Stage I nonsmall cell lung carcinoma

Histology-driven hypofractionated radiation therapy schemes for early-stage lung adenocarcinoma and squamous cell carcinoma

BACKGROUND AND PURPOSE

Histology was found to be an important prognostic factor for local tumor control probability (TCP) after stereotactic body radiotherapy (SBRT) of early-stage non-small-cell lung cancer (NSCLC). A histology-driven SBRT approach has not been explored in routine clinical practice and histology-dependent fractionation schemes remain unknown. Here, we analyzed pooled histologic TCP data as a function of biologically effective dose (BED) to determine histology-driven fractionation schemes for SBRT and hypofractionated radiotherapy of two predominant early-stage NSCLC histologic subtypes adenocarcinoma (ADC) and squamous cell carcinoma (SCC).

MATERIAL AND METHODS

The least-χ2 method was used to fit the collected histologic TCP data of 8510 early-stage NSCLC patients to determine parameters for a well-developed radiobiological model per the Hypofractionated Treatment Effects in the Clinic (HyTEC) initiative.

RESULTS

A fit to the histologic TCP data yielded independent radiobiological parameter sets for radiotherapy of early-stage lung ADC and SCC. TCP increases steeply with BED and reaches an asymptotic maximal plateau, allowing us to determine model-independent optimal fractionation schemes of least doses in 1-30 fractions to achieve maximal tumor control for early-stage lung ADC and SCC, e.g., 30, 44, 48, and 51 Gy for ADC, and 32, 48, 54, and 58 Gy for SCC in 1, 3, 4, and 5 fractions, respectively.

CONCLUSION

We presented the first determination of histology-dependent radiobiological parameters and model-independent histology-driven optimal SBRT and hypofractionated radiation therapy schemes for early-stage lung ADC and SCC. SCC requires substantially higher radiation doses to maximize tumor control than ADC, plausibly attributed to tumor genetic diversity and microenvironment. The determined optimal SBRT schemes agree well with clinical practice for early-stage lung ADC. These proposed optimal fractionation schemes provide first insights for histology-based personalized radiotherapy of two predominant early-stage NSCLC subtypes ADC and SCC, which require further validation with large-scale histologic TCP data.

Optimal Radiation Therapy Fractionation Regimens for Early-Stage Non-Small Cell Lung Cancer

PURPOSE

A series of radiobiological models were developed to study tumor control probability (TCP) for stereotactic body radiation therapy (SBRT) of early-stage non-small cell lung cancer (NSCLC) per the Hypofractionated Treatment Effects in the Clinic (HyTEC) working group. This study was conducted to further validate 3 representative models with the recent clinical TCP data ranging from conventional radiation therapy to SBRT of early-stage NSCLC and to determine systematic optimal fractionation regimens in 1 to 30 fractions for radiation therapy of early-stage NSCLC that were found to be model-independent.

METHODS AND MATERIALS

Recent clinical 1-, 2-, 3-, and 5-year actuarial or Kaplan-Meier TCP data of 9808 patients from 56 published papers were collected for radiation therapy of 2 to 4 Gy per fraction and SBRT of early-stage NSCLC. This data set nearly triples the original HyTEC sample, which was used to further validate the HyTEC model parameters determined from a fit to the clinical TCP data.

RESULTS

TCP data from the expanded data set are well described by the HyTEC models with α/β ratios of about 20 Gy. TCP increases sharply with biologically effective dose and reaches an asymptotic maximal plateau, which allows us to determine optimal fractionation schemes for radiation therapy of early-stage NSCLC.

CONCLUSIONS

The HyTEC radiobiological models with α/β ratios of about 20 Gy determined from the fits to the clinical TCP data for SBRT of early-stage NSCLC describe the recent TCP data well for both radiation therapy of 2 to 4 Gy per fraction and SBRT dose and fractionation schemes of early-stage NSCLC. A steep dose response exists between TCP and biologically effective dose, and TCP reaches an asymptotic maximum. This feature results in model-independent optimal fractionation regimens determined whenever safe for SBRT and hypofractionated radiation therapy of early-stage NSCLC in 1 to 30 fractions to achieve asymptotic maximal tumor control, and T2 tumors require slightly higher optimal doses than T1 tumors. The proposed optimal fractionation schemes are consistent with clinical practice for SBRT of early-stage NSCLC.

Four plasma miRNAs act as biomarkers for diagnosis and prognosis of non-small cell lung cancer

Previous studies have reported that the aberrant expression of circulating microRNAs (miRNAs/miRs) can be used as diagnostic and prognostic markers in non-small cell lung cancer (NSCLC). The present study aimed to assess the diagnostic and prognostic predictive values of four plasma miRNAs for NSCLC. A total of 12 candidate miRNAs were selected that have previously been reported to be aberrantly expressed in NSCLC, and their plasma levels in the training set were detected via reverse transcription-quantitative PCR analysis. The screened out miRNAs were further validated in the testing set. The area under the curve (AUC) of the receiver operating characteristic curve was constructed to evaluate diagnostic performance. Kaplan-Meier survival analysis was performed to assess the association between the plasma miRNA levels and disease-free survival (DFS) time. The results demonstrated that 4/12 plasma miRNAs (miR-210, miR-1290, miR-150 and miR-21-5p) were highly expressed in patients with NSCLC compared with their expression levels in patients with benign lung disease (BLD) and healthy controls in the training and testing sets, respectively. The AUC values of the four-miRNA panel were 0.96 and 0.93 in the training and testing sets, respectively, for distinguishing patients with NSCLC from healthy controls, which were similar to the AUC values for distinguishing patients with NSCLC from patients with BLD (0.96 and 0.94). The AUC values of the four-miRNA panel in patients with stage I NSCLC were comparable to that of patients with stage II-III NSCLC (0.942 and 0.965). Patients with high plasma levels of miR-210 and miR-150 had worse DFS than those with low plasma levels of these miRNAs. In addition, patients whose plasma levels of the four miRNAs decreased by >50% after surgery exhibited a good DFS. Taken together, the results of the present study suggest that these four miRNAs (miR-210, miR-1290, miR-150 and miR-21-5p) act as useful biomarkers for early diagnosis and prognosis of NSCLC.

Defective GaAs nanoribbon-based biosensor for lung cancer biomarkers: a DFT study

Density functional theory-based first-principles investigation is performed on pristine and mono vacancy induced GaAs nanoribbons to detect the presence of three volatile organic compounds (VOCs), aniline, isoprene and o-toluidine, which will aid in sensing lung cancer. The study has shown that pristine nanoribbon senses all three analytes. For the pristine structure, we observe decent adsorbing parameters and the bandgap widens after the adsorption of analytes. However, the introduction of the carrier traps induced by defect causes deep energy wells that vary the electrical properties as indicated in the bandgap analysis of GaAs, wherein adsorption of aniline and o-toluidine reduces the bandgap to 0 eV, making the structure highly conductive in nature. The adsorption energies of defect-induced nanoribbon are more as compared with the pristine counterpart. Nonetheless, the introduction of defects has improved the sensitivity further.

Local Control After Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer

PURPOSE

Numerous dose and fractionation schedules have been used to treat medically inoperable stage I non-small cell lung cancer (NSCLC) with stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy. We evaluated published experiences with SBRT to determine local control (LC) rates as a function of SBRT dose.

METHODS AND MATERIALS

One hundred sixty published articles reporting LC rates after SBRT for stage I NSCLC were identified. Quality of the series was assessed by evaluating the number of patients in the study, homogeneity of the dose regimen, length of follow-up time, and reporting of LC. Clinical data including 1, 2, 3, and 5-year tumor control probabilities for stages T1, T2, and combined T1 and T2 as a function of the biological effective dose were fitted to the linear quadratic, universal survival curve, and regrowth models.

RESULTS

Forty-six studies met inclusion criteria. As measured by the goodness of fit χ2/ndf, with ndf as the number of degrees of freedom, none of the models were ideal fits for the data. Of the 3 models, the regrowth model provides the best fit to the clinical data. For the regrowth model, the fitting yielded an α-to-β ratio of approximately 25 Gy for T1 tumors, 19 Gy for T2 tumors, and 21 Gy for T1 and T2 combined. To achieve the maximal LC rate, the predicted physical dose schemes when prescribed at the periphery of the planning target volume are 43 ± 1 Gy in 3 fractions, 47 ± 1 Gy in 4 fractions, and 50 ± 1 Gy in 5 fractions for combined T1 and T2 tumors.

CONCLUSIONS

Early-stage NSCLC is radioresponsive when treated with SBRT or stereotactic ablative radiation therapy. A steep dose-response relationship exists with high rates of durable LC when physical doses of 43-50 Gy are delivered in 3 to 5 fractions.

An integrated framework for the identification of potential miRNA-disease association based on novel negative samples extraction strategy

MicroRNAs (miRNAs) play an important role in prevention, diagnosis and treatment of human complex diseases. Predicting potential miRNA-disease associations could provide important prior information for medical researchers. Therefore, reliable computational models are expected to be an effective supplement for inferring associations between miRNAs and diseases. In this study, we developed a novel calculative model named Negative Samples Extraction based MiRNA-Disease Association prediction (NSEMDA). NSEMDA filtered reliable negative samples by two positive-unlabeled learning models, namely, the Spy and Rocchio techniques and calculated similarity weights for ambiguous samples. The positive samples, reliable negative samples and ambiguous samples with similarity weights were used to construct a Support Vector Machine-Similarity Weight model to predict miRNA-disease associations. NSEMDA improved the credibility of negative samples and reduced the impact of noise samples by introducing ambiguous samples with similarity weights to train prediction model. As a result, NSEMDA achieved the AUC of 0.8899 in global leave-one-out cross validation (LOOCV) and AUC of 0.8353 under local LOOCV. In 100 times 5-fold cross validation, NSEMDA obtained an average AUC of 0.8878 and standard deviation of 0.0014. These AUCs are higher than many classical models. Besides, we also carried out three kinds of case studies to evaluate the performance of NSEMDA. Among the top 50 potential related miRNAs of esophageal neoplasms, lung neoplasms and carcinoma hepatocellular predicted by NSEMDA, 46, 50 and 45 miRNAs were verified to be associated with the investigated disease by experimental evidences, respectively. Therefore, NSEMDA would be a reliable calculative model for inferring miRNA-disease associations.

Stereotactic body radiation therapy for stage I non-small cell lung carcinomas: Moderate hypofractionation optimizes outcome

OBJECTIVES

In case of inoperability or refusal of surgery, stereotactic body radiation therapy (SBRT) is the most effective treatment for a stage I non-small cell lung carcinoma (NSCLC). The results obtained by this irradiation technique are considerably superior to those observed in the time of conventional 3D irradiation and its toxicities are much less important, which makes it possible in elderly patients, or those presenting cardio-pulmonary comorbidities and a poor perfomance status.

MATERIALS AND METHODS

This study is a retrospective analysis of 90 patients who underwent SBRT for a stage I NSCLC between 2010 and 2015. Its purpose is to describe its effectiveness in term of overall survival (OS), specific survival (SS), local control (LC), regional control (RC) and metastatic control (MC) as well as their prognostic factors, and its tolerance.

RESULTS

LC, RC, MC as well as OS and SS rate at 4 years were comparable to the main prospective studies, respectively 89%, 92%, 70%, 33% and 66%. No LC prognostic factor could be identified. Radiation pneumonitis was observed with a rate of 61.5%, of which 56% were asymptomatic, and 4% of the patients had a rib fracture.

CONCLUSIONS

SBRT is an efficient and well-tolerated treatment for stage I non-small cell lung carcinomas.

[Radiation-induced lung toxicity predictors after stereotactic radiation therapy for non-small cell lung carcinoma stage I]

In case of refusal or contraindication for surgical management of a stage I non-small cell lung carcinoma, the validated alternative therapy is stereotactic irradiation. This technique reaches an equivalent tumour control rate than surgery and significantly higher than conventional radiotherapy. One of the dreaded complications is radiation induced lung toxicity (radiation pneumonitis and lung fibrosis), especially when it is symptomatic, occurring in about 10 % of cases. This article is a literature review of this complication's predictive factors.

Detection of volatile organic compounds in exhaled breath to screen lung cancer: a systematic review

To evaluate the clinical value of volatile organic compounds (VOCs) in exhaled breath for lung cancer (LC) screening, a systematic review was performed. Systematic search for studies about exhaled VOCs for LC screening was conducted according to PRISMA. Thirty eight studies with 4873 participants met the criteria for inclusion in this systematic review. Generally speaking, the results suggest that exhaled VOCs have potential to screen LC and more studies are needed in the future.

Identification of a three-miRNA signature as a blood-borne diagnostic marker for early diagnosis of lung adenocarcinoma

Background

The subtypes of NSCLC have unique characteristics of pathogenic mechanism and responses to targeted therapies. Thus, non-invasive markers for diagnosis of different subtypes of NSCLC at early stage are needed.

Results

Based on the results from the screening and validation process, 3 miRNAs (miR-532, miR-628-3p and miR-425-3p) were found to display significantly different expression levels in early-stage lung adenocarcinoma, as compared to those in healthy controls. ROC analysis showed that the miRNA–based biomarker could distinguish lung adenocarcinoma from healthy controls with high AUC (0.974), sensitivity (91.5%), and specificity (97.8%). Importantly, these three miRNAs could also distinguish lung adenocarcinoma from lung benigh diseases and other subtypes of lung cancer.

Methods

Two hundreds and one early-stage lung adenocarcinoma cases and one hundreds seventy eight age- and sex-matched healthy controls were recruited to this study. We screened the differentially expressed plasma miRNAs using TaqMan Low Density Arrays (TLDA) followed by three-phase qRT-PCR validation. A risk score model was established to evaluate the diagnostic value of the plasma miRNA profiling system.

Conclusions

Taken together, these findings suggest that the 3 miRNA–based biomarker might serve as a novel non-invasive approach for diagnosis of early-stage lung adenocarcinoma.

Comparison of Single- and Three-fraction Schedules of Stereotactic Body Radiation Therapy for Peripheral Early-stage Non-Small-cell Lung Cancer

BACKGROUND

To compare the clinical outcomes of patients with early-stage non-small-cell lung cancer (NSCLC) who had undergone either single-fraction (SF) or three-fraction (TF) stereotactic body radiation therapy (SBRT) at a single institution during over 8-year period.

PATIENTS AND METHODS

Patients with peripherally located early-stage NSCLC who had undergone SBRT from February 2007 to November 2015 were included in the present study. SBRT was delivered without heterogeneity correction. Data were retrospectively reviewed and collected in an institutional review board-approved database. R software (version 3.3.2) was used for statistical analysis.

RESULTS

Of 159 total lung tumors, 65 lesions received 30 Gy (median, 30 Gy) in 1 fraction, and 94 lesions received 48 to 60 Gy (median, 60 Gy) in 3 fractions. Patients with a Karnofsky performance status < 80 were more common in the SF-SBRT cohort (P = .050). After a median follow-up of 22.2 and 26.2 months for the SF-SBRT and TF-SBRT cohorts, respectively (P = .29), no statistically significant difference was found in overall survival (P = .86), progression-free survival (P = .95), local failure (P = .95), nodal failure (P = .91), and distant failure (P = .49) at 24 months. At 1 and 2 years, the overall survival rates were 86.1% and 63.2% for the SF-SBRT cohort and 80.8% and 61.6% for the TF-SBRT cohort, respectively. At 1 and 2 years, the local control rates were 95.1% and 87.8% for the SF-SBRT cohort and 92.7% and 86.2% for the TF-SBRT cohort, respectively. Both regimens were well tolerated.

CONCLUSION

Despite more patients with poor performance status in the SF-SBRT cohort, the SF- and TF-SBRT regimens showed no differences in clinical outcomes. SF-SBRT is now our standard approach.

Polymorphisms in Epithelial-Mesenchymal Transition-Related Genes and the Prognosis of Surgically Treated Non-small Cell Lung Cancer

BACKGROUND

This study was conducted to determine whether single-nucleotide polymorphisms (SNPs) in EMT-related genes may influence the prognosis of NSCLC after surgery.

METHODS

There were 88 SNPs in EMT-related genes evaluated in a discovery set of 376 patients who underwent curative surgery for NSCLC. Significantly, 14 SNPs were evaluated in a validation set of 428 patients. Luciferase assay and RT-PCR were conducted to examine functional relevance of polymorphisms.

RESULTS

Fourteen SNPs that were associated with survival outcomes in a discovery set were selected for validation. Among those, two SNPs (FOXF2 rs1711972A>C and HEYL rs784621G>A) were replicated in a validation study. In combined analysis, FOXF2 rs1711972 AC+CC genotype was associated with significantly better overall survival (OS) and disease-free survival (DFS) compared with AA genotype (adjusted hazard ratio [aHR] for OS = 0.67, 95% confidence interval [CI] 0.51-0.88, P = 0.004; and aHR for DFS = 0.77, 95% CI 0.62-0.95, P = 0.01). HEYL rs784621 AA genotype exhibited a significantly worse OS compared with GG+GA genotype (aHR for OS = 2.65, 95% CI 1.63-4.31, P = 8 × 10^-5). FOXF2 rs1711972C allele had a significantly increased promoter activity than rs1711972A allele (P = 0.01), and HEYL rs784621A allele had a significantly lower promoter activity than rs784621G allele (P = 0.004). FOXF2 rs1711972A>C was significantly associated with increased FOXF2 mRNA expression.

CONCLUSIONS

FOXF2 rs1711972A>C and HEYL rs784621G>A were associated with survival outcomes of surgically treated NSCLC. These SNPs may help to identify patients at high risk of poor disease outcomes.

Tumor control probability modeling for stereotactic body radiation therapy of early-stage lung cancer using multiple bio-physical models

This work is to analyze pooled clinical data using different radiobiological models and to understand the relationship between biologically effective dose (BED) and tumor control probability (TCP) for stereotactic body radiotherapy (SBRT) of early-stage non-small cell lung cancer (NSCLC). The clinical data of 1-, 2-, 3-, and 5-year actuarial or Kaplan-Meier TCP from 46 selected studies were collected for SBRT of NSCLC in the literature. The TCP data were separated for Stage T1 and T2 tumors if possible, otherwise collected for combined stages. BED was calculated at isocenters using six radiobiological models. For each model, the independent model parameters were determined from a fit to the TCP data using the least chi-square (χ²) method with either one set of parameters regardless of tumor stages or two sets for T1 and T2 tumors separately. The fits to the clinic data yield consistent results of large α/β ratios of about 20Gy for all models investigated. The regrowth model that accounts for the tumor repopulation and heterogeneity leads to a better fit to the data, compared to other 5 models where the fits were indistinguishable between the models. The models based on the fitting parameters predict that the T2 tumors require about additional 1Gy physical dose at isocenters per fraction (⩽5 fractions) to achieve the optimal TCP when compared to the T1 tumors. In conclusion, this systematic analysis of a large set of published clinical data using different radiobiological models shows that local TCP for SBRT of early-stage NSCLC has strong dependence on BED with large α/β ratios of about 20Gy. The six models predict that a BED (calculated with α/β of 20) of 90Gy is sufficient to achieve TCP⩾95%. Among the models considered, the regrowth model leads to a better fit to the clinical data.

Patient outcomes of monotherapy with hypofractionated three-dimensional conformal radiation therapy for stage T2 or T3 non-small cell lung cancer: a retrospective study

Background

Hypofractionated three-dimensional conformal radiation therapy (3D-CRT) is a treatment option for patients with early-stage non-small cell lung cancer (NSCLC) who are medically unable to tolerate surgery and who are not amenable to treatment with stereotactic body radiotherapy. This study assessed the efficacy and safety of 3D-CRT as a monotherapy in patients with localized stage T2 or T3 NSCLC.

Methods

This retrospective study consisted of 29 patients (20 males) aged 56–89 years (median, 76 years) with histologically confirmed NSCLC who underwent 3D-CRT between 2005 and 2014.

Results

The median duration of patient observation was 17.0 months (range, 1.0–64.0 months). Complete and partial responses occurred in 13.8 and 44.8 % of patients, respectively, and the overall response rate was 58.2 %. Meanwhile, the 1- and 3-year survival rates were 65.8 and 33.8 %, respectively. In T2 NSCLC, the median survival time (MST) was 12 months, and the 1- and 3-year survival rates were 62.4 and 21.4 %, respectively. In T3 NSCLC, the MST was 17 months, and the 1- and 3-year survival rates were 72.9 and 48.6 %, respectively. Severe toxicities (Common Terminology Criteria Grade 3) were not observed. The mean biologically effective dose required to improve local control exceeded 80 Gy (range, 67.2–96.0 Gy).

Conclusion

These findings support a role for 3D-CRT as a treatment option for patients who refuse or could not tolerate surgical therapy with early-stage NSCLC. Although this was a small, retrospective study, it may form the basis for future, larger controlled studies on 3D-CRT as a monotherapy for NSCLC.

Breath carbonyl compounds as biomarkers of lung cancer

OBJECTIVE

Lung cancer dysregulations impart oxidative stress which results in important metabolic products in the form of volatile organic compounds (VOCs) in exhaled breath. The objective of this work is to use statistical classification models to determine specific carbonyl VOCs in exhaled breath as biomarkers for detection of lung cancer.

MATERIALS AND METHODS

Exhaled breath samples from 85 patients with untreated lung cancer, 34 patients with benign pulmonary nodules and 85 healthy controls were collected. Carbonyl compounds in exhaled breath were captured by silicon microreactors and analyzed by Fourier transform ion cyclotron resonance mass spectrometry (FT-ICR-MS). The concentrations of carbonyl compounds were analyzed using a variety of statistical classification models to determine which compounds best differentiated between the patient sub-populations. Predictive accuracy of each of the models was assessed on a separate test data set.

RESULTS

Six carbonyl compounds (C(4)H(8)O, C(5)H(10)O, C(2)H(4)O(2), C(4)H(8)O(2), C(6)H(10)O(2), C(9)H(16)O(2)) had significantly elevated concentrations in lung cancer patients vs.

CONTROLS

A model based on counting the number of elevated compounds out of these six achieved an overall classification accuracy on the test data of 97% (95% CI 92%-100%), 95% (95% CI 88%-100%), and 89% (95% CI 79%-99%) for classifying lung cancer patients vs. non-smokers, current smokers, and patients with benign nodules, respectively. These results were comparable to benchmarking based on established statistical and machine-learning methods. The sensitivity in each case was 96% or higher, with specificity ranging from 64% for benign nodule patients to 86% for smokers and 100% for non-smokers.

CONCLUSION

A model based on elevated levels of the six carbonyl VOCs effectively discriminates lung cancer patients from healthy controls as well as patients with benign pulmonary nodules.

Insights into the application of let-7 family as promising biomarker in cancer screening

Cancer is a leading cause of death worldwide with its low 5-year survival rate. Studies on the accuracy of let-7 family for human cancers have inconsistent conclusions, leading us to conduct this meta-analysis. This meta-analysis comprised of 11 studies from eight articles involving 805 cancer patients and 483 controls. The pooled parameters were as follows: sensitivity, 77 % (95 % confidence interval (CI) 73-81 %); specificity, 80 % (95 % CI 68-88 %); positive likelihood ratio (PLR), 3.8; negative likelihood ratio (NLR), 0.29; and diagnostic odds ratio (DOR) 13.0. In addition, we plotted the SROC and calculated the area under the curve (AUC) of 0.81 (95 % CI 0.78-0.84), which indicated a relatively high descriptive accuracy. In summary, our data suggested that let-7 family might be applied in noninvasive screening tests for human cancers, which needed to be validated in further large-scale studies.

GATA2 is epigenetically repressed in human and mouse lung tumors and is not requisite for survival of KRAS mutant lung cancer

INTRODUCTION

GATA2 was recently described as a critical survival factor and therapeutic target for KRAS mutant non-small-cell lung cancer (NSCLC). However, whether this role is affected by epigenetic repression of GATA2 in lung cancer is unclear.

METHODS

GATA2 expression and promoter CpG island methylation were evaluated using human and mouse NSCLC cell lines and tumor-normal pairs. In vitro assays were used to study GATA2 repression on cell survival and during tobacco carcinogen-induced transformation.

RESULTS

GATA2 expression in KRAS wild-type (n = 15) and mutant (n = 10) NSCLC cell lines and primary lung tumors (n = 24) was significantly lower, 1.3- to 33.6-fold (p = 2.2 × 10(9)), compared with corresponding normal lung. GATA2 promoter was unmethylated in normal lung (0 of 10) but frequently methylated in lung tumors (96%, 159 of 165) and NSCLC cell lines (97%, 30 of 31). This highly prevalent aberrant methylation was independently validated using The Cancer Genome Atlas data for 369 NSCLC tumor-normal pairs. In vitro studies using an established carcinogen-induced premalignancy model revealed that GATA2 expression was initially repressed by chromatin remodeling followed by cytosine methylation during transformation. Similarly, expression of GATA2 in NNK-induced mouse lung tumors (n = 6) and cell lines (n = 5) was fivefold and 100-fold lower, respectively, than normal mouse lung. Finally, siRNA-mediated knockdown of GATA2 in KRAS mutant (human [n = 4] and murine [n = 5]) and wild-type (human [n = 4]) NSCLC cell lines showed that further reduction of expression (up to 95%) does not induce cell death.

CONCLUSION

GATA2 is epigenetically repressed in human and mouse lung tumors and its further inhibition is not a valid therapeutic strategy for KRAS mutant lung cancer.

Li-Fraumeni syndrome: cancer risk assessment and clinical management

Carriers of germline mutations in the TP53 gene, encoding the cell-cycle regulator and tumour suppressor p53, have a markedly increased risk of cancer-related morbidity and mortality during both childhood and adulthood, and thus require appropriate and effective cancer risk management. However, the predisposition of such patients to multiorgan tumorigenesis presents a specific challenge for cancer risk management programmes. Herein, we review the clinical implications of germline mutations in TP53 and the evidence for cancer screening and prevention strategies in individuals carrying such mutations, as well as examining the potential psychosocial implications of lifelong management for a ubiquitous cancer risk. In addition, we propose an evidence-based framework for the clinical management of TP53 mutation carriers and provide a platform for addressing the management of other cancer predisposition syndromes that can affect multiple organs.

Prognosis of recurrence after complete resection in early-stage non-small cell lung cancer

Background

Tumor recurrence is the most common cause of treatment failure, even after complete resection of early-stage non-small cell lung cancer (NSCLC). In this study, we investigated the prognosis of patients with early recurrence in order to identify independent risk factors related to early recurrence.

Methods

Between February 1995 and December 2012, 242 patients who underwent surgical resection for stage I NSCLC at Dong-A University Hospital were reviewed. The factors predicting overall survival (OS) and early recurrence were investigated. We also investigated the relationship between the patterns and period of recurrence and clinicopathological factors.

Results

For patients with stage IA and IB NSCLC, the 5-year OS rate was 75.7% and 57.3% (p=0.006), respectively. A multivariate Cox proportional hazards model demonstrated that gender (p=0.004), comorbidity number (p=0.038), resection type (p=0.002), and tumor size (p=0.022) were the statistically significant predictors of OS. Moreover, the multivariate analysis revealed that smoking history (p=0.023) and histologic grade (p=0.012) were the independent predictors of early recurrence. Additionally, only histologic grade (poor differentiation) was found to be significantly associated with a higher frequency of distant metastasis; there was no relationship between the patterns and period of recurrence and clinicopathological factors.

Conclusion

The present study demonstrated that smoking history and histologic grade were independent prognostic factors for early recurrence within two years in patients with early-stage NSCLC. Patients with these predictive factors may be good candidates for adjuvant therapy.

Methylation of breast cancer susceptibility gene 1 (BRCA1) predicts recurrence in patients with curatively resected stage I non-small cell lung cancer

BACKGROUND

Even after early detection and curative resection of early stage non-small cell lung cancer (NSCLC), a significant fraction of patients develop recurrent disease. Molecular biomarkers that can predict the risk of recurrence thus need to be identified to improve clinical outcomes.

METHODS

Using the methylation-specific polymerase chain reaction assay, promoter methylation of the breast cancer susceptibility gene 1 (BRCA1) was assessed in cancer tissues from 70 patients with curatively resected stage I NSCLC. The clinical relevance of BRCA1 methylation status was evaluated in terms of outcome of the disease.

RESULTS

Methylation of the BRCA1 promoter was detected in 13 of 70 patients (18.6%). Multiple logistic regression analysis revealed that BRCA1 methylation was an independent risk factor for recurrence (P = .0197) and that patients with BRCA1 methylation demonstrated significantly poorer recurrence-free survival compared to those without (P = .0139). Cox's proportional hazard regression analysis revealed that BRCA1 methylation was an independent risk factor for recurrence-free survival (P = .0155).

CONCLUSIONS

Methylated BRCA1 can be a potential biomarker that predicts the prognosis after curative resection of stage I NSCLC. Considering that BRCA1 plays a role in chemotherapy-induced apoptosis, it is plausible that identification of methylated BRCA1 could provide information that is clinically relevant to tailored adjuvant therapy.

Stereotactic body radiation therapy and 3-dimensional conformal radiotherapy for stage I non-small cell lung cancer: A pooled analysis of biological equivalent dose and local control

PURPOSE

To determine the relationship between tumor control probability (TCP) and biological effective dose (BED) for radiation therapy in medically inoperable stage I non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

Forty-two studies on 3-dimensional conformal radiation therapy (3D-CRT) and SBRT for stage I NSCLC were reviewed for tumor control (TC), defined as crude local control ≥ 2 years, as a function of BED. For each dose-fractionation schedule, BED was calculated at isocenter using the linear quadratic (LQ) and universal survival curve (USC) models. A scatter plot of TC versus BED was generated and fitted to the standard TCP equation for both models.

RESULTS

A total of 2696 patients were included in this study (SBRT: 1640; 3D-CRT: 1056). Daily fraction size was 1.2-4 Gy (total dose: 48-102.9) with 3D-CRT and 6-26 (total dose: 20-66) with SBRT. Median BED was 118.6 Gy (range, 68.5-320.3) and 95.6 Gy (range, 46.1-178.1) for the LQ and USC models, respectively. According to the LQ model, BED to achieve 50% TC (TCD50) was 61 Gy (95% confidence interval, 50.2-71.1). TCP as a function of BED was sigmoidal, with TCP ≥ 90% achieved with BED ≥ 159 Gy and 124 Gy for the LQ and USC models, respectively.

CONCLUSIONS

Dose-escalation beyond a BED 159 by LQ model likely translates into clinically insignificant gain in TCP but may result in clinically significant toxicity. When delivered with SBRT, BED of 159 Gy corresponds to a total dose of 53 Gy in 3 fractions at the isocenter.

Identification of ten serum microRNAs from a genome-wide serum microRNA expression profile as novel noninvasive biomarkers for nonsmall cell lung cancer diagnosis

The detection of nonsmall cell lung cancer (NSCLC) at an early stage presents a daunting challenge due to the lack of a specific noninvasive marker. The discovery of microRNAs (miRNAs), particularly those found in serum, has opened a new avenue for tumor diagnosis. To determine whether the expression profile of serum miRNAs can serve as a NSCLC fingerprint, we performed Taqman probe-based quantitative RT-PCR assay to selected differentially expressed serum miRNAs from a sample set including 400 NSCLC cases and 220 controls, and risk score analysis to evaluate the diagnostic value of the serum miRNA profiling system. After a two-phase selection and validation process, 10 miRNAs were found to have significantly different expression levels in NSCLC serum samples compared with the control serum samples. Risk score analysis showed that this panel of miRNAs was able to distinguish NSCLC cases from controls with high sensitivity and specificity. Under ROC curves, the AUC for tumor identification in training set and validation set were 0.966 and 0.972, respectively. Furthermore, the expression profile of the 10-serum miRNAs was correlated with the stage of NSCLC patients, especially in younger patients and patients with current smoking habits. More importantly, the serum miRNA-based biomarker for early NSCLC detection was supported by a retrospective analysis in which the 10-serum miRNA profile could accurately classify serum samples collected up to 33 months ahead of the clinical NSCLC diagnosis. Taken together, we demonstrate that the profiling of 10-serum miRNAs provides a novel noninvasive biomarker for NSCLC diagnosis.

Circulating microRNAs: a novel class of biomarkers to diagnose and monitor human cancers

Specific and sensitive non-invasive biomarkers for the detection of human epithelial malignancies are urgently required to reduce the worldwide morbidity and mortality caused by cancer. MicroRNAs (miRNAs) are 19-24 nt noncoding RNAs that are frequently dysregulated in cancer and have shown great promise as tissue-based markers for cancer classification. Once thought to be unstable RNA molecules, miRNAs are now shown to be stably expressed in serum, plasma, urine, saliva, and other body fluids. Moreover, the unique expression patterns of these circulating miRNAs are correlated with certain human diseases, including various types of cancer. Therefore, tumor-derived miRNAs in serum or plasma are emerging as novel blood-based fingerprints for the detection of human cancers, especially at an early stage. This review presented newly uncovered cellular and molecular mechanisms of the sources and stability of circulating miRNAs, revealing their great potential as a class of highly specific and sensitive biomarkers for tumor classification and prognostication. Meanwhile, this review also addressed certain critical issues that hinder the wide application of this new approach. Some potential challenges for the transition of circulating miRNAs from a research setting to a clinical application were also highlighted, with a future perspective of the incorporation of circulating miRNAs in the field of clinical oncology, especially their great potential from diagnostic to prognostic and predictive applications.

[Reason for a medical visit in the diagnosis of lung cancer. A review of 481 cases]

INTRODUCTION

Lung cancer is the most frequent cancer death related cause in the world. Its clinical presentation usually corresponds to advanced stages. The indication of screening programs for the diagnosis in early phases has been debated for years.

AIMS

To know the clinical characteristics in the presentation of the lung cancer in our health care area.

MATERIAL AND METHODS

All of the incident lung cancer cases for 3 years (January 1, 1997 to December 31, 1999) among those patients with usual residence in the Santiago de Compostela health care area were retrospectively collected from the available information in the Codification Service. The histological type was graded according to the World Health Organization classification. Date of death was obtained from the patient's clinical history, mortality record, or telephonic calls to the patient's home. The rest of the information was obtained from the clinical records of the patient and Pathology Service.

RESULTS

Four-hundred and eighty-one lung cancer cases were diagnosed (incident gross rate of 41.79 per 100,000 inhabitants and year). Median age was 66.9 years (interquartile range 60.5-74.4), 92.77% being males and 94.1% corresponding to smokers or former smokers. The most prevalent symptoms motivating the visit were general syndrome (20%), thoracic pain (19%) and hemoptisis (17%). A group of patients (56), fundamentally males, had an incidental diagnosis.

CONCLUSIONS

The incidence of lung cancer seems to be high in our health care area. The standard patient with lung cancer in this health care area is a 67-year-old, male, who smokes, diagnosed in advanced stages, who consults due to a general syndrome and/or chest pain. Some of the symptoms appear with significant gender differences. Likewise, there are differences between histologies, the high frequency of chest pain in adenocarcinoma being outstanding, although it is also the first cause for consultation in small cell lung cancer. On the contrary, hemoptisis, the most frequent consultation cause in squamous cell carcinoma and the general syndrome in the big cells type or with clinical-radiological diagnosis.

Application of robotic stereotactic radiotherapy to peripheral stage I non-small cell lung cancer with curative intent

AIMS

To determine the effectiveness of robotic stereotactic radiotherapy with image guidance and real-time respiratory tracking against early stage peripheral lung cancer.

MATERIALS AND METHODS

We treated patients with stage I non-small cell lung cancer (NSCLC) with CyberKnife and analysed their clinical characteristics and outcomes. All patients had co-morbid conditions that precluded lobectomy. The clinical target volume (CTV) included the gross tumour volume (GTV) and a 6mm margin in all directions to account for microscopic extension. The planning target volume (PTV) equalled CTV+2mm in all directions for uncertainty. Tumour motion was tracked using a combination of Synchrony and Xsight Spine tracking methods with the aid of a single gold marker implanted in the centre of the tumour, or using the newer Xsight Lung method without markers for selected tumours. A 60-67.5 Gy dose was prescribed to the 60-80% isodose line (median 65%) and given in three to five fractions. Patients were followed every 3 months for a median of 27.5 months (range 24-53 months).

RESULTS

Of the 67 patients with NSCLC stage IA or IB treated between January 2004 and December 2008, we report the results of a cohort of 31 with peripheral stage I tumours of 0.6-71 cm(3) volume treated between January 2004 and December 2007 with total doses between 60 and 67.5 Gy in three to five fractions. The median D(max) was 88.2 Gy and the median V(95) of the PTV was 99.6% or 27.9 cm(3). No grade 3 or above toxicity was encountered. Four cases of radiation pneumonitis and one case of oesophagitis were observed. In those patients whose pre- and post-treatment results were available, no change in pulmonary function tests was observed. Actuarial local control was 93.2% for 1 year and 85.8% for up to 4.5 years. One-year overall survival was 93.6% and 83.5% for up to 4.5 years, as projected by Kaplan-Meier analyses.

CONCLUSIONS

In this small cohort of patients with stage I peripheral NSCLC, robotic stereotactic radiotherapy seems to be a safe and obviously superior alternative to conventionally fractionated radiotherapy, with results that may be approaching those obtained with lobectomy without the associated morbidity.

Stereotactic body radiation therapy for early-stage non-small-cell lung carcinoma: four-year results of a prospective phase II study

PURPOSE

The 50-month results of a prospective Phase II trial of stereotactic body radiation therapy (SBRT) in medically inoperable patients are reported.

METHODS AND MATERIALS

A total of 70 medically inoperable patients had clinically staged T1 (34 patients) or T2 (36 patients) (< or =7 cm), N0, M0, biopsy-confirmed non-small-cell lung carcinoma (NSCLC) and received SBRT as per our previously published reports. The SBRT treatment dose of 60-66 Gy was prescribed to the 80% isodose volume in three fractions.

RESULTS

Median follow-up was 50.2 months (range, 1.4-64.8 months). Kaplan-Meier local control at 3 years was 88.1%. Regional (nodal) and distant recurrence occurred in 6 (8.6%) and 9 (12.9%) patients, respectively. Median survival (MS) was 32.4 months and 3-year overall survival (OS) was 42.7% (95% confidence interval [95% CI], 31.1-54.3%). Cancer-specific survival at 3 years was 81.7% (95% CI, 70.0-93.4%). For patients with T1 tumors, MS was 38.7 months (95% CI, 25.3-50.2) and for T2 tumors MS was 24.5 months (95% CI, 18.5-37.4) (p = 0.194). Tumor volume (< or =5 cc, 5-10 cc, 10-20 cc, >20 cc) did not significantly impact survival: MS was 36.9 months (95% CI, 18.1-42.9), 34.0 (95% CI, 16.9-57.1), 32.8 (95% CI, 21.3-57.8), and 21.4 months (95% CI, 17.8-41.6), respectively (p = 0.712). There was no significant survival difference between patients with peripheral vs. central tumors (MS 33.2 vs. 24.4 months, p = 0.697). Grade 3 to 5 toxicity occurred in 5 of 48 patients with peripheral lung tumors (10.4%) and in 6 of 22 patients (27.3%) with central tumors (Fisher's exact test, p = 0.088).

CONCLUSION

Based on our study results, use of SBRT results in high rates of local control in medically inoperable patients with Stage I NSCLC.

A multigene assay is prognostic of survival in patients with early-stage lung adenocarcinoma

PURPOSE

Clinical staging does not adequately risk stratify patients with early stage non-small cell lung cancer. We sought to generate a real-time PCR (RT-PCR)-based prognostic model in patients with early stage lung adenocarcinoma, the dominant histology of lung cancer in the United States.

EXPERIMENTAL DESIGN

We studied gene expression of 61 candidate genes in 107 patients with completely surgically resected lung adenocarcinoma using RT-PCR. We used crossvalidation methods to select and validate a prognostic model based on the expression of a limited number of genes. A risk score was generated based on model coefficients, and survival of patients with high- and low-risk scores were analyzed.

RESULTS

We generated a four-gene model based on expression of WNT3a, ERBB3, LCK, and RND3. Risk score predicted mortality better than clinical stage or tumor size (adjusted hazard ratio, 6.7; 95% confidence interval, 1.6-28.9; P=0.001). Among 70 patients with stage I disease, 5-year overall survival was 87% among patients with low-risk scores, and 38% among patients with high-risk scores (P=0.0002). Among all patients, 5-year overall survival was 62% and 41%, respectively (P=0.0054). Disease-free survival was also significantly different among low- and high-risk score patients.

CONCLUSIONS

This multigene assay predicts overall and disease-free survival significantly better than clinical stage and tumor size in patients with early stage lung adenocarcinoma and performs especially well in patients with stage I disease. Prospective clinical trials are needed to determine whether high-risk patients with stage I disease benefit from adjuvant chemotherapy.

Exhaled breath analysis: novel approach for early detection of lung cancer

Lung cancer is a leading cause of cancer death, with the prognosis adversely affected by late diagnosis. Early diagnosis of lung cancer is desirable, but current evidence does not support the application of screening with techniques such as chest radiography, sputum cytology or computed tomography. Breath analysis, which includes gaseous phase analysis that measures volatile organic compounds using electronic noses, exhaled nitric oxide, and exhaled breath condensate (EBC), has been proposed as a non-invasive and simple technique to investigate neoplastic processes in the airways. EBC can be easily collected by breathing into a cooling system that condenses the water vapour in the breath. EBC has already been demonstrated to be useful in investigating inflammatory and oxidative stress changes in various respiratory conditions as it contains measurable mediators of airway inflammation and oxidative stress markers. Furthermore, EBC has also been shown to be a useful method to monitor severity of diseases such as asthma and to act as a surrogate measure of compliance to medical therapy. Presently, there still remains a relative paucity of lung cancer research involving EBC. However, since EBC is a simple, non-invasive technique that can be easily performed, even in ill patients, it has the potential to be validated for use in screening for the early diagnosis of lung cancer.

Ethnic/Racial Disparities in Hospital Procedure Volume for Lung Resection for Lung Cancer

BACKGROUND

Ethnic/racial minorities experience poorer outcomes from lung cancer than non-Hispanic whites. Higher hospital procedure volume is associated with better survival from lung resection for lung cancer.

OBJECTIVES

We examined whether (1) ethnic/racial minorities are more likely to obtain lung resections at lower volume hospitals, (2) ethnicity/race is associated with inpatient mortality, (3) hospital volume mediates this association, and (4) hospital selection is mediated by racial/ethnic segregation, differences in insurance coverage, or limited hospital choice.

METHODS

Six years of data from the Nationwide Inpatient Sample (NIS 1998-2003, unweighted n = 50,245, weighted n = 129,506) were used in multivariate models controlling for sociodemographic factors, case complexity, and hospital characteristics. Additional analyses were conducted using the Area Resource File, which provided data on ethnic density and number of surgical hospitals in the hospital region.

RESULTS

Blacks/African Americans (odds ratio [OR] = 0.45; 0.34-0.58) and Latinos (OR = 0.44; 0.32-0.63) had lower odds of obtaining lung resection at a high-volume hospital than non-Hispanic whites. Blacks/African Americans (OR = 1.30; 1.01-1.67), Latinos (OR = 1.41; 1.02-1.94), and other racial/ethnic minorities (OR = 1.46; 1.04-2.06) also had higher odds of dying in hospital, but this association was statistically nonsignificant after controlling for hospital volume. Hospital location was not associated with lung resection procedure volume, nor did location mediate the association between ethnicity/race and hospital volume.

CONCLUSIONS

Ethnic/racial minorities are obtaining lung resection in lower volume hospitals and are more likely to die in hospital. Hospital volume is associated with higher mortality, but health insurance, segregation, and number of surgical hospitals within a county do not account for observed disparities.

Natural History of Stage I Non-Small Cell Lung Cancer

BACKGROUND

Concern has been raised that early detection of lung cancer may lead to the treatment of clinically indolent cancers. No population-based study has examined the natural history of patients with stage I NSCLC who receive no surgery, chemotherapy, or radiation therapy. Our hypothesis is that long-term survival in patients with untreated stage I non-small cell lung cancer (NSCLC) is uncommon.

METHODS

A total of 101,844 incident cases of NSCLC in the California Cancer Center registry between 1989 and 2003 were analyzed; 19,702 patients had stage I disease, of whom 1,432 did not undergo surgical resection or receive treatment with chemotherapy or radiation. Five-year overall survival (OS) and lung cancer-specific survival were determined for this untreated group, for subsets of patients who were recommended but refused surgical resection, and for T1 tumors.

RESULTS

Only 42 patients with untreated stage I NSCLC were alive 5 years after diagnosis. Five-year OS for untreated stage I NSCLC was 6% overall, 9% for T1 tumors, and 11% for patients who refused surgical resection. Five-year lung cancer-specific survival rates were 16%, 23%, and 22%, respectively. Among these untreated patients, median survival was 9 months overall, 13 months for patients with T1 disease, and 14 months for patients who refused surgical resection.

CONCLUSION

Long-term survival with untreated stage I NSCLC is uncommon, and the vast majority of untreated patients die of lung cancer. Given that median survival is only 13 months in patients with T1 disease, surgical resection or other ablative therapies should not be delayed even in patients with small lung cancers.

[18F-FDG PET and bone scintigraphy to search for bone metastasis of lung cancer]

Initial staging of lung cancer is essential to determine the appropriate therapeutic strategy. 18F-FDG PET is currently considered to be the gold standard. 99mTc bisphonate bone scintigraphy has long been indicated to search for bone metastases but it is not know whether this exploration adds further information after an 18F-FDG PET scan. In order to answer this question, two observers unaware of the clinical situation reread PET scans and bone scintigraphies and results compared with other imaging findings. Between February 2001 and March 2004, 39 patients (13F, 26M, 62 +/- 11 yr) underwent 18FFDG PET and bone scintigraphy (mean interval 17 +/- 17 d). When the two explorations agreed for the diagnosis of bone extension, we considered that bone scintigraphy added nothing. When the two explorations were in disagreement, the other imaging examinations, the clinical features and laboratory results during the five-month minimal follow-up were used to establish the reference diagnosis. 18F-FDG PET and bone scintigraphy were in agreement in 29 patients (74%) with positive results in 12 (31%) and negative results in 17 (43%). The two explorations were in disagreement in 10 patients (26%). Among the five disagreement cases with positive bone scintigraphy and no bone anomaly on the 18F-FDG PET, the anomalies were benign and explained by clinical features (3 patients) or were not confirmed by the clinical course and laboratory results (2 patients). Among the 5 cases with a bone anomaly on the 18F FDG PET, no metastasis could be identified during clinical follow-up. Bone scintigraphy does not enable identification of any bone metastases which were not recognized on the PET scan and therefore should not be performed systematically. Using a computed tomography scan with the 18F-FDG PET could further limit the contribution of bone scintigraphy by providing more precision concerning foci identified on the PET scan.

Incidental lung cancers identified at coronial autopsy: implications for overdiagnosis of lung cancer by screening

BACKGROUND

The extent to which overdiagnosis occurs in lung cancer screening programmes has been debated. Overdiagnosis refers to the detection by screening of cancers that would not have become clinically apparent or symptomatic before that individual died of other causes.

METHODS

A retrospective review of coronial autopsies performed in Victoria between April 1991 and February 2002 was conducted to determine the rate of incidental lung cancer in individuals who died of natural causes.

RESULTS

A total of 24,708 autopsy reports were searched electronically. We estimated that in 56% of these death was from natural causes. Amongst individuals who died naturally there were 167 cases of lung cancer, 47 of these were incidental including five carcinoid tumours, three small cell tumours, 11 cases of carcinoma in situ and 28 invasive nonsmall cell lung cancers. Of the incidental invasive nonsmall cell lung cancers, 86% were stage I.

CONCLUSIONS

Although incidental lung cancer is uncommon, there are some lung cancers that remain undetected during life and do not contribute to death. These findings support the hypothesis that some lung cancers detected by screening may never progress to cause symptoms or death in that individual's lifetime and therefore may be overdiagnosed by screening.

Comparison of whole-body FDG-PET to bone scan for detection of bone metastases in patients with a new diagnosis of lung cancer

The purpose of this study was to compare the accuracy and agreement of whole-body positron-emission tomography (PET) scan to bone scintigraphy for the detection of bony metastases in staging patients with newly diagnosed lung cancer. The tumor registry and nuclear medicine database at our institution were queried and identified all patients between July 1998 and August 2002 with a new diagnosis of lung cancer, a whole-body 2-deoxy-2-[18F]fluoro-D-glucose (FDG)-PET scan, and a bone scan prior to therapy. All of these patients' radiologic reports were then retrospectively reviewed, and confirmation of bone metastases was determined by consideration of all available clinical information. The sensitivity, specificity, and accuracy for each study were then calculated. Two hundred and fifty-seven patients fulfilled the entrance criteria. One hundred and four patients (40%) presented with stage IV disease, and bone metastases were confirmed in 57 (22%) patients. The accuracies of PET and bone scan were 94 and 85% (P < 0.05), sensitivity values were 91 and 75%, and specificity values were 96 and 95%, respectively. The weighted-kappa statistic suggested moderate agreement between the two modalities KW = 0.510, 95% CI, 0.402-0.618). The use of both whole-body PET and bone scintigraphy as initial staging studies in lung cancer patients provides redundant information about the presence of bony metastases. The improvement in accuracy and sensitivity with PET suggests bone scan can be eliminated from the staging evaluation at presentation. Due to its retrospective nature, the results of this study are subject to several forms of bias including selection bias, verification bias, test review bias, and incorporation bias. A prospective trial with appropriate verification of bony metastases is suggested to confirm the results.

Preoperative pulmonary function as a prognostic factor for stage I non–small cell lung carcinoma

BACKGROUND

The aim of this study was to clarify preoperative lung function as a prognostic factor for the long-term survival of, and to discuss the appropriateness of lobectomy for, patients with stage I non-small cell lung carcinoma who have poor preoperative pulmonary function.

METHODS

The study group consisted of 402 lobectomized patients with stage I non-small cell lung carcinoma treated by complete resection from 1985 to 1997. Preoperative percent forced vital capacity [(forced vital capacity/predicted forced vital capacity) x 100], FEV(1)% [(forced expiratory volume in 1 second/forced vital capacity) x 100], arterial carbon dioxide tension, and smoking were statistically analyzed as prognostic factors together with other host and tumor biologic factors.

RESULTS

Multivariate analysis demonstrated that tumor size (p < 0.0001) was the most significant prognostic factor for survival from primary lung cancer. Age (p < 0.0001), sex (p = 0.0036), and FEV(1)% (p = 0.0046) were found to be independent prognostic factors for survival from death by nonprimary lung cancer-related causes. Smoking was highly correlated with FEV(1)% (correlation coefficient = -0.511; p < 0.0001). The 100 patients with a preoperative FEV(1)% less than 70% included 34 patients with nonprimary lung cancer-related deaths, whereas the 302 patients with an FEV(1)% of 70% or greater included only 23 patients (p < 0.0001).

CONCLUSIONS

Along with tumor size, FEV(1)% is the most significant prognostic factor for patients with stage I non-small cell lung carcinoma with regard to survival from death by other causes. Lobectomy may not be preferred as an appropriate surgical modality for patients with stage I non-small cell lung carcinoma with small peripheral nodules who exhibit poor pulmonary function, especially lowered FEV(1)%.

Lung cancer detection by a RT-nested PCR using MAGE A1--6 common primers

BACKGROUND

Since the mortality of lung cancer patients remains very high, the development of a sensitive detection method remains an urgent task. The authors have designed common melanoma antigen gene (MAGE) primers that enable the detection of MAGE A1 to A6 subtypes simultaneously. These primers were applied to the detection of lung cancer using sputum specimens.

METHODS

The study involved, 53 cancer patients and three non-cancer groups (193 healthy people, 235 lung cancer screening group and 140 patients with benign lung diseases) were investigated. One hundred and thirty-six respiratory specimens (55 random sputa, 33 induced sputa, 40 broncho-alveolar lavage (BAL) fluids, and 8 pleural fluids) from different lung cancer patients were blindly tested. The MAGE assay was performed by RT-nested PCR, and the results obtained from sputum were compared with those obtained by telomerase assay and conventional cytology.

RESULTS

In the sputum of the non-cancer groups, the positive rates were less than 2.1%, while the detection rates were 83.3% in the cancer tissues and 54.3% in the sputa of lung cancer patients. For the random sputum samples of lung cancer patients, the detection rate was 47.5%, but in the induced sputum, BAL and pleural fluids, the detection rate was up to over 70.0%. The MAGE assay produced a higher detection rate than the telomerase assay and conventional cytology.

CONCLUSIONS

MAGE A1-6 RT-PCR, which showed high sensitivity and specificity, provides an effective means for the lung cancer detection in sputum.

Tolerance of organs at risk in small-volume, hypofractionated, image-guided radiotherapy for primary and metastatic lung cancers

PURPOSE

To determine the organ at risk and the maximum tolerated dose (MTD) of radiation that could be delivered to lung cancer using small-volume, image-guided radiotherapy (IGRT) using hypofractionated, coplanar, and noncoplanar multiple fields.

MATERIALS AND METHODS

Patients with measurable lung cancer (except small-cell lung cancer) 6 cm or less in diameter for whom surgery was not indicated were eligible for this study. Internal target volume was determined using averaged CT under normal breathing, and for patients with large respiratory motion, using two additional CT scans with breath-holding at the expiratory and inspiratory phases in the same table position. Patients were localized at the isocenter after three-dimensional treatment planning. Their setup was corrected by comparing two linacographies that were orthogonal at the isocenter with corresponding digitally reconstructed images. Megavoltage X-rays using noncoplanar multiple static ports or arcs were used to cover the parenchymal tumor mass. Prophylactic nodal irradiation was not performed. The radiation dose was started at 60 Gy in 8 fractions over 2 weeks (60 Gy/8 Fr/2 weeks) for peripheral lesions 3.0 cm or less, and at 48 Gy/8 Fr/2 weeks at the isocenter for central lesions or tumors more than 3.0 cm at their greatest dimension.

RESULTS

Fifty-seven lesions in 45 patients were treated. Tumor size ranged from 0.6 to 6.0 cm, with a median of 2.6 cm. Using the starting dose, 1 patient with a central lesion died of a radiation-induced ulcer in the esophagus after receiving 48 Gy/8 Fr at isocenter. Although the contour of esophagus received 80% or less of the prescribed dose in the planning, recontouring of esophagus in retrospective review revealed that 1 cc of esophagus might have received 42.5 Gy, with the maximum dose of 50.5 Gy. One patient with a peripheral lesion experienced Grade 2 pain at the internal chest wall or visceral pleura after receiving 54 Gy/8 Fr. No adverse respiratory reaction was noted in the symptoms or respiratory function tests. The 3-year local control rate was 80.4% +/- 7.1% (a standard error) with a median follow-up period of 17 months for survivors. Because of the Grade 5 toxicity, we have halted this Phase I/II study and are planning to rearrange the protocol setting accordingly. The 3-year local control rate was 69.6 +/- 10.6% for patients who received 48 Gy and 100% for patients who received 60 Gy (p = 0.0442).

CONCLUSIONS

Small-volume IGRT using 60 Gy in eight fractions is highly effective for the local control of lung tumors, but MTD has not been determined in this study. The organs at risk are extrapleural organs such as the esophagus and internal chest wall/visceral pleura rather than the pulmonary parenchyma in the present protocol setting. Consideration of the uncertainty in the contouring of normal structures is critically important, as is uncertainty in setup of patients and internal organ in the high-dose hypofractionated IGRT.

Effect of preoperative delay on prognosis for patients with early stage non-small cell lung cancer

OBJECTIVE

Screening for lung cancer will discover many nodules of indeterminate pathology. Observation has the theoretic risk of permitting dissemination of a localized cancer and worsening prognosis, whereas immediate evaluation of benign conditions generates morbidity and cost. This study was conducted to assess the effect of delay in surgical intervention on survival for patients with early stage non-small cell lung cancer.

METHODS

Records for patients with resected pathologic stage I and II non-small cell lung cancer (1989-1999) were abstracted for patient age, race, sex, medical history, date of presentation, date and type of surgical treatment, pathologic stage, and date of death or last follow-up. Kaplan-Meier survival analysis was performed to test for the effect of delay (time from presentation to surgical intervention) on survival.

RESULTS

Eighty-four patients were identified. Median age was 66 years, median preoperative interval was 82 days (range, 1-641 days), and median follow-up was 3.3 years (range, 5 days-11.9 years). Median survival was 3.7 years. Overall 5-year survival was 40%; disease-specific 5-year survival was 63%. Log-rank analysis of the effect of delay on overall survival generated a P value of.54, with an estimated hazard ratio for a 90-day delay of 1.06 (95% confidence interval, 0.87-1.30).

CONCLUSIONS

For this population, we were unable to detect a significant effect of delay on prognosis. Although these results suggest that the risk of judicious observation of indeterminate pulmonary nodules might be low, the 95% confidence interval is broad. Larger sample sizes are needed to reach definitive conclusions.

A half-yearly chest radiograph for early detection of lung cancer following oral cancer

In a retrospective analysis of 339 patients, treated with a curative intention for a squamous cell carcinoma of the oral cavity between 1988-1996, the value of a half-yearly routine chest radiograph during the first 2 years of follow-up, was evaluated. Metastatic or primary lung malignancies developed in 18 (5.3%) of the 339 patients in the first 2 years of the follow-up. In 11 (3.2%) patients these malignancies were detected on routine chest radiographs while in 7 (2.0%) patients these were detected on chest radiographs taken because of pulmonary complaints. The mean survival after detection of the pulmonary malignancy was 8 months. All patients died within 21 months, independent of pathology or therapy. No correlation was found between stage, location or differentiation of the primary tumour. As a result of this study it can be concluded that there is no benefit for the patient for a 6-month thoracic radiograph in routine follow-up for patients with oral squamous cell carcinoma. It gives false certainty and burdens the health care system.

Staging classification of lung cancer. A critical evaluation

The International System for Staging Lung Cancer has been validated as a prognostic index and questioned regarding the implications of factors that require further study. As technology for evaluating the anatomic extent of disease is increasingly refined, the accuracy of clinical staging is greatly improved and provides a major benefit for individualized treatment selection. Advancing knowledge of the origin and development of lung tumors presents the challenge of appropriate integration of this body of science into clinical practice.