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

Exosome-like nanoplatform modified with targeting ligand improves anti-cancer and anti-inflammation effects of imperialine

Currently, most anti-cancer therapies are still haunted by serious and deleterious adverse effects. Here, we report a highly biocompatible tumor cell-targeting delivery systems utilizing exosome-like vesicles (ELVs) that delivers a low-toxicity anti-cancer agent imperialine against non-small cell lung cancer (NSCLC). First, we introduced a novel micelle-aided method to efficiently load imperialine into intact ELVs. Then, integrin α3β1-binding octapeptide cNGQGEQc was modified onto ELV platform for tumor targeting as integrin α3β1 is overexpressed on NSCLC cells. This system not only significantly improved imperialine tumor accumulation and retention, but also had extremely low systemic toxicity both in vitro and in vivo. Our discoveries offer new ways to utilize ELV more efficiently for both drug loading and targeting. The solid pharmacokinetics improvement and extraordinary safety of this system also highlight possibilities of alternative long course cancer therapies using similar strategies.

Ultrasound-Guided Transthoracic Fine-Needle Aspiration: A Reliable Tool in Diagnosis and Molecular Profiling of Lung Masses

INTRODUCTION

Pulmonary adenocarcinoma is a major cause of mortality worldwide. The majority of patients present with advanced stage disease, and minimally invasive procedures are desirable for diagnosis and treatment plans. Herein, we report our experience with percutaneous/transthoracic needle aspiration (TT-NA) in the cytologic diagnosis of pulmonary adenocarcinoma.

MATERIAL AND METHODS

After institutional review board approval, the cytopathology electronic data system was searched for all consecutive TT-NA of the lung masses from January 2011 to November 2015. Patients' medical records were reviewed and cytologic materials were evaluated.

RESULTS

A total of 151 specimens were identified, with a mean age of 62.8 years; 62.9% of the patients had a prior history of malignancy. Carcinoma/adenocarcinoma was the most common (80%) diagnosis. The targeted lesions were predominantly located in the lung (56.3%, 81/151) and pleural based (27.8%, 42/151). The mean size of the lesions was 3.6 cm. Cytology specimens were adequate in 70.9% of the cases, while 72.8% (110/151) of the cases also had concurrent core biopsy. A malignant diagnosis was rendered in the majority of the cases (64.9%). In 71% of the cases, immunohistochemistry/histochemistry studies were successfully performed. Molecular/genetic studies were requested in 80% of the cases and had adequate material. Complications of the procedure were seen in 9.9% of the patients including pneumothorax (7.9%) and hemoptysis (1.9%).

CONCLUSION

TT-NA is a relatively safe and reliable technique in the assessment of pulmonary lesions.

Differential Relapse Patterns for Non-small Cell Lung Cancer Subtypes Adenocarcinoma and Squamous Cell Carcinoma: Implications for Radiation Oncology

AIMS

Curative-intent (radical) radiotherapy aims to control local disease and cure non-small cell lung cancer (NSCLC). The predominant subtypes of NSCLC are adenocarcinoma and squamous cell carcinoma (SCC). The radiotherapy paradigm offered to patients does not differ according to these two subtypes. Relapse patterns and disease control rates for adenocarcinoma and SCC treated with radical radiotherapy were determined.

MATERIALS AND METHODS

A radical radiotherapy database covering the period from 2004 to June 2016 was examined to determine the first sites of relapse and the actuarial local and distant control rates.

RESULTS

In total, 537 patients with known pathological subtype were treated over the period. In 39 (7%), the site of first relapse was uncertain. Of the remainder, 203 (41%) had adenocarcinoma and 295 (59%) had SCC. At a median follow-up of 16.4 months, 58% had relapsed. There was a difference in relapse patterns (chi-squared test P < 0.0005), with a higher rate of first relapse locally in SCC (42% of all patients versus 24%) and a higher rate of first relapse in the brain for adenocarcinoma (14% versus 3%). The actuarial local control rate was worse for SCC (hazard ratio 0.6, 95% confidence interval 0.5-0.9, P = 0.002). The brain metastasis-free survival was worse for adenocarcinoma (hazard ratio 4.1, 95% confidence interval 2.2-7.5, P < 0.0001).

CONCLUSION

There is a difference in relapse patterns between NSCLC histological subtypes, indicating that these are distinct entities. This may have implications for follow-up policy and strategies to improve disease control.

Immunotherapy in inoperable stage III non-small cell lung cancer: a review

The leading cause of cancer-related deaths in the United States continues to be lung cancer. Approximately 25–30% of patients are diagnosed with locally advanced non-small cell lung cancer (NSCLC). Concurrent chemoradiation with a platinum-based doublet is the current standard of care for patients with inoperable stage III NSCLC. Unfortunately, only 15–20% of patients treated with definitive chemoradiation are alive at 5 years. Thus, there has been a major unmet need in this area. In this article, we summarize the current status and ongoing clinical trials incorporating immunotherapy into the management of inoperable stage III NSCLC, and we also present our perspective on the future directions.

Defining priority medical devices for cancer management: a WHO initiative

Medical devices are indispensable for cancer management across the entire cancer care continuum, yet many existing medical interventions are not equally accessible to the global population, contributing to disparate mortality rates between countries with different income levels. Improved access to priority medical technologies is required to implement universal health coverage and deliver high-quality cancer care. However, the selection of appropriate medical devices at all income and hospital levels has been difficult because of the extremely large number of devices needed for the full spectrum of cancer care; the wide variety of options within the medical device sector, ranging from small inexpensive disposable devices to sophisticated diagnostic imaging and treatment units; and insufficient in-country expertise, in many countries, to prioritise cancer interventions and to determine associated technologies. In this Policy Review, we describe the methods, process, and outcome of a WHO initiative to define a list of priority medical devices for cancer management. The methods, approved by the WHO Guidelines Review Committee, can be used as a model approach for future endeavours to define and select medical devices for disease management. The resulting list provides ready-to-use guidance for the selection of devices to establish, maintain, and operate necessary clinical units within the continuum of care for six cancer types, with the goal of promoting efficient resource allocation and increasing access to priority medical devices, particularly in low-income and middle-income countries.

Incorporation of the SUVmax Measured From FDG PET and Neutrophil-to-lymphocyte Ratio Improves Prediction of Clinical Outcomes in Patients With Locally Advanced Non-small-cell Lung Cancer

INTRODUCTION

The aim of the present study was to investigate the value of incorporation 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) maximum standardized uptake value (SUVmax) and neutrophil-to-lymphocyte ratio (NLR) for improving prediction of clinical outcomes of patients with locally advanced non-small-cell lung cancer (LA NSCLC).

MATERIALS AND METHODS

We retrospectively enrolled 138 patients with unresectable LA NSCLC at our institution from July 2010 to August 2017. Spearman correlation analyses were used to estimate the correlations between SUVmax and NLR level. The univariate and multivariate Cox survival analyses were used to evaluate the prognostic indicators, including the incorporation of SUVmax and NLR. We defined the SUVmax and NLR grade (SNG = 0, 1, or 2) score as the number of risk factors among (1) SUVmax > 11.95 and (2) NLR > 3.82. The SNG score prognostic value was evaluated for overall survival (OS) and progression-free survival (PFS).

RESULTS

Univariate analysis showed that tumor stage, SUVmax, SUVmean, NLR, and SNG score were significantly associated with OS and PFS in patients with LA NSCLC. Kaplan-Meier analysis and log-rank test demonstrated significant differences in both OS and PFS among patients in SNG score (OS, P < .001; PFS, P < .001). Spearman correlation analyses showed that SUVmax had a correlation with the NLR (r = 0.237; P = .005). In subgroup analyses for patients with tumor pathologic stage IIIA/IIIB, we found that the SNG score was significantly associated with OS and PFS in each subgroup (P < .001, P < .001 for OS and P = .027, P < .001 for PFS, respectively). Multivariate analysis showed that the SNG score was a significantly independent prognostic factor for OS (hazard ratio, 1.612; 95% confidence interval, 1.157-2.246; P = .005) and PFS (hazard ratio, 2.241; 95% confidence interval, 1.486-3.379; P < .001).

CONCLUSION

Incorporation of the SUVmax and NLR improves prediction of clinical outcomes in patients with LA NSCLC.

Immune checkpoint-inhibitors and chemoradiation in stage III unresectable non-small cell lung cancer

Lung cancer resulted in an estimated 1.8 million deaths worldwide in 2018 and approximately 20% of patients with non-small cell lung cancer (NSCLC) are diagnosed with stage III unresectable disease. Phase III data from the PACIFIC trial show significantly improved progression-free survival for the checkpoint-inhibitor durvalumab given as consolidation following definitive chemoradiotherapy (cCRT). Overall survival results from this study have now been reported, along with outcomes from other phase II trials. A thorough review of the efficacy and safety of checkpoint-inhibitors used in conjunction with cCRT for stage III unresectable NSCLC is needed. Published and presented literature on phase II and III data was identified using the key search terms "non-small cell lung cancer" AND "checkpoint-inhibitors" (OR respective aliases). One randomized phase III clinical trial and three phase II trials reporting outcomes of checkpoint-inhibitors in conjunction with cCRT for stage III unresectable NSCLC were identified. PACIFIC reported significantly improved overall survival for consolidation durvalumab following cCRT compared with placebo. Although discontinuation due to adverse events (AEs) was higher with durvalumab, rates of grade 3/4 pneumonitis or radiation pneumonitis were low and comparable between arms. Results from phase II trials also show promising activity for other checkpoint-inhibitors and alternative sequencing strategies, although these need to be confirmed in a randomized context. Preliminary data suggest differences in the safety profiles between PD-1 and PD-L1 inhibitors. Currently, the role of PD-L1 expression levels for patient selection in this setting remains unclear, and durvalumab should be administered on an individual basis in patients with known driver mutations. Consolidation durvalumab following cCRT significantly improves overall survival with an acceptable safety profile in patients with stage III unresectable NSCLC, now representing a new standard of care.

Anatomical Adaptation-Early Clinical Evidence of Benefit and Future Needs in Lung Cancer

Definitive treatment of locally advanced non-small-cell lung cancer with radiation is challenging. During the course of treatment, anatomical changes such as tumor regression, tumor displacement/deformation, pleural effusion, and/or atelectasis can result in a deviation of the administered radiation dose from the intended prescribed treatment and thereby worsen local control and toxicity. Adaptive radiotherapy can help correct for these changes and can be generally categorized into 3 philosophical paradigms: (1) maintenance of prescribed dose to the initially defined target volume; (2) dose reduction to healthy organs while maintaining initial prescribed dose to a regressing tumor volume; or (3) dose escalation to a regressing tumor volume with isotoxicity to healthy organs. Numerous single institution studies have investigated these methods, and results from large prospective clinical trials will hopefully provide consensus on the method, utility, and efficacy of implementing adaptive radiation therapy (ART) in a clinical setting. Additional development into standardization and automation of the ART workflow, specifically in identifying when ART is warranted and in reducing the manual clinical effort needed to produce an adaptive plan, will be paramount to making ART feasible for the broader radiation therapy community.

Cisplatin resistance involves a metabolic reprogramming through ROS and PGC-1α in NSCLC which can be overcome by OXPHOS inhibition

BACKGROUND

Platinum-based chemotherapy remains the standard of care for most lung cancer cases. However chemoresistance is often developed during the treatment, limiting clinical utility of this drug. Recently, the ability of tumor cells to adapt their metabolism has been associated to resistance to therapies. In this study, we first described the metabolic reprogramming of Non-Small Cell Lung Cancer (NSCLC) in response to cisplatin treatment.

METHODS

Cisplatin-resistant versions of the A549, H1299, and H460 cell lines were generated by continuous drug exposure. The long-term metabolic changes, as well as, the early response to cisplatin treatment were analyzed in both, parental and cisplatin-resistant cell lines. In addition, four Patient-derived xenograft models treated with cisplatin along with paired pre- and post-treatment biopsies from patients were studied. Furthermore, metabolic targeting of these changes in cell lines was performed downregulating PGC-1α expression through siRNA or using OXPHOS inhibitors (metformin and rotenone).

RESULTS

Two out of three cisplatin-resistant cell lines showed a stable increase in mitochondrial function, PGC1-α and mitochondrial mass with reduced glycolisis, that did not affect the cell cycle. This phenomenon was confirmed in vivo. Post-treatment NSCLC tumors showed an increase in mitochondrial mass, PGC-1α, and a decrease in the GAPDH/MT-CO1 ratio. In addition, we demonstrated how a ROS-mediated metabolism reprogramming, involving PGC-1α and increased mitochondrial mass, is induced during short-time cisplatin exposure. Moreover, we tested how cells with increased PGC-1a induced by ZLN005 treatment, showed reduced cisplatin-driven apoptosis. Remarkably, the long-term metabolic changes, as well as the metabolic reprogramming during short-time cisplatin exposure can be exploited as an Achilles' heel of NSCLC cells, as demonstrated by the increased sensitivity to PGC-1α interference or OXPHOS inhibition using metformin or rotenone.

CONCLUSION

These results describe a new cisplatin resistance mechanism in NSCLC based on a metabolic reprogramming that is therapeutically exploitable through PGC-1α downregulation or OXPHOS inhibitors.

Treatment patterns and outcomes in patients with non-small cell lung cancer receiving biosimilar filgrastim for prophylaxis of chemotherapy-induced/febrile neutropaenia: Results from the MONITOR-GCSF study

Objective

Real‐world evidence data on the use of granulocyte colony‐stimulating factor (G‐CSF) in patients with non‐small cell lung cancer (NSCLC) are limited. MONITOR‐GCSF is a pan‐European, multicentre, prospective, non‐interventional study designed to describe patient characteristics, treatment patterns and clinical outcomes in patients receiving biosimilar filgrastim in the prophylaxis of chemotherapy‐induced neutropaenia (CIN) and febrile neutropaenia (FN).

Methods

In this subanalysis, patient characteristics, treatment patterns, and outcomes are described for 345 patients with stage 3 or 4 NSCLC, receiving up to six chemotherapy cycles. Patients were treated with biosimilar filgrastim as per their treating physician's best judgement.

Results

CIN (any grade) occurred in 13.6% of patients in Cycle 1 and in 36.5% of patients in all cycles. FN occurred in 1.4% of patients in Cycle 1 and in 5.2% of patients in all cycles. Grade 3–4 FN occurred in 1.2% of patients in Cycle 1 and in 3.8% of patients in all cycles.

Conclusion

Results show that in real‐life practice in patients with NSCLC, biosimilar filgrastim has similar effectiveness and safety to the known effectiveness and safety profile of reference filgrastim, supporting the use of biosimilar filgrastim for the real‐world treatment of neutropaenia in patients with NSCLC.

Efficacy of PD-1/PD-L1 inhibitors in patients with advanced non-small cell lung cancer: A meta-analysis of randomized clinical trials

Background

This meta‐analysis systematically evaluated the efficacy of PD‐1 and PD‐L1 inhibitors for the treatment of advanced non‐small cell lung cancer (NSCLC) and investigated the efficacy of first‐line therapy and PD‐1 versus PD‐L1 inhibitors.

Methods

PubMed, The Cochrane Library, and Embase were searched up to November 2018 for randomized controlled trials (RCTs) for eligible studies. The outcome of interest was overall survival (OS). The methodology was based on the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses and Cochrane Collaboration guidelines. Data were pooled by using the random effects model and expressed as hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed and quantified (I²).

Results

Seven RCTs were included in this study. PD‐1/PD‐L1 inhibitors achieved superior OS compared to chemotherapy (HR 0.72, 95% CI 0.63–0.82; P < 0.0001). OS was superior in previously treated patients compared to untreated patients (HR 0.69, 95% CI 0.63–0.76; HR 0.82, 95% CI 0.47–1.44, respectively). No significant differences in OS were observed between PD‐1 and PD‐L1 inhibitors (HR 0.71, 95% CI 0.59–0.86; HR 0.73, 95% CI 0.63–0.84, respectively).

Conclusions

PD‐1/PD‐L1 inhibitors significantly prolonged the OS of previously treated patients. No significant differences in OS were observed between PD‐1 and PD‐L1 inhibitors.

Economic burden of lung cancer: A retrospective cohort study in South Korea, 2002-2015

We evaluated the survival rates and medical expenditure in patients with lung cancer using a nationwide claims database in South Korea. A retrospective observational cohort study design was used, and 2,919 lung cancer patients and their matched controls were included. Medical expenditures were analyzed with the Kaplan-Meier sample average method, and patients were categorized into 4 groups by operation and primary treatment method (i.e. Patients with operation: OP = surgery, OP+CTx/RTx = surgery with anti-cancer drugs or radiotherapy; Patients without operation: CTx/RTx = anti-cancer drugs or radiotherapy, Supportive treatment). The 5-year medical expenditure per case was highest in the OP+CTx/RTx group ($36,013), followed by the CTx/RTx ($23,134), OP ($22,686), and supportive treatment group ($3,700). Lung cancer-related anti-cancer drug therapy was the major cost driver, with an average 53% share across all patients. Generalized linear regression revealed that monthly medical expenditure in lung cancer patients, after adjustment for follow-up month, was approximately 3.1–4.3 times higher than that in the control group (cost ratio for OP = 3.116, OP+CTx/RTx = 3.566, CTx/RTx = 4.340, supportive treatment = 4.157). The monthly medical expenditure at end of life was estimated at $2,139 for all decedents, and approximately a quarter of patients had received chemotherapy in the last 3 months. In conclusion, this study presented the quantified treatment costs of lung cancer on various aspects compared with matched controls according to the treatment of choice. In this study, patients with operation incurred lower lifetime treatment costs than patients with CTx/RTx or supportive treatment, indicating that the economic burden of lung cancer was affected by treatment method. Further studies including both cancer stage and treatment modality are needed to confirm these results and to provide more information on the economic burden according to disease severity.

Exosome Analysis in Tumor-Draining Pulmonary Vein Identifies NSCLC Patients with Higher Risk of Relapse after Curative Surgery

Since tumor-draining pulmonary vein blood (PV) is enriched in tumor-secreted products, we hypothesized that it would also be enriched in tumor-derived exosomes, which would be important in the metastasis process. We characterized exosomes from PV of 61 resected non-small cell lung cancer (NSCLC) patients to evaluate its potential as relapse biomarkers. Exosomes were characterized using transmission electron microscopy, western blot and nanoparticle tracking analysis and we examined time to relapse (TTR) and overall survival (OS). Differences between PV and peripheral vein were found. PV was enriched in smaller exosomes than the paired peripheral vein (p = 0.01). Moreover, PV exosome size mode was able to identify relapsed patients (Area under the curve [AUC] = 0.781; 95%CI: 0.6641⁻0.8978), in whom exosome size was smaller (<112 nm; p < 0.001). The combination of PV exosome size and N (lymph node involvement) showed an AUC of 0.89 (95%CI: 0.80⁻0.97). Moreover, smaller PV exosome size was associated with shorter TTR (28.3 months vs. not reached, p < 0.001) and OS (43.9 months vs. not reached, p = 0.009). Multivariate analyses identified PV exosome size and stage as independent prognostic markers for TTR and OS. PV exosome size is a promising relapse biomarker after surgery that can add valuable information to clinical variables.

The role of tumour volume as a prognostic factor in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy

Background

It has been shown that patients with a greater tumour volume have poorer outcomes following definitive radiotherapy but its exact role remains unclear. The purpose of this study is to investigate the role of tumour volume as a prognostic indicator in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy in a single institution over 10 years.

Methods

In total, 167 patients with NSCLC treated by definitive (chemo)radiotherapy were retrospectively reviewed between 2006 and 2015. Patient demographics, disease characteristics and tumour volume parameters were collected. Univariate analyses were carried out using Kaplan–Meier survival curves to assess the association of potential prognostic factors with the primary endpoints of overall survival (OS) rates and locoregional recurrence rates. Multivariate analyses were carried out using a Cox regression method.

Results

The median total tumour volume (TTV), defined as the gross tumour volume plus the volume of involved nodes, was 103 cm3. Patients were divided into small and large tumour groups based on this median. OS rates at 1, 3 and 5 years for smaller volumes were 69%, 24% and 13% and for larger volumes 48%, 14% and 8%, respectively. On univariate survival analyses larger TTV was significantly associated with poorer OS (p= 0·019). The concurrent use of chemotherapy significantly improved survival (p= 0·026). Nodal involvement (p= 0·03) and Eastern Cooperative Oncology Group performance status (p&lt; 0·001) were also significant independent prognostic factors of OS. On multivariate analysis TTV was strongly predictive of survival (p= 0·03; hazard ratio 1·702, 95% confidence interval 1·198–2·415). There was no association between nodal volume, tumour stages, overall stage, age, histology and radiation dose with any of the primary endpoints.

Conclusion

TTV is a significant prognostic factor in patients with advanced NSCLC treated by radical radiotherapy. In this cohort of patients TTV is more reliable at predicting survival than T stage and overall stage.

Systematic and combined endosonographic staging of lung cancer (SCORE study)

Guidelines recommend endosonography for mediastinal nodal staging in patients with resectable nonsmall cell lung cancer (NSCLC). We hypothesise that a systematic endobronchial ultrasound (EBUS) evaluation combined with an oesophageal investigation using the same EBUS bronchoscope (EUS-B) improves mediastinal nodal staging versus the current practice of targeted positron emission tomography (PET)-computed tomography (CT)-guided EBUS staging alone.A prospective, multicentre, international study (NCT02014324) was conducted in consecutive patients with (suspected) resectable NSCLC. After PET-CT, patients underwent systematic EBUS and EUS-B. Node(s) suspicious on CT, PET, EBUS and/or EUS-B imaging and station 4R, 4L and 7 (short axis ≥8 mm) were sampled. For patients without N2/N3 disease determined on endosonography, surgical-pathological staging was the reference standard.229 patients were included in this study. The prevalence of N2/N3 disease was 103 out of 229 patients (45%). A PET-CT-guided targeted approach by EBUS identified 75 patients with N2/N3 disease (sensitivity 73%, 95% CI 63-81%; negative predictive value (NPV) 81%, 95% CI 74-87%). Four additional patients with N2/N3 disease were found by systematic EBUS (sensitivity 77%, 95% CI 67-84%; NPV 84%, 95% CI 76-89%) and five more by EUS-B (84 patients total; sensitivity 82%, 95% CI 72-88%; NPV 87%, 95% CI 80-91%). Additional clinical relevant staging information was obtained in 23 out of 229 patients (10%).Systematic EBUS followed by EUS-B increased sensitivity for the detection of N2/N3 disease by 9% compared to PET-CT-targeted EBUS alone.

PD-L1 Expression in Circulating Tumor Cells Increases during Radio(chemo)therapy and Indicates Poor Prognosis in Non-small Cell Lung Cancer

Preclinical studies demonstrated that radiation up-regulates PD-L1 expression in tumor cells, providing a rationale for combining PD-1/PD-L1 inhibitors with radiation. However this has not been validated in patients with non-small cell lung cancer due to the difficulty to obtain serial biopsies. Measuring PD-L1 expression in circulating tumor cells (CTCs), may allow real-time monitoring of immune activation in tumor. In this study, whole blood from non-metastatic NSCLC patients was collected before, during, and after radiation or chemoradiation using a microfluidic chip. PD-L1 expression in CTCs was assessed by immunofluorescence and qPCR and monitored through the course of treatment. Overall, PD-L1(+) CTCs were detected in 25 out of 38 samples (69.4%) with an average of 4.5 cells/ml. After initiation of radiation therapy, the proportion of PD-L1(+) CTCs increased significantly (median 0.7% vs. 24.7%, P < 0.01), indicating up-regulation of PD-L1 in tumor cells in response to radiation. In addition, patients positive for PD-L1 (≥5% of CTCs positive for PD-L1) at baseline had shorter PFS. Gene expression analysis revealed that higher levels of PD-L1 were associated with poor prognosis. Therefore, CTCs can be used to monitor dynamic changes of PD-L1 during radiation therapy which is potentially prognostic of response to treatment.

Pneumonectomy after induction chemoradiotherapy for locally advanced non-small cell lung cancer: should curative intent pulmonary resection be avoided?

PURPOSE

We conducted a retrospective analysis to assess the practicality of pneumonectomy, especially after concurrent induction chemoradiotherapy (i-CRT), for locally advanced non-small cell lung cancer (LA-NSCLC). The operative risks vs. the survival benefit of this procedure for such patients is a subject of controversy.

METHODS

The subjects of this retrospective study were 71 consecutive LA-NSCLC patients with cStage IIIA-C NSCLC, who underwent i-CRT followed by curative intent pulmonary resection between February, 2001 and March, 2013.

RESULTS

Thirty-two patients underwent pneumonectomy (group P) and 39 patients underwent lobectomy (group L). In group P, 17 (54.8%) patients underwent right pneumonectomy. There was no 30-day postoperative mortality in either group and no significant difference in 90-day postoperative mortality between the groups (3.1% vs. 2.6% in groups P and L, respectively). The 5-year overall survival (OS) rate was 58.7% (95% CI: 41.5-75.9%) in group P and 57.3% (95% CI 41.2-73.4%) in group L, without a significant difference between the groups.

CONCLUSION

Our findings suggest that i-CRT followed by pneumonectomy is feasible, with a similar survival benefit to lobectomy. Thus, pneumonectomy after i-CRT should not be avoided as it is a potentially curative intent strategy for carefully selected patients.

Pulmonary Rehabilitation with a Stabilometric Platform after Thoracic Surgery: A Preliminary Report

The aim of this study was to evaluate the influence of exercises on a stabilometric platform on the physical fitness and mobility of patients with lung cancer after thoracic surgery. The Experimental Group included 22, and the Control Group consisted of 21 patients. All included patients were enrolled after thoracic surgery due to lung cancer. The Experimental and Control Groups were enrolled in a 3-week in-hospital pulmonary rehabilitation program. The Experimental Group additionally performed daily 20-min training sessions on a stabilometric platform. Agility and flexibility were assessed with the Fullerton test before and after rehabilitation in both groups, and quality of life was assessed with the SF-36 questionnaire. Exercise performance stated as a distance in a 6 min walking test (6MWT) significantly improved in both groups with a medium effect size. The results of the Fullerton test indicated improvements in flexibility in both groups after the completion of the program without a significant difference between the groups and with a small effect size. In the Experimental Group, the best results were observed in the Arm curl (p = 0.0001), Chair stand (p = 0.04), Up and go (p = 0.001) and Chair sit and reach (p = 0.0001) tasks. No deterioration in the quality of life was observed in the Experimental or the Control Group after the completion of the program. Between-group analyses revealed significant differences in the Role-Physical (RP) (p = 0.020) and Mental-Health (MH) (p = 0.025) domains of the SF-36. The rehabilitation program with a stabilometric platform improved agility and flexibility of patients after thoracic surgery without an effect size or significant differences between the Experimental and Control Groups.

Incidence and evolution of imaging changes on cone-beam CT during and after radical radiotherapy for non-small cell lung cancer

BACKGROUND AND PURPOSE

Cone beam CT (CBCT) is used to improve accuracy of radical radiotherapy by adjusting treatment to the observed imaging changes. To ensure appropriate adjustment, image interpretation should precede any changes to treatment delivery. This study provides the methodology for image interpretation and the frequency and evolution of the changes in patients undergoing radical radiotherapy for localised and locally advanced non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

From December 2012 to December 2014, 250 patients with localised and locally advanced NSCLC had 2462 chest CBCT scans during the course of fractionated radical radiotherapy (RT) (3-5 daily CBCTs in the first week followed by at least weekly imaging, mean 9.5 per patient, range 1-21). All CBCT images were reviewed describing changes and their evolution using diagnostic imaging definitions and validated by an independent chest radiologist.

RESULTS

During radical RT for NSCLC 328 imaging changes were identified on CBCT in 180 (72%) patients; 104 (32%) had reduction and 41 (13%) increase in tumour size; 48 (15%) had changes in consolidations contiguous to the primary lesion, 26 (8%) non-contiguous consolidations, 43 (13%) changes in tumour cavitation, 36 (11%) pleural effusion and 30 (9%) changes in atelectasis. In 105 patients imaging changes were noted in continuity with the treated tumour of which only 41 (39%) represented tumour enlargement; others included new or enlarging adjacent consolidation (34%), and new or enlarging atelectasis (19%). The changes evolved during treatment.

CONCLUSION

Imaging changes on CBCT include real and apparent changes in tumour size and parenchymal changes which evolve during treatment. Correct image interpretation, particularly when occurring adjacent to the tumour, is essential prior to adjustment to treatment delivery.

HELPER study: A phase II trial of continuous infusion of endostar combined with concurrent etoposide plus cisplatin and radiotherapy for treatment of unresectable stage III non-small-cell lung cancer

PURPOSE

The prognosis of unresectable stage III non-small cell lung cancer (NSCLC) was poor even after concurrent chemoradiotherapy. There remains a great need to develop novel therapeutic agents in combination with CCRT to improve outcomes. This prospective study sought to evaluate the efficacy and toxicities of the addition of endostar, an anti-angiogenesis agent, to concurrent etoposide, cisplatin (EP) and radiotherapy for treatment of patients with NSCLC.

PATIENTS AND METHODS

Patients with untreated pathologically confirmed inoperable stage III NSCLC were eligible. Radiation at doses of 60-66 Gy, four cycles of endostar (7.5 mg/m²/24 h × 120 h, 14 days/cycle), and two cycles of EP (etoposide 50 mg/m² on days 1-5 and cisplatin 50 mg/m² on days 1 and 8, 28 days/cycle) were delivered. The primary endpoint was progression-free survival (PFS). The secondary endpoints were response rate and overall survival (OS), locoregional relapse-free survival (LRFS) distant metastasis-free survival (DMFS) and adverse events (AE).

RESULTS

From November 2012 to June 2015, 73 patients were enrolled, and 67 patients were evaluable. The median age was 59 years. Sixty-six percent of the patients had squamous cell carcinoma. Grade ≥3 AEs occurred in 58.2% of the patients. The most common Grade ≥3 AE was leucopenia (44.8%). The response rate was 76.1%. The median times of PFS and OS were 13.3 months and 34.7 months, respectively. The 2-year PFS, OS, LRFS and DMFS rates were 34.8%, 59.9%, 54.7% and 68.5%, respectively.

CONCLUSIONS

For patients with unresectable stage III NSCLC, continuous intravenous endostar in combination with concurrent EP and radiotherapy did not prolong median PFS, although it got preferable OS, promising 2-year PFS with tolerable toxicities.

Upfront surgery in patients with clinical skip N2 lung cancer based on results of modern radiological examinations

Background

Direct lymphatic drainage from a primary tumor to the right paratracheal or aortic window lymph nodes is often noted in pN2 disease. This multi-institutional retrospective study investigated the outcomes of upfront surgery in patients with clinical skip N2 disease (N2 disease without N1 disease) and a tumor in the right upper lobe or left upper segment based on results of modern radiological examinations, including positron emission tomography (PET).

Methods

We identified 143 patients with cN2 disease who underwent upfront surgery in 12 institutions under the Thoracic Surgery Study Group of Osaka University between January 2006 and December 2013. Among 143 patients, 94 who underwent PET were analyzed. We classified these patients into Group A (n=39; clinical skip N2 disease and a tumor in the right upper lobe or left upper segment) and Group B (n=55; other).

Results

The median follow-up was 56.5 months. Among the 94 patients, 50 (53.2%) had skip N2 disease and 65 (69.1%) had a tumor in the right upper lobe or left upper segment. The 5-year overall survival (OS) rates of the 94 patients with cN2 disease was 47.9%. The 5-year OS rates for the cN2pN0/1 (n=22) and cN2pN2 (n=70) groups were 74.9% and 41.2%, respectively (P=0.034). The univariate analysis of OS revealed no significant differences in age, sex, histology, carcinoembryonic antigen (CEA) level, tumor size, PET findings, and number of metastatic lymph nodes when these parameters were dichotomized. A significantly better 5-year OS rate was observed in Group A than in Group B (64.0% vs. 37.0%; P=0.039). The multivariate analysis of OS revealed that Group A was a significantly prognostic factor (P=0.030).

Conclusions

Patients with cN2 disease in Group A had a more favorable prognosis. Upfront surgery may be a treatment option for such selected patients with non-small lung cancer in the specific group.

Short- and long-term outcomes in elderly patients with locally advanced non-small-cell lung cancer treated using video-assisted thoracic surgery lobectomy

BACKGROUND

In recent years, video-assisted thoracic surgery (VATS) lobectomy has been used to treat locally advanced non-small-cell lung cancer (LA-NSCLC). However, VATS has not been reported in elderly patients (≥70 years) with LA-NSCLC. The purpose of this study was to compare short- and long-term outcomes of patients with LA-NSCLC aged ≥70 years and 55-69 years treated with VATS.

PATIENTS AND METHODS

From January 2012 to January 2018, a total of 83 patients with LA-NSCLC who were ≥55 years of age underwent VATS. Patients were divided into ≥70 years group (37 cases) and 55-69 years group (46 cases), based on their age at the time of VATS. Short- and long-term outcomes of these two groups of patients were compared.

RESULTS

American Society of Anesthesiologists scores of ≥70 years patients were higher than those of 55-69 years patients. No significant differences were observed when comparing the general preoperative data. For short-term outcomes, there was no significant difference between the two groups of patients in length of surgery, intraoperative blood loss, conversion to thoracotomy, postoperative 30-day complication rate and severity, postoperative 30-day mortality, pathological results, compliance with adjuvant chemotherapy, or other factors. Long-term follow-up results showed that recurrence, overall survival, and disease-free survival were similar in both groups. Furthermore, multivariate analysis showed that age was not an independent predictor of overall and disease-free survival.

CONCLUSIONS

VATS in elderly patients (≥70 years) with LA-NSCLC can result in short- and long-term outcomes similar to those of 55-69 years patients with LA-NSCLC.

Anti-PD-1/PD-L1 Antibody Therapy for Pretreated Advanced or Metastatic Nonsmall Cell Lung Carcinomas and the Correlation between PD-L1 Expression and Treatment Effectiveness: An Update Meta-Analysis of Randomized Clinical Trials

PURPOSE

This meta-analysis systematically evaluated the efficacy and safety of anti-PD-1/PD-L1 antibodies for pretreated advanced or metastatic nonsmall cell lung cancer (NSCLC) and investigated the correlation between PD-L1 expression levels and effectiveness of anti-PD-1/PD-L1 antibody.

METHODS

The methodology was based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) and the Cochrane Collaboration guidelines.

RESULTS

Our research included five randomized-controlled trials involving 3,025 patients. We compared anti-PD-1/PD-L1 antibodies (nivolumab, pembrolizumab, and atezolizumab) with docetaxel in pretreated patients with advanced or metastatic NSCLC. The pooled hazard ratio (HR) for overall survival (OS) and progression-free survival (PFS) was 0.69 (95%CI: 0.63-0.75, P<0.0001, and Ph=0.67) and 0.87 (95%CI: 0.81-0.94, P=0.0004, and Ph=0.11), respectively. Meanwhile, the pooled risk ratio (RR) for objective response rate (ORR) was 1.53 (95% CI: 1.16-2.01, P=0.003, and Ph=0.03) in all patients. Subgroup analyses showed that anti-PD-1/PD-L1 treatment significantly improved OS in patients with PD-L1 expression at any level, even in patients with PD-L1<1%. The RR for occurrence of grades 3 to 5 treatment-related adverse effects was 0.23 (95% CI: 0.15-0.36, and P<0.001).

CONCLUSION

OS, PFS, and ORR were significantly more improved for patients treated with anti-PD-1/PD-L1 antibodies than for those treated with docetaxel. Anti-PD-1/PD-L1 therapy resulted in longer OS than docetaxel, regardless of PD-L1 expression; however, higher PD-L1 levels were likely to correlate with better outcome. Anti-PD-1/PD-L1 antibodies also had a better safety profile than docetaxel.

Lynch Syndrome: Genomics Update and Imaging Review

Lynch syndrome is the most common hereditary cancer syndrome, the most common cause of heritable colorectal cancer, and the only known heritable cause of endometrial cancer. Other cancers associated with Lynch syndrome include cancers of the ovary, stomach, urothelial tract, and small bowel, and less frequently, cancers of the brain, biliary tract, pancreas, and prostate. The oncogenic tendency of Lynch syndrome stems from a set of genomic alterations of mismatch repair proteins. Defunct mismatch repair proteins cause unusually high instability of regions of the genome called microsatellites. Over time, the accumulation of mutations in microsatellites and elsewhere in the genome can affect the production of important cellular proteins, spurring tumorigenesis. Universal testing of colorectal tumors for microsatellite instability (MSI) is now recommended to (a) prevent cases of Lynch syndrome being missed owing to the use of clinical criteria alone, (b) reduce morbidity and mortality among the relatives of affected individuals, and (c) guide management decisions. Organ-specific cancer risks and associated screening paradigms vary according to the sex of the affected individual and the type of germline DNA alteration causing the MSI. Furthermore, Lynch syndrome-associated cancers have different pathologic, radiologic, and clinical features compared with their sporadic counterparts. Most notably, Lynch syndrome-associated tumors tend to be more indolent than non-Lynch syndrome-associated neoplasms and thus may respond differently to traditional chemotherapy regimens. The high MSI in cases of colorectal cancer reflects a difference in the biologic features of the tumor, possibly with a unique susceptibility to immunotherapy. ^©RSNA, 2018.

Clinical implications for pro-GRP in small cell lung cancer. A single center experience

BACKGROUND

Recently, pro-gastrin-releasing peptide (pro-GRP) became available as an alternative sensitive, specific and reliable tumor marker for patients with small cell lung cancer (SCLC), both in limited (LD) and diffuse disease (DD).

METHODS

We retrospectively analyzed pro-GRP, neuron-specific enolase (NSE) and CEA in patients with SCLC and non-small cell lung cancer (NSCLC). Serum pro-GRP level was measured with electrochemiluminescence at our laboratory (cutoff 77.8 pg/mL). Continuous variables were analyzed with the Mann-Whitney test, contingency data with Fisher's exact test. Receiver operator characteristic (ROC) curve analysis was performed to identify threshold values to set the highest sensitivity (Sn) and specificity (Sp) values.

RESULTS

A total of 65 patients were studied (49 men, median age 67 years, range 27-79). Thirty-seven patients had SCLC (29 DD, 8 LD) and 28 advanced NSCLC. Median pro-GRP level was 919 pg/mL (range 22-147,350) in SCLC and 32 pg/mL (range 10-119.2) in NSCLC (p<0.0001). NSE was 4.38-fold higher in SCLC patients (p = 0.0005); CEA did not reveal significant differences between groups. Pro-GRP Sn and Sp were 86.4% and 96.4%, respectively. With ROC curve analysis, a cutoff value of 329.3 pg/mL showed a Sn of 75.8% and Sp of 87.5% in discriminating DD from LD. Pro-GRP was not influenced by either liver metastases or renal impairment.

CONCLUSIONS

Pro-GRP is sensitive for SCLC diagnosis. Since high marker levels are related to high disease burden, pro-GRP may have a negative prognostic significance. Follow-up studies are required to define its role in clinical practice in monitoring responses to treatment and early relapses.

1-, 3-, and 5-year survival among early-stage lung cancer patients treated with lobectomy vs SBRT

Background

Lobectomy has traditionally been recommended for fit patients diagnosed with early-stage non-small-cell lung cancer (NSCLC). Recently, however, stereotactic body radiotherapy (SBRT) has been introduced as an alternative treatment option. The purpose of this investigation is to compare survival outcomes for individuals with stage I/II NSCLC treated with lobectomy vs SBRT.

Methods

This retrospective study included 191 patients (100 surgery, 91 SBRT) identified through the Lung Cancer Evaluation Center, Stony Brook, NY, between 2008 and 2012. Survival and recurrence rates were compared using Kaplan–Meier curves, log-rank tests, and Cox proportional hazard models to adjust for possible confounders. A subset of cases was propensity-matched to address potential differences in health status between groups.

Results

1-, 3-, and 5-year survival outcomes were significantly better among patients undergoing lobectomy vs SBRT. Survival rates at 3 years were 92.8% and 59.0% (p<0.001) in the 2 groups, respectively. Propensity-matched analyses indicated similar findings. Recurrence rates were likewise lower among patients undergoing surgery (7.1% vs 21.0%, p<0.01 at 3 years); however, statistical significance was not maintained in the propensity-matched analysis.

Conclusion

These findings add to a growing evidence base supporting the use of lobectomy vs SBRT in the treatment of lung cancer among healthy, early-stage NSCLC patients.

Adjuvant treatment patterns and outcomes in patients with stage IB-IIIA non-small cell lung cancer in France, Germany, and the United Kingdom based on the LuCaBIS burden of illness study

OBJECTIVES

To inform health-technology assessments of new adjuvant treatments, we describe treatment patterns in patients with complete resection of stage IB-IIIA non-small cell lung cancer (NSCLC) in France, Germany, and the United Kingdom (UK).

MATERIALS AND METHODS

Data were collected via medical record abstraction. Patients were aged ≥18 years with completely resected stage IB-IIIA NSCLC, diagnosed between 01 January 2009 and 31 December 2011. Median follow-up was 26 months. Adjuvant treatment patterns and clinical outcomes were summarized descriptively.

RESULTS

Among the 831 patients studied, 239 (29%) had stage IB disease, 179 (22%) had stage IIA disease, 165 (20%) had stage IIB disease, and 248 (30%) had stage IIIA disease. Adjuvant systemic therapy was received by 402 patients (48.4%), (France, 61.8%; Germany, 51.9%; UK, 33.4%). Use of adjuvant therapy increased with increasing stage of disease. Cisplatin/vinorelbine and carboplatin/vinorelbine were the most frequently prescribed adjuvant regimens. Median disease-free survival was 48.0 months (95% confidence interval [CI] 42.3-not estimable); the 25th percentile was 13.2 months (95% CI, 11.0-15.3). 204 patients (24%) died during the follow-up period. The median overall survival was not reached, the 25th percentile was 31.2 months (95% CI 26.8-36.0 months). 272 patients (33%) had disease recurrence during the follow-up period. For 86 of those patients, the first recurrence was local or regional with no distant metastasis and 14 had further progression to metastatic disease during the follow-up time. For the other 186 patients, the first recurrence involved distant metastases. A total of 200 patients had metastatic disease at any time during study follow-up.

CONCLUSIONS

Less than half the patients with stage IB-IIIA NSCLC in this observational study received adjuvant systemic therapy. A high rate of first recurrence with distant metastatic disease was observed, emphasising the need for more effective systemic adjuvant therapies in this population.

The Prevention of Brain Metastases in Non-Small Cell Lung Cancer by Prophylactic Cranial Irradiation

Background

Non-small cell lung cancer (NSCLC) patients frequently develop brain metastases (BM), even though the initial imaging with brain CT or MRI was negative. Stage III patients have the highest risk to develop BM, with an incidence of approximately 30%. BM can lead to neurocognitive disorders, loss of quality of life (QoL), and they are the most important factors influencing patient’s overall survival (OS). Although a radical local treatment of BM may be possible with primary radiosurgery or after resection, the prognosis often remains poor. Preventing the development of BM through prophylactic cranial irradiation (PCI) may improve the outcome of these patients.

Methods

Data from published randomized trials comparing PCI with non-PCI were sought using electronic database (PubMed) searching, hand searching, and by contacting experts. Trials were included if they considered a randomized comparison of PCI and non-PCI, enrolled NSCLC patients, excluded patients with recurrent or metastatic disease, and reported results on BM occurrence. Each randomized controlled trial (RCT) was assessed for methodological quality using the Cochrane collaboration’s tool for the assessment of risk of bias. Study estimates were pooled using a fixed effects sample-weighted meta-analysis approach to calculate an overall estimate and 95% confidence interval (CI). Results on PCI-related toxicity, QoL, and OS were only reported descriptively.

Results

Seven RCTs were included in the meta-analysis. In total, 1,462 patients were analyzed, including 717 patients who received PCI and 745 patients who did not. The risk of developing BM was significantly decreased through PCI (13% reduction, RR 0.33; 95% CI 0.22–0.45). PCI-related toxicity and QoL data were limited. Acute toxicity mostly included fatigue, skin-related toxicity, and nausea or vomiting. Late toxicities such as headache, dyspnea, lethargy, and low grade cognitive impairments were also reported in some of the included RCTs. Results on OS were inconclusive.

Conclusion

The risk of developing BM was reduced in patients who received PCI compared to patients who did not. To implement PCI as the standard treatment for patients with NSCLC, the impact of PCI-related toxicity on QoL should be further investigated, as well as long-term OS. A future individual patient data meta-analysis could produce definitive answers to this clinical question.

Linear Atelectasis around the Hilum on Chest Radiography: A Novel Sign of Early Lung Cancer

BACKGROUND

Linear atelectasis is a focal area of subsegmental atelectasis with a linear shape. Linear atelectasis may occur as a consequence of subsegmental bronchial obstruction.

AIMS

We propose an early roentgen sign of obstructing lung tumors, namely perihilar linear atelectasis, and ascertain whether this phenomenon could be used as a sign to detect radiographically occult primary lung cancer.

MATERIALS AND METHODS

We performed a retrospective review of 45,000 posteroanterior chest radiographs to determine the frequency of appearance and characteristics of perihilar linear atelectasis. The perihilar region of chest radiographs was evaluated for the presence of linear atelectasis. When linear atelectasis was found, the total thickness was measured. Student's t-test was used to evaluate statistical significance, correlating the thickness of atelectasis and the presence of obstructing central primary lung cancer.

RESULTS

Perihilar linear atelectasis was demonstrated in 58 patients. Atelectasis was caused by an obstructing tumor in 21 (36%) cases and a variety of other conditions in 37 (64%) patients. A statistically significant relationship (P < 0.001) was observed between the dimension of perihilar linear atelectasis and primary lung cancer, with 16 of 19 patients with thick (>5.5 mm) perihilar linear atelectasis found to have primary lung cancer.

CONCLUSION

Thick perihilar linear atelectasis is a new diagnostic roentgen sign that suggests subsegmental bronchial obstruction. In this patient subgroup, who are otherwise asymptomatic, a persistent linear atelectasis can be due to primary lung cancer.

Accuracy of rapid on-site evaluation of endobronchial ultrasound guided transbronchial needle aspirates by respiratory registrars in training and medical scientists compared to specialist pathologists-an initial pilot study

Background

Rapid on-site evaluation (ROSE) of endobronchial ultrasound guided transbronchial needle aspirates (EBUS-TBNA) increases diagnostic accuracy but in many institutions requires a specialist pathologist. This study aimed to determine if medical scientists or respiratory registrars could adequately perform ROSE to determine sufficiency of EBUS samples.

Methods

ROSE was performed on the first two EBUS-TBNA passes per patient by a pathologist, a medical scientist and two respiratory registrars. The medical scientists involved had all previously performed ROSE on over 50 procedures. The two respiratory registrars received cytology education from a pathologist in four separate hour-long training sessions. Each ROSE reviewer recorded whether each sample was sufficient or insufficient. Pathologist interpretation was taken as gold standard. Specific diagnosis was not required. Final diagnosis and the total number of passes were also recorded. This study recruited 25 patients (50 passes) for statistical evaluation.

Results

Assessment by specialist pathologists deemed 16/50 (32%) to be sufficient and 34/50 (68%) insufficient respectively. Medical scientists were 90% concordant with the pathologist (K =0.774; 95% CI, 0.587-0.961). The two respiratory registrars were 78% (K =0.568; 95% CI, 0.338-0.798) and 72% (K =0.448; 95% CI, 0.222-0.674) concordant, respectively. The mean number of passes per patient was 4.9 (range, 3-7). A diagnosis was established in 21/25 (82%) patients from the first EBUS-TBNA procedures with the remaining four patients requiring a further procedure or monitoring with serial CT scans to establish the diagnosis. Malignancy was found in 14/25 (56%) patients and a benign process in 11/25 (44%) patients.

Conclusions

Medical scientist review of ROSE samples is not significantly different to a specialist pathologist and is an acceptable alternative. Respiratory registrars are not a realistic alternative for ROSE without more intensive training, which may be difficult to facilitate in addition to existing respiratory training commitments.

Ultrasonic diagnosis combined with targeted ultrasound contrast agent improves diagnostic sensitivity of ultrasonic for non-small cell lung cancer patients

Non-small cell lung cancer (NSCLC) is one of the most prevalent human cancers, which is known for local growth, easily migration, long-distance invasion and reoccurrence. Targeted ultrasound (US) contrast combined with ultrasound for lung cancer diagnosis has been applied in the clinic. In the present study, a novel targeted ultrasound contrast agent containing chistosan/Fe₃O₄-parceled bispecific antibody (TcBab) targeting carcino-embryonic antigen, vascular endothelial growth factor receptor was introduced, and the diagnostic accuracy and sensitivity was investigated in patients with NSCLC. A total of 384 patients with suspected NSCLC were recruited to investigate the accuracy of TcBab-ultrasound (TcBab-US) and ultrasound. Results demonstrated that TcBab-US improved sensitivity and may provide a novel protocol for diagnosing tumors in patients with suspected NSCLC at an early stage. Data analysis demonstrated that TcBab-US diagnosed 154 suspected patients with NSCLC, whereas ultrasound only diagnosed 84 suspected patients with NSCLC out of a total of 384 patients with suspected NSCLC (P<0.01). A dosage experiment revealed that the optimal dose of TcBab was 5 mg/kg for NSCLC patients. Pharmacodynamics analysis showed that TcBab may be metabolized within 16 h in serum of patients. Notably, early diagnosis determined by TcBab-US contributed to improvement of survival for NSCLC patients as determined by a comparison of the survival rate with the survival rate of patients who did not receive TcBab (P<0.05). In conclusion, these investigations suggested that TcBab improves the accuracy and diagnostic confidence of ultrasonic for the diagnosis of early-stage NSCLC, and may have potential application value in the clinic.

Prophylactic Cranial Irradiation Versus Observation in Radically Treated Stage III Non-Small-Cell Lung Cancer: A Randomized Phase III NVALT-11/DLCRG-02 Study

Purpose The purpose of the current study was to investigate whether prophylactic cranial irradiation (PCI) reduces the incidence of symptomatic brain metastases in patients with stage III non-small-cell lung cancer (NSCLC) treated with curative intention. Patients and Methods Patients with stage III NSCLC-staged with a contrast-enhanced brain computed tomography or magnetic resonance imaging-were randomly assigned to either observation or PCI after concurrent/sequential chemoradiotherapy with or without surgery. The primary end point-development of symptomatic brain metastases at 24 months-was defined as one or a combination of key symptoms that suggest brain metastases-signs of increased intracranial pressure, headache, nausea and vomiting, cognitive or affective disturbances, seizures, and focal neurologic symptoms-and magnetic resonance imaging or computed tomography demonstrating the existence of brain metastasis. Adverse effects, survival, quality of life, quality-adjusted survival, and health care costs were secondary end points. Results Between 2009 and 2015, 175 patients were randomly assigned: 87 received PCI and 88 underwent observation only. Median follow-up was 48.5 months (95% CI, 39 to 54 months). Six (7.0%) of 86 patients in the PCI group and 24 (27.2%) of 88 patients in the control group had symptomatic brain metastases ( P = .001). PCI significantly increased the time to develop symptomatic brain metastases (hazard ratio, 0.23; [95% CI, 0.09 to 0.56]; P = .0012). Median time to develop brain metastases was not reached in either arm. Overall survival was not significantly different between both arms. Grade 1 and 2 memory impairment (26 of 86 v seven of 88 patients) and cognitive disturbance (16 of 86 v three of 88 patients) were significantly increased in the PCI arm. Quality of life was only decreased 3 months post-PCI and was similar to the observation arm thereafter. Conclusion PCI significantly decreased the proportion of patients who developed symptomatic brain metastases with an increase of low-grade toxicity.

Immunotherapy in non-metastatic non-small cell lung cancer: Can the benefits of stage IV therapy be translated into earlier stages?

Over the last decade, several steps forward in the treatment of patients with stage IV non-small cell lung cancer (NCSLC) were made. Examples are the use of pemetrexed, pemetrexed maintenance therapy, or bevacizumab for patients with nonsquamous NSCLC. A big leap forward was the use of tyrosine kinase inhibitors in patients selected on the basis of an activating oncogene, such as epidermal growth factor receptor (EGFR) activating mutations or anaplastic lymphoma kinase (ALK) translocations. However, all of these achievements could not be translated into survival benefits when studied in randomized controlled trials in patients with nonmetastatic NSCLC. Aside from chemotherapy and targeted therapy, immunotherapy has become the third pillar in the treatment armamentarium of advanced NSCLC. Antigen-specific immunotherapy (cancer vaccination) has been disappointing in large phase III clinical trials in stages I–III NSCLC. Based on the recent breakthroughs with immune checkpoint inhibitor immunotherapy in metastatic NSCLC, much hope currently rests on the use of this approach in patients with stage I–III NSCLC as well. Here we give a brief overview of how most new therapeutic approaches for advanced NSCLC failed in other stages, and then elaborate on the role of immunotherapy in patients with stage I–III NSCLC.

Post-radiotherapy maintenance treatment with fluticasone propionate and salmeterol for lung cancer patients with grade III radiation pneumonitis: A case report

RATIONALE

This combination of fluticasone propionate (FP) and the long-acting β2-agonist salmeterol (Salm) can control the symptoms of asthma and COPD better than FP or Salm on their own and better than the combination of inhaled corticosteroids plus montelukast. FP/Salm has been shown to control symptoms of asthma and COPD better than a double dose of inhaled steroids. The patient in our report had a history of COPD, and suffered relapse of RP when given only steroids. It is possible that COPD history helps explain this patient's more difficult treatment course. Therefore, this combination may be more effective than inhaled steroids for patients with a history of COPD.

PATIENT CONCERS

This patient suffered adverse reactions triggered by methylprednisolone: weight gain, hyperglycaemia and sleep disturbance after more than two months of intravenous and oral prednisolone. These reactions disappeared when we switched the patients to FP/Salm maintenance therapy.

DIAGNOSES

The patient underwent upper right lobectomy in September 2011. Immunohistochemistry indicated low squamous cell differentiation, and he was diagnosed with stage IIB disease (T2N1M0) according to the Union for International Cancer Control (UICC) (7th edition).One month after repeat radiotherapy, the patient experienced fever (37.6°C), cough, chest distress and shortness of breath. We performed serologic tests, laboratory tests for procalcitonin and C-reactive protein, as well as sputum and blood cultures to rule out bacterial infection. Chest CT showed consolidation with air bronchogram in the hilum of the right lung and ground-glass densities in the right lower lobe and left upper lobe. These radiographic signs are typical of RP. Since the patient required oxygen, he was diagnosed with grade III RP.

INTERVENTIONS

After the patinet was diagnosed with grade III RP. The patient was immediately prescribed oxygen, anti-infectives for prophylaxis, treatments to facilitate expectoration and prevent asthma, and most importantly, intravenous methylprednisone at an initial dose of 60  per day. And we cut the steroid dose in half every one week when the patient's symptoms improved obviously, and the patchy shadow on the chest radiograph sharply reduced. Then we give him FP (500 mg)/Salm (50 mg) twice daily for two months. Then the dose was halved for an additional two months.

OUTCOMES

The patient showed no signs of tumor or RP relapse by the last follow-up in March 2018.

LESSONS

This maintenance therapy of FP/Salm for patient with grade III RP may help avoid relapse when steroid therapy is tapered, particularly for patients with a history of COPD. It may also reduce risk of steroid-associated adverse effects. Based on the results observed with our patient, we intend to design a prospective trial to assess the efficacy of FP/Salm when used as preventive treatment for patients at high risk of RP, and when used as maintenance treatment for patients with grade III RP.

The risk and predictors for severe radiation pneumonitis in lung cancer patients treated with thoracic reirradiation

BACKGROUND

Thoracic reirradiation (re-RT) is increasingly administered. However, radiation pneumonitis (RP) remains to be the most common side effect from retreatment. This study aimed to determine the risk and predictors for severe RP in patients receiving thoracic re-RT.

METHODS

Sixty seven patients with lung cancer received thoracic re-RT for recurrent or metastatic disease. Three-dimensional conformal radiotherapy (3D-CRT)/intensity modulated radiotherapy (IMRT) was used for 60 patients, and stereotactic body radiation therapy (SBRT) was used in 7 patients. Deformable image registration (DIR) was performed to create a composite plan. Severe (grade ≥ 3) RP was graded according to Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

Eighteen patients (26.9%) developed grade ≥ 3 RP (17 of grade 3, and 1 of grade 4). In univariate analyses, V5 and mean lung dose (MLD) of initial RT or re-RT plans, V5 and V20 of composite plans, and the overlap between V5 of initial RT and V5 of re-RT plans/V5 of re-RT plans (overlap-V5/re-V5) were significantly associated with grade ≥ 3 RP (P < 0.05 for each comparison). Multivariate analysis revealed that MLD of the initial RT plans (HR = 14.515, 95%CI:1.778-118.494, P = 0.013), V5 of the composite plans (HR = 7.398, 95%CI:1.319-41.495, P = 0.023), and overlap-V5/re-V5 (P = 0.041) were independent predictors for grade ≥ 3 RP. Out-of-field failures with medium overlap-V5/re-V5 of 0.4-0.8 was associated with higher risk of grade ≥ 3 RP compared with in-field failures (18.3% vs. 50%, P = 0.014).

CONCLUSIONS

The risk of grade ≥ 3 RP could be predicted not only by dose-volume variables from re-RT plan, but also by some from initial-RT and composite plans. Out-of-field failures was associated with higher risk of severe RP compared with in-field failures in some cases.

Progress in the Management of Early-Stage Non-Small Cell Lung Cancer in 2017

The landscape of care for early-stage non-small cell lung cancer continues to evolve. While some of the developments do not seem as dramatic as what has occurred in advanced disease in recent years, there is a continuous improvement in our ability to diagnose disease earlier and more accurately. We have an increased understanding of the diversity of early-stage disease and how to better tailor treatments to make them more tolerable without impacting efficacy. The International Association for the Study of Lung Cancer and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in the care of early-stage lung cancer patients have provided focused updates across multiple areas including screening, pathology, staging, surgical techniques and novel technologies, adjuvant therapy, radiotherapy, surveillance, disparities, and quality of life. The source for information includes large academic meetings, the published literature, or novel unpublished data from other international oncology assemblies.

Radiation Therapy Quality Assurance (RTQA) of Concurrent Chemoradiation Therapy for Locally Advanced Non-Small Cell Lung Cancer in the PROCLAIM Phase 3 Trial

PURPOSE

Chemoradiation therapy trials of different tumors, including lung cancer, have shown a correlation between protocol deviations and adverse outcomes. Radiation therapy quality assurance (RTQA) was mandated for all patients treated in the PROCLAIM trial evaluating 2 different chemoradiation therapy regimens. The RTQA results were evaluated from the PROCLAIM study, and the impact of irradiation deviations on efficacy outcomes was investigated.

METHODS AND MATERIALS

The study was conducted from 2008 to 2014. Review of the irradiation plan was mandated for all patients. Real-time review was performed prior to irradiation start for the first enrolled patient at each site and randomly in 20% of additional patients, with non-real-time review in the remainder. The RTQA criteria evaluated included planning target volume coverage, dose homogeneity, volume of lung receiving ≥20 Gy, and maximum point dose to spinal cord.

RESULTS

Major RTQA violations occurred in 40 of 554 patients, treated at 28 sites. Seven sites treated ≥2 patients with major violations. Stage IIIB disease and larger planning target volume were observed more frequently in patients with major violations. Major violations were more prevalent in sites treating either <6 patients or >15 patients. Patients treated at sites enrolling ≥2 patients with major violations (n = 86) had lower median overall survival (21.1 months vs 29.8 months; hazard ratio, 1.442) and progression-free survival (7.3 months vs 11.3 months; hazard ratio, 1.345) than patients treated at sites without major violations. These findings remained significant for overall survival on multivariate analysis.

CONCLUSIONS

Major violations in treatment plans were uncommon in the PROCLAIM study, possibly reflecting mandatory RTQA. The RTQA violations were more frequent in patients requiring more complex chemoradiation therapy plans. Poorer observed outcomes at centers with multiple major violations are hypothesis generating.

Avicequinone B sensitizes anoikis in human lung cancer cells

BACKGROUND

During metastasis, cancer cells require anokis resistant mechanism to survive until reach the distant secondary tissues. As anoikis sensitization may benefit for cancer therapy, this study demonstrated the potential of avicequinone B, a natural furanonaphthoquinone found in mangrove tree (Avicenniaceae) to sensitize anoikis in human lung cancer cells.

METHODS

Anoikis inducing effect was investigated in human lung cancer H460, H292 and H23 cells that were cultured in ultra-low attachment plate with non-cytotoxic concentrations of avicequinone B. Viability of detached cells was evaluated by XTT assay at 0-24 h of incubation time. Soft agar assay was performed to investigate the inhibitory effect of avicequinone B on anchorage-independent growth. The alteration of anoikis regulating molecules including survival and apoptosis proteins were elucidated by western blot analysis.

RESULTS

Avicequinone B at 4 μM significantly induced anoikis and inhibited proliferation under detachment condition in various human lung cancer cells. The reduction of anti-apoptotic proteins including anti-apoptotic protein B-cell lymphoma 2 (Bcl-2) and myeloid cell leukemia 1 (Mcl-1) associating with the diminution of integrin/focal adhesion kinase (FAK)/Proto-oncogene tyrosine-protein kinase (Src) signals were detected in avicequinone B-treated cells.

CONCLUSIONS

Avicequinone B sensitized anoikis in human lung cancer cells through down-regulation of anti-apoptosis proteins and integrin-mediated survival signaling.

Lung cancer screening with low-dose spiral computed tomography: evidence from a pooled analysis of two Italian randomized trials

The benefits and harms of lung cancer (LC) screening with low-dose computed tomography (LDCT) are debatable. Positive results from the US National Lung Screening Trial were not evident in the European trials, possibly due to their smaller sample sizes. To address this issue, we conducted a patient-level pooled analysis of two Italian randomized controlled trials. Data from DANTE and MILD trials were combined for a total of 3640 individuals in the LDCT arm and 2909 in the control arm. LC and overall mortality were analyzed using multivariate hazard ratios (HRs) and log-rank tests stratified by study. The median follow-up was 8.2 years, with a total of 30 480 person-years in the LDCT arm and 22 157 in the control arm. A total of 192 patients developed LC in the LDCT arm and 105 in the control arm. Half of the LC cases in the LDCT arm had stage IA or IB cancer, as compared with 21% in the control arm. Overall mortality rates/100 000 person-years were 925 in the LDCT arm and 1074 in the control arm, and LC mortality rates were 299 and 357, respectively. The multivariate pooled overall mortality HR was 0.89 (95% confidence interval: 0.74-1.06) and the LC mortality HR was 0.83 (95% confidence interval: 0.61-1.12) for the LDCT arm as compared with the control arm. The present pooled analysis shows a nonsignificant 11% reduction in overall mortality in individuals undergoing LDCT screening as compared with the control arm. A pooled analysis of all European trials would be a useful contribution to assess the real benefit of LDCT screening.

Meta-analysis of gemcitabine in brief versus prolonged low-dose infusion for advanced non-small cell lung cancer

Objective

To evaluate the efficacy and safety of gemcitabine (GEM) at 30 min standard-dose infusion (30 min-SDI) compared with prolonged low-dose infusion (P-LDI) in patients with advanced non-small-cell lung cancer (NSCLC).

Methods

Electronic databases including Pubmed, EMbase, Cochrane Library, CNKI, CBM, and VIP were searched using keywords “GEM”, “P-LDI”, and “NSCLC”. Review Manager 5.3 was used to perform the meta-analysis. Primary endpoints were overall response rate (ORR) and 1-year survival rate (1-year SR). Secondary endpoints were grade 3/4 hematotoxicity and nausea/vomiting. In association. GRADE quality of evidence system was used to assess the results of meta-analysis.

Results

Six randomized controlled trials (RCTs) with a total of 637 patients were included and no statistical heterogeneity was found among the studies. The results showed that P-LDI was superior in ORR (RD = 0.09, 95% CI: 0.02 to 0.16, P = 0.02), but had a similar 1-year SR (RD = 0.05, 95% CI: -0.02 to 0.12, P = 0.18) as compared with 30 min-SDI. For grade 3/4 adverse events, there was no significant difference in anemia (RD = 0.02, 95% CI: -0.01 to 0.04, P = 0.27) and nausea/vomiting (RD = 0.01, 95% CI: -0.04 to 0.06, P = 0.64) between the two treatments. However, patients with P-LDI experienced less leukopenia (RD = -0.08, 95% CI: -0.15 to -0.01, P = 0.03) and thrombocytopenia ((RD = -0.05, 95% CI: -0.09 to –0.01, P = 0.006). The GRADE profile showed that the included RCTs had low quality of evidences.

Conclusion

P-LDI was superior in terms of ORR, experienced less grade 3/4 thrombocytopenia and leukopenia compared with 30 min-SDI, and could be a viable treatment option for advanced NSCLC. However, the results need to be further verified by high quality trials and large samples owing to the low quality of evidences.

miR-449a Suppresses Tumor Growth, Migration, and Invasion in Non-Small Cell Lung Cancer by Targeting a HMGB1-Mediated NF-κB Signaling Pathway

MicroRNAs (miRNAs) have been reported to be involved in many human cancers and tumor progression. The dysregulation of miR-449a is found in many types of malignancies and is associated with tumor growth, migration, and invasion. However, its expression and function in non-small cell lung cancer (NSCLC) still remains unclear. In our study, miR-449a was found to be downregulated in both NSCLC tissues and cell lines, and low miR-449a expression was obviously associated with tumor differentiation, TMN stage, and poor overall survival (OS). Moreover, we demonstrated that miR-449a could inhibit tumor proliferation, migration, and invasion in NSCLC. We also confirmed that HMGB1 was a direct target gene of miR-449a in NSCLC with dual-luciferase reporter assay, and upregulation of HMGB1 could reverse the miR-449a-induced suppression of growth, migration, and invasion in NSCLC cells. Last, we found that miR-449a suppressed tumor initiation and development through the NF-κB signaling pathway. These results indicate that miR-449a functions as a tumor suppressor in NSCLC by targeting the HMGB1-mediated NF-κB signaling pathway in NSCLC.