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Chang JC, Rekhtman N. Pathologic Assessment and Staging of Multiple Non-Small Cell Lung Carcinomas: A Paradigm Shift with the Emerging Role of Molecular Methods. Mod Pathol 2024; 37:100453. [PMID: 38387831 PMCID: PMC11102290 DOI: 10.1016/j.modpat.2024.100453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
Non-small cell lung carcinomas (NSCLCs) commonly present as 2 or more separate tumors. Biologically, this encompasses 2 distinct processes: separate primary lung carcinomas (SPLCs), representing independently arising tumors, and intrapulmonary metastases (IPMs), representing intrapulmonary spread of a single tumor. The advent of computed tomography imaging has substantially increased the detection of multifocal NSCLCs. The strategies and approaches for distinguishing between SPLCs and IPMs have evolved significantly over the years. Recently, genomic sequencing of somatic mutations has been widely adopted to identify targetable alterations in NSCLC. These molecular techniques have enabled pathologists to reliably discern clonal relationships among multiple NSCLCs in clinical practice. However, a standardized approach to evaluating and staging multiple NSCLCs using molecular methods is still lacking. Here, we reviewed the historical context and provided an update on the growing applications of genomic testing as a clinically relevant benchmark for determining clonal relationships in multiple NSCLCs, a practice we have designated "comparative molecular profiling." We examined the strengths and limitations of the morphology-based distinction of SPLCs vs IPMs and highlighted pivotal clinical and pathologic insights that have emerged from studying multiple NSCLCs using genomic approaches as a gold standard. Lastly, we suggest a practical approach for evaluating multiple NSCLCs in the clinical setting, considering the varying availability of molecular techniques.
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Affiliation(s)
- Jason C Chang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Natasha Rekhtman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Zhao L, Wang J, Zhang Y, Wang P, Lv C, Zhao S, Guo T, Li F, Gu C, Zhu Y. Genomic heterogeneity of multiple synchronous lung cancers in Chinese population. Cancer Med 2024; 13:e6928. [PMID: 38348924 PMCID: PMC10839131 DOI: 10.1002/cam4.6928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/24/2023] [Accepted: 12/31/2023] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION It is clinically challenging to infer the phylogenetic relationship between different tumor lesions of patients with multiple synchronous lung cancers (MSLC), whether these lesions are the result of independently evolved tumor or intrapulmonary metastases. METHODS We used the Illumina X10 platform to sequence 128 stage I lung cancer samples collected from 64 patients with MSLC. All samples were analyzed for mutation spectra and phylogenetic inference. RESULTS We detected genetic aberrations within genes previously reported to be recurrently altered in lung adenocarcinoma including, EGFR, ERBB2, TP53, BRAF, and KRAS. Other putative driver mutations identified were enriched in RTK-RAS signaling, TP53 signaling, and cell cycle. Also, we found some interesting cases, two cases that carried EGFR L858R and T790M co-mutation in one tumor and another tumor with only EGFR 19del, and 1 case with two KRAS hotspots in the same tumor. Due to the short follow-up time and early stage, further investigation is needed to determine whether this unique mutation profile will affect their progression-free survival (PFS) and overall survival (OS). Regarding genetic evolution analysis among 64 tumor samples, 50 of them display distinct mutational profiles, suggesting these are independently evolved tumors, which is consistent with histopathological assessment. On the other hand, six patients were identified to be intrapulmonary metastasis as the mutations harbored in different lesions are clonally related. CONCLUSION In summary, unlike intrapulmonary metastases, patients with MSLC harbor distinct genomic profiles in different tumor lesions, and we could distinguish MSLC from intrapulmonary metastases via clonality estimation.
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Affiliation(s)
- Lei Zhao
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Jin Wang
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yixiang Zhang
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Peng Wang
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Changsheng Lv
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Shilei Zhao
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Tao Guo
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Fengzhou Li
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Chundong Gu
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yuntao Zhu
- Department of Thoracic Surgerythe First Affiliated Hospital of Dalian Medical UniversityDalianChina
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Powell CL, Saddoughi SA, Wigle DA. Progress in genome-inspired treatment decisions for multifocal lung adenocarcinoma. Expert Rev Respir Med 2023; 17:1009-1021. [PMID: 37982734 DOI: 10.1080/17476348.2023.2286277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/17/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Multifocal lung adenocarcinoma (MFLA) is becoming increasingly recognized as a distinct subset of lung cancer, with unique biology, disease course, and treatment outcomes. While definitions remain controversial, MFLA is characterized by the development and concurrent presence of multiple independent (non-metastatic) lesions on the lung adenocarcinoma spectrum. Disease progression typically follows an indolent course measured in years, with a lower propensity for nodal and distant metastases than other more common forms of non-small cell lung cancer. AREAS COVERED Traditional imaging and histopathological analyses of tumor biopsies are frequently unable to fully characterize the disease, prompting interest in molecular diagnosis. We highlight some of the key questions in the field, including accurate definitions to identify and stage MLFA, molecular tests to stratify patients and treatment decisions, and the lack of clinical trial data to delineate best management for this poorly understood subset of lung cancer patients. We review the existing literature and progress toward a genomic diagnosis for this unique disease entity. EXPERT OPINION Multifocal lung adenocarcinoma behaves differently than other forms of non-small cell lung cancer. Progress in molecular diagnosis may enhance potential for accurate definition, diagnosis, and optimizing treatment approach.
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Affiliation(s)
- Chelsea L Powell
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sahar A Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dennis A Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Wang Z, Yuan X, Jiang G, Li Y, Yang F, Wang J, Chen K. Towards the molecular era of discriminating multiple lung cancers. EBioMedicine 2023; 90:104508. [PMID: 36958271 PMCID: PMC10040518 DOI: 10.1016/j.ebiom.2023.104508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 03/25/2023] Open
Abstract
In the era of histopathology-based diagnosis, the discrimination between multiple lung cancers (MLCs) poses significant uncertainties and has thus become a clinical dilemma. However, recent significant advances and increased application of molecular technologies in clonal relatedness assessment have led to more precision in distinguishing between multiple primary lung cancers (MPLCs) and intrapulmonary metastasis (IPMs). This review summarizes recent advances in the molecular identification of MLCs and compares various methods based on somatic mutations, chromosome alterations, microRNAs, and tumor microenvironment markers. The paper also discusses current challenges at the forefront of genomics-based discrimination, including the selection of detection technology, application of next-generation sequencing, and intratumoral heterogeneity (ITH). In summary, this paper highlights an entrance into the primary stage of molecule-based diagnostics.
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Affiliation(s)
- Ziyang Wang
- Thoracic Oncology Institute and Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, China
| | - Xiaoqiu Yuan
- Peking University Health Science Center, Beijing, 100191, China
| | - Guanchao Jiang
- Thoracic Oncology Institute and Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, China
| | - Yun Li
- Thoracic Oncology Institute and Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, China
| | - Fan Yang
- Thoracic Oncology Institute and Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, China
| | - Jun Wang
- Thoracic Oncology Institute and Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, China
| | - Kezhong Chen
- Thoracic Oncology Institute and Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, China.
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Comparison of the Clinicopathological Characteristics and Prognosis of Esophageal Squamous Cell Carcinoma with Intramural Metastases and Multiple Primary Carcinomas. World J Surg 2023; 47:707-716. [PMID: 36437350 DOI: 10.1007/s00268-022-06839-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is difficult to distinguish esophageal squamous cell carcinoma with intramural metastases (IM) from multiple primary oesophageal carcinoma (MPEC). Nevertheless, there are significant differences in their prognoses and treatments. Therefore, our study aims to clarify the clinicopathological and prognostic characteristics of these two entities and to provide clues for differential diagnosis. METHODS We retrospectively analyzed 6304 patients who underwent esophagectomy without neoadjuvant therapy. The clinicopathological and prognostic features of patients with IM and MPEC were evaluated. P53 and Rb1 were detected by immunohistochemical (IHC) staining using a tissue microarray. RESULTS Among the 6304 patients, 127 (2.0%) had IM, and 138 (2.2%) had MPEC. Patients with IM were more likely to have an advanced pT (p < 0.001), pN (p < 0.001), more lymphovascular invasion (p < 0.001) and neural invasion (p < 0.001). Additionally, patients with IM had an extremely poor prognosis compared to those with MPEC, with 5-year overall survival (OS) rates of 18.9% and 56.9%, respectively. Meanwhile, IM was found to be an independent poor prognostic indicator for OS and DFS. In the IM group, all patients showed consistent p53 expression in both primary and IM foci. Of note, Rb1 loss was found in 3 pairs of primary foci and metastases, along with p53 nonsense mutation. CONCLUSIONS Patients with IM had more risk factors and extremely worse prognosis than those with MPEC. It is essential to discriminate IM from MPEC when managing multifocal carcinomas. IHC staining of p53 and Rb1 may aid in differential diagnosis.
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Zhang X, Fan X, Sun C, Wang L, Miao Y, Wang L, Yang P, Xu Y, Ren X, Wu X, Xu S. A novel NGS-based diagnostic algorithm for classifying multifocal lung adenocarcinomas in pN0M0 patients. J Pathol Clin Res 2022; 9:108-120. [PMID: 36579550 PMCID: PMC9896159 DOI: 10.1002/cjp2.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/26/2022] [Accepted: 11/23/2022] [Indexed: 12/30/2022]
Abstract
The classification of multifocal lung adenocarcinomas (MLAs), including multiple primary lung adenocarcinomas (MPLAs) and intrapulmonary metastases (IPMs), has great clinical significance in staging and treatment determination. However, the application of molecular approaches in pN0M0 MLA diagnosis has not been well investigated. Here, we performed next-generation sequencing (NGS) analysis in 45 pN0M0 MLA patients (101 lesion pairs) who were initially diagnosed as having MPLA by comprehensive histologic assessment (CHA). Five additional patients with intrathoracic metastases were used as positive controls, while 197 patients with unifocal lung adenocarcinomas (425 random lesion pairs) were used as negative controls. By utilizing a predefined NGS criterion, all IPMs in the positive control group could be accurately classified, whereas 13 lesion pairs (3.1%) in the negative control cohort were misdiagnosed as IPMs. Additionally, 14 IPM lesion pairs were diagnosed in the study group, with at least 7 misdiagnoses. We thus developed a refined algorithm, incorporating both NGS and histologic results, that could correctly diagnose all the known MPLAs and IPMs. In particular, all IPMs identified by the refined algorithm were diagnosed to be IPMs or suspected IPMs by CHA reassessment. The refined algorithm-diagnosed MPLAs patients also had significantly better progression-free survival than the refined algorithm-diagnosed IPMs (p < 0.0001), which is superior to conventional NGS or CHA diagnoses. Overall, we developed an NGS-based algorithm that could accurately distinguish IPMs from MPLAs in MLA patients. Our results demonstrate a promising clinical utility of NGS to complement traditional CHA-based MLA diagnosis and help determine patient staging and treatment.
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Affiliation(s)
- Xin Zhang
- Department of Thoracic SurgeryThe First Hospital of China Medical UniversityShenyangLiaoningPR China
| | - Xiaoxi Fan
- Department of Thoracic SurgeryThe First Hospital of China Medical UniversityShenyangLiaoningPR China
| | - Changbo Sun
- Department of Thoracic SurgeryThe First Hospital of China Medical UniversityShenyangLiaoningPR China,Deparment of Thoracic SurgeryThe University of Tokyo Graduate School of MedicineTokyoJapan
| | - Liang Wang
- Department of PathologyThe First Hospital of China Medical UniversityShenyangLiaoningPR China
| | - Yuan Miao
- Department of PathologyThe First Hospital of China Medical UniversityShenyangLiaoningPR China
| | - Liming Wang
- Department of Thoracic SurgeryThe First Hospital of China Medical UniversityShenyangLiaoningPR China
| | - Peng Yang
- Geneseeq Research InstituteNanjing Geneseeq Technology Inc.NanjingJiangsuPR China
| | - Yang Xu
- Geneseeq Research InstituteNanjing Geneseeq Technology Inc.NanjingJiangsuPR China
| | - Xue Ren
- Geneseeq Research InstituteNanjing Geneseeq Technology Inc.NanjingJiangsuPR China
| | - Xue Wu
- Geneseeq Research InstituteNanjing Geneseeq Technology Inc.NanjingJiangsuPR China
| | - Shun Xu
- Department of Thoracic SurgeryThe First Hospital of China Medical UniversityShenyangLiaoningPR China
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Application of Dynamic 18F-FDG PET/CT for Distinguishing Intrapulmonary Metastases from Synchronous Multiple Primary Lung Cancer. Mol Imaging 2022; 2022:8081299. [PMID: 35903246 PMCID: PMC9281433 DOI: 10.1155/2022/8081299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/27/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
It has been a big challenge to distinguish synchronous multiple primary lung cancer (sMPLC) from primary lung cancer with intrapulmonary metastases (IPM). We aimed to assess the clinical application of dynamic 18F-FDG PET/CT in patients with multiple lung cancer nodules. We enrolled patients with multiple pulmonary nodules who had undergone dynamic 18F-FDG PET/CT and divided them into sMPLC and IPM groups based on comprehensive features. The SUVmax, fitted Ki value based on dynamic scanning, and corresponding maximum diameter (Dmax) from the two largest tumors were determined in each patient. We determined the absolute between-tumor difference of SUVmax/Dmax and Ki/Dmax (ΔSUVmax/Dmax; ΔKi/Dmax) and assessed the between-group differences. Further, the diagnostic accuracy was evaluated by ROC analysis and the correlation between ΔSUVmax/Dmax and ΔKi/Dmax from all groups was determined. There was no significant difference for ΔSUVmax/Dmax between the IPM and sMPLC groups, while the IPM group had a significantly higher ΔKi/Dmax than the sMPLC group. The AUC of ΔKi/Dmax for differentiating sMPLC from IPM was 0.80 (cut-off value of Ki = 0.0059, sensitivity 79%, specificity 75%, p < 0.001). There was a good correlation (Pearson r = 0.91, 95% CI: 0.79-0.96, p < 0.0001) between ΔSUVmax/Dmax and ΔKi/Dmax in the IPM group but not in the sMPLC group (Pearson r = 0.45, p > 0.05). Dynamic 18F-FDG PET/CT could be a useful tool for distinguishing sMPLC from IPM. Ki calculation based on Patlak graphic analysis could be more sensitive than SUVmax in discriminating IPM from sMPLC in patients with multiple lung cancer nodules.
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Vokes NI, Zhang J. The Role of Whole Exome Sequencing in Distinguishing Primary and Secondary Lung Cancers. LUNG CANCER (AUCKLAND, N.Z.) 2021; 12:139-149. [PMID: 34880699 PMCID: PMC8648100 DOI: 10.2147/lctt.s272518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Abstract
Non-small cell lung cancer (NSCLC) that presents with multiple lung tumors (MLTs) poses a challenge to accurate staging and prognosis. MLTs that arise as clonally related secondary metastases from a common primary are higher stage and often require adjuvant chemotherapy or may in fact be incurable stage IV lesions. Conversely, MLTs that represent distinct primaries have a better prognosis and may be overtreated if inappropriately classified as related secondaries. Historically, pathologic and radiographic criteria were used to distinguish between primary and secondary MLTs; however, the advent of genomic profiling has demonstrated limitations to these historic classification systems. In this review, we discuss the use of molecular profiling to distinguish between primary and secondary lung cancers, with a focus on the insights gleaned from whole exome sequencing (WES) analyses. While WES is not yet feasible in routine clinical practice, WES studies have helped elucidate the clonal relationship between primary and secondary lung cancers and provide important context for the application of targeted sequencing panel-based analyses.
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Affiliation(s)
- Natalie I Vokes
- Department of Thoracic and Head and Neck Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianjun Zhang
- Department of Thoracic and Head and Neck Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Goodwin D, Rathi V, Conron M, Wright GM. Genomic and Clinical Significance of Multiple Primary Lung Cancers as Determined by Next-Generation Sequencing. J Thorac Oncol 2021; 16:1166-1175. [PMID: 33845213 DOI: 10.1016/j.jtho.2021.03.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/17/2021] [Accepted: 03/19/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Marked variations in survival rates have brought into question whether standard clinicopathologic classification should be applied to patients presenting with multiple primary lung cancers (MPLCs). This study investigated the genetic profiles of MPLCs in a cohort of patients using next-generation sequencing and correlated results to clinicopathologic data and patient outcome. METHODS Patients treated surgically with curative intent for two putative primaries of similar histopathology from January 2000 to December 2019 at St Vincent's Hospital Melbourne. DNA and RNA was extracted from formalin-fixed, paraffin-embedded tumor tissue and sequenced on an Ion Torrent Personal Genome Machine system. Patient outcome was determined by overall survival and disease-free survival. RESULTS A total of 40 cases fulfilled the inclusion criteria. Mutational profiling was concordant with clinicopathologic diagnosis in most cases; however, seven cases (17.5%) revealed shared mutations suggesting metastatic disease and this was associated with a substantial reduction in overall survival (p < 0.05). CONCLUSIONS Our results suggest that gene sequencing technologies are potentially a more accurate diagnostic and prognostic tool compared with traditional histopathologic evaluation in patients presenting with suspected MPLCs, which could better guide management and predict outcomes.
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Affiliation(s)
- Daryn Goodwin
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, Australia; Alfred Hospital, Melbourne, Australia
| | - Vivek Rathi
- Department of Anatomical Pathology, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, Australia
| | - Matthew Conron
- Department of Respiratory and Sleep Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, Australia
| | - Gavin M Wright
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, Australia; Research and Education Lead Program, Victorian Comprehensive Cancer Centre, Parkville, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Parkville, Australia.
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Han X, Fan J, Liu T, Li N, Alwalid O, Gu J, Shi H. Differentiating synchronous double primary lung adenocarcinomas from intrapulmonary metastasis by CT features, EGFR mutations and ALK rearrangement status. J Thorac Dis 2020; 12:5505-5516. [PMID: 33209384 PMCID: PMC7656436 DOI: 10.21037/jtd-19-3570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Differentiating synchronous double primary lung adenocarcinoma (SDPLA) from interpulmonary metastasis (IPM) has significant therapeutic and prognostic implications. This retrospective study aimed to investigate the potential of computed tomography (CT) features and two known oncogenic driver mutations [epidermal growth factor receptor (EGFR) and anaplastic large-cell lymphoma kinase (ALK)] to discriminate synchronous double primary lung adenocarcinoma from one primary pulmonary adenocarcinoma with intrapulmonary metastasis. Methods Patients with SDPLA were selected at our hospital, and those with IPM served as the control group. All 60 patients (40 with SDPLA and 20 with IPM) were tested for EGFR mutations and ALK status, and they underwent chest CT prior to any treatment. Independent-sample Student's t-test was used for comparisons between two groups of normally distributed variables, and the Chi-square test was used to compare categorical variables. Results The discordance rate of EGFR mutations was significantly higher in patients with SDPLA than in patients with IPM (40% vs. 5%, P<0.001). The incidence of ALK-positive status was 15%, and patients with IPM were more likely to be ALK-positive than patients with SDPLA (35% vs. 5%, P<0.001). Compared to IPM, SDPLA more frequently occurred in different lobes (P=0.024), presented with less lymphadenopathy (P=0.014), showed a smaller difference in diameter (Äd) between tumors (P=0.001) and more commonly presented as lobulated tumors (P<0.001), spiculated masses (P<0.001), ground-glass opacities (GGOs) (P=0.001) and air bronchograms (P=0.020). Conclusion Patients with SDPLA showed higher discordance with EGFR mutations and were less frequently ALK-positive than those with IPM. Thus, the CT characteristics are significantly different between SDPLA and IPM.
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Affiliation(s)
- Xiaoyu Han
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jun Fan
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tong Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Na Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Osamah Alwalid
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jin Gu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Heshui Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Clonal Origin Evaluated by Trunk and Branching Drivers and Prevalence of Mutations in Multiple Lung Tumor Nodules. Mol Diagn Ther 2020; 24:461-472. [DOI: 10.1007/s40291-020-00471-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Chang JC, Alex D, Bott M, Tan KS, Seshan V, Golden A, Sauter JL, Buonocore DJ, Vanderbilt CM, Gupta S, Desmeules P, Bodd FM, Riely GJ, Rusch VW, Jones DR, Arcila ME, Travis WD, Ladanyi M, Rekhtman N. Comprehensive Next-Generation Sequencing Unambiguously Distinguishes Separate Primary Lung Carcinomas From Intrapulmonary Metastases: Comparison with Standard Histopathologic Approach. Clin Cancer Res 2019; 25:7113-7125. [PMID: 31471310 PMCID: PMC7713586 DOI: 10.1158/1078-0432.ccr-19-1700] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/30/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE In patients with >1 non-small cell lung carcinoma (NSCLC), the distinction between separate primary lung carcinomas (SPLCs) and intrapulmonary metastases (IPMs) is a common diagnostic dilemma with critical staging implications. Here, we compared the performance of comprehensive next-generation sequencing (NGS) with standard histopathologic approaches for distinguishing NSCLC clonal relationships in clinical practice. EXPERIMENTAL DESIGN We queried 4,119 NSCLCs analyzed by 341-468 gene MSK-IMPACT NGS assay for patients with >1 surgically resected tumor profiled by NGS. Tumor relatedness predicted by prospective histopathologic assessment was contrasted with comparative genomic profiling by subsequent NGS. RESULTS Sixty patients with NGS performed on >1 NSCLCs were identified, yielding 76 tumor pairs. NGS classified tumor pairs into 51 definite SPLCs (median, 14; up to 72 unique somatic mutations per pair), and 25 IPMs (24 definite, one high probability; median, 5; up to 16 shared somatic mutations per pair). Prospective histologic prediction was discordant with NGS in 17 cases (22%), particularly in the prediction of IPMs (44% discordant). Retrospective review highlighted several histologic challenges, including morphologic progression in some IPMs. We subsampled MSK-IMPACT data to model the performance of less comprehensive assays, and identified several clinicopathologic differences between NGS-defined tumor pairs, including increased risk of subsequent recurrence for IPMs. CONCLUSIONS Comprehensive NGS allows unambiguous delineation of clonal relationship among NSCLCs. In comparison, standard histopathologic approach is adequate in most cases, but has notable limitations in the recognition of IPMs. Our results support the adoption of broad panel NGS to supplement histology for robust discrimination of NSCLC clonal relationships in clinical practice.
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Affiliation(s)
- Jason C Chang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deepu Alex
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew Bott
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Venkatraman Seshan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Golden
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer L Sauter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Darren J Buonocore
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chad M Vanderbilt
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sounak Gupta
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrice Desmeules
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Francis M Bodd
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gregory J Riely
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Valerie W Rusch
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David R Jones
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria E Arcila
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc Ladanyi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Natasha Rekhtman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Jiang L, Zheng X, Wu S, Zhang J, Ru G, Li Y. A Rare Case Of Synchronous Multiple Primary Lung Cancer: Squamous Cell Cancer And Small Cell Lung Cancer. Onco Targets Ther 2019; 12:8801-8806. [PMID: 31749623 PMCID: PMC6817713 DOI: 10.2147/ott.s213259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/01/2019] [Indexed: 11/23/2022] Open
Abstract
The incidence of synchronous multiple primary malignancies has been reported to be low. We report a rare case of synchronous lung squamous cell cancer and small cell lung cancer in an 82-year-old male patient. There is a lack of standard diagnostic criteria for multiple primary lung cancer. Two tumors with similar morphology are difficult to draw conclusions about the same lineage or different lineages. If the patient's physical condition permits, multiple tumors should be sampled and tested. Besides, imaging features are helpful for identification. It is advisable to diagnose synchronous multiple primary malignancies in an early stage, which contributes to a favorable outcome.
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Affiliation(s)
- Luxi Jiang
- Department of Respiratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang310014, People’s Republic of China
| | - Xiangxin Zheng
- Department of General Intensive Care Unit, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang310052, People’s Republic of China
| | - Shengchang Wu
- Department of Respiratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang310014, People’s Republic of China
| | - Jie Zhang
- Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang310014, People’s Republic of China
| | - Guoqing Ru
- Department of Pathology Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang310014, People’s Republic of China
| | - Yaqing Li
- Department of Respiratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang310014, People’s Republic of China
- Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, Zhejiang310014, People’s Republic of China
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14
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Mansuet-Lupo A, Barritault M, Alifano M, Janet-Vendroux A, Zarmaev M, Biton J, Velut Y, Le Hay C, Cremer I, Régnard JF, Fournel L, Rance B, Wislez M, Laurent-Puig P, Herbst R, Damotte D, Blons H. Proposal for a Combined Histomolecular Algorithm to Distinguish Multiple Primary Adenocarcinomas from Intrapulmonary Metastasis in Patients with Multiple Lung Tumors. J Thorac Oncol 2019; 14:844-856. [DOI: 10.1016/j.jtho.2019.01.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/30/2018] [Accepted: 12/01/2018] [Indexed: 10/27/2022]
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15
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Chen C, Huang X, Peng M, Liu W, Yu F, Wang X. Multiple primary lung cancer: a rising challenge. J Thorac Dis 2019; 11:S523-S536. [PMID: 31032071 DOI: 10.21037/jtd.2019.01.56] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
With the use of high-resolution chest imaging system and lung cancer screening program, patients with multiple primary lung cancers (MPLCs) are becoming a growing population in clinical practice worldwide. The diagnostic criteria for MPLCs has been established and modified by three major lung cancer research institutes. However, due to the fact that the differential diagnosis between MPLCs and a recurrence, metastatic, or satellite lesion arising from the original lesion remains ambiguous and confusing, there is still insufficient evidence to support a uniform guideline. Newly developed molecular and genomic methods have the potential to better define the relationship among multiple lesions and bring the possibility of targeted therapy. Surgical resection remains the first choice for the treatment of MPLCs and detailed strategy should be carefully planned taking characteristics of the tumor and status of patients into consideration. For those who are intolerant to surgery, a new technology called stereotactic body radiation therapy (SBRT) is now an optional therapeutic strategy. Furthermore, multiple GGOs are unique MPLCs that need special attentions in the clinical practice.
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Affiliation(s)
- Chen Chen
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Xiaojie Huang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Muyun Peng
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Wenliang Liu
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Fenglei Yu
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Xiang Wang
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
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16
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Yang X, Zhan C, Li M, Huang Y, Zhao M, Yang X, Lin Z, Shi Y, Jiang W, Wang Q. Lobectomy Versus Sublobectomy in Metachronous Second Primary Lung Cancer: A Propensity Score Study. Ann Thorac Surg 2018; 106:880-887. [DOI: 10.1016/j.athoracsur.2018.04.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/26/2018] [Accepted: 04/23/2018] [Indexed: 12/20/2022]
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17
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Tan L, Yin J. [Diagnosis and Treatment for Multiple Primary Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2018; 21:185-189. [PMID: 29587937 PMCID: PMC5973042 DOI: 10.3779/j.issn.1009-3419.2018.03.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Lijie Tan
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Fudan University
| | - Jun Yin
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Fudan University
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18
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Dagogo-Jack I, Saltos A, Shaw AT, Gray JE. Pathology Issues in Thoracic Oncology: Histologic Characterization and Tissue/Plasma Genotyping May Resolve Diagnostic Dilemmas. Am Soc Clin Oncol Educ Book 2017; 37:619-629. [PMID: 28561671 DOI: 10.1200/edbk_175197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Lung cancer is a heterogeneous diagnosis that encompasses a spectrum of histologic and molecular subgroups. A paradigm shift favoring selection of treatment based on histologic and molecular makeup has positively affected prognosis for patients with metastatic lung cancer, with select patients experiencing durable responses to treatment. However, prognosis remains poor for the majority of patients. Furthermore, oncologists are increasingly faced with challenging dilemmas related to histopathologic and molecular characterization of tumors, both at diagnosis and during treatment. In this review, we focus on three particular challenges: (1) management of mixed histology tumors, a particularly aggressive group of lung cancers, (2) distinguishing multiple primary lung tumors from intrapulmonary metastases, and (3) incorporation of liquid biopsies into the diagnostic algorithm and subsequent follow-up of patients with advanced lung cancer. This review will summarize the existing literature and highlight the potential for molecular genotyping to help refine approaches to each of these challenges.
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Affiliation(s)
- Ibiayi Dagogo-Jack
- From the Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; Hematology/Oncology Fellowship Program, Moffitt Cancer Center, Tampa, FL; University of South Florida, Tampa, FL; Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL
| | - Andreas Saltos
- From the Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; Hematology/Oncology Fellowship Program, Moffitt Cancer Center, Tampa, FL; University of South Florida, Tampa, FL; Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL
| | - Alice T Shaw
- From the Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; Hematology/Oncology Fellowship Program, Moffitt Cancer Center, Tampa, FL; University of South Florida, Tampa, FL; Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL
| | - Jhanelle E Gray
- From the Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; Hematology/Oncology Fellowship Program, Moffitt Cancer Center, Tampa, FL; University of South Florida, Tampa, FL; Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL
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19
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Patel SB, Kadi W, Walts AE, Marchevsky AM, Pao A, Aguiluz A, Mudalige T, Liu Z, Deng N, Lopategui J. Next-Generation Sequencing: A Novel Approach to Distinguish Multifocal Primary Lung Adenocarcinomas from Intrapulmonary Metastases. J Mol Diagn 2017; 19:870-880. [PMID: 28866070 DOI: 10.1016/j.jmoldx.2017.07.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023] Open
Abstract
Distinguishing between multiple lung primary tumors and intrapulmonary metastases is imperative for accurate staging. The American Joint Committee on Cancer (AJCC) criteria are routinely used for this purpose but can yield equivocal conclusions. This study evaluated whether next-generation sequencing (NGS) using the 50-gene AmpliSeq Cancer Hotspot Panel version 2 can help facilitate this distinction. NGS was performed on known primary-metastatic pairs (8 patients) and multiple lung adenocarcinomas (11 patients). Primary-metastatic pairs had high mutational concordance. Seven pairs shared mutations, and 1 was concordant for having no mutations. Driver mutations in KRAS (n = 4), EGFR (n = 2), and BRAF (n = 1) were always concordant. Multiple lung tumors from 3 patients were completely concordant and predicted by NGS to be intrapulmonary metastases, whereas 8 had completely discordant mutations and were predicted to be independent primary tumors. The NGS prediction correlated with the AJCC (eighth edition) prediction in all patients for whom the latter was unequivocal (8 of 11). Furthermore, it separated patients by overall survival. Patients with predicted multiple independent primary tumors by NGS had better survival than those with distant metastases (P = 0.016, log-rank test), whereas those with predicted intrapulmonary metastases had no difference (P = 0.527). With further validation, the 50-gene panel has the potential to serve as an adjunct to the AJCC criteria.
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Affiliation(s)
- Snehal B Patel
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wendy Kadi
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ann E Walts
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alberto M Marchevsky
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andy Pao
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Angela Aguiluz
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Tudor Mudalige
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zhenqui Liu
- Biostatistics and Bioinformatics Research Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nan Deng
- Biostatistics and Bioinformatics Research Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jean Lopategui
- Department of Pathology and Laboratory Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Triple synchronous primary lung cancer: a case report and review of the literature. J Med Case Rep 2017; 11:245. [PMID: 28859661 PMCID: PMC5579871 DOI: 10.1186/s13256-017-1410-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 07/27/2017] [Indexed: 11/13/2022] Open
Abstract
Background Multiple primary lung cancer may present in synchronous or metachronous form. Synchronous multiple primary lung cancer is defined as multiple lung lesions that develop at the same time, whereas metachronous multiple primary lung cancer describes multiple lung lesions that develop at different times, typically following treatment of the primary lung cancer. Patients with previously treated lung cancer are at risk for developing metachronous lung cancer, but with the success of computed tomography and positron emission tomography, the ability to detect both synchronous and metachronous lung cancer has increased. Case presentation We present a case of a 63-year-old Hispanic man who came to our hospital for evaluation of chest pain, dry cough, and weight loss. He had recently been diagnosed with adenocarcinoma in the right upper lobe, with a poorly differentiated carcinoma favoring squamous cell cancer based on bronchoalveolar lavage of the right lower lobe for which treatment was started. Later, bronchoscopy incidentally revealed the patient to have an endobronchial lesion that turned out to be mixed small and large cell neuroendocrine lung cancer. Our patient had triple synchronous primary lung cancers that histologically were variant primary cancers. Conclusions Triple synchronous primary lung cancer management continues to be a challenge. Our patient’s case suggests that multiple primary lung cancers may still occur at a greater rate than can be detected by high-resolution computed tomography.
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Solitary Skull Metastasis as the First Presentation of a Metachronous Primary Lung Cancer in a Survivor from Pancreatic Cancer. Case Rep Oncol Med 2017; 2017:5674749. [PMID: 28811947 PMCID: PMC5546056 DOI: 10.1155/2017/5674749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/19/2017] [Indexed: 11/17/2022] Open
Abstract
Skull metastasis from lung cancer is relatively common, yet the first presentation for this malignant disease is a rare occurrence. We herein report a case of a 54-year-old female, who had a good outcome following Whipple procedure for periampullary adenocarcinoma five years before her current presentation. During a routine follow-up, she was found to have a slowly progressive painless right parietal swelling. The systemic screening workup revealed no abdominal disease, but a solitary pulmonary nodule was identified. The presence of these two lesions raised the diagnosis of metastases from a previously treated pancreatic adenocarcinoma. The patient underwent complete excision of the skull lesion and subsequent lung biopsy, both of which proved on histopathological examination to be consistent with a primary lung cancer. This case emphasizes the importance of imaging and histopathological correlation in the diagnosis of solitary skull metastases and their effect on the subsequent management.
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22
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Primary multiple tumor with affection of the thyroid gland, uterus, urinary bladder, mammary gland and other organs. Pathol Res Pract 2017; 213:574-579. [DOI: 10.1016/j.prp.2017.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
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23
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Guo H, Shen-Tu Y. [Research Progress in Diagnosis and Management Strategies
of Multiple Primary Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2017; 19:307-11. [PMID: 27215460 PMCID: PMC5973054 DOI: 10.3779/j.issn.1009-3419.2016.05.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
原发肺癌(multiple primary lung cancer, MPLC)的发病率呈逐年上升趋势,但关于MPLC的发病机制、诊断、鉴别诊断和临床处理策略仍存在诸多争议。本综述将对目前关于MPLC的发病机制、诊断标准、鉴别诊断和处理策略方面的研究进展做一个回顾,旨在为该病的诊疗提供理论基础。
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Affiliation(s)
- Haifa Guo
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center, Shanghai 200039, China
| | - Yang Shen-Tu
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center, Shanghai 200039, China
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24
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Utility of Genomic Analysis in Differentiating Synchronous and Metachronous Lung Adenocarcinomas from Primary Adenocarcinomas with Intrapulmonary Metastasis. Transl Oncol 2017; 10:442-449. [PMID: 28448960 PMCID: PMC5406583 DOI: 10.1016/j.tranon.2017.02.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/15/2017] [Accepted: 02/23/2017] [Indexed: 12/27/2022] Open
Abstract
Distinguishing synchronous and metachronous primary lung adenocarcinomas from adenocarcinomas with intrapulmonary metastasis is essential for optimal patient management. In this study, multiple lung adenocarcinomas occurring in the same patient were evaluated using comprehensive histopathologic evaluation supplemented with molecular analysis. The cohort included 18 patients with a total of 52 lung adenocarcinomas. Eleven patients had a new diagnosis of multiple adenocarcinomas in the same lobe (n = 5) or different lobe (n = 6). Seven patients had a history of lung cancer and developed multiple new tumors. The final diagnosis was made in resection specimens (n = 49), fine needle aspiration (n = 2), and biopsy (n = 1). Adenocarcinomas were non‐mucinous, and histopathologic comparison of tumors was performed. All tumors save for one were subjected to ALK gene rearrangement testing and targeted Next Generation Sequencing (NGS). Using clinical, radiologic, and morphologic features, a confident conclusion favoring synchronous/metachronous or metastatic disease was made in 65% of patients. Cases that proved challenging included ones with more than three tumors showing overlapping growth patterns and lacking a predominant lepidic component. Genomic signatures unique to each tumor were helpful in determining the relationship of multiple carcinomas in 72% of patients. Collectively, morphologic and genomic data proved to be of greater value and achieved a conclusive diagnosis in 94% of patients. Assessment of the genomic profiles of multiple lung adenocarcinomas complements the histological findings, enabling a more comprehensive assessment of synchronous, metachronous, and metastatic lesions in most patients, thereby improving staging accuracy. Targeted NGS can identify genetic alterations with therapeutic implications.
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Guo H, Mao F, Zhang H, Qiu Y, Shen-Tu Y. [Analysis on the Prognostic and Survival Factors of Synchronous Multiple Primary Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2017; 20:21-27. [PMID: 28103969 PMCID: PMC5973290 DOI: 10.3779/j.issn.1009-3419.2017.01.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Synchronous multiple primary lung cancer (sMPLC) is a sparse disease in the past, but there has been a gradual increase in the morbidity of sMPLC recently. However, studies on large sample have never been undertaken. The purpose of this study is to investigate the diagnosis, treatment and prognosis of sMPLC through analyzing the clinical data, and provide supports for the management of sMPLC. METHODS According to Martini-Melamed criteria, 357 patients were diagnosed sMPLC. The pathological staging is on the basis of the 8th edition tumor-node-metastasis (TNM) staging from International Association for the Study of Lung Cancer (IASLC). RESULTS There were 269 patients with double primary lung cancer, 65 patients with triple primary lung cancer and 23 patients with four or more primary lung cancer. Lesions (68.55%, 571/833) were frequently in upper lobe, especially the right upper lobe. Adenocarcinoma (95.56%, 796/833) was the mainly pathological type, followed by squamous cell carcinoma (2.40%, 20/833). The acinar predominant subtype was the main part (70.81%, 313/442) of the all adenocarcinoma specimens. Most of the lesions (68.35%, 244/357) were stage Ib or low. Among the initial lesion and the following lesions ,patients who had the same pathological type (92.72%, 331/357) were more than the different (7.28%, 26/357), of which adenocarcinoma-adenocarcinoma occupied the major proportion (99.40%, 329/331). The 3-year overall survival (OS) and 5-year overall survival were respective 91.93% and 84.37%. Multivariate analysis found that smoking history (P=0.012), the diameter of the maximum lesion (P=0.027), lymph node metastasis (P=0.015) and pleural invasion (P<0.001) were the independent risk factors for prognosis. CONCLUSIONS Tumours in patients with sMPLC are more frequently in the right upper lobe. Adenocarcinoma was the mainly pathological type. Smoking history, the diameter of the maximum lesion, lymph node metastasis and pleural invasion were the independent risk factors for prognosis. Early diagnosis and active operation can obtain better prognosis.
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Affiliation(s)
- Haifa Guo
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center,
Shanghai 200039, China
| | - Feng Mao
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center,
Shanghai 200039, China
| | - Hui Zhang
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center,
Shanghai 200039, China
| | - Yangbo Qiu
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center,
Shanghai 200039, China
| | - Yang Shen-Tu
- Shanghai Chest Hospital, Shanghai Jiaotong University, Department of Shanghai Lung Tumor Clinical Medical Center,
Shanghai 200039, China
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Comprehensive Genomic Profiling Differentiates Metachronous Primary Small-Cell Lung Cancer From Late Recurrence. Clin Lung Cancer 2016; 17:e169-e172. [PMID: 27103378 DOI: 10.1016/j.cllc.2016.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/21/2016] [Indexed: 11/21/2022]
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Rekhtman N. Molecular Assessment of Multiple Pulmonary Carcinomas: An Evolving Area. J Thorac Oncol 2016; 11:e54. [PMID: 27017305 DOI: 10.1016/j.jtho.2016.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Natasha Rekhtman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
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28
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Loukeri AA, Kampolis CF, Ntokou A, Tsoukalas G, Syrigos K. Metachronous and Synchronous Primary Lung Cancers: Diagnostic Aspects, Surgical Treatment, and Prognosis. Clin Lung Cancer 2015; 16:15-23. [DOI: 10.1016/j.cllc.2014.07.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 07/21/2014] [Accepted: 07/29/2014] [Indexed: 11/27/2022]
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29
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Surgical Treatment of Metachronous Second Primary Lung Cancer. Ann Thorac Surg 2014; 98:1192-8. [DOI: 10.1016/j.athoracsur.2014.05.050] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/02/2014] [Accepted: 05/07/2014] [Indexed: 11/19/2022]
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30
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New Aspects of the Clinicopathology and Genetic Profile of Metachronous Multiple Lung Cancers. Ann Surg 2014; 259:1018-24. [DOI: 10.1097/sla.0000000000000385] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lin MW, Wu CT, Kuo SW, Chang YL, Yang PC. Clinicopathology and genetic profile of synchronous multiple small adenocarcinomas: implication for surgical treatment of an uncommon lung malignancy. Ann Surg Oncol 2014; 21:2555-62. [PMID: 24643899 DOI: 10.1245/s10434-014-3642-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Indexed: 12/30/2022]
Abstract
PURPOSE Synchronous multiple small adenocarcinomas are detected more frequently than in the past; however, the genetic profile, treatment, and prognosis of patients remain unclear. For treatment decisions and prognostic applications, we evaluated epidermal growth factor receptor (EGFR), p53, and KRAS somatic mutations in synchronous multiple small lung adenocarcinomas. METHODS The presence of EGFR, p53, and KRAS somatic mutations was determined in 64 synchronous multiple lung adenocarcinomas ≤2 cm in maximal dimension. Mutational analysis was performed on DNA extracted from paraffin-embedded tumors. RESULTS Five-year disease-free survival (DFS) was 86.1 %, and overall survival was 95.8 %. EGFR, p53, and KRAS mutations were detected in 41 (64.1 %), 8 (12.5 %), and 4 (6.3 %) patients, respectively. The high frequency of genetic mutations resulted in a high discrimination rate of tumor clonality (68.8 %; 44/64) in the study group. Fourteen (31.8 %) patients were assessed as having the same clonality, whereas 30 (68.2 %) patients had different clonality, which further supported the concept of field cancerization. Multivariate analysis showed lymph node metastasis (p = 0.003) and smoking (p = 0.011) were significantly correlated with tumor relapse. Surgical method, clonality, and tumor location were not correlated with tumor relapse. CONCLUSIONS Whether these tumors are different or the same clonal, sublobar resection of each lesion can achieve long-term DFS and is the treatment of choice for synchronous multiple small lung adenocarcinomas. Patients with lymph node metastasis are at risk of relapse and adjuvant chemotherapy is indicated.
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Affiliation(s)
- Mong-Wei Lin
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
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Bamousa A, AlKattan K. Impact of the 7th TNM staging lung cancer in surgery. J Infect Public Health 2013; 5 Suppl 1:S41-4. [PMID: 23244187 DOI: 10.1016/j.jiph.2012.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 01/23/2012] [Accepted: 09/20/2012] [Indexed: 11/17/2022] Open
Abstract
Accurate staging of lung cancer is very critical to determine the proper management approach of each patient and to address prognosis issues. In this manuscript, we will discuss the impact of the most recent staging categories (7th TNM staging) on the management of non-small cell lung cancer.
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Affiliation(s)
- Ahmed Bamousa
- Department of Surgery, Riyadh Military Hospital, Riyadh, Saudi Arabia.
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33
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Clonality status of multifocal lung adenocarcinomas based on the mutation patterns of EGFR and K-ras. Lung Cancer 2012; 75:313-20. [DOI: 10.1016/j.lungcan.2011.08.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Revised: 08/10/2011] [Accepted: 08/13/2011] [Indexed: 11/24/2022]
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Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, Beer DG, Powell CA, Riely GJ, Van Schil PE, Garg K, Austin JHM, Asamura H, Rusch VW, Hirsch FR, Scagliotti G, Mitsudomi T, Huber RM, Ishikawa Y, Jett J, Sanchez-Cespedes M, Sculier JP, Takahashi T, Tsuboi M, Vansteenkiste J, Wistuba I, Yang PC, Aberle D, Brambilla C, Flieder D, Franklin W, Gazdar A, Gould M, Hasleton P, Henderson D, Johnson B, Johnson D, Kerr K, Kuriyama K, Lee JS, Miller VA, Petersen I, Roggli V, Rosell R, Saijo N, Thunnissen E, Tsao M, Yankelewitz D. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 2011; 6:244-85. [PMID: 21252716 PMCID: PMC4513953 DOI: 10.1097/jto.0b013e318206a221] [Citation(s) in RCA: 3397] [Impact Index Per Article: 261.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Adenocarcinoma is the most common histologic type of lung cancer. To address advances in oncology, molecular biology, pathology, radiology, and surgery of lung adenocarcinoma, an international multidisciplinary classification was sponsored by the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society. This new adenocarcinoma classification is needed to provide uniform terminology and diagnostic criteria, especially for bronchioloalveolar carcinoma (BAC), the overall approach to small nonresection cancer specimens, and for multidisciplinary strategic management of tissue for molecular and immunohistochemical studies. METHODS An international core panel of experts representing all three societies was formed with oncologists/pulmonologists, pathologists, radiologists, molecular biologists, and thoracic surgeons. A systematic review was performed under the guidance of the American Thoracic Society Documents Development and Implementation Committee. The search strategy identified 11,368 citations of which 312 articles met specified eligibility criteria and were retrieved for full text review. A series of meetings were held to discuss the development of the new classification, to develop the recommendations, and to write the current document. Recommendations for key questions were graded by strength and quality of the evidence according to the Grades of Recommendation, Assessment, Development, and Evaluation approach. RESULTS The classification addresses both resection specimens, and small biopsies and cytology. The terms BAC and mixed subtype adenocarcinoma are no longer used. For resection specimens, new concepts are introduced such as adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) for small solitary adenocarcinomas with either pure lepidic growth (AIS) or predominant lepidic growth with ≤ 5 mm invasion (MIA) to define patients who, if they undergo complete resection, will have 100% or near 100% disease-specific survival, respectively. AIS and MIA are usually nonmucinous but rarely may be mucinous. Invasive adenocarcinomas are classified by predominant pattern after using comprehensive histologic subtyping with lepidic (formerly most mixed subtype tumors with nonmucinous BAC), acinar, papillary, and solid patterns; micropapillary is added as a new histologic subtype. Variants include invasive mucinous adenocarcinoma (formerly mucinous BAC), colloid, fetal, and enteric adenocarcinoma. This classification provides guidance for small biopsies and cytology specimens, as approximately 70% of lung cancers are diagnosed in such samples. Non-small cell lung carcinomas (NSCLCs), in patients with advanced-stage disease, are to be classified into more specific types such as adenocarcinoma or squamous cell carcinoma, whenever possible for several reasons: (1) adenocarcinoma or NSCLC not otherwise specified should be tested for epidermal growth factor receptor (EGFR) mutations as the presence of these mutations is predictive of responsiveness to EGFR tyrosine kinase inhibitors, (2) adenocarcinoma histology is a strong predictor for improved outcome with pemetrexed therapy compared with squamous cell carcinoma, and (3) potential life-threatening hemorrhage may occur in patients with squamous cell carcinoma who receive bevacizumab. If the tumor cannot be classified based on light microscopy alone, special studies such as immunohistochemistry and/or mucin stains should be applied to classify the tumor further. Use of the term NSCLC not otherwise specified should be minimized. CONCLUSIONS This new classification strategy is based on a multidisciplinary approach to diagnosis of lung adenocarcinoma that incorporates clinical, molecular, radiologic, and surgical issues, but it is primarily based on histology. This classification is intended to support clinical practice, and research investigation and clinical trials. As EGFR mutation is a validated predictive marker for response and progression-free survival with EGFR tyrosine kinase inhibitors in advanced lung adenocarcinoma, we recommend that patients with advanced adenocarcinomas be tested for EGFR mutation. This has implications for strategic management of tissue, particularly for small biopsies and cytology samples, to maximize high-quality tissue available for molecular studies. Potential impact for tumor, node, and metastasis staging include adjustment of the size T factor according to only the invasive component (1) pathologically in invasive tumors with lepidic areas or (2) radiologically by measuring the solid component of part-solid nodules.
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Affiliation(s)
- William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Suggestive synchronous triple squamous cell carcinoma of the lung in the same lobe. Gen Thorac Cardiovasc Surg 2010; 58:427-30. [PMID: 20703866 DOI: 10.1007/s11748-009-0476-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Accepted: 05/29/2009] [Indexed: 10/19/2022]
Abstract
We report a case of suggestive synchronous triple squamous cell carcinoma (Sq) of the lung that occurred in the same lobe. Under a clinical diagnosis of triple lung cancer, lobectomy was performed. Pathological examination revealed two well-differentiated Sq and one poorly differentiated Sq. The analysis of epidermal growth factor receptor-tyrosine kinase mutations showed no mutation in each tumor. However, pathological findings and the positive rate of immunochemical reaction of p53 and Ki-67 were different in each tumor.
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Dijkman BG, Schuurbiers OCJ, Vriens D, Looijen-Salamon M, Bussink J, Timmer-Bonte JNH, Snoeren MM, Oyen WJG, van der Heijden HFM, de Geus-Oei LF. The role of (18)F-FDG PET in the differentiation between lung metastases and synchronous second primary lung tumours. Eur J Nucl Med Mol Imaging 2010; 37:2037-47. [PMID: 20533031 PMCID: PMC2948164 DOI: 10.1007/s00259-010-1505-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 05/19/2010] [Indexed: 12/22/2022]
Abstract
Purpose In lung cancer patients with multiple lesions, the differentiation between metastases and second primary tumours has significant therapeutic and prognostic implications. The aim of this retrospective study was to investigate the potential of 18F-FDG PET to discriminate metastatic disease from second primary lung tumours. Methods Of 1,396 patients evaluated by the thoracic oncology group between January 2004 and April 2009 at the Radboud University Nijmegen Medical Centre, patients with a synchronous second primary lung cancer were selected. Patients with metastatic disease involving the lungs served as the control group. Maximum standardized uptake values (SUVs) measured with 18F-FDG PET were determined for two tumours in each patient. The relative difference between the SUVs of these tumours (∆SUV) was determined and compared between the second primary group and metastatic disease group. Receiver-operating characteristic (ROC) curve analysis was performed to determine the sensitivity and specificity of the ∆SUV for an optimal cut-off value. Results A total of 37 patients (21 metastatic disease, 16 second primary cancer) were included for analysis. The ∆SUV was significantly higher in patients with second primary cancer than in those with metastatic disease (58 vs 28%, respectively, p < 0.001). The area under the ROC curve was 0.81 and the odds ratio for the optimal cut-off was 18.4. Conclusion SUVs from 18F-FDG PET images can be helpful in differentiating metastatic disease from second primary tumours in patients with synchronous pulmonary lesions. Further studies are warranted to confirm the consistency of these results.
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Affiliation(s)
- Bernadette G. Dijkman
- Department of Pulmonary Diseases 454, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Olga C. J. Schuurbiers
- Department of Pulmonary Diseases 454, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Dennis Vriens
- Department of Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Monika Looijen-Salamon
- Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Johan Bussink
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Johanna N. H. Timmer-Bonte
- Department of Pulmonary Diseases 454, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Miranda M. Snoeren
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Wim J. G. Oyen
- Department of Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Henricus F. M. van der Heijden
- Department of Pulmonary Diseases 454, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Ostrovnaya I, Begg CB. Testing clonal relatedness of tumors using array comparative genomic hybridization: a statistical challenge. Clin Cancer Res 2010; 16:1358-67. [PMID: 20179213 DOI: 10.1158/1078-0432.ccr-09-2398] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In recent years several investigative groups have sought to use array technologies that characterize somatic alterations in tumors, such as array comparative genomic hybridization (ACGH), to classify pairs of tumors from the same patients as either independent primary cancers or metastases. A wide variety of strategies have been proposed. Several groups have endeavored to use hierarchical clustering for this purpose. This technique was popularized in genomics as a means of finding clusters of patients with similar gene expression patterns with a view to finding subcategories of tumors with distinct clinical characteristics. Unfortunately, this method is not well suited to the problem of classifying individual pairs of tumors as either clonal or independent. In this article we show why hierarchical clustering is unsuitable for this purpose, and why this method has the paradoxical property of producing a declining probability that clonal tumor pairs will be correctly identified as more information is accrued (i.e., more patients). We discuss alternative strategies that have been proposed, which are based on more conventional conceptual formulations for statistical testing and diagnosis, and point to the remaining challenges in constructing valid and robust techniques for this problem.
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Affiliation(s)
- Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Predictors of Outcomes after Surgical Treatment of Synchronous Primary Lung Cancers. J Thorac Oncol 2010; 5:197-205. [DOI: 10.1097/jto.0b013e3181c814c5] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Girard N, Ostrovnaya I, Lau C, Park B, Ladanyi M, Finley D, Deshpande C, Rusch V, Orlow I, Travis WD, Pao W, Begg CB. Genomic and mutational profiling to assess clonal relationships between multiple non-small cell lung cancers. Clin Cancer Res 2009; 15:5184-90. [PMID: 19671847 DOI: 10.1158/1078-0432.ccr-09-0594] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE In cases of multiple non-small cell lung cancer, clinicians must decide whether patients have independent tumors or metastases and tailor treatment accordingly. Decisions are currently made using the Martini and Melamed criteria, which are mostly based on tumor location and histologic type. New genomic tools could improve the ability to assess tumor clonality. EXPERIMENTAL DESIGN We obtained fresh-frozen tumors specimens from patients who underwent surgery on at least two occasions for presumptively independent NSCLC. We did array comparative genomic hybridization (aCGH), mutational profiling of select genes, and detailed clinicopathologic review. RESULTS We analyzed a total of 42 tumors from 20 patients (6 patients with synchronous tumors, 14 patients with metachronous tumors, 24 potential tumor pair comparisons); 22 tumor pairs were evaluable by aCGH. Surprisingly, classification based on genomic profiling contradicted the clinicopathologic diagnosis in four (18%) of the comparisons, identifying independent primaries in one case diagnosed as metastasis and metastases in three cases diagnosed as independent primaries. Matching somatic point mutations were observed in these latter three cases. Another four tumor pairings were assigned an "equivocal" result based on aCGH; however, matching somatic point mutations were also found in these tumor pairs. None of the tumor pairs deemed independent primaries by aCGH harbored matching mutations. CONCLUSION Genomic analysis can help distinguish clonal tumors from independent primaries. The development of rapid, inexpensive, and reliable molecular tools may allow for refinement of clinicopathologic criteria currently used in this setting.
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Affiliation(s)
- Nicolas Girard
- Pao Lab, Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Evaluation of the clonal origin of multiple primary melanomas using molecular profiling. J Invest Dermatol 2009; 129:1972-82. [PMID: 19282844 DOI: 10.1038/jid.2009.4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Numerous investigations have been conducted using molecular profiling to evaluate the possible clonal origin of second malignancies in various cancer types. However, to date no study assessing clonality of multiple primaries has been conducted in melanoma. In this investigation using patients treated at a specialist melanoma treatment center, we compared the somatic mutational profiles of pairs of melanomas designated as independent on the basis of thorough assessment of their clinical and pathologic characteristics. We used a set of highly polymorphic genetic markers selected on the basis of their chromosomal positions and the frequencies of reported allelic losses at these genetic loci. Our statistical testing strategy showed no significant evidence of clonal origin of the two primaries in 17 of the 19 patients examined. The results suggest that most second melanomas designated as independent primary tumors on the basis of their clinicopathologic features are indeed independent occurrences of the disease, supporting the validity of the criteria used by experienced pathologists in distinguishing new primaries from metastases.
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Orlow I, Park BJ, Mujumdar U, Patel H, Siu-Lau P, Clas BA, Downey R, Flores R, Bains M, Rizk N, Dominguez G, Jani J, Berwick M, Begg CB, Kris MG, Rusch VW. DNA damage and repair capacity in patients with lung cancer: prediction of multiple primary tumors. J Clin Oncol 2008; 26:3560-6. [PMID: 18640936 DOI: 10.1200/jco.2007.13.2654] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients who survive one occurrence of non-small-cell lung cancer (NSCLC) are at higher risk of a second malignancy. Capacity to repair damaged DNA may modulate individual susceptibility to develop lung cancer. Therefore, we evaluated constitutive and induced DNA damage, and repair capacity, in patients with multiple NSCLCs (cases) and compared the results to those obtained in patients with a single NSCLC (controls). PATIENTS AND METHODS One hundred eight cases and 99 controls matched by age, sex, and time since diagnosis were studied. DNA damage was assessed on peripheral blood lymphocytes by the comet assay before and after exposing cells to a tobacco-derived carcinogen, using the tail moment and the tail intensity as measures to assess baseline damage, induced damage and repair capacity. RESULTS Constitutive DNA damage, benzo(a)pyrene diol epoxide-induced damage, and repair after BPDE-induced damage were all significantly higher in cases than in controls. These results were confirmed in regression analyses adjusted for potential confounders. CONCLUSION DNA damage as measured by the comet assay is associated with the development of multiple primary tumors in individuals with NSCLC.
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Affiliation(s)
- Irene Orlow
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Late (> 5 years) regional lymph node metastasis of oral squamous cell carcinoma (SCC), proven by p53 mutation analysis. J Craniomaxillofac Surg 2008; 36:415-8. [PMID: 18554920 DOI: 10.1016/j.jcms.2008.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 03/20/2008] [Accepted: 04/17/2008] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A late (> 5 years) neck nodal metastasis of oral cancer, poses a problem to the clinician: is it a late metastasis or a metastasis of a (unknown) second primary tumour? METHODS A 50-year-old male was seen with a contralateral lymph node metastasis, 5 1/2 years after treatment of a pT2N1M0 carcinoma in the floor of the mouth. Both the late metastasis and the original tumour specimen were analysed for p53 mutations. RESULTS Both specimens showed an identical p53 mutation, thereby confirming the lymph node to be a late metastasis. CONCLUSIONS A lymph node metastasis can occur more than 5 years after treatment of an oral squamous cell carcinoma. p53 mutation analysis is of help to discriminate it from a second primary tumour.
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Froio E, D'Adda T, Fellegara G, Ampollini L, Carbognani P, Rindi G. Three different synchronous primary lung tumours: A case report with extensive genetic analysis and review of the literature. Lung Cancer 2008; 59:395-402. [PMID: 17707945 DOI: 10.1016/j.lungcan.2007.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 06/29/2007] [Accepted: 07/03/2007] [Indexed: 10/22/2022]
Abstract
Synchronous triple lung tumours are rare and little is known as for their genetic basis. Here we report a case of a 59 years old male with three synchronous independent and histological different primary tumours of the left lung. Two nodules were located in the upper lobe and consisted of an adenocarcinoma (ADC) and an endobronchial poorly differentiated squamous cell carcinoma (SCC). A third nodule of the lower lobe corresponded to a small cell neuroendocrine carcinoma (SCLC). To assess if they represented independent primary tumours and have common genetic profiles, tumours were investigated for loss of heterozygosity (LOH) at 40 chromosomal markers. A comparable fractional allelic loss of 0.52 was observed in the ADC and SCLC, while it was 0.28 in the SCC. Microallelotyping analysis did not reveal a common genetic profile, supporting the hypothesis that the three synchronous tumours are truly independent primaries with different histogenesis.
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Affiliation(s)
- Elisabetta Froio
- Department of Pathology and Laboratory Medicine, Section of Anatomic Pathology, University of Parma, Parma, Italy
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Banerjee AK, Read CA, Griffiths MH, George PJ, Rabbitts PH. Clonal divergence in lung cancer development is associated with allelic loss on chromosome 4. Genes Chromosomes Cancer 2007; 46:852-60. [PMID: 17592619 DOI: 10.1002/gcc.20472] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Patients who receive curative treatment for lung cancer can develop additional lung tumors that may or may not be related to the original tumor and thus require different clinical management. If a subsequent tumor has a pattern of allele loss, revealed by allelotype analysis, overlapping that of the first tumor, it is believed to be a local recurrence or metastasis. In this case history, we present loss of heterozygosity analyses of the original primary tumor, and two second primary tumors occurring in the ipsilateral and the contra-lateral lungs. The allelotyping suggests that these tumors are all clonally related but concordance is not complete. Our interpretation is that the original primary tumor and the two new primary tumors have developed to full malignancy independently, but are clonally related, possibly via a clone of motile progenitor cells. Deletion mapping of DNA from biopsies of this patient delineated a region in 4p16 that we had previously shown to be lost in the transition from carcinoma in situ to invasive tumor. We identified a minimally deleted region encompassing six genes including two candidate tumor suppressor genes, CRMP1 a lung cancer metastasis-suppressing gene and PPP2R2C a gene for a regulatory subunit of the PP2 complex known to suppress tumorigenesis, particularly viral induced transformation.
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Affiliation(s)
- A K Banerjee
- Department of Thoracic Medicine, University College London Hospitals, London, UK
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Postmus PE, Brambilla E, Chansky K, Crowley J, Goldstraw P, Patz EF, Yokomise H. The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol 2007; 2:686-93. [PMID: 17762334 DOI: 10.1097/jto.0b013e31811f4703] [Citation(s) in RCA: 269] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To analyze all nonlymphatic metastatic components (T4 and M1) of the current TNM system of lung cancer, with the objective of providing suggestions for the next edition of the TNM classification for lung cancer. MATERIAL AND METHODS Data on 100,809 patients were submitted to the International Association for the Study of Lung Cancer International Database. Of these, 5592 selected T4M0 and M1 patients fulfilled the inclusion criteria for the analysis. Specific categories of clinically staged T4 (lesions not continuous with the primary tumor) and M1 cases were compared with respect to overall survival using Kaplan-Meier survival estimates and comparisons via Cox regression analysis. Relevant findings were validated internally by geographic area and type of database and were validated externally by the North American Surveillance, Epidemiology and End Results Registries. RESULTS Median survival for cT4M0 with malignant pleural effusion was significantly worse than that of other cT4M0 patients (8 months versus 13 months) and was more comparable with M1 cases with metastases to the contralateral lung only (10 months). M1 cases with metastases outside the lung/pleura had a significantly poorer prognosis than those with metastases confined to the lung, with a median survival of 6 months. CONCLUSIONS Revisions to the TNM classification system for lung cancer should include grouping cases with malignant pleural effusions and cases with nodules in the contralateral lung in the M1a category, and cases with distant metastases should be designated M1b. In addition, cases with nodule(s) in the ipsilateral lung (nonprimary lobe), currently staged M1, should be reclassified as T4M0, in accordance with the recommendations of the T descriptor subcommittee of the IASLC international staging committee.
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Libè R, Groussin L, Tissier F, Elie C, René-Corail F, Fratticci A, Jullian E, Beck-Peccoz P, Bertagna X, Gicquel C, Bertherat J. Somatic TP53 mutations are relatively rare among adrenocortical cancers with the frequent 17p13 loss of heterozygosity. Clin Cancer Res 2007; 13:844-50. [PMID: 17289876 DOI: 10.1158/1078-0432.ccr-06-2085] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Allelic losses [loss of heterozygosity (LOH)] at the 17p13 locus are frequent (85%) in adrenocortical cancers. The tumor suppressor gene TP53 is located at 17p13. The aim of the study was to determine the frequency of TP53 somatic inactivating mutations in adrenocortical tumors with 17p13 LOH and their clinico-biological correlations. EXPERIMENTAL DESIGN TP53 somatic mutations, intragenic LOH (VNTR1 marker), and p53 overexpression were studied in 36 adrenocortical tumors with 17p13 LOH determined by Southern blot. RESULTS TP53 mutations were detected in 33% of the tumors, and VNTR1 LOH was present in 44% of the cases and did not always correlate with the presence of a TP53 mutation. Only the TP53-mutant tumors exhibit a strong nuclear immunoreactivity. TP53-mutant tumors were significantly larger than wild-type TP53 tumors (median tumor weight: 640 versus 185 g; P=0.02), were associated with a more advanced stage of tumor progression (MacFarlane stage IV; P=0.01), and had a shorter disease-free survival (P=0.03). CONCLUSIONS The finding that only a minority of adrenocortical tumors with 17p13 LOH had either a VNTR1 LOH or a TP53 mutation indicates that TP53 might not be the only or major tumor suppressor gene at 17p13 involved in adrenocortical cancer progression. We suggest that a genetic instability of the 17p13 region, occurring early in adrenocortical cancer development, involves various genes located in this region. TP53 might be only one of them, and its alteration by the occurrence of inactivating mutation is associated with the development of more aggressive tumors.
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Affiliation(s)
- Rossella Libè
- Institut National de la Sante et de la Recherche Medicale U567, Centre National de la Recherche Scientifique UMR8104, Université Paris 5, and Assitance Publique-Hôpitaux de Paris, France
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Chang YL, Wu CT, Lin SC, Hsiao CF, Jou YS, Lee YC. Clonality and prognostic implications of p53 and epidermal growth factor receptor somatic aberrations in multiple primary lung cancers. Clin Cancer Res 2007; 13:52-8. [PMID: 17200338 DOI: 10.1158/1078-0432.ccr-06-1743] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE For treatment decision and prognostic applications, we evaluated p53/epidermal growth factor receptor (EGFR) somatic aberrations in multiple primary lung cancers to differentiate multifocal tumors from intrapulmonary metastasis. EXPERIMENTAL DESIGN Fifty-eight multiple primary lung cancers of 1,037 patients in a 10-year period were identified to investigate somatic mutations and altered expression of p53 and EGFR for clonality assessment. Genomic DNA was extracted from microdissected cells of paraffin-embedded multiple primary lung cancer tissues. Overexpression and somatic mutations in exons of p53 (exons 5-8) and tyrosine kinase domain of EGFR (exons 18-22) were examined by immunohistochemical staining and DNA sequencing, respectively. RESULTS High frequency of somatic mutations in p53 (33 of 58, 56.9%) and/or EGFR (44 of 58, 75.9%) resulted in high discrimination rate of tumor clonality (50 of 58, 86.2%) of multiple primary lung cancers. Twenty-two cases (37.9%) were assessed as having the same clonality and 28 cases (48.3%) were determined as having different clonality, which further supported the carcinogenic theory of field cancerization. Notably, the occurrence of lymph node metastasis was more commonly observed in tumors with the same clonality (P = 0.045) and was associated with poor patient 5-year survival rate (P = 0.001). However, no correlation was found between tumor clonality and patient survival (P = 0.630). The EGFR somatic aberrations in 58 multiple primary lung cancers, including vascular invasion associated with EGFR overexpression (P = 0.012) and mutation (P = 0.025), further suggested the potential benefits of target therapy of inoperable multiple primary lung cancers. CONCLUSIONS Our results suggest that analysis of somatic alterations in p53 and EGFR can significantly improve the clonality assessment and impact management of multiple primary lung cancer patients.
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Affiliation(s)
- Yih-Leong Chang
- Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine
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Berwick M, Orlow I, Hummer AJ, Armstrong BK, Kricker A, Marrett LD, Millikan RC, Gruber SB, Anton-Culver H, Zanetti R, Gallagher RP, Dwyer T, Rebbeck TR, Kanetsky PA, Busam K, From L, Mujumdar U, Wilcox H, Begg CB. The prevalence of CDKN2A germ-line mutations and relative risk for cutaneous malignant melanoma: an international population-based study. Cancer Epidemiol Biomarkers Prev 2006; 15:1520-5. [PMID: 16896043 DOI: 10.1158/1055-9965.epi-06-0270] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Germ-line mutations of CDKN2A have been identified as strong risk factors for melanoma in studies of multiple-case families. However, an assessment of their relative risk for melanoma in the general population has been difficult because they occur infrequently. We addressed this issue using a novel population-based case-control study design in which "cases" have incident second- or higher-order melanomas [multiple primary melanoma (MPM)] and "controls" have incident first primary melanoma [single primary melanoma (SPM)]. Participants were ascertained from nine geographic regions in Australia, Canada, Italy, and United States. In the 1,189 MPM cases and 2,424 SPM controls who were eligible and available for analysis, the relative risk of a subsequent melanoma among patients with functional mutations who have an existing diagnosis of melanoma, after adjustments for age, sex, center, and known phenotypic risk factors, is estimated to be 4.3 (95% confidence interval, 2.3-7.7). The odds ratio varied significantly depending on the type of mutation involved. The results suggest that the relative risk of mutation carriers in the population may be lower than currently believed and that different mutations on the CDKN2A gene may confer substantially different risks of melanoma.
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Affiliation(s)
- Marianne Berwick
- University of New Mexico, Department of Internal Medicine, New Mexico Cancer Research Facility, MSC08 4630, Room 103A, 1 University of New Mexico, Albuquerque, NM 87131, USA.
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Begg CB, Hummer AJ, Mujumdar U, Armstrong BK, Kricker A, Marrett LD, Millikan RC, Gruber SB, Culver HA, Zanetti R, Gallagher RP, Dwyer T, Rebbeck TR, Busam K, From L, Berwick M. A design for cancer case-control studies using only incident cases: experience with the GEM study of melanoma. Int J Epidemiol 2006; 35:756-64. [PMID: 16556646 DOI: 10.1093/ije/dyl044] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The population-based case-control study is not suited to the evaluation of rare genetic (or environmental) factors. The use of a novel case-control design in which cases have second primaries and controls are cancer survivors has been proposed for this purpose. METHODS We report results from an international study of melanoma that involved population-based ascertainment of incident cases of second or subsequent primary melanoma as the 'case' group and incident cases of first primary melanoma as the 'control' group. We evaluate the validity of the study design by comparing the results obtained for phenotypic factors that have been shown consistently to be associated with melanoma in previous conventional studies with the results from a conventional case-control study conducted in Connecticut and from literature reviews. RESULTS All but one of the known risk factors for melanoma were shown to be significantly associated with melanoma in our study, though the individual odds ratios appear to be somewhat attenuated relative to the magnitudes typically observed in the literature. CONCLUSIONS Patients with a second or subsequent primary cancer of a single type represent a potentially valuable and under-utilized resource for the study of cancer aetiology.
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Affiliation(s)
- Colin B Begg
- Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Brock MV, Alberg AJ, Hooker CM, Kammer AL, Xu L, Roig CM, Yang SC. Risk of subsequent primary neoplasms developing in lung cancer patients with prior malignancies. J Thorac Cardiovasc Surg 2004; 127:1119-25. [PMID: 15052211 DOI: 10.1016/j.jtcvs.2003.10.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study was performed to test the hypothesis that a history of other primary neoplasms before a lung cancer diagnosis increases the risk of subsequent malignancy. METHODS Of 8363 lung cancer patients seen from 1978 to 2002, 881 (11%) had at least 1 previous nonlung primary malignancy. Charts were analyzed for the occurrence of subsequent malignancies. RESULTS Lung cancer diagnosis in 881 patients consisted of 75% non-small cell, 12% small cell, and 13% other histologies. The median age was 66 years, with 56% male, 76% white, and 86% smokers. Of the 881 patients, 92% had no subsequent cancer (group 1), and 8% went on to experience the development of a new primary neoplasm (including lung) after their lung cancer (group 2). After adequate follow-up, the cumulative probability of developing a subsequent cancer did not differ markedly between those with and without a prior non-lung cancer diagnosis at 2 years (12% vs 10%) or 5 years (16% vs 15%). Group 1 patients had a significantly lower 1- and 5-year survival than group 2 patients (59% vs 48% and 29% vs 17%, respectively; P =.008). Although multivariate analysis suggested that stage, history of tobacco-associated neoplasm, and history of definitive surgical resection were important determinants in predicting long-term survival, a prior malignancy was not an independent risk factor in the development of subsequent malignancy. CONCLUSIONS The risk of developing a subsequent malignancy is very high in lung cancer patients with prior primary malignancies, but it is not markedly different from the risks experienced by patients with no prior malignancies.
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MESH Headings
- Aged
- Aged, 80 and over
- Baltimore/epidemiology
- Carcinoma, Non-Small-Cell Lung/epidemiology
- Carcinoma, Non-Small-Cell Lung/etiology
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Small Cell/epidemiology
- Carcinoma, Small Cell/etiology
- Carcinoma, Small Cell/pathology
- Female
- Follow-Up Studies
- Humans
- Lung Neoplasms/epidemiology
- Lung Neoplasms/etiology
- Lung Neoplasms/pathology
- Male
- Middle Aged
- Multivariate Analysis
- Neoplasm Staging
- Neoplasms, Multiple Primary/epidemiology
- Neoplasms, Multiple Primary/etiology
- Neoplasms, Multiple Primary/pathology
- Predictive Value of Tests
- Risk Factors
- Smoking/adverse effects
- Survival Analysis
- Time Factors
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