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

Synergistic interaction of gemcitabine and paclitaxel by modulating acetylation and polymerization of tubulin in non-small cell lung cancer cell lines

Background: The combination of gemcitabine (GEM) and paclitaxel (PTX) was appealing for clinical exploration due to different mechanisms of action and partially non-overlapping toxicities.

Purpose: The aim of this study was to elucidate a potential effect of this combination on the proliferation of two non-small cell lung cancer (NSCLC) cell lines, A549 and H520.

Materials and methods: Cell lines were treated with GEM and PTX for 48 hours to evaluate the half maximal inhibitory concentration (IC50). To determine the combination index (CI), cell lines were exposed to GEM and PTX, in a constant ratio of IC50, by various combination treatments. GEM`s effect on tubulin was assessed by western blotting and immunofluorescent staining. GEM was combined with nanoparticle albumin-bound-paclitaxel (NP) in evaluating tumor growth inhibition.

Results: The IC50 of GEM and PTX in A549 and H520 were 6.6 nM and 46.1 nM, and 1.35 nM and 7.59 nM, respectively. Among the sequences explored (GEM→PTX, PTX→GEM, and GEM plus PTX simultaneously [GEM+PTX]), GEM→PTX produced a mean CI <1 in both cell lines. Western blotting and immunofluorescent staining revealed the intention expressions of acetylated tubulin protein and enhancement of tubulin polymerization within GEM→PTX group. A combination order GEM→NP also worked synergistically to suppress tumor growth.

Conclusion: The GEM→PTX sequence may represent a promising candidate regimen for the treatment of NSLCL.

Propensity-matched analysis of adjuvant chemotherapy for completely resected Stage IB non-small-cell lung cancer patients

BACKGROUND

The use of adjuvant chemotherapy (ACT) in completely resected stage IB non-small cell lung cancer (NSCLC) is still controversial. The divergent outcomes of prospective trials have created uncertainty as to the utility of ACT in stage IB NSCLC. This study assesses the effect of postoperative adjuvant chemotherapy in stage IB patients in clinical practice.

METHODS

Patients with pT2aN0M0 stage IB NSCLC who underwent complete resection from 2004 to 2015 were identified from prospectively collected databases in two medical centers. The log-rank test was used to compare overall survival (OS) and disease free survival (DFS). Fine and Gray's competing risks regression model was built to identify predictors of cancer-specific survival. One to one propensity-score matching (PSM) was performed to reduce the selection bias and additional analyses were performed on these subgroups.

RESULTS

Of 1005 patients identified for the study, 202 (20.1%) received ACT and 803 (79.9%) underwent surgery alone (observation group). Compared with the observation group, patients who underwent ACT were younger (p < 0.001), had larger tumors (p = 0.004), and had higher rates of squamous cell carcinoma (p < 0.001) and lymphovascular invasion (p = 0.017). After propensity score matching, 196 pairs of patients were 1:1 matched in the two groups and all baseline characteristics were well balanced. ACT was not associated with improved survival (including OS, DFS; all log-rank p > 0.05) in both unmatched and matched (196 pairs) cohorts. In subgroup analysis of the matched population, ACT was not associated with survival benefits for patients regardless of whether their tumors measured <4 cm or ≥4 cm (both log-rank p > 0.05).

CONCLUSIONS

In patients with completely resected stage IB (T2aN0M0) NSCLC, ACT is not associated with improved prognosis. Further large multicenter studies are needed to confirm these findings.

Advanced PET imaging in oncology: status and developments with current and future relevance to lung cancer care

PURPOSE OF REVIEW

This review highlights the status and developments of PET imaging in oncology, with particular emphasis on lung cancer. We discuss the significance of PET for diagnosis, staging, decision-making, monitoring of treatment response, and drug development. The PET key advantage, the noninvasive assessment of functional and molecular tumor characteristics including tumor heterogeneity, as well as PET trends relevant to cancer care are exemplified.

RECENT FINDINGS

Advances of PET and radiotracer technology are encouraging for multiple fields of oncological research and clinical application, including in-depth assessment of PET images by texture analysis (radiomics). Whole body PET imaging and novel PET tracers allow assessing characteristics of most types of cancer. However, only few PET tracers in addition to F-fluorodeoxyglucose have sufficiently been validated, approved, and are reimbursed for a limited number of indications. Therefore, validation and standardization of PET parameters including tracer dosage, image acquisition, post processing, and reading are required to expand PET imaging as clinically applicable approach.

SUMMARY

Considering the potential of PET imaging for precision medicine and drug development in lung and other types of cancer, increasing efforts are warranted to standardize PET technology and to provide evidence for PET imaging as a guiding biomarker in nearly all areas of cancer treatment.

Role of cytokines in combinatorial immunotherapeutics of non-small cell lung cancer through systems perspective

Lung cancer is the leading cause of deaths related to cancer and accounts for more than a million deaths per year. Various new strategies have been developed and adapted for treatment; still the survival for 5 years is just 16% in patients with non‐small cell lung cancer (NSCLC). Most of these strategies to combat NSCLC whether it is a drug molecule or immunotherapy/vaccine candidate require a big cost and time. Integration of computational modeling with systems biology has opened new avenues for understanding complex cancer biology. Resolving the complex interactions of various pathways and their crosstalk leading to oncogenic changes could identify new therapeutic targets with lesser cost and time. Herein, this review provides an overview of various aspects of NSCLC along with available strategies for its cure concluding with our insight into how systems approach could serve as a therapeutic intervention dissecting the immunologic parameters and cross talk between various pathways involved.

Rethinking Alkylating(-Like) Agents for Solid Tumor Management

Although old molecules, alkylating agents and platinum derivatives are still widely used in the treatment of various solid tumors. However, systemic toxicity and cellular resistance mechanisms impede their efficacy. Innovative strategies, including local administration, optimization of treatment schedule/dosage, synergistic combinations, and the encapsulation of bioactive molecules in smart, multifunctional drug delivery systems, have shown promising results in potentiating anticancer activity while circumventing such hurdles. Furthermore, questioning of the old paradigm according to which nuclear DNA is the critical target of their anticancer activity has shed light on subcellular alternative and neglected targets that obviously participate in the mediation of cytotoxicity or resistance. Thus, rethinking of the use of these pivotal antineoplastic agents appears critical to improve clinical outcomes in the management of solid tumors.

Stereotactic ablative radiation therapy in lung cancer: an emerging standard

PURPOSE OF REVIEW

Significant advances have been made in the field of stereotactic ablative radiotherapy (SABR) for the treatment of pulmonary neoplasms in recent years. This review aims to summarize recent salient evidence on SABR for early-stage nonsmall cell lung cancer (ES-NSCLC).

RECENT FINDINGS

In medically inoperable patients, SABR remains the standard of care. The optimal SABR dosing regimen is being studied. Comparisons with non-SABR radiotherapy regimens with lower doses per fraction revealed benefit of SABR. In operable patients, no prospective clinical trial comparing SABR and surgery has been completed, although multiple trials are currently underway to address this question. SABR is generally cost-effective and safe in most patients, with preserved patient-reported quality of life. However, increased toxicity with SABR is noted in patients with disease close to, or invading the proximal tracheobronchial tree. Significant SABR-related toxicity and mortality is also reported in patients with coexisting interstitial lung disease. Considerations on pathologic confirmation, surveillance and multiple primaries are also addressed.

SUMMARY

SABR is an effective and safe treatment for inoperable ES-NSCLC. Ongoing trials and comparative effectiveness research will help to clarify SABR's role in various lung cancer indications going forward.

Long term efficacy and toxicity after stereotactic ablative reirradiation in locally relapsed stage III non-small cell lung cancer

BACKGROUND

In stage III non-small cell lung cancer (NSCLC) treated with concomitant chemoradiotherapy, there is a high rate of relapse. Some of these relapses are only local and can be treated by stereotactic ablative radiation therapy (SABR). Previous studies reporting outcome after SABR reirradiation of the thorax consisted of a heterogeneous population of various lung cancer stages or even different types of cancer. The purpose of study is to evaluate toxicity and outcome of this strategy in locally relapsed stage III NSCLC only.

METHODS

From February 2007 to November 2015, 46 Stage III NSCLC patients treated with SABR, for lung recurrence following conventionally fractionated radiation therapy (CFRT), were retrospectively analyzed.

RESULTS

Median follow-up was 47.3 months (1-76.9). The 2 and 4-year progression-free survival (PFS), and overall survival (OS) were of 25.5%/8.6 and 48.9%/30.8%, respectively. Highest presenting toxicity in patients (grade 1 through 5) was: 13 (28.3%), 7 (15.2%), 1 (2.2%), 0 and 2 (4.4%), with deaths due to hemoptysis (n = 1) and alveolitis (n = 1). Although the Biological Effective Dose (at Planning Tumor Volume isocenter) was lower for central tumors treated for an in-field relapse (n = 21, 116 Gy versus 168 Gy, p = 0.005), they had no significant difference in OS than the remaining cohort, but with a higher rate of grade 2-5 toxicities (OR = 0.22, [0.06-0.8], p = 0.02).

CONCLUSION

Reirradiation with SABR for local relapse in patients previously treated for stage III NSCLC, is feasible and associated with good outcome. This is also true for central tumors treated for an in-field relapse, but should be radiated with caution to mitigate toxicity.

lncRNA AWPPH promotes proliferation and inhibits apoptosis of non‑small cell lung cancer cells by activating the Wnt/β‑catenin signaling pathway

AWPPH is a newly discovered long non‑coding (lnc)RNA that serves an oncogenic role in the development of several types of cancer; however, its involvement in non‑small cell lung cancer (NSCLC) is unknown. Therefore, the aim of the present study was to investigate the function of AWPPH in NSCLC. The results demonstrated that AWPPH expression levels were significantly upregulated in the lung tissues and serum samples of patients with NSCLC compared with in healthy controls. High expression levels of AWPPH effectively distinguished NSCLC patients from healthy controls. In addition, patients with high expression levels of AWPPH had significantly shorter survival time. AWPPH overexpression in NSCLC cells promoted proliferation and inhibited apoptosis, and activated the Wnt/β‑catenin signaling pathway, which is a classic signaling pathway involved in the development and progression of different types of cancers. Treatment with a Wnt/β‑catenin signaling pathway activator produced no significant effect on AWPPH expression. Therefore, it was concluded that lcRNA AWPPH could promote the growth of NSCLCs by activating the Wnt/β‑catenin signaling pathway.

Individualized accelerated isotoxic concurrent chemo-radiotherapy for stage III non-small cell lung cancer: 5-Year results of a prospective study

BACKGROUND

Stage III non-small cell lung cancer (NSCLC) still has a poor prognosis. Prior studies with individualized, accelerated, isotoxic dose escalation (INDAR) with 3D-CRT showed promising results, especially in patients not treated with concurrent chemo-radiotherapy. We investigated if INDAR delivered with IMRT would improve the overall survival (OS) of stage III NSCLC patients treated with concurrent chemotherapy and radiotherapy.

PATIENTS AND METHODS

Patients eligible for concurrent chemo-radiotherapy were entered in this prospective study. Radiotherapy was given to a dose of 45 Gy/30 fractions BID (1.5 Gy/fraction), followed by QD fractions of 2 Gy until a total dose determined by the normal tissue constraints. The primary endpoint was OS, secondary endpoints were loco-regional relapses and toxicity.

RESULTS

From May 4, 2009 until April 26, 2012, 185 patients were included. The mean tumor dose was 66.0 ± 12.8 Gy (36-73 Gy), delivered in a mean of 39.7 fractions in an overall treatment time of 38.2 days. The mean lung dose (MLD) was 17.3 Gy. The median OS was 19.8 months (95% CI 17.3-22.3) with a 5-year OS of 24.3%. Loco-regional failures as first site of recurrence occurred in 59/185 patients (31.8%). Isolated nodal failures (INF) were observed in 3/185 patients (1.6%). Dyspnea grade 3 was seen in 3.2% of patients and transient dysphagia grade 3 in 22%.

CONCLUSIONS

INDAR with IMRT concurrently with chemotherapy did not lead to a sign of an improved OS in unselected stage III NSCLC patients.

Spectral CT and its specific values in the staging of patients with non-small cell lung cancer: technical possibilities and clinical impact

AIM

To investigate how spectral computed tomography (SCT) values impact the staging of non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

One hundred and thirteen patients with confirmed NSCLC were included in a prospective cohort study. All patients underwent single-phase contrast-enhanced SCT (using the fast tube voltage switching technique, 80-140 kV). SCT values (iodine content [IC], spectral slope pitch, and radiodensity increase) of malignant tissue (primary and metastases) and lymph nodes (LNs) were measured. Adrenal masses were evaluated in a virtual non-contrast series (VNS). If pulmonary embolism was present, pulmonary perfusion was analysed as an additional finding.

RESULTS

Fifty-two untreated primary NSCLC lesions were evaluable. Lung adenocarcinoma had significantly higher normalised IC (NIC: 19.37) than squamous cell carcinoma (NIC: 12.03; p=0.035). Pulmonary metastases were not significantly different from benign lung nodules. A total of 126 LNs were analysed and histologically proven metastatic LNs (2.08 mg/ml) had significantly lower IC than benign LNs (2.58 mg/ml; p=0.023). Among 34 adrenal masses, VNS identified adenomas with high sensitivity (91%) and specificity (100%). In two patients, a perfusion defect due to pulmonary embolism was detected in the iodine images.

CONCLUSION

SCT may contribute to the differentiation of histological NSCLC subtypes and improve the identification of LN metastases. VNS differentiates adrenal adenoma from metastasis. In case of pulmonary embolism, iodine imaging can visualise associated pulmonary perfusion defects.

Next Generation Sequencing and Genetic Alterations in Squamous Cell Lung Carcinoma: Where Are We Today?

Lung cancer is the leading cause of cancer-related mortality and will affect ~6% of the population. It is divided into two broad categories, small cell lung cancer and non-small cell lung cancer (NSCLC), the latter representing 85% of all lung cancers. It mainly comprises adenocarcinoma (65%) and squamous cell carcinoma (30%) histologies. In recent years, there have been two major therapeutic advances in NSCLC. The first, immunotherapy, has greatly improved the prognosis of adenocarcinomas and squamous cell carcinomas. The second, the treatment of targetable driver mutations, has so far only benefited adenocarcinomas. Squamous cell carcinoma carries a high rate of mutations and is found mostly among smokers. This raises two important problems: identifying driver mutations and finding those of clinical relevance. Large-scale genomic analyses such as The Cancer Genome Atlas have allowed for the identification of frequent gene alterations, although their role and potential for targeted therapy remain unknown. The emergence of next generation sequencing has changed the landscape of precision medicine, in particular in lung cancer. In this review, we discuss the landscape of genetic alterations found in squamous cell lung cancer, the results of current targeted therapy trials, the difficulties in identifying and treating these alterations and how to integrate modern tools in clinical practice.

Predictors and survival impact of station 4L metastasis in left non-small cell lung cancer

BACKGROUND

It remains unclear about the predictors and survival impact of station 4L metastasis in left-sided non-small cell lung cancer (NSCLC). This study aims to investigate these issues to explore the significance of station 4L lymph-node dissection (LND).

METHODS

We retrospectively enrolled 405 patients with station 4L LND, and divided them into the positive station 4L metastasis group and the negative station 4L metastasis group. The logistic regression was performed to identify the predictors of station 4L metastasis. The survival outcomes including disease-free survival (DFS) and overall survival (OS) were analyzed in pN2 patients to explore the prognostic effect of station 4L metastasis.

RESULTS

There were 48 (11.9%) patients in the positive station 4L metastasis group and 357 (88.1%) patients in the negative station 4L metastasis group. Station 5 metastasis (P = 0.008, OR 7.578, 95% CI 1.710-33.589), station 10 metastasis (P = 0.004, OR 7.133, 95% CI 1.904-26.717), and cN2 (P = 0.010, OR 5.062, 95% CI 1.473-17.392) were independent risk factors of station 4L metastasis. In pN2 patients, the positive station 4L metastasis group had inferior DFS (P = 0.019) and OS (P = 0.006) compared with the negative station 4L metastasis group, and station 4L metastasis was the independent risk factor for poor prognosis.

CONCLUSION

It is of great necessity to perform station 4L LND in left NSCLC, because station 4L metastasis is not rare and has an unfavorable prognosis.

Radiomic analysis of planning computed tomograms for predicting radiation-induced lung injury and outcome in lung cancer patients treated with robotic stereotactic body radiation therapy

OBJECTIVES

To predict radiation-induced lung injury and outcome in non-small cell lung cancer (NSCLC) patients treated with robotic stereotactic body radiation therapy (SBRT) from radiomic features of the primary tumor.

METHODS

In all, 110 patients with primary stage I/IIa NSCLC were analyzed for local control (LC), disease-free survival (DFS), overall survival (OS) and development of local lung injury up to fibrosis (LF). First-order (histogram), second-order (GLCM, Gray Level Co-occurrence Matrix) and shape-related radiomic features were determined from the unprocessed or filtered planning CT images of the gross tumor volume (GTV), subjected to LASSO (Least Absolute Shrinkage and Selection Operator) regularization and used to construct continuous and dichotomous risk scores for each endpoint.

RESULTS

Continuous scores comprising 1-5 histogram or GLCM features had a significant (p = 0.0001-0.032) impact on all endpoints that was preserved in a multifactorial Cox regression analysis comprising additional clinical and dosimetric factors. At 36 months, LC did not differ between the dichotomous risk groups (93% vs. 85%, HR 0.892, 95%CI 0.222-3.590), while DFS (45% vs. 17%, p < 0.05, HR 0.457, 95%CI 0.240-0.868) and OS (80% vs. 37%, p < 0.001, HR 0.190, 95%CI 0.065-0.556) were significantly lower in the high-risk groups. Also, the frequency of LF differed significantly between the two risk groups (63% vs. 20% at 24 months, p < 0.001, HR 0.158, 95%CI 0.054-0.458).

CONCLUSION

Radiomic analysis of the gross tumor volume may help to predict DFS and OS and the development of local lung fibrosis in early stage NSCLC patients treated with stereotactic radiotherapy.

Patterns of care for stage III non-small cell lung cancer in Australia

Stage III non-small cell lung cancer (NSCLC) makes up a third of all NSCLC cases and is potentially curable. Despite this 5-year survival rates remain between 15% and 20% with chemoradiation treatment alone given with curative intent. With the recent exciting breakthroughs in immunotherapy use (durvalumab) for stage III NSCLC, further improvements in patient survival can be expected. Most patients with stage III NSCLC present initially to their general practitioner (GP). The recommended time from GP referral to first specialist appointment is less than 14 days with treatment initiated within 42 days. Our review found that there is a shortfall in meeting these recommendations, however a number of initiatives have been established in Australia to improve timely and accurate diagnosis and treatment patterns. The lung cancer multidisciplinary team (MDT) is critical to consistency of evidence-based diagnosis and treatment and can improve patient survival. We aimed to review current patterns of care and clinical practice recommendations for stage III NSCLC across Australia and identify opportunities to improve practice in referral, diagnosis and treatment pathways.

Radiotherapy boost in patients with hypoxic lesions identified by 18F-FMISO PET/CT in non-small-cell lung carcinoma: can we expect a better survival outcome without toxicity? [RTEP5 long-term follow-up]

PURPOSE

Chemoradiotherapy is the reference curative-intent treatment for nonresectable locally advanced non-small-cell lung carcinoma (NSCLC), with unsatisfactory survival, partially due to radiation resistance in hypoxic tissues. The objective was to update survival and toxicity at 3 years following radiotherapy boost to hypoxic tumours in NSCLC patients treated with curative-intent chemoradiotherapy.

METHODS

This was an open-label, nonrandomized, multicentre, phase II clinical trial. ¹⁸F-Fluoromisonidazole (¹⁸F-FMISO) PET/CT was used to determine the hypoxic profile of the patients. ¹⁸F-FMISO-positive patients and those without organ-at-risk constraints received a radiotherapy boost (70-84 Gy); the others received standard radiotherapy (66 Gy). Overall survival (OS), progression-free survival (PFS) and safety were assessed.

RESULTS

A total of 54 patients were evaluated. OS and PFS rates at 3 years were 48.5% and 28.8%, respectively. The median OS in the ¹⁸F-FMISO-positive patients was 25.8 months and was not reached in the ¹⁸F-FMISO-negative patients (p = 0.01). A difference between the groups was also observed for PFS (12 months vs. 26.2 months, p = 0.048). In ¹⁸F-FMISO-positive patients, no difference was observed in OS in relation to dose, probably because of the small sample size (p = 0.30). However, the median OS seemed to be in favour of patients who received the radiotherapy boost (26.5 vs. 15.3 months, p = 0.71). In patients who received the radiotherapy boost, no significant late toxicities were observed.

CONCLUSION

¹⁸F-FMISO uptake in NSCLC patients is strongly associated with features indicating a poor prognosis. In ¹⁸F-FMISO-positive patients, the radiotherapy boost seemed to improve the OS by 11.2 months. A further clinical trial is needed to investigate the efficacy of a radiotherapy boost in patients with hypoxic tumours.

Population-based patterns of treatment and survival for patients with stage I and II non-small cell lung cancer aged 65-74 years and 75 years or older

OBJECTIVES

Insights regarding utilization and survival of surgery and radiotherapy (stereotactic body radiotherapy (SBRT) or conventional radiotherapy (RT)) are lacking for older patients with stage I and II non-small cell lung cancer (NSCLC) in clinical practice.

METHODS

Data from the Netherlands Cancer Registry were retrieved for patients ≥65 years with clinical stage I-II NSCLC in 2010-2015. Descriptive analyses, overall survival (OS), and cox regression were stratified for stage I (n = 8742) and II (n = 3439) and compared age groups (65-74 years vs ≥75 years).

RESULTS

Patients aged 65-74 underwent surgery significantly more often compared to those aged ≥75 (stage I 55% vs 27%; stage II: 65% vs 35%), and received SBRT less often (I: 29% vs 42%; II: 5% vs 11%), conventional RT less often (I: 6% vs 11%; II 10% vs 24%) and best supportive care alone less often (BSC, I: 8% vs 19%; II: 9% vs 25%). One-year OS was significantly higher in patients aged 65-74 compared to those aged ≥75 (I: 87% vs 78%; II: 74% vs 60%); as was five-year OS (I: 49% vs 31%; II: 36% vs 18%). After adjustment for gender, histology, stage, treatment, and comorbidity, hazard ratio (HR) of death was higher for patients aged ≥75 compared to those aged 65-74 (I: HR 1.3, 95% confidence interval (CI) 1.1-1.5; II: HR 1.3 95%CI 1.1-1.7).

CONCLUSION

Patients aged ≥75 with stage I-II NSCLC had poorer OS, underwent surgery less often, and received SBRT, conventional RT, and BSC more often than patients aged 65-74. In both stages, one-year OS within age groups was similar for surgery and SBRT. However, long-term OS adjusted for prognostic factors was superior for surgery compared to SBRT and remained poorer for those aged ≥75. Prospective research should focus on predictive characteristics for treatment selection and patient-centered outcomes.

Prognostic value of Ki-67 in stage I non-small-cell lung cancer: A meta-analysis involving 1931 patients

There is growing interest in exploring the prognostic value of Ki-67 in non-small-cell lung cancer (NSCLC). However, whether Ki-67 can be regarded as a routine biomarker in clinical practice is still under debate. The present meta-analysis investigated the relationship between Ki-67 and the overall survival (OS) or disease-free survival (DFS) of patients suffering from stage I NSCLC. We searched the Web of Science, Cochrane, and PubMed databases to extract eligible articles. In total, 15 studies involving 1931 patients were included. Pooled hazard ratio (HR) analysis revealed that patients with high Ki-67 labeling index (LI) had poorer OS (HR = 1.95, 95% confidence interval (CI) = 1.43-2.66, P < 0.0001) and DFS (HR = 3.12, 95% CI = 2.17-4.48, P < 0.00001) than those with low Ki-67 LI. In subgroup analysis, high Ki-67 LI was significantly associated with poor prognoses in stage I adenocarcinoma. In future studies, a consensus for the optimal cutoff value for high Ki-67 LI needs to be explored and demonstrated in stage I NSCLC patients.

The Accuracy of Clinical Staging of Stage I-IIIa Non-Small Cell Lung Cancer: An Analysis Based on Individual Participant Data

BACKGROUND

Clinical staging of non-small cell lung cancer (NSCLC) helps determine the prognosis and treatment of patients; few data exist on the accuracy of clinical staging and the impact on treatment and survival of patients. We assessed whether participant or trial characteristics were associated with clinical staging accuracy as well as impact on survival.

METHODS

We used individual participant data from randomized controlled trials (RCTs), supplied for a meta-analysis of preoperative chemotherapy (± radiotherapy) vs surgery alone (± radiotherapy) in NSCLC. We assessed agreement between clinical TNM (cTNM) stage at randomization and pathologic TNM (pTNM) stage, for participants in the control group.

RESULTS

Results are based on 698 patients who received surgery alone (± radiotherapy) with data for cTNM and pTNM stage. Forty-six percent of cases were cTNM stage I, 23% were cTNM stage II, and 31% were cTNM stage IIIa. cTNM stage disagreed with pTNM stage in 48% of cases, with 34% clinically understaged and 14% clinically overstaged. Agreement was not associated with age (P = .12), sex (P = .62), histology (P = .82), staging method (P = .32), or year of randomization (P = .98). Poorer survival in understaged patients was explained by the underlying pTNM stage. Clinical staging failed to detect T4 disease in 10% of cases and misclassified nodal disease in 38%.

CONCLUSIONS

This study demonstrates suboptimal agreement between clinical and pathologic staging. Discrepancies between clinical and pathologic T and N staging could have led to different treatment decisions in 10% and 38% of cases, respectively. There is therefore a need for further research into improving staging accuracy for patients with stage I-IIIa NSCLC.

Can Inflammatory and Nutritional Serum Markers Predict Chemotherapy Outcomes and Survival in Advanced Stage Nonsmall Cell Lung Cancer Patients?

Purpose. To determine the values of prognostic nutritional and inflammatory markers in chemotherapy outcomes and survival in the patients with advanced nonsmall cell lung cancer (NSCLC) and also in the secondary malnutrition and cachexia. Methods. Twenty-five patients with diagnosis of aNSCLC were registered for the prospective study. Malnutrition was determined by the Subjective Global Assessment (SGA) and performance status by criteria of the Eastern Cooperative Oncology Group (ECOG). Before treatment, serum levels of albumin, prealbumin, vitamin D, zinc (Zn), C-reactive protein (CRP), IL-6, IL-1 β, TNF-α, lipoprotein lipase (LPL), and the Glasgow Prognostic Score (GPS) were recorded. Patients were followed prospectively for treatment outcomes and survival. Results. Due to the deaths of 18 patients during the 4-month follow-up period, no adequate measurements of inflammatory and nutritional markers could be performed. However, seven patients completed the treatment period and evaluations of these markers could be performed during the three periods. Eighty-four percent of patients were male with a mean age of 63.3 ± 8.7 years. Evaluation of the malnutrition by SGA showed that 5 (20%) patients were well nourished (A), 12(48%) were moderately malnourished (B), and 8(32%) were severely malnourished (C). Low levels of serum albumin (<3.5g/dl), prealbumin (<20 mg/ml), 25-hydroxycholecalciferol (<30 ng/ml), and Zn (<70mg/ml) were detected in 15(60%), 17(68%), 24 (96%), and 22 (88%) patients, respectively. Elevated levels of CRP (≥10 mg/L), IL6 (≥18pg/ml), TNF-α (≥24pg/ml), IL-1β (≥10pg/ml), and LPL (<12pg/ml) were found in 24 (96%), 11(44%), 9(36), 13(52%), and 11(44%) patients, respectively. Moderate and severe malnutrition, acute phase response, and reduced survival were determined in patients with NCSLC. In 7 patients that completed the treatment period, there was an association between elevated serum levels of IL-6, IL-1β, TNF-α, CRP, and LPL and also the reduced serum levels of albumin, prealbumin, Zn, vitamin D, and GPS, respectively. Similarly, Friedman analysis indicated that prealbumin significantly increased (p=0.007) in the follow-up period. But the serum levels of CRP (mean 37.3±22.3; Wilcoxon test P=0.368) in the seven patients were lower than those of the 18 patients that expired (mean 75.82±56.2). Conclusion. Malnutrition and cachexia negatively influence oncological outcomes in patients with NSCLC. These nutritional/inflammatory markers may be useful for selection of high risk and reduced survival in patients with aNSCLC undergoing adjuvant chemotherapy.

Solid predominant subtype in lung adenocarcinoma is related to poor prognosis after surgical resection: A systematic review and meta-analysis

BACKGROUND

Recent studies have indicated that solid predominant (SP) subtype of lung adenocarcinoma (LADC) may be associated with early recurrence and worse prognosis. Hence, a systematic review and meta-analysis were performed to evaluate the association between LADC subtype and survival.

METHODS

The MEDLINE, SCOPUS, Web of Science and Cochrane Libraries were reviewed for eligible studies in December 2017. Studies were included if they compared outcomes of patients with and without SP subtype in resection specimens of LADC patients after surgical treatment by using multivariate Cox regression analysis. A meta-analysis for overall survival (OS) and disease-free survival (DFS) was performed. The hazard ratios (HR) or odds ratios with 95% confidence intervals (CIs) from each study were used to calculate pooled HRs. Statistical analyses were performed using Review Manager 5.3.

RESULTS

In total, 14 eligible studies including 12,137 LADC patients were identified, which assessed the impact of SP subtype on OS and DFS in patients treated with pulmonary resection. SP subtype was reported in 1246 (10.2%) patients and was associated with significantly worse OS (pooled HR, 1.51; 1.29-1.75) and DFS (pooled HR, 1.26; 1.14-1.40).

CONCLUSIONS

SP subtype is associated with significantly worse OS and DFS in patients with LADC after pulmonary resection. These data provide evidence for the integration of the distinct histological LADC subtyping into prognostic tools and guidelines for adjuvant treatment after complete surgical resection.

The clinical value of a new method of functional lymph node dissection in video-assisted thoracic surgery right non-small cell lung cancer radical resection

Background

To evaluate the safety, thoroughness and feasibility of "tunnel-type en bloc mediastinal lymph node dissection" in video-assisted thoracic surgery (VATS) for right non-small cell lung cancer (NSCLC) radical resection, which functionally dissected the lymph nodes of station 2R/4R/7.

Methods

A retrospective study was performed in the clinical data of 196 patients with VATS right NSCLC radical resection. According to the different methods of lymph node dissection of station 2R, 4R and 7, they were divided into the tunnel-type group (n=102) and the routine group (n=94). The clinical data of two group were compared.

Results

The analyses of the baselines of the two groups are comparable. For lymph nodes dissection of station 2R/4R/7, operation time, the total number, positive number and metastasis incidence shown no significant difference between two groups (P>0.05). However, the amount of bleeding, postoperative thoracic drainage volume, extubation time, hospitalization days, the incidence of postoperative pulmonary infection and chronic cough were significantly lower in the tunnel-type group (P<0.05). There was no significant difference in 3-year recurrence and metastasis and in 3-year survival between tunnel-type group and routine group.

Conclusions

The tunnel-type group has more advantages, such as less surgical trauma, shorter hospitalization time, faster postoperative rehabilitation, even less postoperative chronic cough compared with the routine group. Therefore, we believe that the tunnel-type en bloc mediastinal lymph node dissection is a safe, thorough and feasible surgical method, which is worthy of being popularized and applied in the VATS right NSCLC radical resection.

Comparison of an expiratory flow accelerator device versus positive expiratory pressure for tracheobronchial airway clearance after lung cancer lobectomy: a preliminary study

OBJECTIVE

A new type of device has recently been introduced in chest physiotherapy as an aid to tracheo-bronchial airway clearance: expiratory flow accelerator (EFA). It promotes mucus clearance without generating any pressure gradient, allowing patients to breathe at tidal volume against no resistance.

DESIGN

Pilot randomized controlled study.

SETTING

Tertiary hospital.

PARTICIPANTS

Fifty adult patients who underwent lung cancer lobectomy were randomized to undergo chest physiotherapy with EFA (n=26) or PEP (n=24).

INTERVENTIONS

EFA; PEP bottle.

MAIN OUTCOMES

Incidence of postoperative pulmonary complications (PPC) and length of stay.

SECONDARY OUTCOMES

trends in inspiratory capacity, respiratory rate, oxygen saturation, and dyspnoea. Patients rated user-friendliness of the two devices on a 5-point Likert scale.

RESULTS

A slightly different incidence of PPCs was observed between the EFA and PEP group. Nevertheless, the length of stay was similar in the two groups. No substantial differences were seen in trends of inspiratory capacity, respiratory rate, oxygen saturation, dyspnoea between the two groups. Patient-reported user-friendliness of the two devices did not differ significantly, although the use of the EFA device appeared less strenuous.

CONCLUSIONS

Results of this pilot study point to the use of EFA as an alternative treatment option rather than as a replacement for the PEP bottle in chest physiotherapy following lung cancer lobectomy. EFA may be preferable for weaker patients and/or with airway leakages in whom PEP has limited indications. Further investigation in a larger sample is required to statistically confirm the findings. Clinical Trial Registration Number ChiCTR-ONC-17013255.

Scutellarin suppresses proliferation and promotes apoptosis in A549 lung adenocarcinoma cells via AKT/mTOR/4EBP1 and STAT3 pathways

Background

Scutellarin (SCU), a flavonoid isolated from Erigeron breviscapus (Vant.) Hand.‐Mazz., increases autophagy and apoptosis in the adenocarcinoma A549 cell line, which is resistant to cisplatin. However, whether SCU alone has antitumor activity against non‐small cell lung cancer (NSCLC) is unknown.

Methods

Cell Counting Kit‐8, flow cytometry, colony formation, Hoechst 33258 staining, and Western blot analyses were used to examine the proliferation and apoptosis of A549 cells treated with SCU and the possible molecular mechanisms.

Results

The cell viability assay indicated that SCU markedly suppressed the proliferation of A549 cells in concentration and time‐dependent manners. SCU caused significant G0/G1 phase arrest and apoptosis, as evidenced by flow cytometric analyses, Hoechst 33258 staining, and Western blot analyses of cyclin D1, cyclin E, BCL‐2, cleaved‐caspase‐3, and BAX. Furthermore, SCU treatment reduced the level of pan‐AKT, phosphorylated (p)‐mTOR, mTOR, BCL‐XL, STAT3, and p‐STAT3, and increased the level of 4EBP1.

Conclusions

SCU can suppress proliferation and promote apoptosis in A549 cells through AKT/mTOR/4EBP1 and STAT3 pathways. This suggests that SCU may be developed into a promising antitumor agent for treating NSCLC.

A Systematic Literature Review on Salvage Radiotherapy for Local or Regional Recurrence After Previous Stereotactic Body Radiotherapy for Lung Cancer

Purpose:

The purpose of this review article was to summarize available data on the efficacy and safety of salvage radiotherapy for isolated local or regional recurrence after prior stereotactic body radiotherapy for lung cancer.

Methods:

Studies were systematically searched on PubMed, following which suitable papers were selected. Reported outcomes and toxicities were qualitatively reviewed.

Results:

Nineteen papers, which were retrospective studies based on single institution experiences, were selected. Sixteen papers were on salvage radiotherapy for local tumor recurrence, and the remaining 3 papers evaluated radiotherapy for regional failures after stereotactic body radiotherapy for lung cancer. Patient cohorts in the selected papers seemed very frail with 2-year survival of 30% to 40% after the salvage. Local control was reported to be approximately 60% to 70%, which is worse than that after primary stereotactic body radiotherapy. Reported rates of toxicity grade 3 or worse were considered acceptable. Larger target volume and central tumor localization were suggested as risk factors for severe toxicities. Dosimetric data on patients having toxicities were found to help with considering dose constraints for organs at risk.

Conclusion:

Based on data from a limited number of articles, salvage radiotherapy is a reasonable treatment option for select patients with local or regional tumor recurrence after prior stereotactic body radiotherapy for lung cancer. Optimal patient selection and dose prescription can be clarified with a larger study that include more data on experiences with salvage radiotherapy.

Predicting tumor responses and patient survival in chemoradiotherapy-treated patients with non-small-cell lung cancer using dynamic contrast-enhanced integrated magnetic resonance-positron-emission tomography

PURPOSE

We investigated whether radiologic parameters by dynamic contrast-enhanced (DCE) integrated magnetic resonance-positron-emission tomography (MR-PET) predicts tumor response to treatment and survival in non-metastatic non-small-cell lung cancer (NSCLC) patients receiving chemoradiotherapy (CRT).

METHODS

Patients underwent DCE integrated MR-PET imaging 1 week before CRT. The following parameters were analyzed: primary tumor size, gross tumor volume, maximal standardized uptake value (SUV_max), total lesion glycolysis (TLG), apparent diffusion coefficient (ADC), volume transfer constant (K^trans), reverse reflux rate constant (k_ep), extracellular extravascular volume fraction (v_e), blood plasma volume fraction (v_p), and initial area under the time-concentration curve defined over the first 60 s post-enhancement (iAUC₆₀). CRT responses were defined using the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1).

RESULTS

Thirty patients were included. Non-responders demonstrated higher baseline TLG (p = 0.012), and lower baseline K^trans (p = 0.020) and iAUC₆₀ (p = 0.016) compared to responders, indicating the usefulness of DCE integrated MR-PET to predict treatment responses. Receiver operating characteristic curve indicated that TLG has the best differentiation capability to predict responders. By setting the threshold of TLG to 277, the sensitivity, specificity, and accuracy were 66.7%, 83.3%, and 75.0%, respectively, with an area under the curve of 0.776. The median follow-up time was 19.6 (range 7.8-32.0) months. In univariate analyses, baseline TLG >277 (p = 0.005) and baseline K^trans <254 (10^-3 min^-1; p = 0.015) correlated with poor survival after CRT. In multivariate analysis, baseline TLG >277 remained the significant factor in predicting progression (p = 0.012) and death (p = 0.031).

CONCLUSIONS

The radiologic parameters derived from DCE integrated MR-PET scans are useful for predicting treatment response in NSCLC patients treated with CRT; furthermore, these parameters are correlated with clinical and survival outcomes including tumor progression and death.

Patient Preferences For Chemotherapy In The Treatment Of Non-Small Cell Lung Cancer: A Multicenter Discrete Choice Experiment (DCE) Study In China

OBJECTIVE

The study aims to quantify patients' risk-benefit preferences for chemotherapy in the treatment of non-small cell lung cancer (NSCLC), and to elicit their willingness to pay (WTP) for treatment outcomes.

METHODS

A face-to-face discrete choice experiment (DCE) was conducted on NSCLC patients in four tertiary hospitals each from Beijing, Shanghai, Guangzhou and Chengdu in China. Patients were invited to complete choice questions that constructed by seven attributes: progression-free survival (PFS), disease control rate (DCR), rash, nausea and vomiting, tiredness, mode of administration and out-of-pocket costs. A mixed logit model was used to evaluate the choice model. Estimates of relative preferences and marginal willingness to pay for each attribute were then explored.

RESULTS

A total of 361 patients completed the survey. Improvements in PFS (10, 95% CI: 8.4-11.6) were the most important attribute for patients, followed by increase in DCR (4.6, 95% CI: 3.4-5.8). Tiredness (3.9, 95% CI: 2.9-5.1) was judged to be the most important risk. While remaining attributes were ranked in decreasing order of importance: nausea and vomiting (1.9, 95% CI: 0.9-3.0), mode of administration (0.8, 95% CI: 0.2-1.4) and rash (0.5, 95% CI: -0.6-1.5). There was little variation in preferences among patients with different sociodemographic characteristics. Patients were monthly willing to pay $2304 (95% CI, $1916-$2754) that guaranteed 11 months of PFS, followed by $1465 (95% CI, $1163-$1767) per month to improve their disease control rate by 90%.

CONCLUSION

The results suggested that efficacy was the most important attribute for patients. Side effects, mode of administration and treatment cost significantly influenced patient preferences. Patient engagement in prioritizing their treatment preferences should be emphasized during the clinical decision-making process and regimen implementation.

Preliminary Study of the Effect of Stereotactic Body Radiotherapy (SBRT) on the Immune System in Lung Cancer Patients Unfit for Surgery: Immunophenotyping Analysis

An immunophenotyping analysis was performed in peripheral blood samples from seven patients with lung cancer unfit for surgery treated with stereotactic body radiotherapy (SBRT). The objective was to characterize the effect of SBRT on the host immune system. Four patients received 60 Gy (7.5 Gy × 8) and three 50 Gy (12.5 Gy × 4). Analyses were performed before SBRT, 72 h after SBRT, and at one, three, and six months after the end of SBRT. Of note, there was a specific increase of the immunoactive component of the immune system, with elevation of CD56^+highCD16+ natural killer (NK) cells (0.95% at baseline to 1.38% at six months), and a decrease of the immunosuppressive component of the immune system, with decreases of CD4+CD25+Foxp3+CDA5RA- regulatory T cells (4.97% at baseline to 4.46% at six months), granulocytic myeloid-derived suppressor cells (G-MDSCs) (from 66.1% at baseline to 62.6% at six months) and monocytic (Mo-MDSCs) (8.2% at baseline to 6.2% at six months). These changes were already apparent at 72 h and persisted over six months. SBRT showed an effect on systemic immune cell populations, which is a relevant finding for supporting future combinations of SBRT with immunotherapy for treating lung cancer patients.

Tumor mutational burden in non-small cell lung cancer-the pathologist's point of view

In non-small cell lung cancer (NSCLC), the pathologist has contributed to the development of personalized medicine from the determination of the right histological type to EGFR and ALK/ROS1 molecular screening for targeted therapies. With the development of immunotherapies, pathologists intervene forefront with programmed death-ligand 1 (PD-L1) immunohistochemical testing, companion test for pembrolizumab monotherapy, first line and complementary test to the other programmed cell death-1 (PD-1) PD-L1 inhibitors. Recently, tumor mutational burden has emerged as a promising tool to evaluate sensitivity to immunotherapy (IO). The pathologist has a crucial role in the setting of tumor mutational burden (TMB) testing for the selection and the preparation of the sample for high throughput molecular analysis, and in the first steps of the next-generation sequencing (NGS) workflow.

Comparison of cytology, chest computed and positron emission tomography findings in malignant pleural effusion from lung cancer

Background

Malignant pleural effusion (MPE) is a common medical problem in lung cancer (LC). Pleural fluid cytology (PFC), chest computed tomography (CCT) and positron emission tomography (PET) findings are helpful as first line approach. The objectives of this study were to evaluate whether there is a correlation between PFC, CCT and PET in patients with MPE due to LC.

Methods

We selected patients from our electronic files. Data of PFC, pleural biopsy (PB), CCT and PET have been recorded and analyzed.

Results

A total of 101 consecutive patients (66 males, 65.3%) with a mean age of 66.2±31 years were selected. Types of LC were adenocarcinoma in 71 patients (70.2%), squamous in 13 (12.8%), small-cell in 12 (11.8%) and large cell in 5 (4.9%). CCT showed nodules in 6 (5.9%), pleural thickening in 8 (7.9%) and both in 17 (16.8%) patients. PFC was positive in 55/91 thoracentesis (60.4%) and 32/52 thoracoscopy (61.5%), while PB in 38/40 performed (95%). PET fixation was found in 32/47 (68%) patients who had MPE at diagnosis. When we associate PFC to CCT and PET findings, the yield in our study becomes 90%. No correlation was observed between CCT findings and PFC (P=0.62) between PFC and PET fixation (P=0.63) or between CCT and PET (P=0.06).

Conclusions

In our cohort of LC patients with MPE, we observed a high sensitivity for PFC, while in most of the cases no findings were observed in CCT. PET had a relative low sensitivity. However, when all 3 methods were combined the yield was 90%.

The present and future burden of previously treated advanced non-small cell lung cancer (NSCLC) by histology and line of therapy in France, Germany, Italy, and Spain: model-based predictions

BACKGROUND

The burden of advanced non-small cell lung cancer (NSCLC) is not well understood, and the number of patients likely to receive treatment in Europe has not been quantified. The aim of this study was to forecast the annual number of patients with squamous and non-squamous advanced NSCLC likely to receive second and third lines of therapy (LOT) from 2016 to 2020 in France, Germany, Italy, and Spain.

METHODS

A patient count model (PCM) was developed in Microsoft Excel to estimate the number of patients with refractory advanced NSCLC eligible to receive systemic treatment. Using historical population-based cancer registry data, segmented linear regression ("Joinpoint") was used to forecast age- and sex-stratified lung cancer incidence rates in each country through 2020. Yearly incident case count totals by country were apportioned according to NSCLC histology and stage at diagnosis. Country-specific treatment rates came from a recent medical chart review study, and early- to advanced-stage disease progression rates were estimated over a 10-year interval. A probabilistic sensitivity analysis (PSA) was performed to estimate variability in the patient counts.

RESULTS

The combined number of squamous and non-squamous advanced NSCLC patients estimated to receive second and third LOT, respectively, in 2016 were France = 11,600 and 3500; Germany = 15,100 and 4900; Italy = 13,500 and 2500; Spain = 9400 and 2100. The forecasted numbers of patients receiving second and third LOT, respectively, in 2020 were France = 13,900 and 4200; Germany = 16,200 and 5200; Italy = 15,100 and 2600; Spain = 11,000 and 2500.

CONCLUSIONS

Driven by growth in the incidence of NSCLC among women, the model forecasts an overall increase in the number of patients with advanced-stage squamous and non-squamous NSCLC likely to receive systemic treatment in the year 2020. The results highlight the significant burden of refractory advanced NSCLC and the need for more robust surveillance data to accurately quantify the burden of disease.

TP53 and DNA-repair gene polymorphisms genotyping as a low-cost lung adenocarcinoma screening tool

AIM

TP53 and DNA repair polymorphisms have been proposed as cancer risk factors. This study evaluated the usability of TP53 Arg72Pro single-nucleotide polymorphism, X RCC1 Arg399Gln and RAD51 G135C as a low-cost lung adenocarcinoma screening tool.

PATIENTS AND METHODS

This case-control study included 78 atients with lung adenocarcinoma and 79 healthy matched controls. TP53, XRCC1 and RAD51 genotyping was done by PCR followed by restriction length polymorphism. Descriptive analyses included genotype and allelic frequencies and deviations of the frequencies from those expected under Hardy-Weinberg equilibrium were assessed using the χ² test. The OR and 95% CIs were calculated as an estimate of relative risk, with significance set at p value <0.05.

RESULTS

The TP53 codon 72 Pro allele and the XRCC1 codon 399 Arg allele in a homozygous state were associated with lung adenocarcinoma (p=0.037; OR (95% CI) 2.42 (1.10 to 5.31)), that is, p=0.037; OR (95% CI) 2.16 (1.08 to 4.33), respectively. Also, carriers of the TP53 codon 72 Pro allele and the XRCC1 codon 399 ArgArg genotype older than 50 showed an even higher risk of developing lung adenocarcinoma (p=0.03 in both cases).

CONCLUSIONS

The TP53 codon 72 Arg allele and XRCC1 codon 399 Gln allele are likely to have a protective effect against lung adenocarcinoma, especially in individuals older than 50 years of age. XRCC1 and TP53 genotyping might be a useful low-cost tool for evaluating individual lung cancer risk, leading to earlier detection and management of this disease.

Assessing the pattern of recurrence in Danish stage I lung cancer patients in relation to the follow-up program: are we failing to identify patients with cerebral recurrence?

BACKGROUND

There is paucity of evidence regarding the optimal follow-up (FU) regimen for lung cancer. Consequently, FU is organized differently across countries. The Danish FU regimen has short FU intervals with a computed tomography (CT) scan of the chest and upper abdomen every three months in the early phase (first 2 years), then every six months in the late phase of FU (3rd, 5th year). Characterizing recurrences missed by the FU program in terms of site, tumor histology, department, and phase of FU, could improve the FU program.

MATERIAL AND METHOD

A case-control study of curatively treated stage I lung cancer patients who attended the Danish FU-program and had recurrence identified through the follow-up program (controls, FU group) or outside FU program (cases, symptomatic group).

RESULTS

Of 233 included patients with recurrence, the FU group constituted 85% (n = 197). Among the 15% (n = 36) in the symptomatic group, 53% had involvement of the central nervous system compared with 3% in the FU group. The unadjusted odds ratio (OR) for having an isolated brain recurrence (IBR) in the symptomatic group was 52.3 (95%CI: 15.1-181.4) as compared with the FU group. The OR for having a symptomatic recurrence in the early phase of FU was 2.5 (95%CI: 0.7-8.7) compared with the late phase.

CONCLUSIONS

The FU program did not identify the majority of patients with IBR. Including cerebral imaging in the FU program may result in an earlier detection of brain metastases. These matters should be studied in a prospective setting.

A surveillance method-oriented detection of post-operative spatial-temporal recurrence for non-small cell lung cancer

Background

This study evaluated spatial-temporal recurrence patterns after curative resection for non-small cell lung cancer (NSCLC) to clarify and recommend appropriate post-operative surveillance.

Methods

A total of 2,486 consecutive patients between January 2005 and December 2012 with NSCLC (stage I-IIIA) who underwent definitive surgical resection were retrospectively analyzed. We used a hazard rate curve to evaluate event dynamics. Disease-free survival (DFS) was evaluated by the Kaplan-Meier method. Univariate and multivariate analyses with Cox proportional hazards regression identified risk factors that predicted DFS.

Results

The median follow-up was 50.1 months. Recurrences were diagnosed in 852 (34.3%) patients. Four hundred eighty-nine events first occurred in the chest, 177 in the brain, 117 in the bone, and 71 in the abdomen. Of all recurrences, 78.5% occurred in the first 3 years. Univariate and multivariate analyses identified the age at diagnosis (P<0.001), histology (P=0.023), tumor size (P<0.001), pathologic N stage (P<0.001), and grade (P=0.043) as independent risk factors for intra-thoracic recurrences. Histology (P<0.001), tumor size (P<0.001), surgical method (P=0.021), pathologic N stage (P<0.001), and grade (P=0.005) were independent to predict extra-thoracic recurrences. The hazard rate curve displayed an initial surge of time to any treatment failure during 12 months after surgery. Based on sub-group analysis, both intra- and extra-recurrences increased with stage and brain recurrences in stage IIIA occurred earlier than stage II. Hazard rate curve of brain recurrences in squamous cell carcinoma showed a moderate peak during 9-15 months. Hazard rate curves of brain and bone recurrences in adenocarcinoma displayed clear peaks at 9-27 and 15-30 months, respectively.

Conclusions

Intra- and extra-thoracic recurrences correlate with different clinicopathological factors. Brain MRI and bone ECT were recommended for selected patients in particular time to early detect extra-thoracic recurrences.

The combination of EBUS-TBNA and the PAB antibody led to a successful treatment for lung cancer in a patient with asymptomatic sarcoidosis mimicking nodal metastasis

Correct staging of lung cancer is important for the selection of the best therapy, but discriminating between lymphadenopathy from lung cancer and from sarcoidosis by imaging examinations is difficult. Additionally, distinguishing lymphadenopathy of sarcoidosis from sarcoid reactions which are sometimes caused by lung cancer is difficult on imaging and pathological findings. A 73-year-old woman was diagnosed as lung cancer clinical T1bN3M0 stage ШB based on false-positive ¹⁸F-fluoro-2-deoxyglucose positron emission tomography uptake. Because the effects of chemotherapy were different between the lymphadenopathy and the primary lesion, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed and revealed sarcoidosis as the cause of the lymphadenopathy with using a specific monoclonal antibody against Propionibacterium acnes (PAB antibody). Accordingly, the stage was changed to clinical T1bN0M0 stage ІA, for which radical operation was performed. EBUS-TBNA should be performed aggressively when the effect of chemotherapy is different between lymphadenopathies and other lesions, and the PAB antibody can help to discriminate between sarcoidosis and sarcoid reactions caused by lung cancer. The combination of EBUS-TBNA and the PAB antibody is expected to be valuable in the definitive diagnosis of a lymphadenopathy for the staging of lung cancer.