Evolution of systemic therapy for stages I-III non-metastatic non-small-cell lung cancer

Angiotensin Receptor Blocker Associated with a Decreased Risk of Lung Cancer: An Updated Meta-Analysis

INTRODUCTION

There have been disputes in the association between angiotensin receptor blockers (ARB) and the incidence of lung cancer. Our meta-analysis reevaluated this problem from the perspectives of race, age, drug type, comparison objects and smoking.

METHOD

We used the following databases to carry out our literature search: Pubmed, Medline, Cochrane Library, and Ovid (From 1 January 2020 to 28 November 2021). The correlation between ARBs and the incidence rate of lung cancer was calculated by risk ratios (RRs). Confidence intervals were selected with 95% confidence intervals.

RESULTS

A total of 10 randomized controlled trials (RCTs), 18 retrospective studies and 3 case-control studies were found to satisfy the inclusion criteria. The use of ARB drugs reduced the incidence of lung cancer. The pooled results of 10 retrospective studies revealed a decreased lung cancer incidence in patients treated with ARBs, especially in patients using Valsartan. A significantly lower lung cancer incidence was found in the ARB drugs than in calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors (ACEIs). Lung cancer occurrence was lower in Asian-based studies, especially in Mongolian-dominated and Caucasian-dominated patient populations. No significant decrease in lung cancer occurrence was found in RCTs or in patients receiving telmisartan, losartan, candesartan, irbesartan, or other placebo or in American and European-dominated patient populations.

CONCLUSION

Compared with ACEIs and CCBs, ARBs significantly reduce the risk of lung cancer, especially in Asian and Mongolian populations. Valsartan has the best effect in reducing the risk of lung cancer in ARB drugs.

EOAI, a ubiquitin-specific peptidase 5 inhibitor, prevents non-small cell lung cancer progression by inducing DNA damage

OBJECTIVE

Targeting deubiquitinases (DUBs) has emerged as a promising avenue for anticancer drug development. However, the effect and mechanism of pan-DUB inhibitor EOAI on non-small cell lung cancer (NSCLC) remains to be studied.

MATERIALS AND METHODS

The expression of ubiquitin-specific peptidase 5 (USP5) in NSCLC was evaluated by immunohistochemistry. The effect of the USP5 inhibitor, EOAI, on NSCLC cell growth and cell cycle was evaluated by CCK-8 and PI staining. Apoptosis was detected by Annexin V-FITC/PI double staining. Autophagy was examined by LC3 immunofluorescence. Comet assay and γ-H2AX immunofluorescence staining were used to detect DNA damage, and Western blotting was used to detect the expression of apoptosis, cycle, autophagy and DNA damage-related proteins. In vivo experiments demonstrated the effect of EOAI on NSCLC.

RESULTS

We also found that USP5 was significantly upregulated in NSCLC tissues in this study. In addition, we show that EOAI can cause DNA damage in NSCLC cells while modulating the transcriptional activity of P53, thereby inducing cell cycle arrest in NSCLC cells, autophagy and apoptosis. In vivo experiments have shown that EOAI can inhibit tumors and synergistically enhance the anti-tumor effect of cisplatin.

CONCLUSION

USP5-mediated epigenetic regulation of oncogenes promotes the occurrence of NSCLC, which provides ideas for developing potential targeted therapy.

Polo-like kinase (PLK) 5, a new member of the PLK family, serves as a biomarker to indicate anabatic tumor burden and poor prognosis for resectable non-small cell lung cancer

Objective

A review argues that polo-like kinase 5 (PLK5) may be linked to unfavorable prognosis in non-small cell lung cancer (NSCLC) patients, which contradicts the discoveries from The Human Protein Atlas database (derived from TCGA analysis). This study intended to comprehensively confirm the association of PLK5 with clinical characteristics and prognosis in NSCLC patients.

Methods

This two-center, retrospective, cohort study enrolled 210 NSCLC patients receiving surgical resection. PLK5 protein and mRNA were detected by immunohistochemistry and RT-qPCR in tumor and nontumor tissues. Moreover, RNA FPKM data for 994 lung cancer patients were obtained from The Human Protein Atlas database.

Results

PLK5 protein was decreased in tumor tissue compared to nontumor tissue (P < 0.001). Additionally, decreased PLK5 protein was linked with increased pathological grade (P = 0.002), lymph node metastasis presence (P = 0.001), elevated tumor-node-metastasis (TNM) stage (P = 0.003), and abnormal cancer antigen 125 (CA125) (P = 0.002). Meanwhile, low PLK5 protein was correlated with shortened disease-free survival (DFS) (P = 0.007) and overall survival (OS) (P = 0.038); further multivariable Cox regression analysis revealed that low PLK5 protein independently predicted unfavorable DFS (hazard ratio = 0.573, P = 0.022). PLK5 mRNA was reduced in tumor tissue compared with nontumor tissue (P < 0.001); its decline was linked with enhanced pathological grade (P = 0.034), climbed TNM stage (P = 0.032), and abnormal CA125 (P = 0.002). Furthermore, low PLK5 mRNA was correlated with unfavorable DFS (P = 0.046). The Human Protein Atlas database also disclosed the link between low PLK5 mRNA and worse OS (P = 0.046).

Conclusion

A PLK5 decrement reflects anabatic tumor burden and poor prognosis in NSCLC patients.

Safety and feasibility of robotic-assisted thoracic surgery after neoadjuvant chemoimmunotherapy in non-small cell lung cancer

Objectives

This study aimed to evaluate the safety and feasibility of robotic-assisted thoracic surgery (RATS) after neoadjuvant chemoimmunotherapy in NSCLC.

Methods

We retrospectively collected data for NSCLC patients who received thoracic surgery after neoadjuvant chemoimmunotherapy from May 2020 to August 2022. Surgery details, pathological response, and perioperative outcome were compared between video-assisted thoracic surgery (VATS) group and RATS group. Inverse probability of treatment weighting (IPTW) was used to equal the baseline characteristics.

Results

A total of 220 patients were divided into 78 VATS patients and 142 RATS patients. There was no 90-day mortality in either group. RATS patients demonstrated better results in conversion rate to thoracotomy (VATS vs. RATS: 28.2% vs. 7.5%, P < 0.001), number of lymph node stations harvested (5.63 ± 1.75 vs. 8.09 ± 5.73, P < 0.001), number of lymph nodes harvested (13.49 ± 9.325 vs. 20.35 ± 10.322, P < 0.001), yield pathologic-N (yp-N) assessment (yp-N0, 88.5% vs. 67.6%; yp-N1, 7.6% vs. 12.6%; yp-N2, 3.8% vs. 19.7%; P < 0.001), and visual analog scale pain score after surgery (4.41 ± 0.93 vs. 3.77 ± 1.21, P=0.002). However, there were no significant differences in pathological response evaluation for neoadjuvant chemoimmunotherapy (P = 0.493) and complication rate (P = 0.803). After IPTW-adjustment, these results remained constant.

Conclusions

RATS reduced the risk of conversion to thoracotomy, provided a better yp-N stage evaluation, and improved pain score; this suggests that RATS is safe and feasible for NSCLC patients after neoadjuvant chemoimmunotherapy.

Neoadjuvant immunotherapy in resectable non-small-cell lung cancer

The advent of immune checkpoint inhibition has pushed the treatment paradigm for resectable non-small-cell lung cancer (NSCLC) toward neoadjuvant therapy. A growing number of promising trials have examined the utility of neoadjuvant immunotherapy, both alone and in combination with other modalities such as radiation therapy (RT) and chemotherapy. The phase II LCMC3 and NEOSTAR trials demonstrated a role for neoadjuvant immunotherapy in inducing meaningful pathologic responses, and another phase II trial established the feasibility of combining neoadjuvant durvalumab with RT. Significant interest in neoadjuvant chemoimmunotherapy resulted in the conduct of multiple successful phase II trials including the Columbia trial, NADIM, SAKK 16/14, and NADIM II. Across these trials, neoadjuvant chemoimmunotherapy led to high rates of pathologic response and improved surgical outcomes without compromising surgical timing or feasibility. CheckMate-816, which was a randomized phase III trial studying neoadjuvant nivolumab in addition to chemotherapy, definitively established a benefit for neoadjuvant chemoimmunotherapy compared to chemotherapy alone for resectable NSCLC. Despite the growing literature and success of these trials, several outstanding questions remain, including the relationship between pathologic response and patient survival, the role of biomarkers such as programmed death ligand 1 and circulating tumor DNA in determining patient selection and treatment course, and the utility of additional adjuvant therapies. Longer follow-up of CheckMate-816 and other ongoing phase III trials may help address these questions. Ultimately, the complexity of managing resectable NSCLC highlights the importance of a multidisciplinary approach to patient care.

NIR-IIb fluorescence-image guided synergistic surgery/starvation/chemodynamic therapy: an innovative treatment paradigm for malignant non-small cell lung cancers

Background: Currently, the prognosis and survival rate for patients bearing non-small cell lung cancer (NSCLC) is still quite poor, mainly due to lack of efficient theranostic paradigms to exert in time diagnostics and therapeutics. Methods: Herein, for NSCLC treatment, we offer a customized theranostic paradigm, termed NIR-IIb fluorescence diagnosis and synergistic surgery/starvation/chemodynamic therapeutics, with a newly designed theranostic nanoplatform PEG/MnCuDCNPs@GOx. The nanoplatform is composed of brightly NIR-II emissive downconversion nanoparticles (DCNPs)-core and Mn/Cu-silica shell loaded with glucose oxidase (GOx) to achieve synergistic starvation and chemodynamic therapy (CDT). Results: It is found that 10% Ce³⁺ doped in the core and 100% Yb³⁺ doped in the middle shell greatly improves the NIR-IIb emission up to even 20.3 times as compared to the core-shell DCNPs without Ce³⁺ doping and middle shell. The bright NIR-IIb emission of the nanoplatform contributes to sensitive margin delineation of early-stage NSCLC (diameter < 1 mm) with a signal-to-background ratio (SBR) of 2.18, and further assists in visualizing drug distribution and guiding surgery/starvation/chemodynamic therapy. Notably, the starvation therapy mediated by GOx-driven oxidation reaction efficiently depletes intratumoral glucose, and supplies H₂O₂ to boost the CDT mediated by the Mn²⁺ and Cu²⁺, which consequently realized a highly effective synergistic treatment for NSCLC. Conclusion: This research demonstrates an efficient treatment paradigm for NSCLC with NIR-IIb fluorescence diganosis and image-guided synergistic surgery/starvation/chemodynamic therapeutics.

Dual-responsive nanoparticles loading bevacizumab and gefitinib for molecular targeted therapy against non-small cell lung cancer

The combination of vascular endothelial growth factor (VEGF) inhibitors and tyrosine kinase inhibitors (TKIs) is newly available for molecular targeted therapy against non-small cell lung cancer (NSCLC) in clinic. However, the therapeutic benefits remain unsatisfying due to the poor drug delivery to targets of interest. In this study, we developed bevacizumab-coated gefitinib-loaded nanoparticles (BCGN) with dual-responsive drug release for inhibiting tumor angiogenesis and phosphorylation of epidermal growth factor receptor (EGFR). Through an exogenous corona strategy, bevacizumab is easily coated on gefitinib-loaded nanoparticles via electrostatic interaction. After intravenous injection, BCGN are efficiently accumulated in NSCLC tumors as confirmed by dual-model imaging. Bevacizumab is released from BCGN upon oxidation in tumor microenvironment, whereas gefitinib is released after being internalized by tumor cells and disassembled in reduction cytoplasm. The dual-responsive release of bevacizumab and gefitinib significantly inhibits tumor growth in both A549 and HCC827 human NSCLC models. Our approach provides a promising strategy to improve combinational molecular targeted therapy of NSCLC with precisely controlled drug release.

SPACES: Our team's experience in lung tumor microwave ablation

The standard treatment of stage I nonsmall cell lung cancer is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I nonsmall cell lung cancer are not candidates for surgery due to severe medical comorbidities (poor cardiopulmonary function). Image-guided thermal ablation is an alternative for those patients, includes radiofrequency ablation, microwave ablation (MWA), cryoablation, and laser ablation. Compared to them, MWA is a relatively new technique with some potential advantages, such as faster heating times, higher intralesional temperatures, larger ablation zones, less procedural pain, relative insensitivity to "heat sinks," and less sensitivity to tissue types. However, some advantages of MWA mentioned above (such as higher intralesional temperatures, larger ablation zones) also have potential risks and problems, and an innovative and standardized guidance system is needed to avoid and solve these risks and problems. This article combs our team's clinical experience over the past decade, summarizes a systematic and standardized guidance system, and names it SPACES (Selection, Procedure, Assessment, Complication, Evaluation, Systemic therapy). Both primary and metastatic pulmonary tumors can be efficiently treated with image-guided thermal ablation in selected candidates. The selection and use of ablation techniques should consider the size and location of the target tumor, the risk of complications, and the expertise and skills of the professionals, among which the size of the target tumor (<3 mm) is a major factor determining the success of ablation.

Emerging Biomarkers in Immune Oncology to Guide Lung Cancer Management

Over the last decade, the use of targeted therapies and immune therapies led to drastic changes in the management lung cancer and translated to improved survival outcomes. This growing arsenal of therapies available for the management of non-small cell lung cancer added more complexity to treatment decisions. The genomic profiling of tumors and the molecular characterization of the tumor microenvironment gradually became essential steps in exploring and identifying markers that can enhance patient selection to facilitate treatment personalization and narrow down therapy options. The advent of innovative diagnostic platforms, such as next-generation sequencing and plasma genotyping (also known as liquid biopsies), has aided in this quest. Currently, programmed cell death ligand 1 expression remains the most recognized and fully validated predictive biomarker of response to immune checkpoint inhibitors. Other markers such as tumor mutational burden, tumor infiltrating lymphocytes, driver mutations, and other molecular elements of the tumor microenvironment bear the potential to be predictive tools; however, the majority are still investigational. In this review, we describe the advances noted thus far on currently validated as well as novel emerging biomarkers that have the potential to guide the use of immunotherapy agents in the management of non-small cell lung cancer.

Multiplex immunofluorescence and single-cell transcriptomic profiling reveal the spatial cell interaction networks in the non-small cell lung cancer microenvironment

BACKGROUND

Conventional immunohistochemistry technologies were limited by the inability to simultaneously detect multiple markers and the lack of identifying spatial relationships among cells, hindering understanding of the biological processes in cancer immunology.

METHODS

Tissue slices of primary tumours from 553 IA∼IIIB non-small cell lung cancer (NSCLC) cases were stained by multiplex immunofluorescence (mIF) assay for 10 markers, including CD4, CD38, CD20, FOXP3, CD66b, CD8, CD68, PD-L1, CD133 and CD163, evaluating the amounts of 26 phenotypes of cells in tumour nest and tumour stroma. StarDist depth learning model was utilised to determine the spatial location of cells based on mIF graphs. Single-cell RNA sequencing (scRNA-seq) on four primary NSCLC cases was conducted to investigate the putative cell interaction networks.

RESULTS

Spatial proximity among CD20+ B cells, CD4+ T cells and CD38+ T cells (r2  = 0.41) was observed, whereas the distribution of regulatory T cells was associated with decreased infiltration levels of CD20+ B cells and CD38+ T cells (r2  = -0.45). Univariate Cox analyses identified closer proximity between CD8+ T cells predicted longer disease-free survival (DFS). In contrast, closer proximity between CD133+ cancer stem cells (CSCs), longer distances between CD4+ T cells and CD20+ B cells, CD4+ T cells and neutrophils, and CD20+ B cells and neutrophils were correlated with dismal DFS. Data from scRNA-seq further showed that spatially adjacent N1-like neutrophils could boost the proliferation and activation of T and B lymphocytes, whereas spatially neighbouring M2-like macrophages showed negative effects. An immune-related risk score (IRRS) system aggregating robust quantitative and spatial prognosticators showed that high-IRRS patients had significantly worse DFS than low-IRRS ones (HR 2.72, 95% CI 1.87-3.94, p < .001).

CONCLUSIONS

We developed a framework to analyse the cell interaction networks in tumour microenvironment, revealing the spatial architecture and intricate interplays between immune and tumour cells.

Inferencing Bulk Tumor and Single-Cell Multi-Omics Regulatory Networks for Discovery of Biomarkers and Therapeutic Targets

There are insufficient accurate biomarkers and effective therapeutic targets in current cancer treatment. Multi-omics regulatory networks in patient bulk tumors and single cells can shed light on molecular disease mechanisms. Integration of multi-omics data with large-scale patient electronic medical records (EMRs) can lead to the discovery of biomarkers and therapeutic targets. In this review, multi-omics data harmonization methods were introduced, and common approaches to molecular network inference were summarized. Our Prediction Logic Boolean Implication Networks (PLBINs) have advantages over other methods in constructing genome-scale multi-omics networks in bulk tumors and single cells in terms of computational efficiency, scalability, and accuracy. Based on the constructed multi-modal regulatory networks, graph theory network centrality metrics can be used in the prioritization of candidates for discovering biomarkers and therapeutic targets. Our approach to integrating multi-omics profiles in a patient cohort with large-scale patient EMRs such as the SEER-Medicare cancer registry combined with extensive external validation can identify potential biomarkers applicable in large patient populations. These methodologies form a conceptually innovative framework to analyze various available information from research laboratories and healthcare systems, accelerating the discovery of biomarkers and therapeutic targets to ultimately improve cancer patient survival outcomes.

Thermal ablation versus radiotherapy for inoperable stage III non-small cell lung cancer: a propensity score matching analysis

OBJECTIVE

To compare the survival benefits of thermal ablation (TA) and radiotherapy in inoperable patients with stage III non-small cell lung cancer (NSCLC).

METHOD

A retrospective analysis was conducted using the data from the Surveillance, Epidemiology, and End Results (SEER) program. Propensity score matching (PSM) was conducted to balance potential baseline confounding factors. Survival analyses were conducted using Kaplan-Meier and Cox regression methods.

RESULTS

The present study included 33,393 inoperable patients with stage III NSCLC, including 106 patients treated with TA and 33,287 patients treated with radiotherapy. No statistical difference in overall survival (OS) (p = .065) or cancer-specific survival (CSS) (p = .996) was found between the patients treated with TA and those treated with radiotherapy. Using 1:3 matching, a matched cohort of 420 patients (105 patients treated with TA, 315 patients treated with radiotherapy) was identified. The differences in OS (p = .177) and CSS (p = .605) were still not significant between the radiotherapy and TA groups after PSM. According to subgroup analyses, TA showed comparable survival benefits in almost all subgroups compared to radiotherapy.

CONCLUSION

For inoperable stage III NSCLC, the survival benefit of TA was comparable to radiotherapy. TA may be a potential therapeutic modality for inoperable stage III NSCLC.

[Research Progress of Treatment for NSCLC in Young Patients]

Non-small cell lung cancer (NSCLC) young patients (≤45 years old), despite their low prevalence, have unique clinical and pathological features. Its morbidity has been on the rise in recent years. With the concept of individualized lung cancer treatment, related researches are gradually gaining attention. In addition, the treatment response and prognosis in NSCLC young patients are different from older patients, so the study of NSCLC young patients is of great clinical significance. This article reviews the clinical manifestations, treatment and prognosis of NSCLC young patients.
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Clinical implications of T cell exhaustion for cancer immunotherapy

Immunotherapy has been a remarkable clinical advancement in the treatment of cancer. T cells are pivotal to the efficacy of current cancer immunotherapies, including immune-checkpoint inhibitors and adoptive cell therapies. However, cancer is associated with T cell exhaustion, a hypofunctional state characterized by progressive loss of T cell effector functions and self-renewal capacity. The 'un-exhausting' of T cells in the tumour microenvironment is commonly regarded as a key mechanism of action for immune-checkpoint inhibitors, and T cell exhaustion is considered a pathway of resistance for cellular immunotherapies. Several elegant studies have provided important insights into the transcriptional and epigenetic programmes that govern T cell exhaustion. In this Review, we highlight recent discoveries related to the immunobiology of T cell exhaustion that offer a more nuanced perspective beyond this hypofunctional state being entirely undesirable. We review evidence that T cell exhaustion might be as much a reflection as it is the cause of poor tumour control. Furthermore, we hypothesize that, in certain contexts of chronic antigen stimulation, interruption of the exhaustion programme might impair T cell persistence. Therefore, the prioritization of interventions that mitigate the development of T cell exhaustion, including orthogonal cytoreduction therapies and novel cellular engineering strategies, might ultimately confer superior clinical outcomes and the greatest advances in cancer immunotherapy.

The efficacy of postoperative radiotherapy for patients with non-small cell lung cancer: An updated systematic review and meta-analysis

The controversy over the efficacy of postoperative radiotherapy (PORT) has existed for a long time. The present study reassessed the overall survival (OS) and disease-free survival (DFS) data to investigate whether PORT can improve survival in resectable non-small cell lung cancer (NSCLC) patients. The following databases were used to perform literature search: PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), and Embase (from January 1, 1986 to July 5, 2021). The results of overall survival (OS) and disease-free survival (DFS) were calculated as hazard ratio (HR). Confidence intervals are chosen with 95% confidence intervals. A total of 12 RCTs and 19 retrospective cohort studies were found to meet the inclusion criteria. A significant DFS improvement was detected in the PORT group (4111 patients from 15 studies), although statistical difference was not detected for OS between the non-PORT and PORT groups (31 studies, 49,342 total patients). PORT prolonged OS in patients undergoing PORT plus postoperative chemotherapy (POCT) and in pN2 patients. Patients with a median radiation dose of 50.4 Gy and a median radiation dose of 54 Gy had a better OS after PORT. However, if the total radiotherapy dose went up to 60 Gy, PORT increased the risk of death in NSCLC patients. Significant difference in OS was not found in the results of studies with regard to treatment methods, pathologic stages, study type, radiation beam quality, and radiation dose. Patients undergoing postoperative chemoradiotherapy and pN2 patients can benefit from PORT. Patients exposed to median radiation doses of 50.4 and 54 Gy demonstrated relatively good efficacy. For patients with non-small-cell lung cancer, PORT has not been proven to extend OS, but its effect on DFS remains strong.

Multi-Omics Immune Interaction Networks in Lung Cancer Tumorigenesis, Proliferation, and Survival

There are currently no effective biomarkers for prognosis and optimal treatment selection to improve non-small cell lung cancer (NSCLC) survival outcomes. This study further validated a seven-gene panel for diagnosis and prognosis of NSCLC using RNA sequencing and proteomic profiles of patient tumors. Within the seven-gene panel, ZNF71 expression combined with dendritic cell activities defined NSCLC patient subgroups (n = 966) with distinct survival outcomes (p = 0.04, Kaplan-Meier analysis). ZNF71 expression was significantly associated with the activities of natural killer cells (p = 0.014) and natural killer T cells (p = 0.003) in NSCLC patient tumors (n = 1016) using Chi-squared tests. Overexpression of ZNF71 resulted in decreased expression of multiple components of the intracellular intrinsic and innate immune systems, including dsRNA and dsDNA sensors. Multi-omics networks of ZNF71 and the intracellular intrinsic and innate immune systems were computed as relevant to NSCLC tumorigenesis, proliferation, and survival using patient clinical information and in-vitro CRISPR-Cas9/RNAi screening data. From these networks, pan-sensitive and pan-resistant genes to 21 NCCN-recommended drugs for treating NSCLC were selected. Based on the gene associations with patient survival and in-vitro CRISPR-Cas9, RNAi, and drug screening data, MEK1/2 inhibitors PD-198306 and U-0126, VEGFR inhibitor ZM-306416, and IGF-1R inhibitor PQ-401 were discovered as potential targeted therapy that may also induce an immune response for treating NSCLC.

A clinical risk model for assessing the survival of patients with stage IA-IIA non-small cell lung cancer after surgery

BACKGROUND

The survival of patients with stage IA-IIA non-small cell lung cancer (NSCLC) after surgery is heterogeneous. This study aimed to construct a prognostic risk model to predict the overall survival (OS) of these patients.

METHODS

Data from patients (n=9,914) from the Surveillance Epidemiology and End Results (SEER) database were analyzed. The cases were randomly divided into the training and the validation groups. Patients from the Shanghai Pulmonary Hospital (n=270) were also included as an external cohort. Independent significant factors affecting survival in the training cohort were used to construct a nomogram. The precision was evaluated using the concordance index (C-index) and calibration plots. The X-tile software was used to confirm the optimal cut-off value to classify the patients.

RESULTS

Sex, age at diagnosis, tumor size, visceral pleura invasion (VPI), tumor grade, and the number of examined lymph nodes were deemed independent prognostic factors and were selected to establish the nomogram. The C-indices of the nomogram for predicting OS were 0.671 [95% confidence interval (CI): 0.653-0.689] in the training group, and 0.668 (95% CI: 0.650-0.687) and 0.707 (95% CI: 0.651-0.763) in the validation and the testing groups, respectively. The cut-off value of risk points was 106.0, which stratified the patients into high-risk and low-risk groups. The high-risk patients had shorter 5-year OS than low-risk patients (P<0.001).

CONCLUSIONS

The established nomogram could evaluate the survival in patients with stage IA-IIA NSCLC after surgery and may provide prognostic information for clinicians to make decisions in the management of adjuvant therapy.

Prognostic Value of Circulating Tumor DNA (ctDNA) in Oncogene-Driven NSCLC: Current Knowledge and Future Perspectives

Simple Summary

Personalized medicine has significantly changed the clinical outcome of oncogene-driven non-small cell lung cancer (NSCLC) due to the efficacy of molecular targeted therapies. Despite the advances in the management of this group of patients, the need for powerful biomarkers with the potential for a real-time assessment of the tumor genomic profile as well as for detecting and monitoring minimal residual disease (MRD) remains unmet. The aim of this article is to present the current knowledge and the future perspectives regarding the prognostic value of ctDNA in NSCLC, focusing on the most common druggable driver mutations, including those in epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS1), rearranged during transfection (RET), kirsten rat sarcoma virus (KRAS), B-Raf proto-oncogene (BRAF), and mesenchymal epithelial transition factor receptor (MET) genes.

Abstract

As we enter an unprecedented era of personalized medicine, molecular targeted therapies have the potential to induce improved survival outcome in patients with non-small cell lung cancer (NSCLC). However, a significant percentage of oncogene-driven NSCLC patients will relapse even after definitive treatment, whereas chronic and durable response to targeted therapies is a less common event in advanced-stage lung cancer. This phenomenon could be attributed to minimal residual disease (MRD), defined as a population of disseminated tumor cells that survive during the course or after treatment, eventually leading to recurrence and limiting patient survival. Circulating tumor DNA (ctDNA) is a powerful biomarker for MRD detection and monitoring and is a non-invasive approach of treating cancer, and especially NSCLC, based on a real-time assessment of the tumor genomic landscape. In this review, we present the key findings of studies that have used ctDNA with regard to its prognostic value and in respect to the most common druggable driver mutations of genes in NSCLC, such as epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS1), rearranged during transfection (RET), Kirsten rat sarcoma virus (KRAS), B-Raf proto-oncogene (BRAF), and mesenchymal epithelial transition factor receptor (MET).

Multimodal integration of radiology, pathology and genomics for prediction of response to PD-(L)1 blockade in patients with non-small cell lung cancer

Immunotherapy is used to treat almost all patients with advanced non-small cell lung cancer (NSCLC); however, identifying robust predictive biomarkers remains challenging. Here we show the predictive capacity of integrating medical imaging, histopathologic and genomic features to predict immunotherapy response using a cohort of 247 patients with advanced NSCLC with multimodal baseline data obtained during diagnostic clinical workup, including computed tomography scan images, digitized programmed death ligand-1 immunohistochemistry slides and known outcomes to immunotherapy. Using domain expert annotations, we developed a computational workflow to extract patient-level features and used a machine-learning approach to integrate multimodal features into a risk prediction model. Our multimodal model (area under the curve (AUC) = 0.80, 95% confidence interval (CI) 0.74-0.86) outperformed unimodal measures, including tumor mutational burden (AUC = 0.61, 95% CI 0.52-0.70) and programmed death ligand-1 immunohistochemistry score (AUC = 0.73, 95% CI 0.65-0.81). Our study therefore provides a quantitative rationale for using multimodal features to improve prediction of immunotherapy response in patients with NSCLC using expert-guided machine learning.

Recent Advances in DNA Vaccines against Lung Cancer: A Mini Review

Lung cancer is regarded as the major causes of patient death around the world. Although the novel tumor immunotherapy has made great progress in the past decades, such as utilizing immune checkpoint inhibitors or oncolytic viruses, the overall 5-year survival of patients with lung cancers is still low. Thus, development of effective vaccines to treat lung cancer is urgently required. In this regard, DNA vaccines are now considered as a promising immunotherapy strategy to activate the host immune system against lung cancer. DNA vaccines are able to induce both effective humoral and cellular immune responses, and they possess several potential advantages such as greater stability, higher safety, and being easier to manufacture compared to conventional vaccination. In the present review, we provide a global overview of the mechanism of cancer DNA vaccines and summarize the innovative neoantigens, delivery platforms, and adjuvants in lung cancer that have been investigated or approved. Importantly, we highlight the recent advance of clinical studies in the field of lung cancer DNA vaccine, focusing on their safety and efficacy, which might accelerate the personalized design of DNA vaccine against lung cancer.

Molecular, clinicopathological characteristics and surgical results of resectable SMARCA4-deficient thoracic tumors

PURPOSE

SMARCA4-deficient thoracic tumors are rapid aggressive malignancies, often diagnosed at an advanced and inoperable stage. The value of pulmonary resection for resectable SMARCA4-deficient thoracic tumors is largely unknown.

METHODS

In this observational study, we included 45 patients who received surgery for stage I-III SMARCA4-deficient tumors. We compared the molecular, clinicopathological characteristics and survival between SMARCA4-dNSCLC and SMARCA4-deficient undifferentiated tumor (SMARCA4-dUT) patients.

RESULTS

Thirty-four SMARCA4-dNSCLC and 11 SMARCA4-dUT patients were included in this study. Molecular profiles were available in 33 out of 45 patients. The most common mutated gene was TP53 (21, 64%), and followed by STK11 (9, 27%), KRAS (5, 15%), FGFR1 (4, 12%) and ROS1 (4, 12%). There were 3 patients that harbored ALK mutation including 1 EML4-ALK rearrangement. There were 2 patients that harbored EGFR rare site missense mutation. SMARCA4-dUT patients had significance worse TTP (HR = 4.35 95% CI 1.77-10.71, p = 0.001) and OS (HR = 4.27, 95% CI 1.12-16.35, p = 0.022) compared to SMARCA4-dNSCLC patients. SMARCA4-dUT histologic type, stage II/III, R1/2 resection and lymphovascular invasion were independent poor prognostic predictors for both TTP and OS. There were 8 patients who received immunotherapy, the objective response rate was 50%. The SMARCA4-dNSCLC patient with ALK rearrangement was treated with crizotinib as second-line therapy, and achieved stable disease for 9.7 months.

CONCLUSION

Patients with SMARCA4-deficient tumors have a high probability of early recurrence after surgery, except for stage I patients. Immunotherapy seems to be a valuable strategy to treat recurrence.

Conversion therapy from unresectable stage IIIC non-small-cell lung cancer to radical surgery via anti-PD-1 immunotherapy combined with chemotherapy and anti-angiogenesis: A case report and literature review

The prognosis of patients with stage IIIC non-small-cell lung cancer (NSCLC) is poor due to the loss of surgical treatment opportunities. Improving the prognosis of these patients with IIIC NSCLC urgently needs to be addressed. Here, we report a stage IIIC (T4N3M0 IIIC (AJCC 8th)) NSCLC patient treated with 2 cycles of anti-PD-1 immunotherapy combined with chemotherapy and anti-angiogenesis therapy; after two cycles of treatment, the patient achieved a partial response and obtained the opportunity for surgical treatment. After the operation, the patient achieved a pathological complete response and successfully transformed from unresectable stage IIIC lung cancer to radical surgery (ypT0N0M0). Our study is expected to provide new ideas for treating patients with unresectable stage IIIC NSCLC in the future.

Determination of a prediction model for therapeutic response and prognosis based on chemokine signaling-related genes in stage I–III lung squamous cell carcinoma

Background: The chemokine signaling pathway plays an essential role in the development, progression, and immune surveillance of lung squamous cell carcinoma (LUSC). Our study aimed to systematically analyze chemokine signaling-related genes (CSRGs) in LUSC patients with stage I–III disease and develop a prediction model to predict the prognosis and therapeutic response.

Methods: A total of 610 LUSC patients with stage I–III disease from three independent cohorts were included in our study. Least absolute shrinkage and selection operator (LASSO) and stepwise multivariate Cox regression analyses were used to develop a CSRG-related signature. GSVA and GSEA were performed to identify potential biological pathways. The ESTIMATE algorithm, ssGSEA method, and CIBERSORT analyses were applied to explore the correlation between the CSRG signature and the tumor immune microenvironment. The TCIA database and pRRophetic algorithm were utilized to predict responses to immunochemotherapy and targeted therapy.

Results: A signature based on three CSRGs (CCL15, CXCL7, and VAV2) was developed in the TCGA training set and validated in the TCGA testing set and GEO external validation sets. A Kaplan–Meier survival analysis revealed that patients in the high-risk group had significantly shorter survival than those in the low-risk group. A nomogram combined with clinical parameters was established for clinical OS prediction. The calibration and DCA curves confirmed that the prognostic nomogram had good discrimination and accuracy. An immune cell landscape analysis demonstrated that immune score and immune-related functions were abundant in the high-risk group. Interestingly, the proportion of CD8 T-cells was higher in the low-risk group than in the high-risk group. Immunotherapy response prediction indicated that patients in the high-risk group had a better response to CTLA-4 inhibitors. We also found that patients in the low-risk group were more sensitive to first-line chemotherapeutic treatment and EGFR tyrosine kinase inhibitors. In addition, the expression of genes in the CSRG signature was validated by qRT‒PCR in clinical tumor specimens.

Conclusion: In the present study, we developed a CSRG-related signature that could predict the prognosis and sensitivity to immunochemotherapy and targeted therapy in LUSC patients with stage I–III disease. Our study provides an insight into the multifaceted role of the chemokine signaling pathway in LUSC and may help clinicians implement optimal individualized treatment for patients.

Self-carried nanodrug (SCND-SIS3): A targeted therapy for lung cancer with superior biocompatibility and immune boosting effects

Transforming growth factor β (TGF-β) is a well-known key mediator for the progression and metastasis of lung carcinoma. However, cost-effective anti-TGF-β therapeutics for lung cancer remain to be explored. Specifically, the low efficacy in drug delivery greatly limits the clinical application of small molecular inhibitors of TGF-β. In the present study, specific inhibitor of Smad3 (SIS3) is developed into a self-carried nanodrug (SCND-SIS3) using the reprecipitation method, which largely improves its solubility and bioavailability while reduces its nephrotoxicity. Compared to unmodified-SIS3, SCND-SIS3 demonstrates better anti-cancer effects through inducing tumor cell apoptosis, inhibiting angiogenesis, and boosting NK cell-mediated immune responses in syngeneic Lewis Lung Cancer (LLC) mouse model. Better still, it could achieve comparable anti-cancer effect with just one-fifth the dose of unmodified-SIS3. Mechanistically, RNA-sequencing analysis and cytokine array results unveil a TGF-β/Smad3-dependent immunoregulatory landscape in NK cells. In particular, SCND-SIS3 promotes NK cell cytotoxicity by ameliorating Smad3-mediated transcriptional inhibition of Ndrg1. Furthermore, improved NK cell cytotoxicity by SCND-SIS3 is associated with higher expression of activation receptor Nkp46, and suppressed levels of Trib3 and TSP1 as compared with unmodified-SIS3. Taken together, SCND-SIS3 possesses superior anti-cancer effects with enhanced bioavailability and biocompatibility, therefore representing as a novel therapeutic strategy for lung carcinoma with promising clinical potential.

Tumor-Promoting ATAD2 and Its Preclinical Challenges

ATAD2 has received extensive attention in recent years as one prospective oncogene with tumor-promoting features in many malignancies. ATAD2 is a highly conserved bromodomain family protein that exerts its biological functions by mainly AAA ATPase and bromodomain. ATAD2 acts as an epigenetic decoder and transcription factor or co-activator, which is engaged in cellular activities, such as transcriptional regulation, DNA replication, and protein modification. ATAD2 has been reported to be highly expressed in a variety of human malignancies, including gastrointestinal malignancies, reproductive malignancies, urological malignancies, lung cancer, and other types of malignancies. ATAD2 is involved in the activation of multiple oncogenic signaling pathways and is closely associated with tumorigenesis, progression, chemoresistance, and poor prognosis, but the oncogenic mechanisms vary in different cancer types. Moreover, the direct targeting of ATAD2’s bromodomain may be a very challenging task. In this review, we summarized the role of ATAD2 in various types of malignancies and pointed out the pharmacological direction.

Targeted Therapy in Early Stage Non-small Cell Lung Cancer

OPINION STATEMENT

Tyrosine kinase inhibitors (TKIs) have dramatically improved tumor response rates and survival benefits in advanced oncogenic non-small-cell lung cancer (NSCLC). Given the impressive success, a renewed interest has been raised in the study of these agents in the perioperative setting. Preliminary data have shown dramatic effectiveness compared to conventional chemotherapy. Given the explicit need to induce durable responses and raise cure rates, we summarize the current progression, identify key challenges, and raise potential opportunities for perioperative targeted therapy that range from precise biomarkers to optimal adjuvant regimens for individual patients. As perioperative treatment indeed provides researchers with a unique platform to address the challenges mentioned above, investigators could obtain a comprehensive analysis of genomic profiling and trace resistance mechanisms. Multidisciplinary collaboration and adaptive clinical trial designs are warranted to integrate translational research into personalized perioperative TKI treatment paradigms.

The emergence of nanoporous materials in lung cancer therapy

Lung cancer is one of the most common cancers, affecting more than 2.1 million people across the globe every year. A very high occurrence and mortality rate of lung cancer have prompted active research in this area with both conventional and novel forms of therapies including the use of nanomaterials based drug delivery agents. Specifically, the unique physico-chemical and biological properties of porous nanomaterials have gained significant momentum as drug delivery agents for delivering a combination of drugs or merging diagnosis with targeted therapy for cancer treatment. This review focuses on the emergence of nano-porous materials for drug delivery in lung cancer. The review analyses the currently used nanoporous materials, including inorganic, organic and hybrid porous materials for delivering drugs for various types of therapies, including chemo, radio and phototherapy. It also analyses the selected research on stimuli-responsive nanoporous materials for drug delivery in lung cancer before summarizing the various findings and projecting the future of emerging trends. This review provides a strong foundation for the current status of the research on nanoporous materials, their limitations and the potential for improving their design to overcome the unique challenges of delivering drugs for the treatment of lung cancer.

Explainable Machine Learning Model to Prediction EGFR Mutation in Lung Cancer

Objectives

The aim of this study is to determine whether the clinical features including blood markers can establish an explainable machine learning model to predict epidermal growth factor receptor (EGFR) mutation in lung cancer.

Methods

We retrospectively analyzed 7,413 patients with lung adenocarcinoma (LA) diagnosed by gene sequencing in West China Hospital of the Sichuan University from April 2015 to June 2019. The machine learning algorithms (MLAs) included logistic regression (LR), random forest (RF), LightGBM, support vector machine (SVM), multi-layer perceptron (MLP), extreme gradient boosting (XGBoost), and decision tree (DT). Demographic characteristics, personal history, and blood markers were taken into. The area under the receiver operating characteristic curve (AUC) and SHapley Additive exPlanation (SHAP) value were used to explain the prediction models.

Results

Of the 7,413 patients with LA (47.6%), 3,527 were identified with EGFR mutation; RF achieved greatest performance in predicting EGFR mutation AUC [0.771, 95% confidence interval (CI): 0.770, 0.772], which was like XGBoost with AUC (0.740, 95% CI: 0.739, 0.741). The five most influential features were smoking consumption, sex, cholesterol, age, and albumin globulin ratio. The SHAP summary and dependence plot have been used to explain the affection of the 12 features to this model and how a single feature influences the output, respectively.

Conclusion

We established EGFR mutation prediction models by MLAs and revealed that the RF was preferred, AUC (0.771, 95% CI: 0.770, 0.772), which was better than the traditional models. Therefore, the artificial intelligence–based MLA predicting model may become a practical tool to guide in diagnosis and therapy of LA.

A novel deep learning prognostic system improves survival predictions for stage III non-small cell lung cancer

Background

Accurate prognostic prediction plays a crucial role in the clinical setting. However, the TNM staging system fails to provide satisfactory individual survival prediction for stage III non‐small cell lung cancer (NSCLC). The performance of the deep learning network for survival prediction in stage III NSCLC has not been explored.

Objectives

This study aimed to develop a deep learning‐based prognostic system that could achieve better predictive performance than the existing staging system for stage III NSCLC.

Methods

In this study, a deep survival learning model (DSLM) for stage III NSCLC was developed based on the Surveillance, Epidemiology, and End Results (SEER) database and was independently tested with another external cohort from our institute. DSLM was compared with the Cox proportional hazard (CPH) and random survival forest (RSF) models. A new prognostic system for stage III NSCLC was also proposed based on the established deep learning model.

Results

The study included 16,613 patients with stage III NSCLC from the SEER database. DSLM showed the best performance in survival prediction, with a C‐index of 0.725 in the validation set, followed by RSF (0.688) and CPH (0.683). DSLM also showed C‐indices of 0.719 and 0.665 in the internal and real‐world external testing datasets, respectively. In addition, the new prognostic system based on DSLM (AUROC = 0.744) showed better performance than the TNM staging system (AUROC = 0.561).

Conclusion

In this study, a new, integrated deep learning‐based prognostic model was developed and evaluated for stage III NSCLC. This novel approach may be valuable in improving patient stratification and potentially provide meaningful prognostic information that contributes to personalized therapy.

Distinct immune gene programs associated with host tumor immunity, neoadjuvant chemotherapy and chemoimmunotherapy in resectable NSCLC

PURPOSE

Our understanding of the immunopathology of resectable NSCLC is still limited. Here, we explore immune programs that inform of tumor immunity and response to neoadjuvant chemotherapy and chemoimmunotherapy in localized NSCLC.

EXPERIMENTAL DESIGN

Targeted immune gene sequencing using the HTG Precision Immuno-Oncology panel was performed in localized NSCLCs from three cohorts based on treatment: naïve (n=190), neoadjuvant chemotherapy (n=38) and neoadjuvant chemoimmunotherapy (n=21). Tumor immune microenvironment (TIME) phenotypes based on the location of CD8+ T cells (inflamed, cold, excluded), tumoral PD-L1 expression (&lt;1% and {greater than or equal to}1%), and tumor infiltrating lymphocytes (TILs). Immune programs and signatures were statistically analyzed based on tumoral PD-L1 expression, immune phenotypes, pathological response and were cross-compared across the three cohorts.

RESULTS

PD-L1 positive tumors exhibited increased signature scores for various lymphoid and myeloid cell subsets (p&lt;0.05). TIME phenotypes exhibited disparate frequencies by stage, PD-L1 expression, and mutational burden. Inflamed and PD-L1+/TILs+ NSCLCs displayed overall significantly heightened levels of immune signatures, with the excluded group representing an intermediate state. A cytotoxic T cell signature was associated with favorable survival in neoadjuvant chemotherapy-treated NSCLCs (p&lt;0.05). Pathological response to chemoimmunotherapy was positively associated with higher expression of genes involved in immune activation, chemotaxis, as well as T and NK cells (p&lt;0.05 for all). Among the three cohorts, chemoimmunotherapy-treated NSCLCs exhibited highest scores for various immune cell subsets including T effector and B cells (p&lt;0.05).

CONCLUSIONS

Our findings highlight immune gene programs that may underlie host tumor immunity and response to neoadjuvant chemotherapy and chemoimmunotherapy in resectable NSCLC.

Neoadjuvant Immunotherapy: Leveraging the Immune System to Treat Early-Stage Disease

Given the success of immunotherapy in treating patients with metastatic disease in a variety of tumor types, there is tremendous enthusiasm for expanding the use of immunotherapy to those with early-stage cancer. Administering immunotherapy in the neoadjuvant, preoperative setting is a biologically sound approach because preclinical studies have shown that stronger and broader immune responses can be generated if immunotherapy is administered while the tumor and/or draining lymph nodes are intact. It is therefore likely that administering immunotherapy preoperatively will generate optimal immune responses, leading to high rates of pathologic response as well as improved long-term survival. Although neoadjuvant immunotherapy is currently only approved for use in combination with chemotherapy in triple-negative breast cancer and non-small cell lung cancer, it is anticipated that ongoing and future clinical trials will further define the role of neoadjuvant immunotherapy in many cancer types. These trials should be designed with appropriate survival endpoints and rigorous correlative studies to include imaging and biospecimen-based analyses to address currently unanswered questions that must be resolved to optimize the use of immunotherapy in early-stage disease.

Daily Practice Assessment of KRAS Status in NSCLC Patients: A New Challenge for the Thoracic Pathologist Is Right around the Corner

Simple Summary

RAS mutation is the most frequent oncogenic alteration in human cancers and KRAS is the most frequently mutated, notably in non-small cell lung carcinomas (NSCLC). Various attempts to inhibit KRAS in the past were unsuccessful in these latter tumors. However, recently, several small molecules (AMG510, MRTX849, JNJ-74699157, and LY3499446) have been developed to specifically target KRAS G12C-mutated tumors, which seems promising for patient treatment and should soon be administered in daily practice for non-squamous (NS)-NSCLC. In this context, it will be mandatory to systematically assess the KRAS status in routine clinical practice, at least in advanced NS-NSCLC, leading to new challenges for thoracic oncologists.

Abstract

KRAS mutations are among the most frequent genomic alterations identified in non-squamous non-small cell lung carcinomas (NS-NSCLC), notably in lung adenocarcinomas. In most cases, these mutations are mutually exclusive, with different genomic alterations currently known to be sensitive to therapies targeting EGFR, ALK, BRAF, ROS1, and NTRK. Recently, several promising clinical trials targeting KRAS mutations, particularly for KRAS G12C-mutated NSCLC, have established new hope for better treatment of patients. In parallel, other studies have shown that NSCLC harboring co-mutations in KRAS and STK11 or KEAP1 have demonstrated primary resistance to immune checkpoint inhibitors. Thus, the assessment of the KRAS status in advanced-stage NS-NSCLC has become essential to setting up an optimal therapeutic strategy in these patients. This stimulated the development of new algorithms for the management of NSCLC samples in pathology laboratories and conditioned reorganization of optimal health care of lung cancer patients by the thoracic pathologists. This review addresses the recent data concerning the detection of KRAS mutations in NSCLC and focuses on the new challenges facing pathologists in daily practice for KRAS status assessment.

Updated Prognostic Factors in Localized NSCLC

Lung cancer is the most common cause of cancer mortality worldwide, and non-small cell lung cancer (NSCLC) represents 80% of lung cancer subtypes. Patients with localized non-small cell lung cancer may be considered for upfront surgical treatment. However, the overall 5-year survival rate is 59%. To improve survival, adjuvant chemotherapy (ACT) was largely explored and showed an overall benefit of survival at 5 years < 7%. The evaluation of recurrence risk and subsequent need for ACT is only based on tumor stage (TNM classification); however, more than 25% of patients with stage IA/B tumors will relapse. Recently, adjuvant targeted therapy has been approved for EGFR-mutated resected NSCLC and trials are evaluating other targeted therapies and immunotherapies in adjuvant settings. Costs, treatment duration, emergence of resistant clones and side effects stress the need for a better selection of patients. The identification and validation of prognostic and theranostic markers to better stratify patients who could benefit from adjuvant therapies are needed. In this review, we report current validated clinical, pathological and molecular prognosis biomarkers that influence outcome in resected NSCLC, and we also describe molecular biomarkers under evaluation that could be available in daily practice to drive ACT in resected NSCLC.

Indications and Parameters Around Postoperative Radiation Therapy for Lung Cancer

Patients with locally advanced resected non-small-cell lung cancer present a high risk of relapse. Although adjuvant platinum-based chemotherapy has become the standard of care, the role of postoperative radiation therapy (PORT) has been controversial for years. In patients with incomplete resection, PORT should be proposed, on the basis of a strong consensus, despite the absence of randomized evidence. In patients with completely resected (R0) non-small-cell lung cancer, a meta-analysis showed poorer outcomes after PORT in the absence of mediastinal involvement (pN0 and pN1). In patients with pN2, the role of PORT was less clear and required further research. The meta-analysis included trials using older radiation techniques and poorer quality of surgery according to today's standards, and selection of patients was not positron emission tomography-based. Newer retrospective and nonrandomized studies and subgroup analyses of randomized trials evaluating adjuvant chemotherapy suggested a survival benefit of PORT in patients with pN2 R0. Two recent randomized trials (Lung ART and PORT-C) evaluating conformal PORT versus no PORT retrieved no disease-free survival advantage for stage IIIA-N2 patients, even if mediastinal relapse was significantly decreased with PORT. PORT had no effect on survival, possibly given the high rate of distant relapse and risk of additional cardiopulmonary toxicity. Ongoing and future analyses are planned in Lung ART to identify patients for whom PORT could be recommended. Incorporation of newer systemic treatments (immune checkpoint inhibitors or targeted therapy in oncogene-addicted patients) is underway in the neoadjuvant and/or adjuvant setting. Better identification of patients at a high risk of disease recurrence, with analysis of circulating tumor DNA, on the basis of the detection of postsurgical minimal (or molecular) residual disease is warranted in future studies.

Surgical Issues for Operable Early-Stage Non-Small-Cell Lung Cancer

Surgical care for early stage non-small-cell lung cancer continuously evolves with new procedures, techniques and care pathways. The most obvious recent change was the transition to minimally invasive procedures, but numerous other aspects of care have also been refined to improve safety and tolerability. These care advancements are essential as we move into an era with increased early detection as a result of screening and greater indications for the use of adjuvant and neoadjuvant strategies.

Comprehensive Assessment of Serum hsa_circ_0070354 as a Novel Diagnostic and Predictive Biomarker in Non-small Cell Lung Cancer

Background: More and more studies have shown that circular RNAs (circRNAs) play an essential role in the occurrence and development of tumors. Hence, they can be used as biomarkers to assist in diagnosing tumors. This study focuses on exploring the role of circular RNA (hsa_circ_0070354) in the diagnosis and prognosis of non-small cell lung cancer (NSCLC). Materials and Methods: First of all, high-throughput sequencing was used to find the difference in the expression of circular RNA between NSCLC and adjacent tissues. The circRNAs with higher differences in expression were selected to verify their expressions in tissues, cells, and serum using qRT-PCR. Secondly, the hsa_circ_0070354 with a significant difference was chosen as the research goal, and the molecular properties were verified by agarose gel electrophoresis and Sanger sequencing, etc. Then, actinomycin D and repeated freeze-thaw were used to explore the stability and repeatability of hsa_circ_0070354. Finally, the expression of hsa_circ_0070354 in serum of 133 patients with NSCLC and 97 normal donors was detected, and its sensitivity, specificity, and prognosis as tumor markers were statistically analyzed. Results: Hsa_circ_0070354 was highly expressed in tissues, cells, and serum of NSCLC, and it has the characteristics of sensitivity, stability, and repeatability. The ROC curve indicates that hsa_circ_0070354 is superior to conventional tumor markers in detecting NSCLC, and the combined diagnosis is of more significance in the diagnosis. The high expression of hsa_circ_0070354 is closely related to the late-stage, poor differentiation of the tumor and the short survival time of the patients, which is an independent indicator of poor prognosis. Conclusion: Hsa_circ_0070354 is not only a novel sensitive index for the diagnosis of NSCLC but also a crucial marker for bad biological behavior.

Early Palliative Care in Patients With Non-Small-Cell Lung Cancer: A Randomized Controlled Trial in Southwest China

PURPOSE

Effective interventions to improve prognosis in non-small-cell lung cancer (NSCLC) are urgently needed. We assessed the effect of the early integration of interdisciplinary palliative care (based on WARM model) for patients with NSCLC on the quality of life (QoL), psychological state, cancer pain and nutritional status.

METHODS

In this randomized controlled trial, 120 newly diagnosed NSCLC patients were enrolled and randomly assigned (1:1) to the combined early palliative care (CEPC) group integrated with standard oncologic care or standard oncological care (SC) group. QoL and psychological state were assessed at baseline and at 24 weeks by Functional Assessment of Cancer Therapy-Lung (FACT-L) scale, the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire-9 (PHQ-9), respectively. Cancer nutritional and pain status were assessed with the use of the Patient-Generated Subjective Global Assessment (PG-SGA) and Numerical Rating Scale (NRS), respectively. The primary outcome was the change in the quality of life, psychological state and nutritional status at 24 weeks. Analysis was by intention to treat.

RESULTS

120 patients were enrolled: 60 in CEPC group (38 completed) and 60 in the SC group (32 completed). CEPC group had a better QoL than SC group (P < .05). In addition, fewer patients in the CEPC group than in the SC group had depressive (P = .005) symptoms. Furthermore, patients in CEPC group had a better nutritional status than SC group (P = .001).

CONCLUSION

Among patients with non-small-cell lung cancer, early palliative care led to significant improvements in quality of life, psychological state and nutritional status.

COVID-19 vaccination and cancer immunotherapy: should they stick together?

The combination of COVID-19 vaccination with immunotherapy by checkpoint inhibitors in cancer patients could intensify immunological stimulation with potential reciprocal benefits. Here, we examine more closely the possible adverse events that can arise in each treatment modality. Our conclusion is that caution should be exercised when combining both treatments.

Deep learning reveals cuproptosis features assist in predict prognosis and guide immunotherapy in lung adenocarcinoma

BACKGROUND

Cuproptosis is a recently found non-apoptotic cell death type that holds promise as an emerging therapeutic modality in lung adenocarcinoma (LUAD) patients who develop resistance to radiotherapy and chemotherapy. However, the Cuproptosis' role in the onset and progression of LUAD remains unclear.

METHODS

Cuproptosis-related genes (CRGs) were identified by a co-expression network approach based on LUAD cell line data from radiotherapy, and a robust risk model was developed using deep learning techniques based on prognostic CRGs and explored the value of deep learning models systematically for clinical applications, functional enrichment analysis, immune infiltration analysis, and genomic variation analysis.

RESULTS

A three-layer artificial neural network risk model was constructed based on 15 independent prognostic radiotherapy-related CRGs. The risk model was observed as a robust independent prognostic factor for LUAD in the training as well as three external validation cohorts. The patients present in the low-risk group were found to have immune "hot" tumors exhibiting anticancer activity, whereas the high-risk group patients had immune "cold" tumors with active metabolism and proliferation. The high-risk group patients were more sensitive to chemotherapy whereas the low-risk group patients were more sensitive to immunotherapy. Genomic variants did not vary considerably among both groups of patients.

CONCLUSION

Our findings advance the understanding of cuproptosis and offer fresh perspectives on the clinical management and precision therapy of LUAD.

Conversion Surgery for Advanced Thoracic SMARCA4-Deficient Undifferentiated Tumor With Atezolizumab in Combination With Bevacizumab, Paclitaxel, and Carboplatin Treatment: A Case Report

A SMARCA4-deficient undifferentiated tumor (SMARCA4-UT) is a rapidly progressing subtype of lung cancer with a poor prognosis and causes early postoperative recurrence among operable patients. In this study, we present a case of SMARCA4-UT with vertebral and chest wall invasion that successfully underwent conversion surgery after treatment with atezolizumab in combination with bevacizumab, paclitaxel, and carboplatin. The surgical specimen comprised SMARCA4-deficient and SMARCA2-positive adenocarcinoma, confirming intratumor heterogeneity. Gene panel analysis revealed no substantial differences in mutant gene profiles among tumors and no differences in SMARCA2 mutations. Furthermore, no recurrence occurred for 9 months after surgery. Thus, this case illustrates the possibility of multidisciplinary treatment including neoadjuvant therapy with immunotherapy and conversion surgery for SMARCA4-UT.

EGFR Status Assessment for Better Care of Early Stage Non-Small Cell Lung Carcinoma: What Is Changing in the Daily Practice of Pathologists?

The recent emergence of novel neoadjuvant and/or adjuvant therapies for early stage (I-IIIA) non-small cell lung carcinoma (NSCLC), mainly tyrosine kinase inhibitors (TKIs) targeting EGFR mutations and immunotherapy or chemo-immunotherapy, has suddenly required the evaluation of biomarkers predictive of the efficacy of different treatments in these patients. Currently, the choice of one or another of these treatments mainly depends on the results of immunohistochemistry for PD-L1 and of the status of EGFR and ALK. This new development has led to the setup of different analyses for clinical and molecular pathology laboratories, which have had to rapidly integrate a number of new challenges into daily practice and to establish new organization for decision making. This review outlines the impact of the management of biological samples in laboratories and discusses perspectives for pathologists within the framework of EGFR TKIs in early stage NSCLC.

Nodal immune flare mimics nodal disease progression following neoadjuvant immune checkpoint inhibitors in non-small cell lung cancer

Radiographic imaging is the standard approach for evaluating the disease involvement of lymph nodes in patients with operable NSCLC although the impact of neoadjuvant immune checkpoint inhibitors (ICIs) on lymph nodes has not yet been characterized. Herein, we present an ad hoc analysis of the NEOSTAR trial (NCT03158129) where we observed a phenomenon we refer to as “nodal immune flare” (NIF) in which patients treated with neoadjuvant ICIs demonstrate radiologically abnormal nodes post-therapy that upon pathological evaluation are devoid of cancer and demonstrate de novo non-caseating granulomas. Abnormal lymph nodes are analyzed by computed tomography and ¹⁸F-fluorodeoxyglucose positron emission tomography/computer tomography to evaluate the size and the maximum standard uptake value post- and pre-therapy in NEOSTAR and an independent neoadjuvant chemotherapy cohort. NIF occurs in 16% (7/44) of patients treated with ICIs but in 0% (0/28) of patients after neoadjuvant chemotherapy. NIF is associated with an inflamed nodal immune microenvironment and with fecal abundance of genera belonging to the family Coriobacteriaceae of phylum Actinobacteria, but not with tumor responses or treatment-related toxicity. Our findings suggest that this apparent radiological cancer progression in lymph nodes may occur due to an inflammatory response after neoadjuvant immunotherapy, and such cases should be evaluated by pathological examination to distinguish NIF from true nodal progression and to ensure appropriate clinical treatment planning.

Granulomatous/sarcoid-like lesions have been reported in patients treated with immune checkpoint inhibitors (ICIs). Here the authors report the occurrence of “nodal immune flare”, an apparent radiological cancer progression in the nodes characterized by the absence of cancer and the presence of non-caseating granulomas, in patients with non-small cell lung cancer following neoadjuvant ICI treatment.