 2.16) were associated with the independent predictors of 2-year recurrence, and stage IIA (OR = 3.52), solid texture (solid part > 50 %: OR = 3.56; solid part = 100 %: OR = 2.44) and pleural attachment (OR = 4.57) were associated with 5-year recurrence. Combined radiological and clinicopathological features could be significant indicators of 2- and 5-year recurrences (AUC = 0.784 and AUC = 0.815, respectively).

CONCLUSIONS

The combination of radiological and clinicopathological features has the potential to help predict postoperative recurrence in patients with stage IA-IIA lung adenocarcinomas and guide oncologists and patients whether to undergo additional treatment after surgery.

Prognostic Impact of PD-L1 Expression in pN1 NSCLC: A Retrospective Single-Center Analysis

Simple Summary

The analysis of prognostic biomarkers (e.g., PD-L1) helps to define treatment for lung cancer patients. To date, these markers have only been examined in metastatic or inoperable situations. We analyzed the PD-L1 expression-levels of tumors from 277 lung cancer patients that underwent curative intent surgery. PD-L1 was identified as a prognostic factor, depending on histologic subtype.

Abstract

The programmed death-ligand 1 (PD-L1) plays a crucial role in immunomodulatory treatment concepts for end-stage non-small cell lung cancer (NSCLC). To date, its prognostic significance in patients with curative surgical treatment but regional nodal metastases, reflecting tumor spread beyond the primary site, is unclear. We evaluated the prognostic impact of PD-L1 expression in a surgical cohort of 277 consecutive patients with pN1 NSCLC on a tissue microarray. Patients with PD-L1 staining (clone SP263) on >1% of tumor cells were defined as PD-L1 positive. Tumor-specific survival (TSS) of the entire cohort was 64% at five years. Low tumor stage (p < 0.0001) and adjuvant therapy (p = 0.036) were identified as independent positive prognostic factors in multivariate analysis for TSS. PD-L1 negative patients had a significantly better survival following adjuvant chemotherapy than PD-L1 positive patients. The benefit of adjuvant therapy diminished in patients with PD-L1 expression in more than 10% of tumor cells. Stratification towards histologic subtype identified PD-L1 as a significant positive predictive factor for TSS after adjuvant therapy in patients with adenocarcinoma, but not squamous cell carcinoma. Routine PD-L1 assessment in curative intent treatment may help to identify patients with a better prognosis. Further research is needed to elucidate the predictive value of PD-L1 in an adjuvant setting.

Validation of the T Descriptor (TNM-8) in T3N0 Non-Small-Cell Lung Cancer Patients; a Bicentric Cohort Analysis with Arguments for Redefinition

Simple Summary

Lung cancer patients have different survival outcomes depending on tumor size and growth pattern after surgery. This study aims to optimize tumor classification, and identify patients who could benefit the most from additional chemotherapy after surgery. In a specific lung cancer cohort, we study how a new redefinition of tumor classification could lead to a more solid recommendation of which patients to offer chemotherapy after surgery.

Abstract

The current pT3N0 category represents a heterogeneous subgroup involving tumor size, separate tumor nodes in one lobe, and locoregional growth pattern. We aim to validate outcomes according to the eighth edition of the TNM staging classification. A total of 281 patients who had undergone curative lung cancer surgery staged with TNM-7 in two German centers were retrospectively analyzed. The subtypes tumor size >7 cm and multiple nodules were grouped as T3a, and the subtypes parietal pleura invasion and mixed were grouped as T3b. We stratified survival by subtype and investigated the relative benefit of adjuvant chemotherapy according to subtype. The 5-year overall survival (OS) rates differed between the different subtypes tumor diameter >7 cm (71.5%), multiple nodules in one lobe (71.0%) (grouped as T3a), parietal pleura invasion (59.%), and mixed subtype (5-year OS 50.3%) (grouped as T3b), respectively. The cohort as a whole did not gain significant OS benefit from adjuvant chemotherapy. In contrast, adjuvant chemotherapy significantly improved OS in the T3b subgroup (logrank p = 0.03). This multicenter cohort analysis of pT3N0 patients identifies a new prognostic mixed subtype. Tumors >7 cm should not be moved to pT4. Patients with T3b tumors have significantly worse survival than patients with T3a tumors.

A nomogram for predicting overall survival in patients with resected non-small cell lung cancer treated with chemotherapy

Background

Chemotherapy is a common treatment for patients with resected non-small cell lung cancer (NSCLC). However, there are few models for predicting the survival outcomes of these patients. Here, we developed a clinical nomogram for predicting overall survival (OS) in this cohort.

Methods

A total of 16,661 patients with resected NSCLC treated with chemotherapy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. We identified prognostic factors and integrated them into a nomogram. The model was subjected to bootstrap internal validation using the SEER database and external validation using a database in China and the National Cancer Database (NCDB). The model’s predictive accuracy and discriminative ability were tested by calibration and concordance index (C-index).

Results

Age, sex, number of dissected lymph nodes, extent of surgery, N stage, T stage, and grade were independent factors for OS and were integrated into the model. The calibration curves for probability of 1-, 3-, and 5-year OS showed excellent agreement between the predicted and actual survivals. The C-index of the nomogram was higher than that of the Tumor-Node-Metastasis staging system for predicting OS (training cohort, 0.62 vs. 0.58; China cohort, 0.68 vs. 0.63; NCDB cohort, 0.59 vs. 0.57).

Conclusions

We developed a nomogram that can present individual prediction of OS for patients with resected NSCLC who are undergoing chemotherapy. This practical prognostic tool may help clinicians in treatment planning.

Lung cancer chemotherapy using nanoparticles: Enhanced target ability of redox-responsive and pH-sensitive cisplatin prodrug and paclitaxel

Platinum-based combination therapy is more effective and less toxic, but lack of targeting, and is not capable to enrich in the tumor zone. To obstacle these drawbacks, prodrug and nanotechnology strategies have been investigated in this study. GSH-responsive and pH-responsive cisplatin prodrug was synthesized. Cisplatin prodrug and paclitaxel co-loaded nanoparticles: DDP-P/PTX NPs were constructed. The drug release behavior and cytotoxicity of nanoparticles was assessed in vitro. In vivo anticancer efficiency and toxicity were evaluated on lung cancer bearing mice animal model. DDP-P/PTX NPs had a nanoscale size of 112.9 ± 3.5 nm. A reduction and pH triggered drug release with a synergistic tumor cell inhibition ability was observed by DDP-P/PTX NPs. DDP-P/PTX NPs also exhibited high tumor distribution, low systemic toxicity and remarkable antitumor effects in vivo. DDP-P/PTX NPs could be applied as promising anticancer system for the treatment of NSCLC.

Neoadjuvant immunotherapy combined with chemotherapy for local advanced non-small cell lung cancer: a case report

Immunotherapy has revolutionized lung cancer management and revitalized the field of tumor immunology. Anti-programmed death 1 (anti-PD-1) immunotherapy can significantly improve the survival of patients with advanced non-small cell lung cancer (NSCLC), but its role in neoadjuvant therapy of local advanced NSCLC remains uncertain. Herein, we reported a case from a clinical trial of our department, a patient who achieved excellent outcome after neoadjuvant immunotherapy and chemotherapy for local advanced NSCLC. A 70 years old male patient with stage IIIA squamous cell carcinoma was admitted in our hospital, who initially needed to undergo pneumonectomy. After two cycles of neoadjuvant immunotherapy combined with chemotherapy, the tumor significantly shrank and the patient underwent left upper lobectomy finally. The patient had grade 2 myelosuppression and recovered after injection with recombinant human granulocyte colony stimulating factor. There was no operation-related complication the patient was discharged uneventfully. The patient received two cycles adjuvant chemotherapy combined with immunotherapy, then immunotherapy alone monthly. The patient was well during the 4-month follow-up after surgery and would receive immunotherapy till one year after surgery. Our case added evidence of the feasibility and efficacy of neoadjuvant immunotherapy combined with chemotherapy in local advanced NSCLC. Randomized, controlled, multi-center studies are needed to confirm these findings.

Optimal Surgery Type and Adjuvant Therapy for T1N0M0 Lung Large Cell Neuroendocrine Carcinoma

Background

The appropriate treatment strategy for T1N0M0 lung large cell neuroendocrine carcinoma (LCNEC) was not well illustrated. We evaluated the efficacy of different surgery types and adjuvant therapy on patients with T1N0M0 LCNEC.

Methods

Patients diagnosed T1N0M0 LCNEC from 2004 to 2016 were identified in the surveillance, epidemiology, and end results (SEER) database. Clinical characteristics, treatment and survival data were collected. The efficacy of surgery type and adjuvant therapy stratified by tumor size was assessed. Overall survival(OS) was evaluated by the Kaplan-Meier method, and relevant survival variables were identified by the Cox proportional hazard model.

Results

From 2004 to 2016, 425 patients were included in this study, 253 (59.5%) patients received lobectomy, and 236 (55.5%) patients had 4 or more lymph nodes removed. Patients received lobectomy had better survival than those received sublobar resection(P=0.000). No matter tumor size less than 2 cm or 2 to 3 cm, lobectomy was significantly prolonged survival. Compared with no lymph nodes removed, lymph nodes dissection was associated with more remarkable OS(P<0.000). 4 or more regional lymph nodes dissection predicted better OS compared with 1 to 3 regional lymph nodes dissection(P=0.014). After surgery, adjuvant chemotherapy did not contribute to extended survival in patients with tumor less than 2 cm(P=0.658), and possibly for tumor 2 to 3 cm(P=0.082). Multivariate analysis showed that age and lobectomy were independent prognostic factors(P=0.000).

Conclusion

Our results suggest that lobectomy and lymph nodes dissection were associated with significantly better survival. Extensive regional lymph node dissection(4 or more) was more effective in prolonging survival than 1 to 3 lymph nodes dissection. Adjuvant chemotherapy was not associated with extended survival for tumor less than 2 cm, and possibly for tumor 2 to 3 cm.

Preoperative nivolumab to evaluate pathological response in patients with stage I non-small cell lung cancer: a study protocol of phase II trial (POTENTIAL)

INTRODUCTION

Recently, inhibition of programmed cell death 1 or its ligand has shown therapeutic effects on non-small cell lung cancer (NSCLC). However, the effectiveness of preoperative nivolumab monotherapy for stage I NSCLC remains unknown. The present study aimed to investigate the pathological response of preoperative treatment with nivolumab for clinically node negative but having a high risk of NSCLC recurrence.

METHODS AND ANALYSIS

The Preoperative Nivolumab (Opdivo) to evaluate pathologic response in patients with stage I non-small cell lung cancer: a phase 2 trial (POTENTIAL) study is a multicentre phase II trial investigating efficacy of preoperative nivolumab for clinical stage I patients at high risk of recurrence. This study includes histologically or cytologically confirmed NSCLC patients with clinical N0 who were found on preoperative high-resolution CT to have a pure solid tumour without a ground-glass opacity component (clinical T1b, T1c or T2a) or a solid component measuring 2-4 cm in size (clinical T1c or T2a). Patients with epidermal growth factor receptor (EGFR) mutation (deletion of exon 19 or point mutation on exon21, L858R), anaplastic lymphoma kinase (ALK) translocation or c-ros oncogene 1 (ROS-1) translocation are excluded from this study. Nivolumab (240 mg/body) is administrated intravenously as preoperative therapy every 2 weeks for three cycles. Afterward, lobectomy and mediastinal lymph node dissection (ND 2a-1 or ND 2a-2) are performed. The primary endpoint is a pathological complete response in the resected specimens. The secondary endpoints are safety, response rates and major pathological response. The planed sample size is 50 patients. Patients have been enrolled since April 2019.

ETHICS AND DISSEMINATION

This trial was approved by the Institutional Review Board of Hiroshima University Hospital and other participating institutions. This trial will help examine the efficacy of preoperative nivolumab therapy for clinical stage I NSCLC.

TRIAL REGISTRATION NUMBER

jRCT2061180016.

A randomized phase II study of S-1 monotherapy versus cisplatin with vinorelbine for completely resected stage II/IIIA non-small cell lung cancer: rationale and study protocol design for the LOGIK1702 study

Background

The current standard postoperative treatment for stage II-IIIA non-small cell lung cancer (NSCLC) is a regimen of platinum doublet adjuvant chemotherapy. These regimens, which are the same as for solid NSCLC tumors, often cause severe adverse reactions in the treated patients. Therefore, an effective treatment regimen with fewer side effects is needed.

Methods/design

The purpose of this study is to evaluate the effectiveness and safety of S-1 monotherapy (80 mg/m² orally administrated twice daily, at day 1–14, 16 cycles) and cisplatin with vinorelbine combination therapy (cisplatin 80 mg/m² at day 1,vinorelbine 25 mg/m² at day 1, 8, 4 cycles) in patients with II/IIIA stage non-small-cell lung cancer who underwent a total resection. In addition, we will also evaluate the level of treatment side effects by assessing quality of life (QOL), work productivity and activity performance. The primary endpoint is a 2-year relapse free survival (RFS) and the second primary endpoints are 2-year overall survival (OS), rate of treatment completion, safety, work productivity and activity, and quality of adjusted life years (QALY). At the same time, we aim to obtain precise information required to perform future phase 3 randomized controlled trials. The study is designed to estimate the primary endpoint with accuracy determined as the width of its 95% confidence interval to be less than 20%. Recruitment started in May 2017 and is ongoing.

Discussion

This study has been conceived to establish a superior regimen for completely resected NSCLC based on efficacy, safety and QOL.

Trial registration

Registry number: UMIN000027435. Registered May 22, 2017.

Enhanced expression of FGF19 predicts poor prognosis in patients with non-small cell lung cancer

Background

Lung cancer is one of the most common cancers and a leading cause of cancer-related death worldwide. Although many treatment options exist for lung cancer, some patients still suffer postoperative recurrence, and a consequent reduction of overall survival (OS). Our study aimed to investigate the correlation of FGF19 expression with the clinicopathological features and survival outcomes of non-small cell lung cancer (NSCLC) patients.

Methods

Bioinformatics analysis was conducted using the data from The Cancer Genome Atlas (TCGA) database to distinguish between the FGF19 levels of tumor and normal tissue and to determine their correlation with the OS. A total of 187 NSCLC patients who underwent radical resection of lung cancer were enrolled, and tissues were collected to determine FGF19 expression by immunohistochemistry (IHC) assay. Clinicopathological features including the survival date were collected for detailed research.

Results

According to the analysis based on the TCGA database, we found that the NSCLC tissues exhibited enhanced FGF19 messenger RNA (mRNA) expression and that the FGF19 mRNA levels correlated with shorter OS in NSCLC patients. IHC staining indicated that 88 (47.1%) patients had high FGF19 expression and 99 (52.9%) patients had low FGF19 expression. Meanwhile, survival data showed that high FGF19 expression was correlated with reduced OS (P<0.001). Moreover, both the univariate analysis and the forward stepwise multivariate Cox regression revealed that high FGF19 expression was an independent prognostic factor for decreased OS (P=0.001).

Conclusions

The expression of FGF19 is significantly upregulated in NSCLC, and the overexpression of FGF19 is correlated with poor OS, especially in lung adenocarcinoma (LUAD) cases. FGF19 might serve as a potential biomarker for predicting poor OS in NSCLC patients.

Current state and prospect of the perioperative strategy for non-small cell lung cancer

This paper provides an overview of perioperative treatment for non-small cell lung cancer (NSCLC), including the current widespread use of cytotoxic anticancer agents, promising molecular targeted agents, and immuno-checkpoint inhibitors. Multiple clinical trials have confirmed that postoperative chemotherapy with cytotoxic anticancer agents should be given for stage IIB to III (according to the 8th edition of the TNM classification for NSCLC) if possible, and preoperative treatment also is recommended for patients with N2 or higher stage. However, advances in concurrent chemoradiotherapy are expected to change the significance of neoadjuvant therapy. Perioperative treatment with molecular targeted agents appears to extend disease-free survival, but there is currently no evidence that it can extend overall survival. Perioperative treatment with immune checkpoint inhibitors requires further evidence but is likely to be effective. Although perioperative treatment of NSCLC could be costly it continues to evolve in hopes of a cure.

Loss-of-function alleles of P2RX7 and TLR4 fail to affect the response to chemotherapy in non-small cell lung cancer

The success of anticancer chemotherapy relies at least in part on the induction of an immune response against tumor cells. Thus, tumors growing on mice that lack the pattern recognition receptor TLR4 or the purinergic receptor P2RX7 fail to respond to chemotherapy with anthracyclins or oxaliplatin in conditions in which the same neoplasms growing on immunocompetent mice would do so. Similarly, the therapeutic efficacy (measured as progression-free survival) of adjuvant chemotherapy with anthracyclins is reduced in breast cancer patients bearing loss-of-function alleles of TLR4 or P2RX7. TLR4 loss-of-function alleles also have a negative impact on the therapeutic outcome of oxaliplatin in colorectal cancer patients. Here, we report that loss-of-function TLR4 and P2RX7 alleles do not affect overall survival in non-small cell lung cancer (NSCLC) patients, irrespective of the administration and type of chemotherapy. The intrinsic characteristics of NSCLC (which near-to-always is chemoresistant and associated with poor prognosis) and/or the type of therapy that is employed to treat this malignancy (which near-to-always is based on cisplatin) may explain why two genes that affect the immune response to dying cells fail to influence the clinical progression of NSCLC patients.

Prognostic and predictive effect of KRAS gene copy number and mutation status in early stage non-small cell lung cancer patients

Background

In the current analysis, we characterize the prognostic significance of KRAS mutations with concomitant copy number aberrations (CNA) in early stage non-small cell lung cancer (NSCLC), and evaluate the ability to predict survival benefit from adjuvant chemotherapy.

Methods

Clinical and genomic data from the LACE (Lung Adjuvant Cisplatin Evaluation)-Bio consortium was utilized. CNAs were categorized as Gain (CN ≥2) or Neutral (Neut)/Loss; KRAS status was defined as wild type (WT) or mutant (MUT). The following groups were compared in all patients and the adenocarcinoma subgroup, and were correlated to survival endpoints using a Cox proportional hazards model: WT + Neut/Loss (reference), WT + Gain, MUT + Gain and MUT + Neut/Loss. A treatment-by-variable interaction was added to evaluate predictive effect.

Results

Of the 946 (399 adenocarcinoma) NSCLC patients, 41 [30] had MUT + Gain, 145 [99] MUT + Neut/Loss, 125 [16] WT + Gain, and 635 [254] WT + Neut/Loss. A non-significant trend towards worse lung cancer-specific survival (LCSS; HR =1.34; 95% CI, 0.83-2.17, P=0.232), DFS (HR =1.34; 95% CI, 0.86-2.09, P=0.202) and OS (HR =1.59; 95% CI, 0.99-2.54, P=0.055) was seen in KRAS MUT + Gain patients relative to KRAS WT + Neut/Loss patients. A negative prognostic effect of KRAS MUT + Neut/Loss was observed for LCSS (HR =1.32; 95% CI, 1.01-1.71, P=0.038) relative to KRAS WT + Neut/Loss on univariable analysis, but to a lesser extent after adjusting for covariates (HR =1.28; 95% CI, 0.97-1.68, P=0.078). KRAS MUT + Gain was associated with a greater beneficial effect of chemotherapy on DFS compared to KRAS WT + Neut/Loss patients (rHR =0.33; 95% CI, 0.11-0.99, P=0.048), with a non-significant trend also seen for LCSS (rHR =0.41; 95% CI, 0.13-1.33, P=0.138) and OS (rHR =0.40; 95% CI, 0.13-1.26, P=0.116) in the adenocarcinoma subgroup.

Conclusions

A small prognostic effect of KRAS mutation was identified for LCSS, and a trend towards worse LCSS, DFS and OS was noted for KRAS MUT + Gain. A potential predictive effect of concomitant KRAS mutation and copy number gain was observed for DFS in adenocarcinoma patients. These results could be driven by the small number of patients and require validation.

Neoadjuvant anti-programmed death-1 immunotherapy by pembrolizumab in resectable non-small cell lung cancer: First clinical experience

OBJECTIVES

A phase II trial investigating the therapeutic effect of neoadjuvant programmed cell death 1 (PD-1) inhibitor pembrolizumab (MK-3475, KEYTRUDA®) administered prior to surgery for the treatment of non-small cell lung cancer (NSCLC) has been conducted (NCT03197467). We report the first clinical results of a planned interim safety analysis after 15 patients were enrolled.

MATERIAL AND METHODS

Patients with resectable NSCLC stage II/IIIA were included. Two cycles of pembrolizumab (200 mg intravenously once every 3 weeks) were administered prior to surgery. The primary objectives were to assess the feasibility and safety of neoadjuvant pembrolizumab therapy and to evaluate antitumor activity. We analyzed the clinical parameters as well as pathological and radiological tumor response data.

RESULTS

The NSCLC histology was adenocarcinoma for 13 patients and squamous cell carcinoma for 2 patients. All patients but two underwent 2 cycles of pembrolizumab prior to surgery. Four patients (27 %) presented a major pathologic response. Significant tumor target response in positron emission tomography computed tomography (PET-CT) was detected in all 4 pathologic responders. Nevertheless, the PET findings mismatched the tumor load in some patients. A PD-L1 expression ≥10 % in the pretreatment biopsy was associated with at least major pathologic response. Five patients (33 %) presented grade 2-3 treatment related adverse events (TRAE), the overall postoperative morbidity was 7 % and 30-day mortality was 0 %.

CONCLUSION

Neoadjuvant pembrolizumab is a feasible therapy in surgical lung cancer patients. It was associated with tolerable toxicity and did not compromise tumor resection.

Prognostic impact of lymph node ratio in patients with pT1-2N1M0 non-small cell lung cancer

Background

This study evaluated the lymph node ratio (LNR) defined as the ratio of the number of metastatic lymph nodes to the number of dissected lymph nodes as a prognostic factor for survival in patients with pT1–2N1M0 non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 413 patients with pathologic T1–2N1M0 NSCLC after complete surgical resection and mediastinal LN dissection between January 2004 and December 2012. The cut-off value for LNR was determined using χ² tests, which were calculated using Cox proportional hazards regression model. Based on this model, the optimal cut-off value for LNR was 0.1.

Results

The study included 337 males and 76 females with a mean age of 62 years (range, 34–83 years). Patients with a high LNR (≥0.1) were more likely to be female and have more adenocarcinomas compared with patients with a low LNR (<0.1). The overall survival (OS) and disease-free survival (DFS) rates were significantly worse in the high LNR group than the low LNR group (OS, 55.4% vs. 69.8%, respectively P=0.003; DFS, 33.2% vs. 61.7%, P<0.001). In the multivariate analysis, a high LNR was associated with significantly worse OS [adjusted hazard ratio (aHR), 2.69; 95% confidence interval (CI), 1.74–4.17] and DFS (aHR, 2.41; 95% CI, 1.57–3.68).

Conclusions

LNR is an independent prognostic factor for survival in patients with pT1–2N1M0 NSCLC. These findings may provide useful prognostic information to allow the selection of patients for more aggressive postoperative therapy or follow-up strategies.

CheXLocNet: Automatic localization of pneumothorax in chest radiographs using deep convolutional neural networks

BACKGROUND

Pneumothorax can lead to a life-threatening emergency. The experienced radiologists can offer precise diagnosis according to the chest radiographs. The localization of the pneumothorax lesions will help to quickly diagnose, which will be benefit for the patients in the underdevelopment areas lack of the experienced radiologists. In recent years, with the development of large neural network architectures and medical imaging datasets, deep learning methods have become a methodology of choice for analyzing medical images. The objective of this study was to the construct convolutional neural networks to localize the pneumothorax lesions in chest radiographs.

METHODS AND FINDINGS

We developed a convolutional neural network, called CheXLocNet, for the segmentation of pneumothorax lesions. The SIIM-ACR Pneumothorax Segmentation dataset was used to train and validate CheXLocNets. The training dataset contained 2079 radiographs with the annotated lesion areas. We trained six CheXLocNets with various hyperparameters. Another 300 annotated radiographs were used to select parameters of these CheXLocNets as the validation set. We determined the optimal parameters by the AP50 (average precision at the intersection over union (IoU) equal to 0.50), a segmentation evaluation metric used by several well-known competitions. Then CheXLocNets were evaluated by a test set (1082 normal radiographs and 290 disease radiographs), based on the classification metrics: area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive predictive value (PPV); segmentation metrics: IoU and Dice score. For the classification, CheXLocNet with best sensitivity produced an AUC of 0.87, sensitivity of 0.78 (95% CI 0.73-0.83), and specificity of 0.78 (95% CI 0.76-0.81). CheXLocNet with best specificity produced an AUC of 0.79, sensitivity of 0.46 (95% CI 0.40-0.52), and specificity of 0.92 (95% CI 0.90-0.94). For the segmentation, CheXLocNet with best sensitivity produced an IoU of 0.69 and Dice score of 0.72. CheXLocNet with best specificity produced an IoU of 0.77 and Dice score of 0.79. We combined them to form an ensemble CheXLocNet. The ensemble CheXLocNet produced an IoU of 0.81 and Dice score of 0.82. Our CheXLocNet succeeded in automatically detecting pneumothorax lesions, without any human guidance.

CONCLUSIONS

In this study, we proposed a deep learning network, called, CheXLocNet, for the automatic segmentation of chest radiographs to detect pneumothorax. Our CheXLocNets generated accurate classification results and high-quality segmentation masks for the pneumothorax at the same time. This technology has the potential to improve healthcare delivery and increase access to chest radiograph expertise for the detection of diseases. Furthermore, the segmentation results can offer comprehensive geometric information of lesions, which can benefit monitoring the sequential development of lesions with high accuracy. Thus, CheXLocNets can be further extended to be a reliable clinical decision support tool. Although we used transfer learning in training CheXLocNet, the parameters of CheXLocNet was still large for the radiograph dataset. Further work is necessary to prune CheXLocNet suitable for the radiograph dataset.

Frequent Germline and Somatic Single Nucleotide Variants in the Promoter Region of the Ribosomal RNA Gene in Japanese Lung Adenocarcinoma Patients

Ribosomal RNA (rRNA), the most abundant non-coding RNA species, is a major component of the ribosome. Impaired ribosome biogenesis causes the dysfunction of protein synthesis and diseases called “ribosomopathies,” including genetic disorders with cancer risk. However, the potential role of rRNA gene (rDNA) alterations in cancer is unknown. We investigated germline and somatic single-nucleotide variants (SNVs) in the rDNA promoter region (positions −248 to +100, relative to the transcription start site) in 82 lung adenocarcinomas (LUAC). Twenty-nine tumors (35.4%) carried germline SNVs, and eight tumors (9.8%) harbored somatic SNVs. Interestingly, the presence of germline SNVs between positions +1 and +100 (n = 12; 14.6%) was associated with significantly shorter recurrence-free survival (RFS) and overall survival (OS) by univariate analysis (p < 0.05, respectively), and was an independent prognostic factor for RFS and OS by multivariate analysis. LUAC cell line PC9, carrying rDNA promoter SNV at position +49, showed significantly higher ribosome biogenesis than H1650 cells without SNV. Upon nucleolar stress induced by actinomycin D, PC9 retained significantly higher ribosome biogenesis than H1650. These results highlight the possible functional role of SNVs at specific sites of the rDNA promoter region in ribosome biogenesis, the progression of LUAC, and their potential prognostic value.

Influence of adjuvant chemotherapy on survival for patients with stage IB and IIA non-small cell lung cancer

Background

The role of adjuvant chemotherapy (ACT) for patients with stage IB–IIA non‐small cell lung cancer (NSCLC) according to the eighth edition of the AJCC TNM staging system remains controversial.

Methods

Data were collected from patients with NSCLC stage IB–IIA according to the eighth edition of the AJCC TNM staging system who underwent surgical resection from 2008 to 2015. The relationship between ACT and overall survival (OS) or disease‐free survival (DFS) was analyzed using the Kaplan–Meier method and Cox proportional hazards model.

Results

The study included 648 patients with completely resected NSCLC stage IB–IIA; 312 underwent ACT after surgical resection and 336 were placed under observation. After propensity score matching, 247 pairs of patients were matched and the five‐year OS was 88.08% and 83.12% (P = 0.13) in ACT and non‐ACT settings, respectively. Subgroup analyses demonstrated that ACT treatment was correlated with an improved five‐year OS in patients with visceral pleural invasion (VPI) in the 3 < tumor ≤ 4 cm subgroup (93.98% and 68.93%, P < 0.01).

Conclusions

ACT was not significantly associated with improved five‐year OS in stage IB–IIA NSCLC patients. However, further subgroup analysis showed that patients with VPI in the 3 < tumor ≤ 4 cm (T2aN0M0, stage IB) subgroup might benefit more from ACT. Further studies are required to validate the findings and better systemic strategies need to be developed in these patients.

Key points

Significant findings of the study

For patients with stage IB–IIA NSCLC according to the eighth edition of the AJCC TNM staging system, the effect of ACT remains unclear.

ACT was not significantly associated with improved five‐year OS in stage IB–IIA NSCLC patients. However, it was correlated with better DFS before or after PSM.

Patients with VPI in the 3 < tumor ≤ 4 cm subgroup may benefit from ACT.

What this study adds

ACT was not significantly associated with improved five‐year OS in stage IB–IIA NSCLC patients. However, it was correlated with better DFS before or after PSM.

Patients with VPI in the 3 < tumor ≤ 4 cm subgroup may benefit from ACT.

Neoadjuvant chemotherapy and Avelumab in early stage resectable nonsmall cell lung cancer

Multiple randomized studies have shown that combination of chemotherapy and immune checkpoint inhibitors (ICIs) leads to better response rates and survival as compared to chemotherapy alone in the advanced stage of NSCLC. Data suggesting a benefit to using ICIs in the neoadjuvant therapy of patients with early stage NSCLC are emerging. Eligible subjects were treatment naïve patients with stage IB, II, and resectable IIIA NSCLC. Patients received three cycles of neoadjuvant chemotherapy with four doses of avelumab every 2 weeks. Patients with squamous cell cancer received cisplatin or carboplatin on day 1 and gemcitabine on days 1 and 8 of each cycle of chemotherapy. Patients with nonsquamous histology received cisplatin or carboplatin with pemetrexed on day 1 of each cycle. Patients then proceeded to their planned surgery. Out of 15 patients accrued as part of stage 1 of the study, four had a radiologic response (1 complete response), lower than the minimum of six responses needed to continue to phase 2 of the study. The study was therefore terminated. Majority had adenocarcinoma histology and stage IIIA disease. The treatment was well tolerated with no unexpected side effects. Four patients (26.7%) had grade III/IV CTCAE toxicity. This study confirms that the preoperative administration of chemotherapy and avelumab is safe. There was no indication of increased surgical complications. The benefit of adding immunotherapy to chemotherapy did not appear to enhance the overall response rate of patients in the neoadjuvant setting in patients with resectable NSCLC because this study failed to meet its primary endpoint.

Negative Effect of Reduced NME1 Expression on Recurrence-Free Survival in Early Stage Non-Small Cell Lung Cancer

This study aimed to understand whether the effect of non-metastatic cells 1 (NME1) on recurrence-free survival (RFS) in early stage non-small cell lung cancer (NSCLC) can be modified by β-catenin overexpression and cisplatin-based adjuvant chemotherapy. Expression levels of NME1 and β-catenin were analyzed using immunohistochemistry in formalin-fixed paraffin-embedded tissues from 425 early stage NSCLC patients. Reduced NME1 expression was found in 39% of samples. The median duration of follow-up was 56 months, and recurrence was found in 186 (44%) of 425 patients. The negative effect of reduced NME1 expression on RFS was worsened by cisplatin-based adjuvant chemotherapy (adjusted hazard ratio = 3.26, 95% CI = 1.16–9.17, p = 0.03). β-catenin overexpression exacerbated the effect of reduced NME1 expression on RFS and the negative effect was greater when receiving cisplatin-based adjuvant chemotherapy: among patients treated with cisplatin-based adjuvant chemotherapy, hazard ratios of patients with reduced NME1 expression increased from 5.59 (95% confidence interval (CI) = 0.62–50.91, p = 0.13) to 15.52 (95% CI = 2.94–82.38, p = 0.001) by β-catenin overexpression, after adjusting for confounding factors. In conclusion, the present study suggests that cisplatin-based adjuvant chemotherapy needs to be carefully applied to early stage NSCLC patients with overexpressed β-catenin in combination with reduced NME1 expression.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Lung cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Lung cancer is the leading cause of cancer mortality and has a wide variation in treatment and outcomes in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must only be carried out in lung cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Evaluation of Postoperative Radiotherapy Effect on Survival of Resected Stage III-N2 Non-small Cell Lung Cancer Patients

Objective: The role of postoperative radiotherapy (PORT) in resected stage IIIA-N2 non-small cell lung cancer (NSCLC) patients remains controversial. This study aimed to explore the effect of PORT on survival of resected stage IIIA-N2 NSCLC patients.

Methods: Resected stage IIIA-N2 NSCLC patients aged 18 years or older were identified from the SEER (Surveillance, Epidemiology, and End Results) database from 2010 to 2015. Cox regression analysis was used to identify factors including PORT associated with survival time. A subgroup analysis of patients stratified by number of lymph node metastases was also performed. Overall survival (OS) and overall mortality were compared among the different groups.

Results: A total of 3,445 patients were included in the study. Multivariate Cox analysis showed that PORT had no significant impact on survival of patients with <6 positive lymph node [hazard ratio (HR) = 1.012, P = 0.858, 95% CI: 0.886–1.156]. Postoperative chemotherapy (POCT) (HR = 0.605, P < 0.001, 95% CI: 0.468–0.783) and PORT (HR = 0.724, P = 0.007, 95% CI: 0.574–0.914) are both favorable prognostic factors for stage IIIA-N2 patients with ≥6 positive lymph nodes. In 2,735 patients who featured <6 number of positive regional lymph nodes, patients who received PORT had better survival and lower 3-years and 5-years overall mortality rate than patients who underwent surgery only (41 vs. 28 months, P < 0.015). There was no significant difference in the survival of postoperative patients who underwent POCT in view of whether received PORT (44 vs. 53 months, P = 0.176). A total of 710 patients who featured ≥6 number of positive regional lymph node metastasis were divided into two groups by PORT. PORT did not prolong survival for postoperative patients who did not receive chemotherapy (12 vs. 15 months, P = 0.632). PORT showed a significant advantage in influencing OS in patients who received PORT combined with POCT as compared with those who received POCT only (32 vs. 25 months, P = 0.006).

Conclusions: For IIIA-N2 patients with <6 lymph node metastases, use of PORT can be encouraged to improve survival. For patients with ≥6 positive lymph nodes, PORT combined with POCT significantly improved OS and decreased overall mortality.

Multi-Institutional Prospective Validation of Prognostic mRNA Signatures in Early Stage Squamous Lung Cancer (Alliance)

INTRODUCTION

Surgical resection is curative for some patients with early lung squamous cell carcinoma. Staging and clinical factors do not adequately predict recurrence risk. We sought to validate the discriminative performance of proposed prognostic gene expression signatures at a level of rigor sufficient to support clinical use.

METHODS

The two-stage validation used independent core laboratories, objective quality control standards, locked test parameters, and large multi-institutional specimen and data sets. The first stage validation confirmed a signature's ability to stratify patient survival. The second-stage validation determined which signature(s) optimally improved risk discrimination when added to baseline clinical predictors. Participants were prospectively enrolled in institutional (cohort I) or cooperative group (cohort II) biospecimen and data collection protocols. All cases underwent a central review of clinical, pathologic, and biospecimen parameters using objective criteria to determine final inclusion (cohort I: n = 249; cohort II: n = 234). Primary selection required that a signature significantly predict a 3-year survival after surgical resection in cohort I. Signatures meeting this criterion were further tested in cohort II, comparing risk prediction using baseline risk factors alone versus in combination with the signature.

RESULTS

Male sex, advanced age, and higher stage were associated with shorter survival in cohort I and established a baseline clinical model. Of the three signatures validated in cohort I, one signature was validated in cohort II and statistically significantly enhanced the prognosis relative to the baseline model (C-index difference 0.122; p < 0.05).

CONCLUSIONS

These results represent the first rigorous validation of a test appropriate to direct adjuvant treatment or clinical trials for patients with lung squamous cell carcinoma.

Changes and Influential Factors of Chemotherapy Usage for Non-Small Cell Lung Cancer Patients in China: A Multicenter 10-Year (2005-2014) Retrospective Study

Background

Chemotherapy has improved the survival of non-small cell lung cancer (NSCLC) patients over the past few decades. However, there have not been any epidemiological studies on chemotherapy for Chinese NSCLC patients.

Patients and Methods

The patients diagnosed as primary lung cancer between January 1, 2005, and December 31, 2014, in eight hospitals from eight provinces in China were retrospectively reviewed. Demographic and clinical data were extracted from medical history systems. Chi-square test and logistic regression were used to analyze the changes of chemotherapy usage and influential factors.

Results

A total of 7184 lung cancer cases were eligible, among which 6481 NSCLC cases were included in this analysis. Among stage I/II patients, the percentages of receiving adjuvant chemotherapy did not change significantly between the earlier (28.5%) and the latter five years (25.7%) (p = 0.1288). Among stage IIIA patients, the percentages of chemotherapy usage did not change significantly between the earlier and the latter five years in neo-adjuvant (7.5% vs 5.6%, p = 0.1478) and adjuvant (23.1% vs 26.8%, p = 0.1129) treatment. The proportions of first-line platinum-based doublets for stage IIIB/IV patients changed significantly over the 10 years (p < 0.0001). Patients from provinces with inferior gross domestic product, with lower medical reimbursement rates and without smoking history were more likely to use the docetaxel/paclitaxel doublets, comparing with the gemcitabine doublets.

Conclusion

From 2005 to 2014, there was no significant change in the chemotherapy pattern of early NSCLC. Economic factors mainly contributed to the significant changes in the first-line chemotherapy regimen selection for advanced patients.

Machine learning-based histological classification that predicts recurrence of peripheral lung squamous cell carcinoma

BACKGROUND

Cancer tissue is composed of both a cancer cell component and a stromal component. The aim of this study was to investigate if the component ratio predicts a prognosis for lung squamous cell carcinoma (SqCC) patients by using a machine learning method.

METHODS

A total of 135 peripheral SqCC cases (tumor size: 3-5 cm) were enrolled in this study. The areas of the cancer cell component, the necrotic component, and the stromal component were accurately measured via a machine learning method. Each case was divided into the following three subtypes: 1) predominant cancer cell, 2) predominant necrosis, and 3) predominant stroma. The study examined if a particular subtype had prognostic significance.

RESULTS

The number of cases per subtype of predominant cancer cell, predominant necrosis, and predominant stroma was 59, 6, and 70, respectively. Patients with the predominant stroma subtype had a significantly shorter recurrence free survival (RFS) than did those with the predominant cancer cell subtype (5-yr RFS: 42.3 % vs. 84.3 %,p < 0.01). Also, in pathological stage I patients, the 5-year RFS rate for the predominant stroma subtype was significantly shorter (5-yr RFS: 64.3 % vs. 88.4 %, p < 0.01). In the multivariate analysis of p-stage I patients, the predominant stroma subtype was confirmed to be an independent prognostic factor for RFS (p < 0.01).

CONCLUSION

Using machine learning, the study confirmed that the predominant stroma subtype was an independent factor for RFS, suggesting that the ratio of the stromal component correlates with the malignant potential of SqCC.

Identification of an Immune Gene Expression Signature for Predicting Lung Squamous Cell Carcinoma Prognosis

Growing evidence indicates that immune-related biomarkers play an important role in tumor processes. This study investigates immune-related gene expression and its prognostic value in lung squamous cell carcinoma (LUSC). A cohort of 493 samples of patients with LUSC was collected and analyzed from data generated by the TCGA Research Network and ImmPort database. The R coxph package was employed to mine significant immune-related genes using univariate analysis. Lasso and stepwise regression analyses were used to construct the LUSC prognosis prediction model, and clusterProfiler was used for gene functional annotation and enrichment analysis. The Kaplan-Meier analysis and ROC were used to evaluate the model efficiency in predicting and classifying LUSC case prognoses. We identified 14 immune-related genes to incorporate into our prognosis model. The patients were divided into two subgroups (Risk-H and Risk-L) according to their risk score values. Compared to Risk-L patients, Risk-H patients showed significantly improved overall survival (OS) in both training and testing sets. Functional annotation indicated that the 14 identified genes were mainly enriched in several immune-related pathways. Our results also revealed that a risk score value was correlated with various signaling pathways, such as the JAK-STA signaling pathway. Establishment of a nomogram for clinical application demonstrated that our immune-related model exhibited good predictive prognostic performance. Our predictive prognosis model based on immune signatures has potential clinical implications for assessing the overall survival and precise treatment for patients with LUSC.

Adjuvant therapy in stage IIIA-N2 non-small cell lung cancer after neoadjuvant concurrent chemoradiotherapy followed by surgery

Background

This study aimed to determine whether adjuvant therapy improves survival in patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) after neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery.

Methods

We retrospectively reviewed 467 consecutive patients with stage IIIA-N2 NSCLC who received neoadjuvant CCRT followed by surgery between 2004 and 2013. From these, we identified 398 eligible patients and their clinical outcomes were compared according to whether adjuvant therapy was provided.

Results

In total, 296 patients (74%) received adjuvant therapy consisting of chemotherapy alone (n=71) radiotherapy alone (n=118) and both chemotherapy and radiotherapy (n=107). Adjuvant therapy was not given to remaining 102 patients. Patients who receiving adjuvant therapy were significantly younger (P=0.001), and predominantly male (P=0.014) compared to patients who did not receive adjuvant therapy. Regarding to the pathologic response, the adjuvant therapy group had a significantly poor pathologic response. However, the 5-year overall survival (OS) rate did not significantly differ between the groups (adjuvant therapy group, 52.9%; no adjuvant therapy group, 54.9%; P=0.369). After adjusting for age, sex, type of operation, cell type and yp stage, adjuvant therapy was significantly associated with better OS (hazard ratio =0.59; 95% CI, 0.38–0.92; P=0.019) and disease free survival (hazard ratio =0.62; 95% CI, 0.44–0.87; P=0.006).

Conclusions

Our data indicate that adjuvant therapy is more often given to patients with poor pathologic findings. Adjuvant treatment after trimodal therapy is a significant predictor of survival after adjustment of clinical variables.

A pilot study of adjuvant chemotherapy with carboplatin and oral S-1 for patients with completely resected stage II to IIIA non-small cell lung cancer

Background

Adjuvant chemotherapy with platinum‐based regimens for completely resected early‐stage non‐small cell lung cancer (NSCLC) provides overall survival benefit in several clinical trials.

Objectives

We conducted this prospective study to evaluate the efficacy and safety of adjuvant chemotherapy with carboplatin and S‐1 for patients with completely resected stage II to IIIA NSCLC.

Methods

Patients with completely resected stage IIA to IIIA NSCLC were treated with four cycles of carboplatin with area under the concentration time curve of 5 mg/mL/min on day 1 plus S‐1 at 80–120 mg/bodyweight per day for two weeks, followed by one‐week rest as adjuvant chemotherapy. The primary endpoint was the completion rate of three cycles of the treatment. The secondary endpoints were safety and two‐year survival rate.

Results

A total of 19 patients were enrolled, until the study was terminated prematurely because of fatal pulmonary embolism in two patients. The median number of treatment cycles was three (range: 1–4). The completion rate of three cycles was 78.9% (95% confidence interval [CI]: 56.6–91.4%). Two‐year disease‐free survival rate was 57.8%. Grade 3 or 4 hematological toxicities included neutropenia (26.2%), anemia (5.2%), and thrombocytopenia (15.7%). Grade 3 or 4 nonhematological toxicities were anorexia (10.5%) and nausea (10.5%). Febrile neutropenia developed in 5.2%. In two patients (10.5%), grade five pulmonary embolism was observed, and the causal relationship with treatment could not be denied.

Conclusions

Carboplatin and oral S‐1 had modest survival benefit, but this regimen was not tolerable in an adjuvant setting because fatal pulmonary embolism occurred in two patients.

Key points

Carboplatin and oral S‐1 had modest survival benefit but this regimen was not tolerable.

Fatal pulmonary embolism occurred in this regimen.

Immune Checkpoint Inhibition in Non-metastatic Non-small Cell Lung Cancer: Chance for Cure?

Immune checkpoint inhibition of programmed-death receptor 1 (PD-1) or its ligand (PD-L1) has become a standard in the treatment of metastatic non-small cell lung cancer, either as monotherapy or in combination. Recently, it could be shown that immunotherapy works as consolidation after chemoradiotherapy in locally advanced disease if the tumours express PD-L1. A significant and meaningful survival benefit for consolidation with durvalumab after chemoradiotherapy compared to chemoradiotherapy alone was observed in the PACIFIC trial. In addition, there is a growing body of evidence that this treatment modality is also effective in a neoadjuvant setting in early stages, whereas the role as adjuvant treatment after surgery needs to be determined. The impact of combination therapies in non-metastatic stages-either neoadjuvant or adjuvant-needs to be evaluated in future trials. It is yet unclear whether PD-L1 and tumour mutational burden are predictive biomarkers as randomised trials are missing.

Conquering lung cancer: current status and prospects for the future

Lung cancer is a major global health problem. Several strategies are required to conquer this cancer. Stricter implementations of tobacco control measures are necessary. Early detection programs should be implemented to decrease lung cancer mortality. Although chemotherapy remains a cornerstone of treatment, targeted therapies and immune checkpoint inhibitors improved treatment of metastatic cancers and are hoped to improve outcome of adjuvant and induction therapies. Novel immunotherapy approaches hold great promise. Better understanding of the molecular biology of lung cancer should lead to rational drug design.

Epigenetic therapy inhibits metastases by disrupting premetastatic niches

Cancer recurrence after surgery remains an unresolved clinical problem^1-3. Myeloid cells derived from bone marrow contribute to the formation of the premetastatic microenvironment, which is required for disseminating tumour cells to engraft distant sites^4-6. There are currently no effective interventions that prevent the formation of the premetastatic microenvironment^6,7. Here we show that, after surgical removal of primary lung, breast and oesophageal cancers, low-dose adjuvant epigenetic therapy disrupts the premetastatic microenvironment and inhibits both the formation and growth of lung metastases through its selective effect on myeloid-derived suppressor cells (MDSCs). In mouse models of pulmonary metastases, MDSCs are key factors in the formation of the premetastatic microenvironment after resection of primary tumours. Adjuvant epigenetic therapy that uses low-dose DNA methyltransferase and histone deacetylase inhibitors, 5-azacytidine and entinostat, disrupts the premetastatic niche by inhibiting the trafficking of MDSCs through the downregulation of CCR2 and CXCR2, and by promoting MDSC differentiation into a more-interstitial macrophage-like phenotype. A decreased accumulation of MDSCs in the premetastatic lung produces longer periods of disease-free survival and increased overall survival, compared with chemotherapy. Our data demonstrate that, even after removal of the primary tumour, MDSCs contribute to the development of premetastatic niches and settlement of residual tumour cells. A combination of low-dose adjuvant epigenetic modifiers that disrupts this premetastatic microenvironment and inhibits metastases may permit an adjuvant approach to cancer therapy.

CT derived radiomic score for predicting the added benefit of adjuvant chemotherapy following surgery in stage I, II resectable non-small cell lung cancer: a retrospective multicohort study for outcome prediction

BACKGROUND

Use of adjuvant chemotherapy in patients with early-stage lung cancer is controversial because no definite biomarker exists to identify patients who would receive added benefit from it. We aimed to develop and validate a quantitative radiomic risk score (QuRiS) and associated nomogram (QuRNom) for early-stage non-small cell lung cancer (NSCLC) that is prognostic of disease-free survival and predictive of the added benefit of adjuvant chemotherapy following surgery.

METHODS

We did a retrospective multicohort study of individuals with early-stage NSCLC (stage I and II) who either received surgery alone or surgery plus adjuvant chemotherapy. We selected patients for whom we had available pre-treatment diagnostic CT scans and corresponding survival information. We used radiomic texture features derived from within and outside the primary lung nodule on chest CT scans of patients from the Cleveland Clinic Foundation (Cleveland, OH, USA; cohort D₁) to develop QuRiS. A least absolute shrinkage and selection operator-Cox regularisation model was used for data dimension reduction, feature selection, and QuRiS construction. QuRiS was independently validated on a cohort of patients from the University of Pennsylvania (Philadephia, PA, USA; cohort D₂) and a cohort of patients whose CT scans were derived from The Cancer Imaging Archive (cohort D₃). QuRNom was constructed by integrating QuRiS with tumour and node descriptors (according to the tumour, node, metastasis staging system) and lymphovascular invasion. The primary endpoint of the study was the assessment of the performance of QuRiS and QuRNom in predicting disease-free survival. The added benefit of adjuvant chemotherapy estimated using QuRiS and QuRNom was validated by comparing patients who received adjuvant chemotherapy versus patients who underwent surgery alone in cohorts D₁-D₃.

FINDINGS

We included: 329 patients in cohort D₁ (73 [22%] had surgery plus adjuvant chemotherapy and 256 (78%) had surgery alone); 114 patients in cohort D₂ (33 [29%] had surgery plus adjuvant chemotherapy and 81 (71%) had surgery alone); and 82 patients in cohort D₃ (24 [29%] had surgery plus adjuvant chemotherapy and 58 (71%) had surgery alone). QuRiS comprised three intratumoral and 10 peritumoral CT-radiomic features and was found to be significantly associated with disease-free survival (ie, prognostic validation of QuRiS; hazard ratio for predicted high-risk vs predicted low-risk groups 1·56, 95% CI 1·08-2·23, p=0·016 for cohort D₁; 2·66, 1·24-5·68, p=0·011 for cohort D₂; and 2·67, 1·39-5·11, p=0·0029 for cohort D₃). To validate the predictive performance of QuRiS, patients were partitioned into three risk groups (high, intermediate, and low risk) on the basis of their corresponding QuRiS. Patients in the high-risk group were observed to have significantly longer survival with adjuvant chemotherapy than patients who underwent surgery alone (0·27, 0·08-0·95, p=0·042, for cohort D₁; 0·08, 0·01-0·42, p=0·0029, for cohorts D₂ and D₃ combined). As concerns QuRNom, the nomogram-estimated survival benefit was predictive of the actual efficacy of adjuvant chemotherapy (0·25, 0·12-0·55, p<0·0001, for cohort D₁; 0·13, <0·01-0·99, p=0·0019 for cohort D₃).

INTERPRETATION

QuRiS and QuRNom were validated as being prognostic of disease-free survival and predictive of the added benefit of adjuvant chemotherapy, especially in clinically defined low-risk groups. Since QuRiS is based on routine chest CT imaging, with additional multisite independent validation it could potentially be employed for decision management in non-invasive treatment of resectable lung cancer.

FUNDING

National Cancer Institute of the US National Institutes of Health, National Center for Research Resources, US Department of Veterans Affairs Biomedical Laboratory Research and Development Service, Department of Defence, National Institute of Diabetes and Digestive and Kidney Diseases, Wallace H Coulter Foundation, Case Western Reserve University, and Dana Foundation.

Mechanistic Understanding of Curcumin's Therapeutic Effects in Lung Cancer

Lung cancer is among the most common cancers with a high mortality rate worldwide. Despite the significant advances in diagnostic and therapeutic approaches, lung cancer prognoses and survival rates remain poor due to late diagnosis, drug resistance, and adverse effects. Therefore, new intervention therapies, such as the use of natural compounds with decreased toxicities, have been considered in lung cancer therapy. Curcumin, a natural occurring polyphenol derived from turmeric (Curcuma longa) has been studied extensively in recent years for its therapeutic effects. It has been shown that curcumin demonstrates anti-cancer effects in lung cancer through various mechanisms, including inhibition of cell proliferation, invasion, and metastasis, induction of apoptosis, epigenetic alterations, and regulation of microRNA expression. Several in vitro and in vivo studies have shown that these mechanisms are modulated by multiple molecular targets such as STAT3, EGFR, FOXO3a, TGF-β, eIF2α, COX-2, Bcl-2, PI3KAkt/mTOR, ROS, Fas/FasL, Cdc42, E-cadherin, MMPs, and adiponectin. In addition, limitations, strategies to overcome curcumin bioavailability, and potential side effects as well as clinical trials were also reviewed.

Comparison of Conventional TNM and Novel TNMB Staging Systems for Non-Small Cell Lung Cancer

IMPORTANCE

Improved staging for non-small cell lung cancer (NSCLC) represents a critical unmet need. External validations of the eighth edition of the TNM staging system have yielded disappointing results, with persistently high mortality observed in early-stage disease.

OBJECTIVE

To determine whether incorporation of a molecular prognostic classifier into conventional TNM staging for NSCLC improves estimation of disease-free survival.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted at an academic, quaternary care medical center from 2012 to 2018. A consecutive series of 238 patients underwent surgical resection of stage I to IIIC nonsquamous NSCLC and had molecular prognostic classifier testing performed. Data analysis was conducted in May 2019.

EXPOSURES

Patients were restaged according to the seventh and eighth editions of the TNM staging system and the novel TMMB staging system, which maintains the order and structure of the eighth edition of the TNM but downstages or upstages according to low or high molecular risk, respectively.

MAIN OUTCOMES AND MEASURES

The primary outcome was disease-free survival 3 years from the time of surgical resection. Reclassification statistics were then used to evaluate performance and improvement measures of the TNM seventh and eighth editions and the TNMB staging system.

RESULTS

Two hundred thirty-eight patients (144 [60.5%] female; median [interquartile range] age, 70 [63-75] years) were analyzed. The median (interquartile range) follow-up was 25 (14-40) months, and the disease-free survival rate was estimated to be 58.3% (95% CI, 45.7% to 69.0%). One hundred fifty-nine patients (66.8%) were reclassified by the TNMB staging system. Overall model fit remained the same for the seventh and eighth editions of the TNM staging system, whereas the R2 statistic (change from 0.22 to 0.31), concordance index (change from 0.68 to 0.73), and log-rank χ2 (change from 38 to 108) were all associated with improvements after TNMB adoption. The TNMB system, compared with the TNM eighth edition, was associated with enhanced identification of high-risk patients and better differentiation of those without recurrence from those who had recurrence (net reclassification improvement, 0.28; 95% CI, 0.08 to 0.46; P < .001), whereas the eighth edition compared with the seventh edition was not associated with improvement of this measure (net reclassification improvement, 0.02; 95% CI, -0.18 to 0.21; P = .87).

CONCLUSIONS AND RELEVANCE

The TNMB staging system was associated with improved estimation of disease-free survival compared with conventional TNM staging. Incorporation of a molecular prognostic classifier into staging for NSCLC may lead to better identification of high-risk patients.

Randomized phase II trial of adjuvant chemotherapy with docetaxel plus cisplatin versus paclitaxel plus carboplatin in patients with completely resected non-small cell lung cancer: TORG 0503

OBJECTIVE

Adjuvant chemotherapy is standard of care for patients with completely resected stage IB, II and IIIA NSCLC. However, optimum chemotherapy regimen has not been determined. TORG0503 was undertaken to select a preferred platinum-based 3^rd generation regimen in this clinical setting.

MATERIALS AND METHODS

Patients with completely resected stage IB, IIA, IIB or stage IIIA NSCLC were stratified by stage (IB/IIA vs. IIB/IIIA) and institutions, and randomized to receive 3 cycles of docetaxel (60 mg/m²) plus cisplatin (80 mg/m²) (arm A) or paclitaxel (200 mg/m²) plus carboplatin (AUC 6) (arm B) on day 1, every 3 weeks. The primary endpoint of the study was 2-year relapse free survival, and the key secondary endpoints included overall survival, feasibility and toxicity.

RESULTS

111 patients were randomized, 58 patients to arm A and 53 to arm B. Patient demographics were balanced between the two arms. 93 % (54/58) of patients on the arm A and 92 % (49/53) patients on the arm B completed the planned 3 cycles of chemotherapy. There was no treatment-related death in both arms. The 2 and 5 year relapse free survival was 74.5 % (95 %CI: 68.6-80.4) and 61.6 % in the arm A, and 72.0 % (95 %CI: 65.7-78.3) and 46.0 % in the arm B. The overall 2, 5-year survival was 89.7 %, 73.9 % in the arm A and 86.9 %, 67.5 % in the arm B.

CONCLUSION

Both docetaxel plus cisplatin and paclitaxel plus carboplatin are safe and feasible regimens as adjuvant chemotherapy. We choose docetaxel plus cisplatin as the control regimen for the next clinical trial.

[Adjuvant and inductive systemic treatment in non-small cell lung cancer]

A large number of randomized trials have demonstrated an undoubted advantage of adjuvant chemotherapy in comparison to surgery alone. This is true for all lymph node positive cases of non-small cell lung cancer (NSCLC) with a tumor size of 4 cm or more. Worldwide, the application of adjuvant chemotherapy for these indications is regarded as standard treatment. Due to the positive results of adjuvant chemotherapy, nearly all studies focusing on neoadjuvant chemotherapy were stopped early because control arms with surgery alone were no longer regarded as ethically justified; however, in meta-analyses the effect of neoadjuvant chemotherapy seems be as strong as the effect of adjuvant chemotherapy. In clinical practice neoadjuvant chemotherapy is not routinely established in early stage disease. This approach is more often applied in advanced stages, such as N2 lymph node involvement or in patients where the tumor most probably requires pneumectomy for resection. In the last decade the options for systemic treatment of NSCLC have dramatically changed. In addition to chemotherapy, targeted treatment of patients with molecularly altered tumors and immunotherapy have been used very successfully in advanced stages. The options might also have a high impact on survival in early stages and the integration of these treatment modalities in the management of early stage disease is warranted. This article summarizes the established and new options in additive systemic treatment and presents the current state of treatment.

Randomised phase 3 study of adjuvant chemotherapy with or without nadroparin in patients with completely resected non-small-cell lung cancer: the NVALT-8 study

Background

Retrospective studies suggest that low molecular weight heparin may delay the development of metastasis in patients with resected NSCLC.

Methods

Multicentre phase 3 study with patients with completely resected NSCLC who were randomised after surgery to receive chemotherapy with or without nadroparin. The main exclusion criteria were R1/2 and wedge/segmental resection. FDG-PET was required. The primary endpoint was recurrence-free survival (RFS).

Results

Among 235 registered patients, 202 were randomised (nadroparin: n = 100; control n = 102). Slow accrual enabled a decrease in the number of patients needed from 600 to 202, providing 80% power to compare RFS with 94 events (α = 0.05; 2-sided). There were no differences in bleeding events between the two groups. The median RFS was 65.2 months (95% CI, 36—NA) in the nadroparin arm and 37.7 months (95% CI, 22.7—NA) in the control arm (HR 0.77 (95% CI, 0.53–1.13, P = 0.19). FDG-PET SUVmax ≥10 predicted a greater likelihood of recurrence in the first year (HR 0.48, 95% CI 0.22–0.9, P = 0.05).

Conclusions

Adjuvant nadroparin did not improve RFS in patients with resected NSCLC. In this study, a high SUVmax predicted a greater likelihood of recurrence in the first year.

Clinical trial registration

Netherlands Trial registry: NTR1250/1217.

Genomic landscape and its correlations with tumor mutational burden, PD-L1 expression, and immune cells infiltration in Chinese lung squamous cell carcinoma

INTRODUCTION

To depict the genomic landscape of Chinese early-stage lung squamous cell carcinoma (LUSC) and investigate its correlation with tumor mutation burden (TMB), PD-L1 expression, and immune infiltrates.

METHODS

Whole-exome sequencing was performed on 189 surgically resected LUSC. TMB was defined as the sum of nonsynonymous single nucleotide and indel variants. CD8⁺ tumor-infiltrating lymphocyte (TIL) density and PD-L1 expression were evaluated by immunohistochemistry. Six immune infiltrates were estimated using an online database.

RESULTS

The median TMB was 9.43 mutations per megabase. Positive PD-L1 expression and CD8⁺ TILs density were identified in 24.3% and 78.8%. PIK3CA amplification was associated with significantly higher TMB (P = 0.036). Frequent genetic alterations had no impact on PD-L1 expression but PIK3CA amplification and KEAP1 mutation were independently associated with significantly lower CD8⁺ TIL density (P < 0.001, P = 0.005, respectively). Low TMB and high CD8⁺ TIL density were independently associated with longer disease-free survival (DFS) while none of them could individually predict the overall survival (OS). Combination of TMB and PD-L1 expression or TMB and CD8⁺ TIL density could stratify total populations into two groups with distinct prognosis. Classifying tumor-immune microenvironment based on PD-L1 expression and CD8⁺ TIL density showed discrepant genomic alterations but similar TMB, clinical features, and OS. Notably, patients with different smoking status had distinct prognostic factors.

CONCLUSION

The combination of TMB, PD-L1 expression, immune infiltrates, and smoking status showed the feasibility to subgroup stratification in Chinese patients with early-stage LUSC, which might be helpful for future design of personalized immunotherapy trials in LUSC.

Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer

Stage III non-small cell lung cancer (NSCLC) is a very heterogeneous disease that encompasses patients with resected, potentially resectable and unresectable tumours. To improve the prognostic capacity of the TNM classification, it has been agreed to divide stage III into sub-stages IIIA, IIIB and IIIC that have very different 5-year survival rates (36, 26 and 13%, respectively). Currently, it is considered that both staging and optimal treatment of stage III NSCLC requires the joint work of a multidisciplinary team of expert physicians within the tumour committee. To improve the care of patients with stage III NSCLC, different scientific societies involved in the diagnosis and treatment of this disease have agreed to issue a series of recommendations that can contribute to homogenise the management of this disease, and ultimately to improve patient care.

Neoadjuvant anti-programmed Death-1 immunotherapy by Pembrolizumab in resectable nodal positive stage II/IIIa non-small-cell lung cancer (NSCLC): the NEOMUN trial

Background

Immunotherapies targeting the PD1/PD-L1 pathway have had a large impact on the treatment of advanced NSCLC. Concerning multimodality tumor therapy, only few trials until today have been performed investigating neoadjuvant treatment with anti PD-1 immunotherapy prior to curative intent surgery. Aim of the NEOMUN investigator initiated trial (EudraCT-Number: 2017–000105-20; ClinicalTrials.gov Identifier: NCT03197467) is to assess feasibility and safety of pre-surgical anti PD-1 treatment in order to improve long term survival.

Methods

The study is designed as an open-label, single arm, prospective, monocenter, phase II study including 30 patients with NSCLC stage II/IIIA suitable for curative intent surgery. Investigational drug is Pembrolizumab. After 2 cycles of immunotherapy (à 200 mg q3w i.v.), tumor resection with lobectomy or bilobectomy will be performed. Primary objectives are to assess the feasibility and safety of a neoadjuvant immunotherapy and to assess antitumor activity of Pembrolizumab with regard to clinical and pathological tumor response. Secondary objective is disease free and overall survival. Exploratory objective is to analyze potential predictive biomarkers and to evaluate the therapeutic efficacy of Pembrolizumab by extended immune cell and cytokine analysis of tumor tissue.

The study protocol was approved by the local ethics committee and the federal authority. Start of patient enrollment is scheduled for June 2018.

Discussion

The NEOMUN trial will be one of the first clinical trials investigating a multimodal treatment strategy including neoadjuvant immunotherapy using Pembrolizumab as an investigational drug. Assessing the safety and therapeutic potential of neoadjuvant immunotherapy in connection with lung surgery will be of great interest for thoracic surgeons.

Trial registration

Prospectively, the NEOMUN study has been registered on www.clinicaltrials.gov; NCT03197467 (first post: June 23rd, 2017).

Incorporation of a Molecular Prognostic Classifier Improves Conventional Non-Small Cell Lung Cancer Staging

INTRODUCTION

Despite adoption of molecular biomarkers in the management of NSCLC, the recently adopted eighth edition of the TNM staging system utilized only clinicopathologic characteristics and validated improvement in risk stratification of early-stage disease has remained elusive. We therefore evaluated the integration of a clinically validated molecular prognostic classifier into conventional staging.

METHODS

A novel staging system, the TNMB (with the B denoting biology) system, which integrates a 14-gene molecular prognostic classifier into the eighth edition of the TNM staging system, was developed by using data from 321 patients with NSCLC at the University of California, San Francisco. The TNMB staging system was subsequently validated in an independent, multicenter cohort of 1373 patients, and its implementation was compared with adoption of the seventh and eighth edition staging systems utilizing metrics of reclassification.

RESULTS

Compared with staging according to the eighth edition of the TNM system, the TNMB staging system enhanced the identification of high-risk patients, with a net reclassification improvement of 0.33 (95% confidence interval [CI]: 0.24-0.41). It better predicted differences in survival, with a relative integrated discrimination improvement of 22.1% (95% CI: 8.8%-35.3%), and it improved agreement between observed and predicted survival, with a decrease in the reclassification calibration statistic of from 39 to 21. The seventh and eighth editions failed to change the net reclassification improvement (0.01 [95% CI: -0.04 to 0.03] and 0.03 [95% CI: 0.00 to 0.06], respectively) or relative integrated discrimination improvement (2.1% [95% CI: -5.8 to 9.9] and -2.5% [95% CI: -17.6 to 12.4], respectively); in addition, the eighth edition worsened calibration, with an increase in the reclassification calibration statistic from 23 to 25.

CONCLUSIONS

Incorporation of a molecular prognostic classifier significantly improved identification of high-risk patients and survival predictions compared with when conventional staging is used. The TNMB staging system may lead to improved survival of early-stage disease through more effective application of adjuvant therapy.

Lung cancer stem cells and their aggressive progeny, controlled by EGFR/MIG6 inverse expression, dictate a novel NSCLC treatment approach

The lung cancer stem cell (LuCSC) model comprises an attractive framework to explore acquired drug resistance in non-small cell lung cancer (NSCLC) treatment. Here, we used NSCLC cell line model to translate cellular heterogeneity into tractable populations to understand the origin of lung cancers and drug resistance. The epithelial LuCSCs, presumably arising from alveolar bipotent stem/progenitor cells, were lineage naïve, noninvasive, and prone to creating aggressive progeny expressing AT2/AT1 markers. LuCSC-holoclones were able to initiate rimmed niches, where their specialization created pseudo-alveoli structures. Mechanistically, LuCSC transitioning from self-renewal (β-catenin and Nanog signaling) to malignant lineage differentiation is regulated by EGFR activation and the inverse inhibition of tumor suppressor MIG6. We further identified the functional roles of endogenous EGFR signaling in mediating progeny invasiveness and their ligands in LuCSC differentiation. Importantly, drug screening demonstrated that EGFR driving progeny were strongly responsive to TKIs; however, the LuCSCs were exclusively resistant but sensitive to AMPK agonist Metformin, antibiotic Salinomycin and to a lesser degree Carboplatin. Our data reveals previously an unknown mechanism of NSCLC resistance to EGFR-TKIs, which is associated with LuCSCs bearing a silenced EGFR and inversely expressed MIG6 suppressor gene. Taken altogether, successful NSCLC treatment requires development of a novel combination of drugs, efficiently targeting both LuCSCs and heterogeneous progeny.

A Nomogram for Predicting Cancer-Specific Survival of TNM 8th Edition Stage I Non-small-cell Lung Cancer

BACKGROUND

Models for predicting the survival outcomes of stage I non-small-cell lung cancer (NSCLC) defined by the newly released 8th edition TNM staging system are scarce. This study aimed to develop a nomogram for predicting the cancer-specific survival (CSS) of these patients and identifying individuals with a higher risk for CSS.

METHODS

A total of 30,475 NSCLC cases were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. We identified and integrated the risk factors to build a nomogram. The model was subjected to bootstrap internal validation with the SEER database, and external validation with a multicenter cohort of 1133 patients from China. The difference in the impact of adjuvant chemotherapy on model-defined high- and low-risk patients was examined using the National Cancer Database (NCDB).

RESULTS

Eight independent prognostic factors were identified and integrated into the model. The calibration curves showed good agreement. The concordance index (C-index) of the nomogram was higher than that of the staging system (IA1, IA2, IA3, and IB) (internal validation set 0.63 vs. 0.56; external validation set 0.66 vs. 0.55; both p < 0.01). Specifically, 21.7% of stage IB patients (7.5% of all stage I) were categorized into the high-risk group (score > 30). There was a significant interaction effect between the adjuvant chemotherapy and risk groups in the NCDB cohort (p = 0.003).

CONCLUSIONS

We established a practical nomogram to predict CSS for 8th edition stage I NSCLC. A prospective study is warranted to determine its role in identifying adjuvant chemotherapy candidates.

Stereotactic body radiation therapy for non-small cell lung cancer: A review

Stereotactic body radiation therapy (SBRT) is the treatment of choice for medically inoperable patients with early stage non-small cell lung cancer (NSCLC). A literature search primarily based on PubMed electronic databases was completed in July 2018. Inclusion and exclusion criteria were determined prior to the search, and only prospective clinical trials were included. Nineteen trials from 2005 to 2018 met the inclusion criteria, reporting the outcomes of 1434 patients with central and peripheral early stage NSCLC. Patient eligibility, prescription dose and delivery, and follow up duration varied widely. Three-years overall survival ranged from 43% to 95% with loco-regional control of up to 98% at 3 years. Up to 33% of patients failed distantly after SBRT at 3 years. SBRT was generally well tolerated with 10%-30% grade 3-4 toxicities and a few treatment-related deaths. No differences in outcomes were observed between conventionally fractionated radiation therapy and SBRT, central and peripheral lung tumors, or inoperable and operable patients. SBRT remains a reasonable treatment option for medically inoperable and select operable patients with early stage NSCLC. SBRT has shown excellent local and regional control with toxicity rates equivalent to surgery. Decreasing fractionation schedules have been consistently shown to be both safe and effective. Distant failure is common, and chemotherapy may be considered for select patients. However, the survival benefit of additional interventions, such as chemotherapy, for early stage NSCLC treated with SBRT remains unclear.

Updates in Local-Regionally Advanced Non-Small Cell Lung Cancer

The landscape for therapy in local-regionally advanced non-small cell lung cancer (NSCLC) has shifted dramatically in the last year as a result of the PACIFIC trial, which demonstrated a significant survival benefit with the addition of 1 year of durvalumab after concurrent chemoradiation. This is a new standard of care for unresectable local-regionally advanced NSCLC and is the first trial to show that immunotherapy can increase survival in earlier-stage NSCLC. Several clinical trials are underway or in development to explore the role of adding immunotherapy to concurrent chemoradiation, followed by a year of immunotherapy or to even replace chemotherapy in this treatment paradigm. In resectable disease, adjuvant chemotherapy is still the standard of care for stage IB (tumors ≥ 4 cm) through stage III disease. However, new studies are investigating the role of adding immunotherapy to neoadjuvant chemotherapy or as adjuvant therapy for 1 year after resection. Molecular profiling for early-stage disease is not currently the standard of care, but several national clinical trials are studying the benefit of adding adjuvant-targeted therapies. This article will detail the current standard practices in early-stage and local-regionally advanced NSCLC and describe the evolving strategies that are under investigation that may further refine our current practice.