The IASLC Lung Cancer Staging Project: External Validation of the Revision of the TNM Stage Groupings in the Eighth Edition of the TNM Classification of Lung Cancer

Diagnostic Accuracy of Next Generation Sequencing Panel using Circulating Tumor DNA in Patients with Advanced Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Until now, no meta-analysis has been published to evaluate the diagnostic performance of next-generation sequencing (NGS) panel using circulating tumor (ctDNA) in patients with advanced non-small cell lung cancer (aNSCLC). The aim of the study was to carry out a systematic review and a meta-analysis in order to determine the accuracy of NGS of ctDNA to detect six oncogenic driver alterations: epidermal growth factor receptor (EGFR); anaplastic lymphoma kinase (ALK); ROS proto-oncogene 1, receptor tyrosine kinase (ROS-1); serine/threonine-protein kinase B-RAF (BRAF); RET proto-oncogene (RET); and MET proto-oncogene, receptor tyrosine kinase (MET) exon 14 in patients with aNSCLC.

METHODS

MEDLINE/PubMed, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), and Centre for Reviews and Dissemination databases and articles obtained from other sources were searched for relevant studies that evaluate the accuracy (sensitivity and specificity) of NGS using ctDNA in patients with aNSCLC. The studies were eligible when NGS of ctDNA was compared with tissue tests to detect at least one of the six oncogenic driver alterations. Diagnostic measures (sensitivity and specificity) were pooled with a bivariate diagnostic random effect. All statistical analyses were performed with software R, v.4.0.0.

RESULTS

Ten studies were eligible for data extraction. The overall pooled estimates of sensitivity and specificity were 0.766 (95% CI: 0.678-0.835); 0.999 (95% CI: 0.990-1.000), respectively.

CONCLUSIONS

The analysis has demonstrated that the NGS panel using ctDNA has a high accuracy to identify the six actionable oncogenic driver alterations in patients with aNSCLC. Therefore, it can be considered a reliable alternative to guide the patients with aNSCLC to the right treatment who cannot undergo an invasive procedure or have insufficient tissue material for molecular tests.

ACR Appropriateness Criteria® Noninvasive Clinical Staging of Primary Lung Cancer

Lung cancer is the leading cause of cancer-related deaths in both men and women. The major risk factor for lung cancer is personal tobacco smoking, particularly for small-cell lung cancer (SCLC) and squamous cell lung cancers, but other significant risk factors include exposure to secondhand smoke, environmental radon, occupational exposures, and air pollution. Education and socioeconomic status affect both incidence and outcomes. Non-small-cell lung cancer (NSCLC), including adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, comprises about 85% of lung cancers. SCLC accounts for approximately 13% to 15% of cases. Prognosis is directly related to stage at presentation. NSCLC is staged using the eighth edition of the tumor-node-metastasis (TNM) criteria of the American Joint Committee on Cancer. For SCLC the eighth edition of TNM staging is recommended to be used in conjunction with the modified Veterans Administration Lung Study Group classification system distinguishing limited stage from extensive stage SCLC. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A case of different gene mutations in primary and metastatic lesions after EGFR-TKI treatment of lung cancer

BACKGROUND

It remains controversial whether patients with EGFR-mutant lung adenocarcinoma should stop using epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) after progression during treatment.

CASE REPORT

We report a 35-year-old man with poorly differentiated adenocarcinoma of the left upper lobe and an exon 19 deletion (Ex19Del) mutation found by large-panel next-generation sequencing. The patient underwent video-assisted thoracoscopic surgery 12 months after oral administration of icotinib 125 mg tid, and the left upper lobe and surrounding lymph nodes were removed. Postoperative pathology supported a diagnosis of left upper lobe adenocarcinoma and subcarinal (1/2), main pulmonary artery window (1/2), and left hilar (1/2) lymph node metastases. The EGFR mutations in the residual lesions had disappeared, and Ex19Del mutations were still visible in the mediastinal lymph node metastasis.

CONCLUSION

Spatial heterogeneity of the resistance mechanism may explain why patients who continue to receive EGFR-TKIs in combination with local therapies (e.g., radiotherapy) for progressing lesions may benefit even after progression during EGFR-TKI therapy. The loss of the EGFR mutation allele as a putative resistance mechanism requires additional preclinical and clinical confirmation.

[Stereotaxic radiotherapy of primary extracranial tumors]

Stereotactic radiotherapy is a fundamental change from the conventional fractionated radiotherapy and represents a new therapeutic indication. Stereotactic radiotherapy is now a standard of care for inoperable patients or patients who refuse surgery. The results are encouraging with local control and survival rates very high in selected populations. The rate of late toxicity remains acceptable. Good tolerability makes it appropriate even for elderly and frail patients. In these fragile patients or in certain specific clinical situations, different surgical, radiotherapy or interventional radiology attitudes can be discussed on a case-by-case basis. These situations are considered in this article for the pulmonary, hepatic and prostatic localizations.

Striving toward Improved Outcomes for Surgically Resectable Non-Small Cell Lung Cancer: the Promise and Challenges of Neoadjuvant Immunotherapy

PURPOSE OF REVIEW

Immunotherapy has revolutionized the treatment of non-surgical stage III and stage IV non-small cell lung cancer (NSCLC). Here, we review emerging data on the safety, feasibility, and efficacy of neoadjuvant immunotherapy in the setting of earlier stage surgically resectable lung cancer.

RECENT FINDINGS

Several small studies support the safety and feasibility of neoadjuvant immunotherapy, noting similar perioperative rates of morbidity and mortality compared with historical controls. Data from several phase II trials have shown high rates of major pathologic response (MPR), though it is unclear if this will correlate with a survival benefit. Phase III trials of neoadjuvant immunotherapy alone or in combination with chemotherapy are ongoing. Neoadjuvant immunotherapy offers a promising treatment modality in earlier stage NSCLC patients. Results of ongoing phase II and phase III trials will be essential in determining how to best integrate this treatment modality in the future.

A Review About Pembrolizumab in First-Line Treatment of Advanced NSCLC: Focus on KEYNOTE Studies

 Lung cancer is currently the malignant tumor with the highest incidence and mortality in the world, while non-small cell lung cancer (NSCLC) is the most common pathological type of lung caner. In the past few decades, the only treatment options available for advanced NSCLC patients have been targeted therapy or chemotherapy, but these therapies are inevitably tolerated by tumors.  The discovery of immune checkpints that mediate the immune escape of tumor cells have been promoting a series of immune checkpoint inhibitors to be used in cancer treatment and achieved great results. Among them, pembrolizumab is currently the only PD-1 inhibitor approved for first-line treatment of NSCLC, whether it is monotherapy or combination therapy, for creditable performance in KEYNOTE studies. In this review, we systematically integrate the latest series of clinical trial results, pharmacological mechanisms, adverse events (AEs) and predictive biomarkers in the first-line treatment of NSCLC. We hope pembrolizumab could become a better choice for more clinicians and benefit more patients with advanced NSCLC.

Primary Driver Mutations in GTF2I Specific to the Development of Thymomas

Thymomas are rare mediastinal tumors that are difficult to treat and pose a major public health concern. Identifying mutations in target genes is vital for the development of novel therapeutic strategies. Type A thymomas possess a missense mutation in GTF2I (chromosome 7 c.74146970T>A) with high frequency. However, the molecular pathways underlying the tumorigenesis of other thymomas remain to be elucidated. We aimed to detect this missense mutation in GTF2I in other thymoma subtypes (types B). This study involved 22 patients who underwent surgery for thymomas between January 2014 and August 2019. We isolated tumor cells from formalin-fixed paraffin-embedded tissues from the primary lesions using laser-capture microdissection. Subsequently, we performed targeted sequencing to detect mutant GTF2I coupled with molecular barcoding. We used PyClone analysis to determine the fraction of tumor cells harboring mutant GTF2I. We detected the missense mutation (chromosome 7 c.74146970T>A) in GTF2I in 14 thymomas among the 22 samples (64%). This mutation was harbored in many type B thymomas as well as type A and AB thymomas. The allele fraction for the tumors containing the mutations was variable, primarily owing to the coexistence of normal lymphocytes in the tumors, especially in type B thymomas. PyClone analysis revealed a high cellular prevalence of mutant GTF2I in tumor cells. Mutant GTF2I was not detected in other carcinomas (lung, gastric, colorectal, or hepatocellular carcinoma) or lymphomas. In conclusion, the majority of thymomas harbor mutations in GTF2I that can be potentially used as a novel therapeutic target in patients with thymomas.

Expression of Cripto-1 predicts poor prognosis in stage I non-small cell lung cancer

Cripto-1 (CR-1) is related to the biological behaviour and prognosis of carcinomas. The purpose of this study was to investigate the significance of CR-1 expression in surgically resected stage I non-small cell lung cancer (NSCLC). One hundred and forty-eight patients with completely resected stage I NSCLC and available clinical follow-up data were assessed. The protein expression of CR-1 in the tumours was detected by immunohistochemistry. CR-1 was highly expressed in 64 of 148 tumours. Among patients with high CR-1 expression, progression-free survival and overall survival rate were significantly lower than those of patients with low CR-1 levels (P = .013 and P = .019, respectively). The incidence of distant metastasis in patients with high CR-1 expression was significantly higher than that of in patients with low CR-1 expression (57.13% vs 21.43%, P = .001). The results of the multivariate analysis confirmed that a high CR-1 was a significant factor for poor prognosis. In conclusion, CR-1 could be a useful prognostic factor in patients with stage I NSCLC, likely as an indicator of the metastatic propensity of the tumour.

Therapy Line and Associated Predictors of Response to PD-1/PD-L1-Inhibitor Monotherapy in Advanced Non-small-Cell Lung Cancer: A Retrospective Bi-centric Cohort Study

BACKGROUND

Evidence on PD-1/PD-L1-directed immune checkpoint inhibitor (ICI) therapy for advanced non-small-cell lung cancer (NSCLC) is mainly based on clinical trials in first- or second-line settings.

OBJECTIVE

We aimed to investigate response and prognostic factors with special regard to third- or later-line therapy.

PATIENTS AND METHODS

We retrospectively analyzed all patients who had received ICI monotherapy with nivolumab, pembrolizumab, or atezolizumab for advanced NSCLC. Computed tomography evaluations were analyzed using response evaluation criteria in solid tumors (RECIST, version 1.1). Kaplan-Meier analyses were conducted to calculate progression-free (PFS) and overall (OS) survival; the impact of influencing variables was evaluated using uni- and multivariate Cox-regression analyses.

RESULTS

Among 153 patients (59% men, mean age 66 years), median PFS was 4 months [mo; 95% confidence interval (95% CI) 3-5], OS was 13 mo (10-17), and objective response rate (ORR) was 22%. Therapy line ≥ 3 was associated with significantly inferior PFS (p = 0.003) and OS (p = 0.001). In first-line therapy PFS, OS, and ORR were 7 mo (3-11), 17 mo [9-not evaluable (n.e.)], and 36%; in second-line 4 mo (3-7), 18 mo (13-n.e.) and 19%, and in ≥ third-line 2 mo (1-3), 9 mo (4-12), and 13%. PFS was significantly influenced by PD-L1 expression in first-line therapy (p = 0.006). In ≥ third-line patients, Eastern Cooperative Oncology Group (ECOG) performance status significantly affected PFS and OS (both p < 0.001).

CONCLUSIONS

Third- or later-line single-agent anti-PD-1/PD-L1 therapy is less efficacious as compared to first- and second-line treatment. In that setting, ECOG performance status predominates known predictors like PD-L1 expression or presence of an alteration in EGFR or ALK.

Primary pneumonectomy, pneumonectomy after induction therapy, and salvage pneumonectomy: a comparison of surgical and prognostic outcomes

Background

Surgical outcomes of pneumonectomy for lung cancer differ based on various therapeutic strategies.

Methods

One hundred and fifty-one patients who underwent pneumonectomy were divided into three groups based on patients' therapeutic conditions: a primary pneumonectomy group (no preoperative treatment, n=137), an induction group (planned surgery after induction chemotherapy or chemoradiotherapy, n=10), and a salvage group (surgery for residual or enlarged lesions after radical non-operative therapies, n=4).

Results

Multivariate analysis showed that completeness of resection (P=0.003), subcategorization of whether there was no invasion, infiltration only to the main bronchus or pleura, or invasion of other deeper structures (P=0.008), and the presence or absence of mediastinal lymph node metastasis (P=0.033) were significant prognostic factors. Severe postoperative complications occurred in 5.1% (7/137), 20% (2/10), and 0% (0/4) in the primary pneumonectomy, induction, and salvage groups, respectively. Among patients with pN0-1 disease, the 3-year overall survival rate was 58.7% in the primary pneumonectomy group, 100% and 40% in cases with high and low pathological effects in the induction group, respectively, and 50% in the salvage group. Among patients with pN2 disease, this rate was 41.4% in the primary pneumonectomy group, and no patients survived for postoperative 2 years in the other groups.

Conclusions

For patients undergoing pneumonectomy, subcategorization based on the invasion status (none/bronchus/pleura or other deeper structures) is a crucial prognostic factor. To consider pneumonectomy in the induction or salvage setting, selecting patients with pN0-1 disease may be mandatory.

What is the role of reirradiation in the management of locoregionally relapsed non small-cell lung cancer?

The prognosis of lung cancer patients has improved in the last few years. Despite definitive therapy, local recurrence or a second primary tumour can occur in many patients within previously irradiated areas. Recent developement of more accurate techniques in radiation oncology allows delivery of high radiation dose to the tumor with the aim of improving local control, delaying disease progression and in some cases even curing. Nevertheless, the use of high dose in the reirradiation setting is not without risks, especially when treatment volumes overlap with previously irradiated tissues. The risk of adverse effects must be balanced with the choice of an effective treatment by selecting suitable candidates and the best radiation technique. In this systemic review efficacy and toxicity of reirradiation in locoregionally recurrent non-small-cell lung cancer is extensively discussed. Results indicate that reirradiation might be beneficial in well-selected patients. Prospective and high quality studies are necessary in this field.

Pretreatment Neutrophil-to-Lymphocyte Ratio (NLR) May Predict the Outcomes of Advanced Non-small-cell Lung Cancer (NSCLC) Patients Treated With Immune Checkpoint Inhibitors (ICIs)

Background: Recent studies have demonstrated the predictive value of pretreatment neutrophil-to-lymphocyte ratio (NLR) in advanced cancers; however, the role of NLR in patients with advanced non-small-cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs) remained to be explored. Thus, we aimed to investigate whether pretreatment NLR was associated with the outcomes of advanced NSCLC patients treated with ICIs.

Methods: A comprehensive literature research was first conducted in PubMed, the Cochrane Central Library, and Embase for studies that evaluated the association between pretreatment NLR and survival of advanced NSCLC patients with ICIs treatment. We then conducted a retrospective study in Chinese People's Liberation Army (PLA) General Hospital (Beijing, China) to validate these findings.

Results: A total of 17 eligible studies with 2,106 patients were included in our meta-analysis, of which, 12 studies reported progression-free survival (PFS), and 13 studies reported overall survival (OS). The pooled results showed that high pretreatment NLR was significantly associated with poorer PFS (HR = 1.44, 95% CI 1.26–1.65; P < 0.001) and OS (HR = 2.86, 95% CI 2.11–3.87; P < 0.001) compared with those with low pretreatment NLR. Subgroup analysis demonstrated that the association between baseline NLR and PFS remained significant except that the cut-off value of NLR was 3 (HR = 1.48, 95% CI 0.93–2.37; P = 0.098) and region of Asia (HR = 1.55, 95% CI 1.00–2.39; P = 0.051). These results were further validated in our retrospective study that patients with pretreatment NLR ≥ 6.0 had shorter PFS (median: 5.0 vs. 9.1 months, HR = 1.39; 95% CI 1.01–1.91; P = 0.02) and OS (median: 10.0 vs. 17.3 months, HR = 1.71; 95% CI 1.18–2.46; P < 0.001) compared with those with NLR < 6.0. The associations between NLR and survival were consistent in subgroup analysis stratified by age, gender, ECOG PS, histology, stage, smoking history, treatment, and prior lines of therapy. Dynamics of NLR (dNLR) that increased ≥3.0 from baseline was also significantly associated with worse PFS (median: 3.1 vs. 9.1 months; P = 0.01) and OS (median: 6.8 vs. 17.0 months; P < 0.0001).

Conclusions: Our study demonstrates that pretreatment NLR and dNLR from baseline are associated with the outcomes of advanced NSCLC patients treated with ICIs; however, it warrants further prospective studies.

External Validation of AJCC Eighth Edition of Non-small-cell Lung Cancer Staging Among African Americans

INTRODUCTION

The American Joint Committee on Cancer (AJCC) eighth staging classification system for non-small-cell lung cancer was based on data from a multinational study consisting of 94,708 patients. African Americans were not included in this large database.

MATERIALS AND METHODS

The authors aimed to compare the performance of the AJCC eighth staging system with that of the seventh in predicting overall survival among African Americans utilizing the National Cancer Database. Cases with T- and M- categories were classified into 2 groups based on the AJCC seventh and eighth edition staging systems. Kaplan-Meier curves for overall survival were then constructed for each subgroup. Concordance index was computed using Uno's methodology to assess the overall performance between the 2 staging systems in predicting the mortality. Time-dependent area under the curve was calculated at each follow-up event for the seventh and eighth edition clinical and pathologic staging using an inverse probability of censoring weighted methodology. A 2-sided P-value < .05 was considered to show statistical significance.

RESULTS

The database identified a total of 70,606 African American patients in the study period of 2004 through 2014. Area under the curve values were consistently higher for the eighth edition scheme compared with the seventh edition (concordance 0.630 vs. 0.624, respectively; P < .0001 for clinical staging scheme and 0.596 vs. 0.591, respectively; P = .01 for pathologic staging scheme).

CONCLUSION

The AJCC eighth edition staging system showed better prognostic value in predicting overall survival when compared with the AJCC seventh edition staging scheme among African American patients with non-small-cell lung cancer.

Novel treatment strategies for early-stage lung cancer: the oncologist's perspective

Management of early-stage non-small cell lung cancer (NSCLC) consists in multimodal treatment, including surgery, radiotherapy and chemotherapy. The mainstay of treatment is radical surgery. Definitive radiotherapy using stereotactic techniques can provide adequate local disease control, and is the treatment of choice in medically inoperable patients. Most early-stage patients are at significant risk of disease relapse after local treatment. Adjuvant platinum-based chemotherapy has demonstrated to provide an absolute survival benefit of 5% compared to observation. However, unlike advanced/metastatic disease, little progress has been made in the treatment of early-stage NSCLC over the past decade. In recent years, plenty of research has focused on the optimization of adjuvant and neoadjuvant treatment. Several trials with novel drugs, such as targeted agents and immune-checkpoint inhibitors are currently underway, with preliminary positive results. Customization of treatment on patients’ characteristics before, and major pathological response after therapy, will further improve survival outcomes in this subset of patients.

Efficacy of immune checkpoint inhibitor monotherapy for patients with massive non-small-cell lung cancer

PURPOSE

Baseline tumor size (BTS) and the presence of massive lesions are important for predicting the clinical course of cancer. However, their impact on survival and clinical response in patients with advanced NSCLC undergoing immune checkpoint inhibitor (ICI) treatment has been scarcely investigated.

METHODS

We retrospectively reviewed 294 patients who underwent ICI therapy for advanced or recurrent non-small-cell lung cancer (NSCLC) between January 2016 and July 2019.

RESULTS

Of these 294 patients, 284 (96.6%) had at least one measurable lesion. Of these, 263 patients treated with ICI monotherapy were included in the analysis. The median total and maximum target lesion diameters were 96.5 mm and 49.1 mm, respectively. Median progression-free survival (PFS) with massive lesions (max BTS > 50 mm, group A) and without massive lesions (max BTS ≤ 50 mm, group B) was 2.5 months (95% CI 1.8-3.7) and 6.7 months (95% CI 5.1-9.7), respectively. Median overall survival (OS) for groups A and B was 9.5 months (95% CI 5.5-12.3) and 20.0 months (95% CI 13.3-32.0), respectively. The multivariate analysis revealed marked associations between the presence of massive lesions and both PFS and OS.

CONCLUSION

The presence of massive lesions (max diameters > 50 mm) is an independent prognostic factor in advanced NSCLC treated with ICI monotherapy. Although overall response rates were similar between groups A and B, the disease control rate was significantly poorer for group A. Max BTS might be useful for predicting clinical outcomes for patients undergoing immunotherapy as a parameter reflecting their tumor burden.

Evolutionary Action Score of TP53 Enhances the Prognostic Prediction for Stage I Lung Adenocarcinoma

Stage I lung adenocarcinoma usually has a good prognosis after surgery. However, some patients do suffer disease recurrence during follow-up. Here, we report the prognostic value of evolutionary action score of TP53, which calculates the functional prediction of TP53, in patients with stage I lung adenocarcinoma. From January 2011 to August 2013, 83 patients with a complete follow-up history (36 with a disease recurrence and 47 without recurrence during follow-up) who were pathologically confirmed stage I lung adenocarcinoma were included. Whole-exome sequencing were performed on those paired tumor-normal specimens. Evolutionary action score of TP53 (EAp53) was calculated and patients were divided into groups according to their TP53 mutational status. Tumor mutational burden and survival analyses were performed to assess the prognostic value of EAp53. TP53 mutation was identified in 31 patients (37.3%). Of them, 11 were high-risk point mutations, 9 were low-risk point mutations, and 11 were truncating mutations. The high-risk group showed a poorer recurrence-free survival compared with the low-risk group (P = 0.046) and the wild-type group (P = 0.007). In multivariable analysis, the high-risk/truncating group showed a poorer recurrence-free survival (P = 0.007) and overall survival (P = 0.009) compared with the low-risk/wild-type group. Moreover, tumor mutational burden was higher in the high-risk/truncating group (P < 0.001). EAp53 is of prognostic value in patients with stage I lung adenocarcinoma. The mutational type of TP53 should be paid attention to when predicting the prognosis of patients with stage I lung adenocarcinoma.

The association of depressive symptoms, personality traits, and sociodemographic factors with health-related quality of life and quality of life in patients with advanced-stage lung cancer: an observational multi-center cohort study

Background

Identification of patient-related factors associated with Health-Related Quality of Life (HRQoL) and Quality of Life (QoL) at the start of treatment may identify patients who are prone to a decrease in HRQoL and/or QoL resulting from chemotherapy. Identification of these factors may offer opportunities to enhance patient care during treatment by adapting communication strategies and directing medical and psychological interventions. The aim was to examine the association of sociodemographic factors, personality traits, and depressive symptoms with HRQoL and QoL in patients with advanced-stage lung cancer at the start of chemotherapy.

Methods

Patients (n = 151) completed the State-Trait Anxiety Inventory (trait anxiety subscale), the Neuroticism-Extraversion-Openness-Five Factor Inventory (NEO-FFI), the Center for Epidemiologic Studies Depression (CES-D), the World Health Organization Quality of Life-BREF (WHOQOL-BREF), and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Simple linear regression analyses were performed to select HRQoL and QoL associated factors (a P ≤ 0.10 was used to prevent non-identification of important factors) followed by multiple linear regression analyses (P ≤ 0.05).

Results

In the multiple regression analyses, CES-D score (β = − 0.63 to − 0.53; P-values < 0.001) was most often associated with the WHOQOL-BREF domains and general facet, whereas CES-D score (β = − 0.67 to − 0.40; P-values < 0.001) and Eastern Cooperative Oncology Group (ECOG) performance status (β = − 0.30 to − 0.30; P-values < 0.001) were most often associated with the scales of the EORTC QLQ-C30. Personality traits were not related with HRQoL or QoL except for trait anxiety (Role functioning: β = 0.30; P = 0.02, Environment: β = − 0.39; P = 0.007) and conscientiousness (Physical health: β = 0.20; P-value < 0.04).

Conclusions

Higher scores on depressive symptoms and ECOG performance status were related to lower HRQoL and QoL in patients with advanced-stage non-small cell lung cancer. Supportive care interventions aimed at improvement of depressive symptoms and performance score may facilitate an increase of HRQoL and/or QoL during treatment.

Short and mid-term outcomes of multimodal treatment for locally-advanced non-small cell lung cancer in elderly patients

OBJECTIVE

Multimodality treatments are effective for locally advanced non-small cell lung cancer (LA-NSCLC) showing benefits in overall (OS) and disease-free survival (DFS), but these options are frequently denied to elderly patients.

METHODS

The objectives of this retrospective study were: to investigate mortality, morbidity and oncological outcomes of pulmonary resection after induction therapy (IT) for NSCLC in elderly patients. We divided the cohort into two: patients < 70 years (group A) and patients ≥70 years (group B). A multivariable logistic regression was built to identify factors associated with morbidity.

RESULTS

77 patients underwent pulmonary resection after IT, 27 were aged ≥70 years. Type of chemotherapy, surgical procedures, pathological stages were comparable between the two groups, while the preoperative use of chemo-radiation therapy regimen was more frequent in group A (p = 0.027). In-hospital mortality was similar, while the percentage of patients with complications (38% vs 48.1%, p = 0.47) and the complication rate (50% vs 77%, p = 0.01) were higher in group B, but the severity of complications was comparable. The multivariable analysis did not identify any risk factors associated with morbidity. OS at 3 years and DFS at 2 years were not different (61% vs 48.5%, p = 0.64; 61.7% vs 44%, p = 0.393).

CONCLUSIONS

Lung resection for LA-NSCLC after IT can be performed safely in selected elderly patients with favourable postoperative and mid-term oncological results.

Ribcage procedure after neoadjuvant chemoradiotherapy for non-small cell lung cancer involving the chest wall

PURPOSE

Non-small cell lung cancer (NSCLC) involving the chest wall is usually treated with en bloc rib resection or parietal pleurectomy; however, the former causes chest wall deformity and the latter is associated with local recurrence. To prevent both these sequalae, we performed the "ribcage" procedure for tumors involving the chest wall after induction chemoradiotherapy.

METHODS

This was a single center retrospective study conducted from 2012 to 2018. The "ribcage" procedure is designed to preserve the ribs of patients with lung tumors involving chest wall and involves peeling the intercostal muscles and periosteum from the ribs, resulting in a birdcage-like appearance. Seventeen patients with NSCLC clearly involving the chest wall, but not destroying the ribs, were treated with induction chemoradiotherapy, followed by the ribcage procedure. A negative margin at the ribs was confirmed by intraoperative frozen sections in 16 of these patients, who then underwent the ribcage procedure.

RESULTS

Complete resection was achieved in all 16 patients, none of whom experienced major postoperative complications. After a median follow-up period of 37 months, there was no evidence of local recurrence in any of the patients.

CONCLUSION

Our findings suggest that the ribcage procedure is the preferable surgical option as it can prevent chest wall deformities as well as local recurrence.

Survival outcomes of resection for pulmonary malignancies including non-small cell lung cancer and pulmonary metastasis after esophagectomy for esophageal carcinoma

OBJECTIVES

This study investigated survival outcomes of resection for pulmonary malignancies after esophagectomy for esophageal carcinoma, comparing non-small cell lung cancer and pulmonary metastases.

METHODS

We retrospectively reviewed consecutive patients who underwent resection for pulmonary malignancies after esophagectomy for esophageal carcinoma between 2009 and 2018. The overall survival and relapse-free survival rate were assessed using Kaplan-Meier analysis.

RESULTS

Eleven patients had non-small cell lung cancer and eight patients had pulmonary metastases from esophageal carcinoma. The 5-year overall survival rate was 92.9% in all patients with a median follow-up period of 50.4 (range: 9.1-130.2) months. While the 5-year overall survival rate was 100.0% in patients with non-small cell lung cancer, it was 85.7% in patients with pulmonary metastases from esophageal carcinoma. The 5-year relapse-free survival rate was 85.7% in patients with non-small cell lung cancer.

CONCLUSIONS

Our data suggest that resection for pulmonary malignancies after esophagectomy for esophageal carcinoma is associated with favorable survival outcomes and should be considered in selected patients.

A prognostic 11-DNA methylation signature for lung squamous cell carcinoma

Background

Lung squamous cell carcinoma (LUSC), as the second frequent subtype of lung cancer, causes lots of mortalities primarily due to a lack of precise prognostic markers and timely treatment intervention. Previous studies have constructed several risk prognostic models based on DNA methylation sites in multiple tumors, whereas, DNA methylation signature of LUSC remains to be built, and its predictive value need to be evaluated.

Methods

The genome-wide DNA methylation data of LUSC samples was obtained from The Cancer Genome Atlas dataset. Univariate Cox analysis and the least absolute shrinkage and selection operator (LASSO) were implemented to identify DNA methylation sites related to overall survival of LUSC patients. Thus, we performed multivariate Cox regression to establish a DNA methylation signature. The Kaplan-Meier (K-M) survival curves and time-dependent receiver operating characteristic (ROC) curves were plotted to estimate the prognostic power of the signature. Comparison with other known prognostic biomarkers, our DNA methylation signature showed higher predictive specificity and sensitivity. In addition, multivariate Cox regression screened out independent prognostic factors and constructed a nomogram.

Results

Several statistical methods were performed to construct an 11-DNA methylation signature. LUSC patients were divided into low- and high-risk group based on risk score, and high-risk group had a shorter survival time. According to the results of K-M and ROC analyses, the 11-DNA methylation signature showed significant sensitivity and specificity in predicting the LUSC patients’ overall survival. Finally, we integrated some independent prognostic factors (risk score, metastasis stage, and tobacco smoking history) to construct a nomogram, which has excellent prognostic power and may provide guidance for the therapeutic strategies.

Conclusions

We constructed the first risk prognosis model based on DNA methylation site in LUSC, which showed better predictive ability. In addition, a nomogram integrating the DNA methylation signature, metastasis stage, and tobacco smoking history was developed.

The diagnostic value of a seven-autoantibody panel and a nomogram with a scoring table for predicting the risk of non-small-cell lung cancer

The early detection of non-small-cell lung cancer (NSCLC) remains a common concern. The aim of our study was to validate the diagnostic value of a seven-autoantibody (7-AAB) panel compared with radiological diagnosis for NSCLC. We constructed a nomogram and a scoring table based on the 7-AAB panel's result to predict the risk of NSCLC. We prospectively enrolled 268 patients who presented with radiological lesions and underwent both the 7-AAB panel test and pathological diagnosis by surgical resection. A comparison between the 7-AAB panel and radiological diagnosis was performed. A nomogram and a scoring table based on the 7-AAB panel's result to predict the risk of NSCLC were constructed and internally validated. The 7-AAB panel test had a specificity of 90.2% and a positive predictive value (PPV) of 92.7%, which were significantly higher than those of the radiological diagnosis. The 7-AAB panel also showed a preferable sensitivity in patients with early-stage disease. Seven factors, including the 7-AAB panel results, were integrated into the nomogram. For more convenient application, we formulated a scoring table based on the nomogram. The area under the receiver operating characteristic curve was 0.840 and 0.860 in the training group and validation group, respectively, which was higher than that using the 7-AAB panel or radiological diagnosis alone. This study reveals that our 7-AAB panel has clinical value in the diagnosis of NSCLC. The utility of our nomogram and the scoring table indicated that they have the potential to assist clinicians in avoiding unnecessary treatment or needless follow-up.

Correlation between Skip N2 Metastases and SUVmax, Long Diameter of Tumor, and Ki67 Expression in Patients with Non-Small-Cell Lung Cancer

Background

We aim at investigating the correlation between skip N2 metastases (SN2) and SUV_max, long diameter of tumor mass after ¹⁸F-FDG PET/CT, and pathological Ki67 expression in patients with non-small-cell lung cancer (NSCLC).

Methods and Results

We retrospectively analyzed the factors that might affect the pathogenesis of SN2 in these patients. The clinical SN2 symptoms in patients with squamous carcinoma or adenocarcinoma were investigated. The work curve was utilized to analyze the optimal cutoff value for the SUV_max and long diameter of tumor. Multivariate analysis revealed that high expression of Ki67 was a risk factor for mediastinal SN2 (OR = 1.042, 95% CI: 1.009-1.076). Subgroup analysis indicated that the SUV_max of the non-SN2 group was significantly higher than that of the SN2 group in patients with squamous carcinoma (16.3 ± 6.0 vs. 10.7 ± 5.6, P = 0.026). In the patients with adenocarcinoma, the long diameter of tumor in the SN2 group was significantly longer than that of the non-SN2 group (43.8 ± 16.3 mm vs. 30.1 ± 13.8 mm, P = 0.032). The Ki67 expression in the SN2 group was significantly higher than that of the non-SN2 group (51.7 ± 24.0 vs. 30.0 ± 19.2, P = 0.028).

Conclusions

The differences of clinical features of the patients in the SN2 group and non-SN2 group in the NSCLC patients were associated with the pathological subtypes, which were featured by lower SUV_max in the SN2 of the squamous carcinoma, and longer diameter of SN2 in the adenocarcinoma patients.

Evaluation of major complications associated with percutaneous CT-guided biopsy of lung nodules below 3 cm

Background/aim

The aim of this study was to evaluate retrospectively the incidence and risk factors for the serious complications of pneumothorax and/or parenchymal haemorrhage occurring after computed tomography (CT) guided transthoracic biopsy.

Materials and methods

The relation between the incidence of pneumothorax and parenchymal haemorrhage due to biopsy, age, sex, lesion localization, lesion size, duration of the procedure, depth of lesion, number of pleural insertions of the biopsy needle and pathology results were statistically evaluated.

Results

Between 2016 and 2017, 309 cases with lesions below 3 cm in diameter of a total of 768 (40.2%) CT-guided chest biopsy patients were selected for retrospective review. The rate of pneumothorax and parenchymal haemorrhage was 18.1% (59/309) and 51% (158/309), respectively post biopsy. The number of needle pleural insertions was correlated with the development of pneumothorax (P = 0.002). At regression analysis, for parenchymal haemorrhage, lesion depth (P < 0.001) and total procedure time (p=0.036) were determined as the most important independent risk factors.

Conclusion

Pneumothorax and parenchymal haemorrhage are common complications after CT-guided percutaneous biopsy. The minimum number of needle-pleural insertions, the optimal access route to the lesion and as quick as possible biopsy procedure should be selected to reduce the risk of pneumothorax and parenchymal haemorrhage.

Low-Dose CT Screening for Lung Cancer: Evidence from 2 Decades of Study

Lung cancer remains the overwhelmingly greatest cause of cancer death in the United States, accounting for more annual deaths than breast, prostate, and colon cancer combined. Accumulated evidence since the mid to late 1990s, however, indicates that low-dose CT screening of high-risk patients enables detection of lung cancer at an early stage and can reduce the risk of dying from lung cancer. CT screening is now a recommended clinical service in the United States, subject to guidelines and reimbursement requirements intended to standardize practice and optimize the balance of benefits and risks. In this review, the evidence on the effectiveness of CT screening will be summarized and the current guidelines and standards will be described in the context of knowledge gained from lung cancer screening studies. In addition, an overview of the potential advances that may improve CT screening will be presented, and the need to better understand the performance in clinical practice outside of the research trial setting will be discussed. © RSNA, 2020.

Pulmonary resection is associated with long-term survival and should remain a therapeutic option in oligometastatic lung cancer

OBJECTIVES

Comprehensive local consolidative therapy led to improved overall survival in oligometastatic non-small cell lung cancer in a recent phase II trial, yet the role of pulmonary resection in ongoing oligometastatic trials is a matter of controversy. We sought to examine outcomes after pulmonary resection with radiotherapy used as a benchmark comparator.

METHODS

Patients treated at a single institution (2000-2017) with cT1-3N0-2M1 non-small cell lung cancer, 3 or less synchronous metastases, and performance status 0 to 1, and who received comprehensive local consolidative therapy were analyzed according to local consolidative therapy modality for the primary lesion. Progression was analyzed with death as a competing risk.

RESULTS

Of 88 patients meeting inclusion criteria, 63 (71.6%) received radiotherapy for local consolidative therapy modality for the primary lesion and 25 (28.4%) underwent surgery (lobectomy 20/25 [80.0%], pneumonectomy 3/25 [12.0%], sublobar 2/25 [8.0%]). Time from diagnosis to local consolidative therapy modality for the primary lesion was similar. Surgical patients were younger and had lower intrathoracic disease burden. Ninety-day post-treatment mortality was low (surgery 0/25 [0.0%], radiotherapy 1/63 [1.6%]). Median postoperative survival time was 55.2 months (95% confidence interval, 20.1 to not reached), with 1- and 5-year overall survivals of 95.7% and 48.0%, respectively. After radiotherapy, median postoperative survival time was 23.4 months (confidence interval, 17.2-35.9); 1- and 5-year overall survivals were 74.3% and 24.2%, respectively. No differences were observed between modalities in site of first failure, cumulative incidence of locoregional failure (P = .635), or systemic progression (P = .747).

CONCLUSIONS

Pulmonary resection is feasible and associated with long-term survival in selected patients with synchronous oligometastatic non-small cell lung cancer. Surgery should remain a local consolidative therapeutic option for patients with operable oligometastatic non-small cell lung cancer enrolled in ongoing and future randomized clinical trials.

A miRNA-based diagnostic model predicts resectable lung cancer in humans with high accuracy

Lung cancer, the leading cause of cancer death worldwide, is most frequently detected through imaging tests. In this study, we investigated serum microRNAs (miRNAs) as a possible early screening tool for resectable lung cancer. First, we used serum samples from participants with and without lung cancer to comprehensively create 2588 miRNAs profiles; next, we established a diagnostic model based on the combined expression levels of two miRNAs (miR-1268b and miR-6075) in the discovery set (208 lung cancer patients and 208 non-cancer participants). The model displayed a sensitivity of 99% and specificity of 99% in the validation set (1358 patients and 1970 non-cancer participants) and exhibited high sensitivity regardless of histological type and pathological TNM stage of the cancer. Moreover, the diagnostic index markedly decreased after lung cancer resection. Thus, the model we developed has the potential to markedly improve screening for resectable lung cancer.

Asakura, Kadota et al. demonstrate the diagnostic potential of serum microRNAs for resectable lung cancer. Their diagnostic model based on the combined expression levels of two miRNAs predicts resectable lung cancer with 99% sensitivity, regardless of histological types and pathological stages of cancer, suggesting its promising, diagnostic utility.

Diagnostic imaging of typical lung carcinoids: relationship between MDCT, 111In-Octreoscan and 18F-FDG-PET imaging features with Ki-67 index

AIMS

This study analyses the capability of contrast-enhanced multi-detector computed tomography (MDCT) and spectrum of molecular imaging to characterize typical carcinoids (TCs) of lung and their relationship with Ki-67 index.

MATERIALS AND METHODS

We analysed 68 patients with histological diagnosis of pulmonary TC, which underwent both MDCT and nuclear molecular imaging (somatostatin receptor scintigraphy/SPECT with ¹¹¹In-pentetreotide and ¹⁸F-FDG-PET/CT) at staging evaluation before surgery. The MDCT scan was reviewed for the following features: size, margins, contrast enhancement, presence of calcifications, bronchial obstruction, lymph nodes and metastases. In ¹¹¹In-pentetreotide SPECT, tumour/non-tumour ratio was measured at 4- and 24-h post-injection and the per cent difference was calculated (T/NT%). FDG uptake was measured as the ratio between lesion SUVmax and liver SUVmean (SUV ratio). All imaging features were correlated between them and with Ki-67 index.

RESULTS

Forty-four of the 68 lesions (65%) were in the right lung. In MDCT, scan lesions appeared as a well-defined nodule in 44 patients (65%) and irregular mass in 24 patients (35%). Contrast intense enhancement was present in 53 patients (78%), calcifications in 20 patients (29%) and bronchial obstruction in 24 patients (35%). Lymph nodes and metastasis were present in 13 (19%) and 15 (22%) patients. Ki-67 index was negatively correlated with T/NT% and positively with SUV ratio; T/NT% and SUV ratio were inversely correlated. The presence of irregular margins and metastases was negatively related to T/NT%. The presence of a mass, irregular margins, bronchial obstruction, lymph nodes and metastasis was positively related to higher SUV ratio. The presence of irregular margins, bronchial obstruction, lymph nodes and metastases was significantly correlated with a higher grade of Ki-67 index.

CONCLUSIONS

MDCT and nuclear molecular imaging are important to characterize lung TCs. The majority of TCs appear as a well-defined nodule generally not associated with extra-thorax signs. We found a significant correlation between some MDCT aspects, nuclear medicine features and Ki-67 index. The association of MDCT and nuclear medicine imaging may be useful in predicting proliferative activity and prognosis of lung TCs.

Robotic Sleeve Resection of the Airway: Outcomes and Technical Conduct Using Video Vignettes

BACKGROUND

Our objectives are to report our outcomes and to demonstrate our evolving technique for robotic sleeve resection of the airway, with or without lobectomy, using video vignettes.

METHODS

We retrospectively reviewed a single-surgeon prospective database from October 2010 to October 2019.

RESULTS

Over 9 years, of 5573 operations 1951 were planned for a robotic approach. There were 755 robotic lobectomies and 306 robotic segmentectomies, and 23 consecutive patients were scheduled for elective completely portal, robotic sleeve resection. Sleeve lobectomy was performed in 18 patients: 10 right upper lobe, 6 left upper lobe, and 2 right lower lobe. Two patients had mainstem bronchus resections and 2 underwent right bronchus intermedius resections that preserved the entire lung. One patient had a robotic pneumonectomy. One operation was converted to open thoracotomy because of concern for anastomotic tension in a patient who received neoadjuvant therapy. All patients had an R0 resection. In the last 10 operations we modified our airway anastomosis, using a running self-locking absorbable suture. The median length of hospital stay was 3 days (range, 1-11), with no 30- or 90-day mortalities. Within a median follow-up of 18 months, there were no anastomotic strictures and no recurrent cancers.

CONCLUSIONS

Our early and midterm results show that a completely portal robotic sleeve resection is safe and oncologically effective. Trhe technical aspects of a robotic sleeve resection of the airway are demonstrated using video vignettes.

Validation of the 8th lung cancer TNM classification and clinical staging system in a German cohort of surgically resected patients

OBJECTIVES

The updated 8th edition of the tumor, node, metastases (TNM) classification system for non-small cell lung cancer (NSCLC) attempts to improve on the previous 7th edition in predicting outcomes and guiding management decisions. This study sought to determine whether the 8th edition was more accurate in predicting long-term survival in a European population of surgically treated NSCLC patients.

METHODS

We scanned the archives of the Heckeshorn Lung Clinic for patients with preoperative clinical stages of IIIA or lower (based on the 7th edition), who received surgery for NSCLC between 2009 and 2014. We used pathologists' reports and data on tumor size and location to reassign tumor stages according to the 8th edition. We then analyzed stage specific survival and compared the accuracy of the two systems in predicting long-term survival. We excluded patients with neoadjuvant treatment, incomplete follow-up data, tumor histologies other than NSCLC, or death within 30 days of surgery.

RESULTS

The final analysis included 1,013 patients. Overall five-year survival was 47.3%. The median overall survival (OS) was 63 months (range 1-222), and the median disease-free survival (DFS) was 50 months (0-122). The median follow-up time for non-censored patients was 84 months (range 60-122).

CONCLUSIONS

We found significant survival differences between the newly defined stages 1A1, 1A2 and 1A3 (previously 1A). We also found that the 8th edition of TMN classification was a significantly better predictor of long-term survival, compared to the 7th edition.

Identification of Clonality through Genomic Profile Analysis in Multiple Lung Cancers

In cases of multiple lung cancers, individual tumors may represent either a primary lung cancer or both primary and metastatic lung cancers. In this study, we investigated the differences between clinical/histopathological and genomic diagnoses to determine whether they are primary or metastatic. 37 patients with multiple lung cancers were enrolled in this study. Tumor cells were selected from tissue samples using laser capture microdissection. DNA was extracted from those cells and subjected to targeted deep sequencing. In multicentric primary lung cancers, the driver mutation profile was mutually exclusive among the individual tumors, while it was consistent between metastasized tumors and the primary lesion. In 11 patients (29.7%), discrepancies were observed between genomic and clinical/histopathological diagnoses. For the lymph node metastatic lesions, the mutation profile was consistent with only one of the two primary lesions. In three of five cases with lymph node metastases, the lymph node metastatic route detected by genomic diagnosis differed from the clinical and/or pathological diagnoses. In conclusion, in patients with multiple primary lung cancers, cancer-specific mutations can serve as clonal markers, affording a more accurate understanding of the pathology of multiple lung cancers and their lymphatic metastases and thus improving both the treatment selection and outcome.

IRGS: an immune-related gene classifier for lung adenocarcinoma prognosis

Background

Tumour cells interfere with normal immune functions by affecting the expression of some immune-related genes, which play roles in the prognosis of cancer patients. In recent years, immunotherapy for tumours has been widely studied, but a practical prognostic model based on immune-related genes in lung adenocarcinoma comparable to existing model has not been established and reported.

Methods

We first obtained publicly accessible lung adenocarcinoma RNA expression data from The Cancer Genome Atlas (TCGA) for differential gene expression analysis and then filtered immune-related genes based on the ImmPort database. By using the lasso algorithm and multivariate Cox Proportional-Hazards (CoxPH) regression analysis, we identified candidate genes for model development and validation. The robustness of the model was further examined by comparing the model with three established gene models.

Results

Gene expression data from a total of 524 lung adenocarcinoma patients from TCGA were used for model development. We identified four biomarkers (MAP3K8, CCL20, VEGFC, and ANGPTL4) that could predict overall survival in lung adenocarcinoma (HR = 1.98, 95% CI 1.48 to 2.64, P = 4.19e−06) and this model could be used as a classifier for the evaluation of low-risk and high-risk groups. This model was validated with independent microarray data and was highly comparable with previously reported gene expression signatures for lung adenocarcinoma prognosis.

Conclusions

In this study, we identified a practical and robust four-gene prognostic model based on an immune gene dataset with cross-platform compatibility. This model has potential value in improving TNM staging for survival predictions in patients with lung adenocarcinoma.

Impact

The study provides a method of immune relevant gene prognosis model and the identification of immune gene classifier for the prediction of lung adenocarcinoma prognosis with RNA sequencing and microarray compatibility.

Validation of the Eighth Edition TNM Lung Cancer Staging System

INTRODUCTION

We performed a validation study at our institution, the International Union Against Cancer (Union for International Cancer Control latest version of TNM Classification of Malignant Tumors Eighth Edition).

METHODS

Data were collected from the Queensland Oncology Online registry of NSCLC or SCLC cases between 2000 and 2015 and validated against the Queensland Integrated Lung Cancer Outcomes Project registry using case identification number, first name, last name, and date of birth. Where data were available, cases were classified according to the Union for International Cancer Control TNM seventh edition stage groupings and then compared with the eighth edition groupings. Kaplan-Meier curves were plotted, and the log-rank test of survival differences was performed with SPSS version 25 (IBM Corp, Armonk, NY).

RESULTS

Of the 3636 cases, 3352 and 1031 had complete clinical and pathologic staging, respectively. Median survival time was found to reduce with increasing clinical stage: seventh edition (IA: 88, IB: 44, IIA: 31, IIB: 18, IIIA: 15, IIIB: 8, and IV: 5 mo) versus eighth edition TNM stage (IA1: not reached, IA2: 88, IA3: 53, IB: 56, IIA: 36, IIB: 22, IIIA: 14, IIIB: 9, IIIC: 8, IVA: 6, and IVB: 3 mo). A similar overall pattern was reflected in the pathologic stage: seventh edition (IA: 124, IB: 110, IIA: 48, IIB: 42, IIIA: 26, IIIB: 31, and IV: 27 mo) versus eighth edition (IA1: not reached, IA2: 122, IA3: 125, IB: 144, IIA: 98, IIB: 57, IIIA: 31, IIIB: 24, and IVA: 7 mo). The log-rank test for survival curves was significant at p < 0.001.

CONCLUSIONS

Our external validation study confirms the prognostic accuracy of the eighth edition TNM lung cancer classification. Our analyses also indicated that IIIB, IIIC, and IVA stage groups had similar survival outcomes and suggest further research for refinement.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Primary pulmonary lymphoepithelioma-like carcinoma: a rare type of lung cancer with a favorable outcome in comparison to squamous carcinoma

Background

Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare tumor and often misdiagnosed as squamous carcinoma. In the current study, clinical characteristics and outcome of primary pulmonary LELC were systematically compared with pulmonary squamous carcinoma.

Methods

Forty-two cases of primary pulmonary LELC and 134 squamous carcinomas were enrolled retrospectively. Characteristic and prognosis difference between the two groups was compared, and the independent prognostic factor for pulmonary LELC was identified as well.

Results

In comparison to squamous carcinoma, pulmonary LELC was more common in women with a younger median age and less smokers. LELC seemed to be smaller in diameter on computed tomography (CT) scans than squamous carcinoma, with scarce spiculation and vascular convergence signs. Epstein-Bar virus-encoded RNA (EBER) by in-situ hybridization was detected in 33 LELC cases, among whom 27 ones were positive in serum EBV-DNA examination. LELC patients presented a much longer median progression-free survival (PFS) than squamous carcinoma. Positive serum EBV-DNA, distant lymph node invasion, advanced clinical stage and receiving radiotherapy were correlated with the shorter PFS in LELC patients. However, only positive serum EBV-DNA was the independent PFS predictor.

Conclusion

Pulmonary LELC looks like distinct from squamous carcinoma. Middle-aged women and nonsmokers are comparatively predominated. CT features of pulmonary LELC are relatively less-malignant. Correspondently, the progression of pulmonary LELC is seemingly favorable than squamous carcinoma and the positive serum EBV-DNA appears to be the predictor of PFS.

Accuracy of positron emission tomography and computed tomography (PET/CT) in detecting nodal metastasis according to histology of non-small cell lung cancer

Positron emission tomography and computed tomography (PET-CT) is the non-invasive gold standard method for determining the oncological stage of patient with diagnosis of lung cancer. A correct preoperative staging is significant because only patients who do not have a history of regional or distant disease are those who will benefit from a surgical treatment. However, due to the different values of the PET-CT in terms of sensitivity and specificity to evaluate the mediastinal lymph node involvement, it is often necessary to perform a surgical mediastinal sampling through a cervical video mediastinoscopy (VM). Patient's risk factors which could modify the results of the PET scan, performing differences between non-invasive staging and the lymph node sampling due to VM are not yet clearly established in the literature. This knowledge will allow to identify in whom a surgical staging by sampling the mediastinal lymph nodes is needed. We included 234 patients with diagnosis of lung cancer who underwent a mediastinal lymph node staging by PET-CT images and histopathological results of mediastinal sampling by VM, analyzing the sensitivity and specificity of this non-invasive imaging study. We also analyzed variables that could modify the results of PET-CT, such as tumor type, location of the tumor and patient's history. We showed that those PET-CT presented an overall sensitivity and specificity of 93.8 and 62.7%, respectively, with negative and positive predictive values of 95.05 and 57.1%, respectively. The false-positive rate was 25% (57 of 234 patients). Analyzing risk factors involved in this false-positive rate (n = 57), we found that the only statistically significant factor that could explain these results was the histology of squamous carcinoma (p < 0.03). In this group of patients, it is essential to perform a mediastinal lymph node biopsy to know the real state of lymph node involvement.

Prognostic significance of minichromosome maintenance mRNA expression in human lung adenocarcinoma

The minichromosome maintenance (MCM) gene family plays an essential role in DNA replication and cell cycle progression. However, MCM gene expression has not been well-studied in lung adenocarcinoma (LUAD). In the present study, the expression, prognostic value and functions of MCMs in LUAD were investigated using several databases and bioinformatic tools, including Oncomine, GEPIA, cBioPortal, CancerSEA and Kaplan-Meier plotter. It was demonstrated that the mRNA expression of MCM2, MCM4 and MCM10 were significantly increased in patients with LUAD. High mRNA expression of MCM2-5, MCM8 and MCM10 were associated with poor overall survival and progression-free survival. High MCM4 expression was associated with adverse post-progression survival. In addition, the Human Protein Atlas database showed that MCM protein expression was consistent with the mRNA expression. These results demonstrate that MCM2, MCM4 and MCM10 are potential prognostic markers and therapeutic targets for LUAD.

Trends in Small-Cell Lung Cancer Survival in 1993-2006 Based on Population-Based Cancer Registry Data in Japan

BACKGROUND

Lung cancers are classified into small-cell lung cancer (SCLC) and non-small-cell lung cancer due to their different treatment and prognosis. Although many studies have reported the specific survival of SCLC patients treated at cancer hospitals, survival from population-based data has rarely been reported.

METHODS

We analyzed survival of SCLC cases diagnosed from 1993 through 2006 from a population-based cancer registry of six prefectures. To assess trends in SCLC survival, we defined three periods that mirrored developments in SCLC treatment: period 1, 1993-1998; period 2, 1999-2001; and period 3, 2002-2006. Assessments were based on relative survival (RS), excess hazard, and conditional survival.

RESULTS

A total of 10,911 SCLC patients were analyzed. Five-year RS among limited disease SCLC (LD-SCLC) in periods 1 to 3 was 16.8%, 21.1%, and 21.4%, respectively. Five-year RS among extensive disease SCLC (ED-SCLC) in periods 1 to 3 was 2.3%, 2.8%, and 2.7%, respectively. Improvement in 5-year RS in periods 2 and 3 compared with period 1 was significant among both LD- and ED-SCLC patients (all P < 0.001). Conditional 5-year RS of LD-SCLC increased from 21% at year 0 to 73% at year 5, while that of ED-SCLC was 3% at year 0 and 53% at year 5.

CONCLUSIONS

The prognosis of SCLC patients improved from 1999-2001 but plateaued in 2002-2006, after which no further significant improvement was seen. Continuous survey based on population-based data is helpful in monitoring the impact of developments in treatment.

Comparison of the 7th and 8th Edition of the UICC/AJCC TNM Staging System in Primary Resected Squamous Cell Carcinomas of the Lung-A Single Center Analysis of 354 Cases

Background: The AJCC/UICC TNM (tumor, node, metastasis) classification is a standardized system for the description of anatomical extent and stage grouping of solid malignant tumors and is regularly updated. We aimed at testing the new 2017 8th edition of the TNM classification (TNM8) compared to the former 2009 7th edition (TNM7), in pulmonary squamous cell carcinomas (pSQCC). Methods: We analyzed a clinico-pathologically well-annotated Western single-center cohort of 354 consecutive pSQCC, resected 2000-2013, without previous neoadjuvant therapy. Patients with a clinical history of SQCC of other organs were excluded to reliably exclude lung metastases. Patients in whom TNM was unclear due to multiple tumor nodules were excluded. We reevaluated all pathological records and slides and retrospectively validated pleural invasion for all cases. Raw data of our cohort are provided as Supplementary Material. Results: The stage distribution according to TNM7 was as follows: IA (2009): 59 (16.7%), IB: 75 (21.2%), IIA: 71 (20.1%), IIB: 53 (15.0%), IIIA: 79 (22.3%), IIIB: 7 (2.0%), IV: 10 (2.8%). Staging the cases according to TNM8, 7/354 (2.0%) cases were down-staged, 154 (43.5%) were upstaged; most pronounced between stages IIA(TNM7) and IIB(TNM8), and IIB(TNM7) and IIIA(TNM8). Both staging systems showed significant prognostic impact for overall survival, disease free and disease specific survival and time to recurrence, without significant differences regarding goodness-of-fit criteria (Akaike Information Criterion and Schwarz Bayesian Criterion). Conclusion: In conclusion, we show a significant stage migration between tumors staged using TNM7 and TNM8, without benefit regarding prognostication in our cohort of primary resected pSQCC.

Radiomics Signature: A Biomarker for the Preoperative Distant Metastatic Prediction of Stage I Nonsmall Cell Lung Cancer

OBJECTIVES

To evaluate the predictive value of radiomics features on the distant metastasis (DM) of stage I nonsmall cell lung cancer (NSCLC) preoperatively, by comparing with clinical characteristics and CT morphological features, and to screen the important prognostic predictors.

METHODS

One hundred ninety-four stage I NSCLC patients were retrospectively enrolled, DM free survival (DMFS) was evaluated. The consensus clustering analysis was used to build the radiomics signatures in the primary cohort and validated in the validation cohort. The univariate survival analysis was performed in clinical characteristics, CT morphological features and radiomics signatures, respectively. Cox model was performed and C-index was calculated.

RESULTS

There were 25 patients (12.9%) with DM. The median DMFS was 15 months. Three hundred thirteen radiomics features were selected, then classified into five groups, two subtypes (I and II) with each group. The RS1 showed the best prognostic ability with C-index of 0.355(95% confidence interval [CI], 0.269-0.442; p < 0.001). The histological type exhibited a good prognostic ability with C-index of 0.123 (95% CI, 0.000-0.305; p < 0.001) for DMFS. Cox model showed RS1(hazard ratio [HR] 18.025, 95% CI 2.366-137.340), pleural indentation sign (HR 2.623, 95% CI 1.070-6.426) and histological type (HR 4.461, 95% CI 1.783-11.162) were the independent prognostic factors (p < 0.05).

CONCLUSION

Radiomics provided a new modality for the distant metastatic prediction of stage I NSCLC. Patients with type II of RS1, pleural indentation sign and nonadenocarcinoma indicated the high probability of postsurgical DM.

Assessment of kidney transplant suitability for patients with prior cancers: is it time for a rethink?

Kidney transplant recipients have up to a 100-fold greater risk of incident cancer compared with the age/sex-matched general population, attributed largely to chronic immunosuppression. In patients with a prior history of treated cancers, the type, stage and the potential for cancer recurrence post-transplant of prior cancers are important factors when determining transplant suitability. Consequently, one of the predicaments facing transplant clinicians is to determine whether patients with prior cancers are eligible for transplantation, balancing between the accelerated risk of death on dialysis, the projected survival benefit and quality of life gains with transplantation, and the premature mortality associated with the potential risk of cancer recurrence post-transplant. The guidelines informing transplant eligibility or screening and preventive strategies against cancer recurrence for patients with prior cancers are inconsistent, underpinned by uncertain evidence on the estimates of the incidence of cancer recurrence and the lack of stage-specific outcomes data, particularly among those with multiple myeloma or immune-driven malignancies such as melanomas. With the advent of newer anti-cancer treatment options, it is unclear whether the current guidelines for those with prior cancers remain appropriate. This review will summarize the uncertainties of evidence informing the current recommendations regarding transplant eligibility of patients with prior cancers.

Improved Overall Survival With Comprehensive Local Consolidative Therapy in Synchronous Oligometastatic Non-Small-Cell Lung Cancer

BACKGROUND

Local consolidative therapy (LCT) to optimize disease control is an evolving management paradigm in non-small-cell lung cancer (NSCLC) patients who present with a limited metastatic disease burden. We hypothesized that LCT to all sites of disease would be associated with improved overall survival (OS) among patients with synchronous oligometastatic NSCLC.

PATIENTS AND METHODS

Patients presenting to a single institution (2000-2017) with stage IV NSCLC and ≤ 3 synchronous metastases were identified. Intrathoracic nodal disease was counted as one site. Landmark and propensity-adjusted Cox regression analyses were performed to identify factors associated with OS.

RESULTS

Of 194 patients, 143 (74%) had 2 or 3 sites of metastasis. LCT was delivered to all sites of disease in 121 patients (62%), to some but not all sites in 52 (27%), and were not used in 21 (11%). Comprehensive LCT was independently associated with improved OS (hazard ratio [HR] = 0.67; 95% confidence interval [CI], 0.46-0.97; P = .034), with the greatest therapeutic effect among patients without thoracic nodal disease, bone metastases, or > 1 metastatic site. Among patients who underwent comprehensive LCT, tumor histology (squamous: HR = 2.32; 95% CI, 1.28-4.22; P = .006), intrathoracic disease burden (T3-4: HR = 1.67; 95% CI, 0.97-2.86; P = .065; N3: HR = 1.90; 95% CI, 0.90-4.03; P = .093), and bone metastases (HR = 1.74; 95% CI, 1.02-3.00; P = .044) were associated with poor OS.

CONCLUSION

Comprehensive LCT was associated with improved OS in this large cohort of patients with synchronous oligometastatic NSCLC. These results support ongoing prospective efforts to characterize the therapeutic benefits associated with this management strategy.

Circulating tumor cells in pulmonary vein and peripheral arterial provide a metric for PD-L1 diagnosis and prognosis of patients with non-small cell lung cancer

Background

Lung cancer is the leading cause of death caused by malignant tumors. PD-L1(programmed cell death protein-1) has shown tremendous achievement in treating NSCLC. We sought to find the relationship between CTCs in the pulmonary vein and postoperative PFS, besides we detected PD-L1 in CTCs.

Method

We enrolled 112 NSCLC patients. CTC tests were performed at four time points (preoperative, pulmonary vein, intraoperative and postoperative) on every NSCLC patient who received surgery. The RNA of PD-L1 was tested by FISH. The levels of the PD-L1 mRNA and protein in tissue samples were detected.

Results

The CTCs in the PV were the highest (P< 0.001), and CTCs in the PPA were the lowest (P< 0.001). The PFS in the group with PV CTCs≥ 16/5 ml was shorter than that in the group with PV CTCs< 16/5 ml (11.1 months vs 21.2 months, respectively; P< 0.001). The PFS in the group with PPA CTCs≥ 3/5 ml was shorter than that in the group with CTCs< 3/5 ml (14.8 months vs 20.7 months, respectively; P< 0.001). The CTCs in stage I were lower than those in stage II-IV (P = 0.025). No linear relationship was found between the CTCs and tumor size (P> 0.05) or LN metastasis (P> 0.05). In total, fifty-two (50.5%) patients had positive PD-L1 expression in CTC. In PD-L1-positive CTC patients, the value of PD-L1 tissue expression was higher than that in PD-L1-negative CTC patients (P = 0.0153).

Conclusion

CTCs in the pulmonary vein can be an effective prognosis indicator of NSCLC patients.