Mind-mapping for lung cancer: towards a personalized therapeutics approach

[Relationship between EGFR, ALK Gene Mutation and Imaging and Pathological Features in Invasive Lung Adenocarcinoma]

BACKGROUND

At present, the research progress of targeted therapy for epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) gene mutations in lung adenocarcinoma is very rapid, which brings new hope for the treatment of advanced lung adenocarcinoma patients. However, the specific imaging and pathological features of EGFR and ALK gene mutations in adenocarcinoma are still controversial. This study will further explore the correlation between EGFR, ALK gene mutations and imaging and pathological features in invasive lung adenocarcinoma.

METHODS

A total of 525 patients with lung adenocarcinoma who underwent surgery in our center from January 2018 to December 2019 were included. According to the results of postoperative gene detection, the patients were divided into EGFR gene mutation group, ALK gene mutation group and wild group, and the EGFR gene mutation group was divided into exon 19 and exon 21 subtypes. The pathological features of the mutation group and wild group, such as histological subtype, lymph node metastasis, visceral pleural invasion (VPI) and imaging features such as tumor diameter, consolidation tumor ratio (CTR), lobulation sign, spiculation sign, pleural retraction sign, air bronchus sign and vacuole sign were analyzed by univariate analysis and multivariate Logistic regression analysis to explore whether the gene mutation group had specific manifestations.

RESULTS

EGFR gene mutation group was common in women (OR=2.041, P=0.001), with more pleural traction sign (OR=1.506, P=0.042), and had little correlation with lymph node metastasis and VPI (P>0.05). Among them, exon 21 subtype was more common in older (OR=1.022, P=0.036), women (OR=2.010, P=0.007), and was associated with larger tumor diameter (OR=1.360, P=0.039) and pleural traction sign (OR=1.754, P=0.029). Exon 19 subtype was common in women (OR=2.230, P=0.009), with a high proportion of solid components (OR=1.589, P=0.047) and more lobulation sign (OR=2.762, P=0.026). ALK gene mutations were likely to occur in younger patients (OR=2.950, P=0.045), with somking history (OR=1.070, P=0.002), and there were more micropapillary components (OR=4.184, P=0.019) and VPI (OR=2.986, P=0.034) in pathology.

CONCLUSIONS

The EGFR and ALK genes mutated adenocarcinomas have specific imaging and clinicopathological features, and the mutations in exon 19 or exon 21 subtype have different imaging features, which is of great significance in guiding the clinical diagnosis and treatment of pulmonary nodules.

[Information tool about labor and delivery designed by Delphi method]

OBJECTIVE

The integration of couples in decision making in obstetrics is necessary to improve the experience of giving birth. The objective of this work is to elaborate a new tool to provide information to health professionals.

METHODS

A 5-round Delphi method was used to define the information points. The 20 multi-disciplinary experts answered 5 surveys on the information to deliver concerning childbirth. The selected items were organized with mind mapping.

RESULTS

54 items were identified on the first round. 5 were retained after the second survey while the rest were reformulated and submitted for the third round. Amongst the 47 items submitted, 19 were retained, the rest were removed, merged or reworded. The fourth survey included 22 items of which 11 were retained. The fifth survey concerned the 11 remaining items and 2 new ones. During this round, 7 items were retained. This round made it possible to reach the consensus. In total, 42 items reached the consensus of the experts. They were then split into 5 mind maps allowing their visual organization to form the information tool.

CONCLUSION

The tool elaborated in a multi-disciplinary manner offers complementary information to that already given during childbirth preparation courses. It is a framework for the information to be given that leaves the content up to each professional.

iQbD: a TRL-indexed Quality-by-Design Paradigm for Medical Device Engineering

Risk assessment is a critical step in the roadmap of medical device development. Failure modes, effects and criticality analysis is a common approach based on declarative prior information that proved beneficial in the risk assessment of well established processes. But at early steps of development when innovative materials or technologies are embedded, the lack of experience on those innovations introduces too much subjectivity in FMECA for a robust risk assessment. Since mid-2000, the Quality-by-Design guideline has been proposed within the pharmaceutical industry as a proactive engineering approach of drug development. This paradigm enables a data-driven risk assessment throughout the development workflow, which completes risk assessment provided by FMECA. Nevertheless, its implementation guide is unclear and not flexible enough to be efficiently applied to the development of medical devices. To address this issue, a new QbD paradigm indexed on the technological readiness level of the innovative product is proposed. It covers the development of medical devices throughout the whole preclinical phase and is composed of at least nine learning cycles. The first part of this medical device QbD layout, composed of three consecutive risk assessment cycles, is evaluated through a real study case with the objective to demonstrate the proof of concept of a photobleaching controller in photodynamic therapy. Beyond this experimental result, this application has confirmed practical ability of the iQbD approach to complete FMECA and to provide an alternative solution to risk assessment when prior knowledge on the technological innovation is not available.

Using Mind Mapping in Family Meetings to Support Shared Decision Making with Pediatric and Geriatric Patients

INTRODUCTION

Divergent objectives and narratives among members of a healthcare team may lead to suffering, underscoring the need to align patient care with the patient's self-identified priorities and goals. Shared decision making (SDM) with patients who may not be able to make healthcare decisions for themselves presents a unique challenge to healthcare providers, caregivers, and patients. Children and the elderly are two such groups where substituted decision making is often required. Family meetings, wherein stakeholders in a patient's care are gathered, present opportunities to align expectations and clinical goals. There is a clear need for a technique exploring all facets of the patient's story within the context of the biopsychosocial-spiritual model. We sought to promote narrative equity among stakeholders and maintain patient focus during family meetings. We describe the use of Mind Mapping in the family meeting to meet these objectives.

METHODS

Using two clinical scenarios, one involving a geriatric patient and another involving a pediatric patient, we describe the stepwise development of Mind Maps and how their use informed discussions among stakeholders in the family meeting.

RESULTS

Stakeholders found the Mind Maps easy to draw and helpful in eliciting their own priorities and preferences. Group exploration and refinement of the Mind Maps helped stakeholders to appreciate others' sometimes divergent perspectives, to ensure that the patient's voice was heard, and to ensure that care decisions were patient focused.

DISCUSSION

Mind Mapping was easily performed in two clinical scenarios, allowing the patient, family, and medical team to explore the biopsychosocial-spiritual model extensively, to appreciate each stakeholder's priorities, and to identify areas for further development. We have found that Mind Mapping helps define the 'topography' of relationships, prioritizes team discussions, finds shared interests in seemingly divergent objectives, and identifies which team member may best lead a discussion on a particular topic.

CONCLUSION

Mind Mapping may be a useful tool for family meetings, particularly for geriatric and pediatric patients with multiple stakeholders involved.

Effects of a Mind Map-Based Life Review Program on Anxiety and Depressive Symptoms on Cancer Patients Undergoing Chemotherapy: A Randomized Controlled Trial

BACKGROUND

Cancer patients undergoing chemotherapy often experience psychological distress. The mind map-based life review program (MBLRP) offers the potential to reduce patients' negative emotions. However, its effects remain unknown.

OBJECTIVE

The objective of this study is to determine the effects of the MBLRP on anxiety and depressive symptoms in cancer patients undergoing chemotherapy.

METHODS

A randomized controlled trial with repeated measures was adopted. Eighty-four cancer patients undergoing chemotherapy were recruited from a general hospital in Fujian, China. Participants were randomly assigned to an experimental group (n = 40) or a control group (n = 44). The participants in the experimental group received the MBLRP plus routine care. The participants in the control group received routine care. Outcomes were measured at baseline, on the second day, and at 4 weeks after the MBLRP.

RESULTS

In terms of anxiety, multivariate test statistics showed significant differences in within-group (F = 11.343, P < .001), between-group (F = 8.873, P = .004), and interaction effects (group × time) (F = 19.595, P < .001). For the depressive symptoms, the results showed that the within-group effect (F = 12.385, P < .001), group effect (F = 18.000, P < .001), and group × time effect (F = 26.544, P < .001) were statistically significant, favoring the MBLRP experimental group.

CONCLUSIONS

The MBLRP has the potential to reduce anxiety and depressive symptoms in cancer patients undergoing chemotherapy. Further research is needed within larger more representative samples.

IMPLICATIONS FOR PRACTICE

The MBLRP is a nurse-led, nonpharmacological program that could be recommended for cancer patients undergoing chemotherapy and integrated into clinical practice.

Effects of cognitive education on the perceived control and symptom distress of lung cancer patients receiving chemotherapy: A randomised controlled trial

AIM

A randomised controlled trial (RCT) was implemented to verify the feasibility and acceptability of cognitive education in the format of mind maps for increasing perceived control and decreasing the symptom distress of lung cancer patients who were receiving chemotherapy.

METHODS

A total of 136 lung cancer patients who were receiving chemotherapy were randomised using stratified blocks (1:1 ratio, from March 2016 to April 2017). The intervention group was given cognitive education in the format of mind maps. The control group was provided conventional education. The primary outcomes were perceived control, including cancer experience and cancer efficacy; the secondary outcomes included symptom distress (arising from fatigue, distress, sleep disturbance, poor appetite, drowsiness, shortness of breath, etc.). The Mann-Whitney U test, chi-squared test, two-sample t test and repeated measurement analysis of variance were used.

RESULTS

Ninety-four patients completed the final study. The results of the repeated measurement analysis of variance indicated that at the 8th or 12th week following cognitive education intervention in the format of mind maps, the cancer experience, cancer efficacy (except personal efficacy) and symptom distress (arising from fatigue, distress, sleep disturbance, and sadness and its total scores) of the patients in the intervention group were considerably improved compared with those of the control group (p < 0.05). The longer the intervention was, the higher the level of the patients' perceived control was and the lower the degree of patient symptom distress was (p < 0.05).

CONCLUSIONS

Our findings suggest that cognitive education in the format of mind maps could improve perceived control and decrease the symptom distress of lung cancer patients who were receiving chemotherapy and that it was feasible and acceptable. Cognitive education in the format of mind maps was found to be an effective teaching tool for lung cancer patients who were receiving chemotherapy.

Use of mind maps and iterative decision trees to develop a guideline-based clinical decision support system for routine surgical practice: case study in thyroid nodules

OBJECTIVE

The study sought to develop a clinical decision support system (CDSS) for the treatment of thyroid nodules, using a mind map and iterative decision tree (IDT) approach to the integration of clinical practice guidelines (CPGs).

MATERIALS AND METHODS

Thyroid nodule CPGs of the American Thyroid Association and Korean Thyroid Association were analyzed by endocrine surgeons (domain experts) and computer scientists. Clinical knowledge from the CPGs was expressed using mind maps. The mind maps were analyzed and converted into IDTs. The final IDT was implemented as a set of candidate rules (3700) for a knowledge-based CDSS. The system was evaluated via a retrospective review of the medical records of 483 patients who had undergone thyroidectomy between January and December 2015 at a single tertiary center (Seoul National University Hospital Bundang, Korea).

RESULTS

Concordance between CDSS recommendations and treatment in routine clinical practice was 78.9%. In the 21.1% discordant cases, deviation from the CDSS treatment recommendation was mainly attributable to (1) refusal of the patient to undergo total thyroidectomy and (2) conversion from lobectomy to total thyroidectomy following an unexpected histological finding during intraoperative frozen biopsy lymph node analysis.

CONCLUSIONS

The present study demonstrated that a knowledge-based CDSS is feasible in the treatment of thyroid nodules. A high-quality knowledge-based CDSS was developed, and medical domain and computer scientists collaborated effectively in an integrated development environment. The mind map and IDT approach represents a pioneering method of integrating knowledge from CPGs.

Essential roles of mitochondrial and heme function in lung cancer bioenergetics and tumorigenesis

Contrary to Warburg’s hypothesis, mitochondrial oxidative phosphorylation (OXPHOS) contributes significantly to fueling cancer cells. Several recent studies have demonstrated that radiotherapy-resistant and chemotherapy-resistant cancer cells depend on OXPHOS for survival and progression. Several cancers exhibit an increased risk in association with heme intake. Mitochondria are widely known to carry out oxidative phosphorylation. In addition, mitochondria are also involved in heme synthesis. Heme serves as a prosthetic group for several proteins that constitute the complexes of mitochondrial electron transport chain. Therefore, heme plays a pivotal role in OXPHOS and oxygen consumption. Further, lung cancer cells exhibit heme accumulation and require heme for proliferation and invasion in vitro. Abnormalities in mitochondrial biogenesis and mutations are implicated in cancer. This review delves into mitochondrial OXPHOS and lesser explored area of heme metabolism in lung cancer.

Gene expression profiling analysis of lung adenocarcinoma

The present study screened potential genes related to lung adenocarcinoma, with the aim of further understanding disease pathogenesis. The GSE2514 dataset including 20 lung adenocarcinoma and 19 adjacent normal tissue samples from 10 patients with lung adenocarcinoma aged 45-73 years was downloaded from Gene Expression Omnibus. Differentially expressed genes (DEGs) between the two groups were screened using the t-test. Potential gene functions were predicted using functional and pathway enrichment analysis, and protein-protein interaction (PPI) networks obtained from the STRING database were constructed with Cytoscape. Module analysis of PPI networks was performed through MCODE in Cytoscape. In total, 535 upregulated and 465 downregulated DEGs were identified. These included ATP5D, UQCRC2, UQCR11 and genes encoding nicotinamide adenine dinucleotide (NADH), which are mainly associated with mitochondrial ATP synthesis coupled electron transport, and which were enriched in the oxidative phosphorylation pathway. Other DEGs were associated with DNA replication (PRIM1, MCM3, and RNASEH2A), cell surface receptor-linked signal transduction and the enzyme-linked receptor protein signaling pathway (MAPK1, STAT3, RAF1, and JAK1), and regulation of the cytoskeleton and phosphatidylinositol signaling system (PIP5K1B, PIP5K1C, and PIP4K2B). Our findings suggest that DEGs encoding subunits of NADH, PRIM1, MCM3, MAPK1, STAT3, RAF1, and JAK1 might be associated with the development of lung adenocarcinoma.

[Driver genes and its clinical significance in non-small cell lung cancer]

With the development of molecular biology technology and the transforming patterns of drug research, guiding molecular targeted therapy according to the drive gene mutation spectrum in lung cancer has gradually become a reality. Definition of the mutation incidence and whether existing advantage population groups in non-small cell lung cancer (NSCLC) have important guiding significance in clinical practice. The purpose of this paper will draw a summary on the general characteristics, demographic features and clinical significance of driver genes in NSCLC.

U.S. Food and Drug Administration approval summary: Erlotinib for the first-line treatment of metastatic non-small cell lung cancer with epidermal growth factor receptor exon 19 deletions or exon 21 (L858R) substitution mutations

On May 14, 2013, the U.S. Food and Drug Administration approved erlotinib (Tarceva, Astellas Pharma Inc., Northbrook, IL, http://www.us.astellas.com/) for the first-line treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations. This indication for erlotinib was approved concurrently with the cobas EGFR Mutation Test (Roche Molecular Systems, Inc., Basel, Switzerland, http://www.molecular.roche.com), a companion diagnostic test for patient selection. The approval was based on clinically important improvements in progression-free survival (PFS) and objective response rate (ORR) and an acceptable toxicity profile demonstrated in a multicenter, open label trial enrolling 174 patients with metastatic NSCLC whose tumors had EGFR mutations as determined by a laboratory-developed test. Patients were randomized (1:1) to receive erlotinib (150 mg/day) or platinum-based doublet chemotherapy. The primary endpoint was investigator-assessed PFS. Secondary endpoints included overall survival (OS) and ORR. Superior PFS (hazard ratio [HR] 0.34; 95% confidence interval [CI]: 0.23, 0.49; p < .001) and ORR (65% vs. 16%) were observed in the erlotinib arm. Median PFS was 10.4 months and 5.2 months in the erlotinib and chemotherapy arms, respectively. There was no difference in OS (HR 0.93; 95% CI: 0.64, 1.35) with median OS of 22.9 months and 19.5 months in the erlotinib and chemotherapy arms, respectively. The most frequent (≥30%) adverse reactions in the erlotinib-treated patients were rash, diarrhea, asthenia, cough, dyspnea, and decreased appetite. The most frequent (≥5%) grade 3 and 4 adverse reactions were rash and diarrhea.

Mind maps: Enhancing midwifery education

Educationalists need to think outside the box to facilitate students to learn key information essential for professional practice. The use of mind maps incorporated into an assessment strategy and programme is an innovative way of facilitating students to understand key information. Mind maps have the potential to provide students with a strategy for retaining information, integrating critical thinking and problem solving skills. This article reviews the current discussion on mind maps and discusses the integration of mind maps into a component of an assessment strategy.

[Advances of molecular subtype and targeted therapy of lung cancer]

The discovery of multiple molecular mechanisms underlying the development, progression, and prognosis of lung cancer, has created new opportunities for targeted therapy. Each subtype is associated with molecular tests that define the subtype and drugs that may have potential therapeutic effect on lung cancer. In 2004, mutations in the epidermal growth factor receptor (epidermal growth factor receptor, EGFR) gene were discovered in non-small cell lung cancers (NSCLC), especially in adenocarcinomas. And they are strongly associated with sensitivity to EGFR-tyrosine kinase inhibitors (EGFR-TKIs). Moreover, in 2007 the existence of the echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion gene was discovered in NSCLC, and the same as EGFR-TKIs, ALK inhibitors are being found to be highly effective in lung cancers. At present, multiple molecular subtype of lung cancer and relevant targeted drugs are undering study. Here, we review the remarkable progress in molecular subtype of lung cancer and the related targeted therapy.

A novel classification of lung cancer into molecular subtypes

The remarkably heterogeneous nature of lung cancer has become more apparent over the last decade. In general, advanced lung cancer is an aggressive malignancy with a poor prognosis. The discovery of multiple molecular mechanisms underlying the development, progression, and prognosis of lung cancer, however, has created new opportunities for targeted therapy and improved outcome. In this paper, we define "molecular subtypes" of lung cancer based on specific actionable genetic aberrations. Each subtype is associated with molecular tests that define the subtype and drugs that may potentially treat it. We hope this paper will be a useful guide to clinicians and researchers alike by assisting in therapy decision making and acting as a platform for further study. In this new era of cancer treatment, the 'one-size-fits-all' paradigm is being forcibly pushed aside-allowing for more effective, personalized oncologic care to emerge.