Utility of Routine PET Imaging to Predict Response and Survival After Induction Therapy for Non-Small Cell Lung Cancer

Circulating tumor DNA to guide diagnosis and treatment of localized and locally advanced non-small cell lung cancer

Liquid biopsy is a minimally invasive method for biomarkers detection in body fluids, particularly in blood, which offers an elevated and growing number of clinical applications in oncology. As a result of the improvement in the techniques for DNA analysis, above all next-generation sequencing (NGS) assays, circulating tumor DNA (ctDNA) has become the most informing tumor-derived material for most types of cancer, including non-small cell lung cancer (NSCLC). Although ctDNA concentration is higher in patients with advanced tumors, it can be detected even in patients with early-stage disease. Therefore, numerous clinical applications of ctDNA in the management of early-stage lung cancer are emerging, such as lung cancer screening, the identification of minimal residual disease (MRD), and the prediction of relapse before radiologic progression. Moreover, a high number of clinical trials are ongoing to better define the impact of ctDNA evaluation in this setting. Aim of this review is to offer a comprehensive overview of the most relevant implementations in using ctDNA for the management of early-stage lung cancer, addressing available data, technical aspects, limitations, and future perspectives.

The usefulness of 18F-FDG PET/CT in follow-up and recurrence detection for patients with lung carcinoma and its impact on the survival outcome

Background

We assess the usefulness of 18F-FDG PET/CT for detection of recurrent or residual tumor in post treatment patients with NSCLC and comparing the results with CECT, and we evaluate its impact to the clinical assessment and overall survival of lung cancer patients.

Results

A prospective study of 63 patients with potentially resectable NSCLC, were divided into 2 groups according to the initial staging of the disease and the early response to treatment.

Group A (n=29) patients were treated by curative treatment, and group B (n=34) patients were treated by palliative treatment.

Evaluation of patients was done during the follow-up period clinically every 3 months and by 18F-FDG PET/CT and CECT imaging at 6 months intervals.

In group A, 18F-FDG PET/CT correctly diagnosed all recurrent or residual tumors (n=7) whereas CECT diagnosed only 5 with 2 false negative cases.

In group B, 18F-FDG PET/CT correctly diagnosed all recurrent or residual tumors (n=23) whereas CECT diagnosed 16 patients with 7 false negative cases.

By comparison of 18F-FDG PET/CT and CECT in detection of residual or recurrent lung cancer (n=30), the sensitivity, specificity, PPV, NPV, and accuracy of 18F-FDG PET/CT were 100%, 92%, 92%, 100%, and 96% respectively, while of CECT were 72%, 95%, 94%, 79%, and 84% respectively in correlation with reference standard data. The calculated SUV max ranged from 2.1 to 4.9.

There was a significant difference in overall survival between patients in routine scan who had positive 18F FDG PET/CT result (median survival 18 months) and those who had negative result (median survival 45 months) (P<0.0001).

Conclusion

18 F-FDG PET/CT plays an important role in distinguishing post treatment changes from tumor recurrence in patients with lung cancer. Follow-up or surveillance 18 F-FDG PET/CT is a prognostic indicator for overall survival of patients.

circ_0005962 functions as an oncogene to aggravate NSCLC progression

Background

Non-small cell lung cancer (NSCLC) is a leading threat to human lives with high incidence and mortality. Circular RNAs were reported to play important roles in human cancers. The purpose of this study was to investigate the role of circ_0005962 and explore the underlying functional mechanisms.

Methods

The protein levels of Beclin 1, light chain3 (LC3-II/LC3-I), Pyruvate dehydrogenase kinase 4 (PDK4), Cleaved Caspase 3 (C-caspase 3), and proliferating cell nuclear antigen were examined using western blot analysis. Glycolysis was determined according to the levels of glucose consumption and lactate production. Xenograft model was constructed to investigate the role of circ_0005962 in vivo.

Result

circ_0005962 expressed with a high level in NSCLC tissues and cells. circ_0005962 knockdown inhibited proliferation, autophagy, and glycolysis but promoted apoptosis in NSCLC cells. miR-382-5p was targeted by circ_0005962, and its inhibition reversed the role of circ_0005962 knockdown. Besides, PDK4, a target of miR-382-5p, was regulated by circ_0005962 through miR-382-5p, and its overexpression abolished the effects of miR-382-5p reintroduction. circ_0005962 knockdown suppressed tumor growth in vivo.

Conclusion

circ_0005962 knockdown restrained cell proliferation, autophagy, and glycolysis but stimulated apoptosis through modulating the circ_0005962/miR-382-5p/PDK4 axis. Our study broadened the insights into understanding the mechanism of NSCLC progression.

Evaluation of tumor response after stereotactic body radiation therapy for lung cancer: Role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography

BACKGROUND

Early identification of patients who fail to lung stereotactic body radiation therapy (SBRT) is vital as they can benefit from salvage therapy. Main guidelines recommend computed tomography (CT) to assess response and use of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT only when a local recurrence is suspected in CT. The pattern of radiation-induced lung injury caused by SBRT is different from changes seen after conventional radiation therapy in terms of extent, time of manifestation, and morphologic characteristics, and knowing this is crucial for proper monitoring of the tumor response. In certain cases, it may be difficult to differentiate response from progression or recurrence on CT and, in addition, some changes in CT take a long time to evolve before they are considered suspicious, making early diagnosis difficult. Metabolic changes often precede morphological changes, so 18F-FDG PET/CT quantitative and qualitative metabolic criteria can be useful in assessing early response and detecting relapses. However, the optimal practice for follow-up remains unclear and there is an active search for imaging markers for recurrent disease, including CT texture analysis, biomarker assays, new PET/CT isotopes, and magnetic resonance imaging.

AIM

The aim of the study was to review the radiological changes that are objectified after pulmonary SBRT and the metabolic changes in 1F-FDG PET/CT, to assess the usefulness of following up patients with 18F-FDG PET/CT.

RELEVANCE FOR PATIENTS

At present, the evaluation of response and diagnosis of relapse after SBRT are difficult and the incorporation of routine 18F-FDG PET/CT may have value in early diagnosis of relapse when the patient may still benefit from rescue treatment.

The Association Between RAPSN Methylation in Peripheral Blood and Early Stage Lung Cancer Detected in Case-Control Cohort

Background

Early detection is essential to improve the survival and life quality of lung cancer (LC) patients. Changes of peripheral blood DNA methylation could be associated with malignancy but were mostly studied in Caucasians.

Methods

Here, in a Chinese population, we performed mass spectrometry assays to investigate the association between very early stage LC and methylation levels of RAPSN in the peripheral blood by a case–control cohort using of 221 LC patients (93.2% LC at stage I) and 285 unrelated cancer free control individuals.

Results

The odds ratios (ORs) of all CpG sites were evaluated for their risk to LC using inter-quartile analyses by logistic regression. In general, we observed an association between very early LC and decreased methylation of RAPSN_CpG_1.15 and RAPSN_CpG_3.4 (referring to Q4, OR range from 1.64 to 1.81, p<0.05). Stratified by gender, while hypomethylation of RAPSN_CpG_1.15, RAPSN_CpG_3.4 and RAPSN_CpG_7.14 were associated with LC in males (referring to Q4, ORs range from 1.94 to 2.31, p<0.05), RAPSN_CpG_2 and RAPSN_CpG_5 showed significantly lower methylation in female LC patients comparing to controls (referring to Q4, ORs range from 2.49 to 3.60, p<0.05). The risk of RAPSN hypomethylation to LC was enhanced by aging, and typically for people older than 55 years (referring to Q4, ORs range from 2.17 to 3.61 in six out of all 10 analyzed CpG groups, p<0.05).

Conclusion

Our study reveals an association between RAPSN hypomethylation in peripheral blood and LC and suggests the occurrence of altered blood-based methylation at the early stage of cancer.

18F-FDG PET/CT in Restaging and Evaluation of Response to Therapy in Lung Cancer: State of the Art

BACKGROUND

Metabolic information provided by 18F-FDG PET/CT are useful for initial staging, therapy planning, response evaluation, and to a lesser extent for the follow-up of non-small cell lung cancer (NSCLC). To date, there are no established clinical guidelines in treatment response and early detection of recurrence.

OBJECTIVE

To provide an overview of 18F-FDG PET/CT in NSCLC and in particular, to discuss its utility in treatment response evaluation and restaging of lung cancer.

METHODS

A comprehensive search was used based on PubMed results. From all studies published in English those that explored the role of 18F-FDG PET/CT in the treatment response scenario were selected.

RESULTS

Several studies have demonstrated that modifications in metabolic activity, expressed by changes in SUV both in the primary tumor as well as in regional lymph nodes, are associated with tumor response and survival. Beside SUV, other metabolic parameters (i.e. MTV, TLG, and percentage changes) are emerging to be helpful for predicting clinical outcomes.

CONCLUSION

18F-FDG parameters appear to be promising factors for evaluating treatment response and for detecting recurrences, although larger prospective trials are needed to confirm these evidences and to determine optimal cut-off values.

Prognostic value of 18F-FDG PET parameters in patients with locally advanced non-small cell lung cancer treated with induction chemotherapy

AIM

To investigate predictive and prognostic role of metabolic parameters using [¹⁸ F]-2-fluoro-2-deoxy-D-glucose positron emission tomography (¹⁸ F-FDG PET) in patients with locally advanced non-small cell lung cancer (NSCLC) treated with docetaxel-platinum induction chemotherapy (IC).

METHODS

Medical records of 31 patients with pre- and post-IC ¹⁸ F-FDG PET were reviewed. Using ¹⁸ F-FDG PET, metabolic parameters, including metabolic tumor response, adjusted peak standardized uptake values using lean body mass at baseline (pre-SUL_peak ) and after IC (post-SUL_peak ), and percentage change of pre- and post-SUL_peak (ΔSUL_peak ), were assessed.

RESULTS

Response rate (RR) was 71%, with a metabolic RR of 83.9%. Nineteen (61.3%) patients underwent surgery, R0 resection was achieved for 17 (89.5%) patients. Median relapse-free survival (RFS) and overall survival (OS) were 8.9 months (95% CI: 4.5-12.1) and 24.1 months (95% CI: 17.1-34.1), respectively. Post-SUL_peak  < 2 was identified as a favorable prognostic factor for RFS (hazard ratio [HR]: 0.12; P = .004), while ΔSUL_peak ≥60% and R0 resection were found as positive prognostic factors for OS (HR: 0.09 and 0.13; P = .011 and P = .042, respectively). Using a receiver operating characteristics curve, post-SUL_peak  > 1.4 could predict recurrence with a sensitivity of 84% and a specificity of 100%.

CONCLUSION

In patients with locally advanced NSCLC receiving IC, post-SUL_peak and ΔSUL_peak showed clinical significance for survival outcome.

Dexamethasone and lenvatinib inhibit migration and invasion of non-small cell lung cancer by regulating EKR/AKT and VEGF signal pathways

Migration and invasion is one of the most important features in tumor metastasis and development. Non-small cell lung cancer (NSCLC) is one of the most common types of cancer globally, and has been linked to air contamination. Evidence indicates that cysteine-rich angiogenic inducer 61 (CYR61) is associated with the migration and invasion of NSCLC. Overexpression of CYR61 protein promotes the migration and the transition of tumor-derived vascular endothelial cells in NSCLC. However, the association between CYR61 and NSCLC remains poorly understood. Lenvatinib is an oral multi-target drug that targets various receptors upon tumor angiogenesis. Dexamethasone is widely approved for combination therapy in patients with NSCLC. In the current study, the expression and function of CYR61 in NSCLC was analyzed during the progression of NSCLC. Inhibitory effects on migration and invasion induced by lenvatinib and dexamethasone were determined by migratory and invasion assays. Migratory pathways of extracellular signal-regulated kinases (ERK) and protein kinase B (AKT) were also investigated by targeting vascular endothelial growth factor (VEGF) and CYR61 via synergistic treatment with transforming growth factor-β1 (TGF-β1) and dexamethasone. Therapeutic outcomes of combined treatment with lenvatinib and dexamethasone were assessed in NSCLC-bearing mice. The results of the present study indicate that cooperative treatment of lenvatinib and dexamethasone significantly inhibited TGF-β1-induced cell migration and suppressed tumor growth (P<0.01). Notably, the results demonstrated that dexamethasone eradicated the promotion effects of TGF-β1 on the AKT/epithelial-mesenchymal transition process and lenvatinib extinguished tumor cell metastasis by targeting VEGF. The results of the current study also demonstrate that dexamethasone suppressed the expression of CAG-I and enhanced expression of matrix metalloproteinase-1. Synergistic treatment for NSCLC was demonstrated to be efficacious. In conclusion, dexamethasone inhibited AKT/ERK phosphorylation and lenvatinib antagonism bound VEGF leading to the limitation of migration and invasion of cancer cells in NSCLC.

Polyphyllin VI, a saponin from Trillium tschonoskii Maxim. induces apoptotic and autophagic cell death via the ROS triggered mTOR signaling pathway in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancers. Our previous studies have proven that Trillium tschonoskii Maxim. (TTM), a traditional Chinese medicine, possesses potent anti-tumor effect. However, the detailed components and molecular mechanism of TTM in anti-NSCLC are still unknown. In the present experiment, polyphyllin VI (PPVI) was successfully isolated from TTM with guidance of the anti-proliferative effect in A549 cells, and the cell death of PPVI treated A549 and H1299 cells was closely linked with the increased intracellular ROS levels. In addition, PPVI induced apoptosis by promoting the protein expression of Bax/Bcl2, caspase-3 and caspase-9, and activated autophagy by improving LC3 II conversion and GFP-LC3 puncta formation in A549 and H1299 cells. The mechanism study found that the activity of mTOR which regulates cell growth, proliferation and autophagy was significantly suppressed by PPVI. Accordingly, the PI3K/AKT and MEK/ERK pathways positively regulating mTOR were inhibited, and AMPK negatively regulating mTOR was activated. In addition, the downstream of mTOR, ULK1 at Ser 757 which downregulates autophagy was inhibited by PPVI. The apoptotic cell death induced by PPVI was confirmed, and it was significantly suppressed by the overexpression of AKT, ERK and mTOR, and the induced autophagic cell death which was depended on the Atg7 was decreased by the inhibitors, such as LY294002 (LY), Bafilomycin A1 (Baf), Compound C (CC) and SBI-0206965 (SBI). Furthermore, the mTOR signaling pathway was regulated by the increased ROS as the initial signal in A549 and H1299 cells. Finally, the anti-tumor growth activity of PPVI in vivo was validated in A549 bearing athymic nude mice. Taken together, our data have firstly demonstrated that PPVI is the main component in TTM that exerts the anti-proliferative effect by inducing apoptotic and autophagic cell death in NSCLC via the ROS-triggered mTOR signaling pathway, and PPVI may be a promising candidate for the treatment of NSCLC in future.

Predictive and Prognostic Role of Metabolic Response in Patients With Stage III NSCLC Treated With Neoadjuvant Chemotherapy

INTRODUCTION

The purpose of this study was to assess the predictive and prognostic role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in candidates with stage III non-small-cell lung cancer (NSCLC) to neoadjuvant chemotherapy.

PATIENTS AND METHODS

Sixty-six patients with stage III NSCLC treated with induction chemotherapy from March 2013 to December 2017 were retrospectively identified. Response assessment were evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and European Organisation for Research and Treatment of Cancer (EORTC) criteria. 18F-FDG PET/CT metabolic parameters were analyzed as absolute values as well as percentage changes (Δ) between 2 consecutive scans, for primary tumor (T) and for regional lymph nodes (N). All clinical variables and metabolic parameters were compared with treatment response and correlated with progression-free survival (PFS) and overall survival (OS), based on a median follow-up of 9.4 months.

RESULTS

Post-induction therapy standardized uptake value (SUV)max_T, SUVmean_T, metabolic tumor volume (MTV_T), and total lesion glycolysis of the tumor (TLG_T) varied significantly between responders and non-responders (6.6 vs. 13.8; P = .001; 4.2 vs. 8.1; P < .001; 6 vs. 17.9; P = .002; and 24.1 vs. 136.3; P < .001, respectively). Likewise, percentage changes (Δ_T) were significantly different between the 2 groups (P < .001). Along with primary tumor, also post-SUVmax_N, post-SUVmean_N, and post-TLG_N (P = .024, P = .015, and P = .024, respectively), as well as all percentage changes (Δ_N) were different between responders and non-responders. RECIST 1.1 and EORTC response classifications were discordant in 27 patients (40.9%; κ = 0.265; P = .003). On multivariate analysis, post-TLG_N was an independent predictor for both PFS and OS, whereas RECIST 1.1 was a predictor only for OS.

CONCLUSIONS

Several metabolic parameters may differentiate responders from non-responders following neoadjuvant chemotherapy in stage III NSCLC. As compared with RECIST 1.1, EORTC seems to be more appropriate for evaluation therapeutic response. Finally, post-TLG_N has significant prognostic information.

The Warburg effect: persistence of stem-cell metabolism in cancers as a failure of differentiation

Background

Two recent observations regarding the Warburg effect are that (i) the metabolism of stem cells is constitutive (aerobic) glycolysis while normal cellular differentiation involves a transition to oxidative phosphorylation and (ii) the degree of glucose uptake of a malignancy as imaged by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is associated with histologic measures of tumor differentiation. Combining these observations, we hypothesized that the high levels of glucose uptake observed in poorly differentiated cancers may reflect persistence of the glycolytic metabolism of stem cells in malignant cells that fail to fully differentiate.

Patients and methods

Tumor glucose uptake was measured by FDG-PET in 552 patients with histologically diverse cancers. We used normal mixture modeling to explore FDG-PET standardized uptake value (SUV) distributions and tested for associations between glucose uptake and histological differentiation, risk of lymph node metastasis, and survival. Using RNA-seq data, we carried out pathway and transcription factor analyses to compare tumors with high and low levels of glucose uptake.

Results

We found that well-differentiated tumors had low FDG uptake, while moderately and poorly differentiated tumors had higher uptake. The distribution of SUV for each histology was bimodal, with a low peak around SUV 2-5 and a high peak at SUV 8-14. The cancers in the two modes were clinically distinct in terms of the risk of nodal metastases and death. Carbohydrate metabolism and the pentose-related pathway were elevated in the poorly differentiated/high SUV clusters. Embryonic stem cell-related signatures were activated in poorly differentiated/high SUV clusters.

Conclusions

Our findings support the hypothesis that the biological basis for the Warburg effect is a persistence of stem cell metabolism (i.e. aerobic glycolysis) in cancers as a failure to transition from glycolysis-utilizing undifferentiated cells to oxidative phosphorylation-utilizing differentiated cells. We found that cancers cluster along the differentiation pathway into two groups, utilizing either glycolysis or oxidative phosphorylation. Our results have implications for multiple areas of clinical oncology.

Comprehensive analysis of marker gene detection and computed tomography for the diagnosis of human lung cancer

Non-small cell lung cancer (NSCLC) is one of leading causes of cancer-associated mortality, with a high number of cases caused by metastasis. The early diagnosis of cancer contributes to the successful treatment of patients with lung cancer. The aim of the present study was to analyze the efficacy of marker gene detection and computed tomography (CT) in diagnosing human lung cancer. Lung cancer marker genes, including carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), tissue polypeptide antigen (TPA), pro-gastrin-releasing peptide (ProGRB), cytokeratin fragment 21-1 (Cyfra21-1) and neuron-specific enolase (NSE), were analyzed in patients with lung cancer. The tumor size was evaluated using CT, and the association between lung serum levels of marker gene protein expression and tumor size was investigated. A total of 328 patients with lung cancer were identified, including 204 adenocarcinoma, 75 large cell carcinoma and 49 squamous cell carcinoma cases. All patients were indicated to have a high serum level of CEA, CA125, TPA, ProGRB, Cyfra21-1 and NSE, compared with the normal range. Immunohistochemistry demonstrated higher expression levels of CEA, CA125, TPA, ProGRB, Cyfra21-1 and NSE in lung tumor tissues, compared with the normal range. Results indicated that CT was able to diagnose tumor size for patients with lung cancer. The CEA and CA125 expression levels were associated with CT-diagnosed adenocarcinoma tumor size. Large cell carcinoma tumor size was associated with serum levels of CEA, TPA and ProGRB. Results indicated that Cyfra21-1 and NSE were associated with the squamous cell carcinoma cases, as demonstrated using CT. In conclusion, these results indicated that comprehensive analysis of marker gene detection and CT results may be used to diagnose human lung cancer.

Therapeutic effects of lenvatinib in combination with rAd-p53 for the treatment of non-small cell lung cancer

The aim of the present study was to analyze the effects of the combined treatment of lenvatinib and adenoviral delivered p53 gene (rAd-p53) on non-small cell lung cancer (NSCLC) cells and a total of 120 patients with NSCLC. The therapeutic effects of gene therapy of rAd-p53 and target therapy of Lenvatinib were investigated in NSCLC patients. The anti-tumor effects of combined treatment of llenvatinib and rAd-p53 was administered orally once-daily in NSCLC patients. Patients with NSCLC were divided into three groups and received lenvatinib (n=40), rAd-p53 (n=40) or combined treatment of lenvatinib and rAd-p53 (n=40) for a total of 30 days. Results showed that p53 was down-regulated and VEGFR, FGFR and PDGFR-β were up-regulated in NSCLC tissues compared to adjacent normal tissues. Combined treatment of Lenvatinib and rAd-p53 markedly inhibited NSCLC cell growth, migration and invasion, and promoted apoptosis compared to either lenvatinib or rAd-p53 alone. The most common treatment-related adverse events included hypertension, diarrhea, nausea, proteinuria and body weight loss. Outcomes indicated that combined treatment of lenvatinib and rAd-p53 markedly inhibited tumor growth compared to lenvatinib and rAd-p53 alone for NSCLC patients. Combined treatment of lenvatinib and rAd-p53 did not exhibit drug accumulation after 30-day treatment. In conclusion, these outcomes indicate that combined treatment of lenvatinib and rAd-p53 may be an efficient therapeutic schedule for the treatment of NSCLC patients.

Targeting cysteine-rich angiogenic inducer-61 by antibody immunotherapy suppresses growth and migration of non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the most frequent type of human lung cancer; lung cancer is responsible for the highest rates of cancer-associated mortality in the world. Cysteine-rich angiogenic inducer-61 (CYR-61) has been identified as a tumorigenesis-, development- and metastasis-related gene, and is reported to enhance proliferation, migration and invasion through hepatocyte growth factor (HGF)-induced scattering and the metastasis-inducing HGF/Met signaling pathway in tumor cells and xenograft models. CYR-61 is a protein that promotes human lung cancer cell metastasis and is closely related to the patient's prognosis in NSCLC. The purpose of the present study was to investigate whether CYR-61 may serve as a dual potential target for gene therapy of human NSCLC. In the present study, an antibody targeted against CYR-61 (anti-CYR-61) was constructed and the therapeutic effects and underlying mechanism of this antibody in NSCLC cells and mice with NSCLC was investigated. It was observed that NSCLC cell viability, migration and invasion were inhibited while cell apoptosis was induced by the neutralization of CYR-61 protein by anti-CYR-61. Western blotting demonstrated that extracellular signal-regulated kinase (ERK) and protein kinase B (AKT) expression levels in NSCLC cells were decreased following treatment with anti-CYR-61. In addition, it was observed that inhibition of NSCLC cell viability was achieved by the suppression of the epithelial-mesenchymal transition signaling pathway. ERK and AKT phosphorylation levels were downregulated in NSCLC cells and tumors following anti-CYR-61 treatment. Analysis of a murine model indicated that tumor growth was inhibited and tumor metastasis was significantly suppressed (P<0.01) following anti-CYR-61 treatment for CYR-61. In conclusion, CYR-61 may serve as a potential target for gene therapy for the treatment of human NSCLC.

SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer

Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.

Calotropin regulates the apoptosis of non‑small cell cancer by regulating the cytotoxic T‑lymphocyte associated antigen 4‑mediated TGF‑β/ERK signaling pathway

Non-small-cell lung cancer (NSCLC) is one of the most common malignancies that is responsible for a high level of cancer-associated mortalities worldwide. Previous evidence has shown that Calotropin is an upstream activator of protein kinase B, which can further inhibit the growth and promote the apoptosis of NSCLC cells. In the present study, the efficacy of Calotropin on growth, aggressiveness and apoptosis of NSCLC cells was investigated, as well as the potential underlying mechanism. The results demonstrated that Calotropin inhibited H358 cell growth, migration and invasion. Flow cytometry assay showed that Calotropin promoted the apoptosis of H358 cells in vitro. Western blot analysis demonstrated that Calotropin inhibited fibronectin (FN), Vimentin (VIM) and E-cadherin (Eca) protein expression levels in H358 cells in vitro. In addition, Calotropin treatment upregulated pro-apoptosis gene expression, including caspase-3, caspase-8 and apoptotic protease activating factor-1, and downregulated anti-apoptosis gene expression, including P53, B-cell lymphoma (Bcl) 2 and Bcl-2-like protein 2 in H358 cells. The results also revealed that the expression levels of cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) were decreased by Calotropin treatment in H358 cells. Analyses of the underlying mechanism indicated that Calotropin inhibited transforming growth factor-β (TGF-β) and extracellular signal-regulated kinase (ERK) expression. Overexpression of CTLA-4 inhibited Calotropin-mediated downregulation of TGF-β and ERK expression in H358 cells. In vivo assay revealed that Calotropin administration significantly inhibited tumor growth and prolonged animal survival over the 120-day observation period. Immunohistochemistry demonstrated that the number of apoptotic cells increased and the expression levels of CTLA-4 were decreased in the Calotropin-treated tumor group when compared with control. In addition, the expression levels of TGF-β and ERK were downregulated in the Calotropin-treated tumor group compared with control. In conclusion, the results of the present study indicated that Calotropin administration regulated NSCLC apoptosis by downregulating the CTLA-4-mediated TGF-β/ERK signaling pathway, suggesting that Calotropin may be a potential anti-cancer agent for the treatment of NSCLC.

Metastasis-associated protein 2 promotes the metastasis of non-small cell lung carcinoma by regulating the ERK/AKT and VEGF signaling pathways

Non-small cell lung carcinoma (NSCLC) is the most common cause of cancer‑associated mortality in the world and accounts for ~85% of human lung cancers. Metastasis‑associated protein 2 (MTA2) is a component of the histone deacetylase complex and serves a role in tumor progression; however, the mechanism through which MTA2 is involved in the progression of NSCLC remains unclear. The aim of the present study was to investigate the expression and function of MTA2 and the MTA2‑mediated signaling pathway in NSCLC cells. Expression of MTA2 and its target genes was analyzed in MTA2‑overexpressing and anti‑MTA2 antibody (AbMTA2)‑treated NSCLC cells, as well as growth, migration, invasion and apoptotic‑resistance. The inhibitory effects on tumor formation were analyzed using AbMTA2‑treated NSCLC cells and in a mouse model. Histological assessment was conducted to analyze the expressions levels of extracellular signal‑regulated kinase (ERK), RAC‑α serine/threonine protein kinase (AKT) and vascular endothelial growth factor (VEGF) in experimental tumors. Results of the present study demonstrated that MTA2 was overexpressed in NSCLC cells. The growth, migration and invasion of NSCLC cells were markedly inhibited by AbMTA2. In addition, it was observed that the ERK/AKT and VEGF signaling pathways were both upregulated in MTA2‑overexpressing NSCLC cells, and downregulated following silencing of MTA2 activation. ERK and AKT phosphorylation levels were downregulated in NSCLC cells and tumors following MTA2 silencing. The in vivo study demonstrated that tumor growth was markedly inhibited following siRNA‑MTA2 treatment. In conclusion, the results of the present study suggested that MTA2 silencing may significantly inhibit the growth and aggressiveness of NSCLC cells. Results from the present study indicated that the mechanism underlying the MTA2‑mediated invasive potential of NSCLC cells involved the ERK/AKT and VEGF signaling pathways, which may be a potential therapeutic target for the treatment of NSCLC.

Imaging skeletal muscle volume, density, and FDG uptake before and after induction therapy for non-small cell lung cancer

AIM

To assess whether changes in body composition could be assessed serially using conventional thoracic computed tomography (CT) and positron-emission tomography (PET)/CT imaging in patients receiving induction chemotherapy for non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

CT-based skeletal muscle volume and density were measured retrospectively from thoracic and lumbar segment CT images from 88 patients with newly diagnosed and untreated NSCLC before and after induction chemotherapy. Skeletal muscle 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) uptake was measured from PET/CT images from a subset of patients (n=42). Comparisons of each metric before and after induction chemotherapy were conducted using the non-parametric Wilcoxon signed-rank test for paired data. The association between clinical factors and percentage change in muscle volume was examined using univariate linear regression models, with adjustment for baseline muscle volume.

RESULTS

Following induction chemotherapy, thoracic (-3.3%, p=0.0005) and lumbar (-2.6%, p=0.0101) skeletal muscle volume were reduced (adiposity remained unchanged). The proportion of skeletal muscle with a density <0 HU increased (7.9%, p<0.0001), reflecting a decrease in skeletal muscle density and skeletal muscle FDG uptake increased (10.4-31%, p<0.05). No imaging biomarkers were correlated with overall survival.

CONCLUSION

Changes in body composition can be measured from routine thoracic imaging. During chemotherapy skeletal muscle volume and metabolism are altered; however, there was no impact on survival in this retrospective series, and further validation in prospective, well-controlled studies are required.

SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer

Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision-making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.

MACC‑1 antibody target therapy suppresses growth and migration of non‑small cell lung cancer

Non‑small‑cell lung cancer (NSCLC) accounts for ~80% of human lung cancers that result in mortalities worldwide. Metastasis‑associated in colon cancer‑1 (MACC‑1) has been demonstrated to be significantly expressed in cases of NSCLC and promotes tumor cell migration and metastasis through transactivation of the metastasis‑inducing hepatocyte growth factor/MET proto‑gene, receptor tyrosine kinase (HGF/MET) signaling pathway. The present study constructed a chimeric antibody (Chanti‑MACC‑1) targeting MACC‑1 and investigated its potential as a molecular therapeutic target in the treatment of NSCLC therapy. The expression of MACC‑1 was detected by reverse transcription‑quantitative polymerase chain reaction and western blotting in lung cancer cell lines and tissues. MTT assay was used to detect proliferation of A549 cells treated by Chanti‑MACC‑1, whereas the functional and regulatory effects of Chanti‑MACC‑1 in the migration and metastasis of NSCLC cells was investigated by a cell invasion assay. The therapeutic effect and survival time was observed in animal models. The results demonstrated that MACC‑1 expression was increased and overexpression of MACC‑1 promoted the progression of the cell cycle, significantly promoted NSCLC cell growth and enhanced tumor migration and invasion through the HGF/MET signaling pathway. It was further demonstrated that Chanti‑MACC‑1 efficiently suppressed MACC‑1 expression and significantly inhibited NSCLC cell proliferation, migration and invasion by blocking the HGF/MET signaling pathway. The data revealed that Chanti‑MACC‑1 was not only beneficial for tumor remission, however additionally contributed to the long‑term survival of NSCLC ‑bearing mice. The findings of the present study indicated that MACC‑1 was significantly upregulated and promoted tumor cell growth and migration in NSCLC cells and tissues via transactivation of the metastasis‑inducing HGF/MET signaling pathway. However, Chanti‑MACC‑1significantly inhibited tumor growth and metastasis, which suggested that MACC‑1 may be essential for tumor initiation and progression by negatively regulating tumor suppressors.

Prognostic Value of 18F-Fluorodeoxyglucose PET/Computed Tomography in Non-Small-Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is a leading cause of cancer-related death with a poor prognosis. Numerous factors contribute to treatment outcome. 18F-fluorodeoxyglucose (FDG) uptake reflects tumor metabolic activity and is an important prognosticator in patients with NSCLC. Volume-based FDG-PET parameters reflect the metabolic status of a malignancy more accurately than maximum standardized uptake value and thus are better prognostic markers in lung cancer. FDG-avid tumor burden parameters may help clinicians to predict treatment outcomes before and during therapy so that treatment can be adjusted to achieve the best possible outcomes while avoiding side effects.

Contrast-enhanced ultrasound with a novel nanoparticle contrast agent for clinical diagnosis in patients with non-small cell lung cancer

Non-small cell lung cancer (NSCLC) initiates in the non-small cells of the lung and is one of the most common types of human cancer. It is known for its rapid growth, easy migration, invasion and reoccurrence, and has the highest incidence rate of all types of cancer. Early detection of NSCLC is difficult to achieve and this is the primary reason for low survival rates in NSCLC. Contrast-enhanced ultrasound is the most common application for evaluating patients diagnosed with NSCLC. In the present study, a contrast-enhanced ultrasound combined with nanoparticles was performed with the aim of identifying patients with NSCLC at an early stage. The present study evaluated the effectiveness of administering a nanoparticle contrast agent through respiration in combination with enhanced ultrasound at improving image quality compared with traditional ultrasound. This maybe a novel method of detecting early-stage tumors in patients. There are numerous benefits to conducting diagnoses of NSCLC using contrast-enhanced ultrasound. It is a non-invasive imaging modality, induces little pain, has a low cost, an extensive range and produces high-resolution images. This means that it is safer and more beneficial to use in patients with NSCLC than conventional imaging examinations, including X-ray and bronchoscopy. Furthermore, the nanoscale microbubble contrast agent containing liposome-encapsulated epidermal growth factor receptor was inhaled by nebulization, which may lead to an enhanced ultrasound image. The sensitivity of contrast-enhanced ultrasound was investigated in mice with early stage NSCLC. The results indicated that ultrasound administrated with nanoscale microbubble enhanced sensitivity and improved image quality compared with simple ultrasound. Furthermore, enhanced ultrasound resulted in a reliable and sensitive assessment of tumor mass in early-stage tumors. Altogether, contrast-enhanced ultrasound facilitated the efficient detection of NSCLC in patients in situ at an early stage. This protocol improved the understanding of the pathophysiology of NSCLC and may be applied in the detection of early-stage tumors in patients suspected of having cancer.

Chimeric antibody targeting SRPK-1 in the treatment of non-small cell lung cancer by inhibiting growth, migration and invasion

Non-small cell lung cancer (NSCLC) is one of the most common types of cancer in humans, and is characterized by rapid growth, migration, invasion and reoccurrence. Evidence has indicated that the protein and mRNA levels of serine‑arginine protein kinase‑1 (SRPK‑1) are upregulated in NSCLC tissues. However, the functions of SRPK1 and targeted therapy for SRPK1 in the progression and treatment of NSCLC remain to be fully elucidated. In the present study, the mRNA and protein expression levels of SRPK‑1 in NSCLC cells and tissues were analyzed using reverse transcription‑quantitative polymerase chain reaction analysis and SDS‑PAGE, and the role of SRPK1 in the progression of NSCLC was investigated. In addition, a chimeric antibody target for SRPK‑1 (ChanSRPK‑1) was constructed, and the therapeutic effects of ChanSRPK‑1 were investigated in H358‑bearing mice. The curative effects of ChanSRPK‑1 on the inhibition of growth, migration and invasion of NSCLC were also examined in vitro and in vivo. The results revealed that the mRNA and protein levels of SRPK‑1 were upregulated in NSCLC cells and tumor tissues. Higher expression of SRPK1 promoted NSCLC cell growth, migration and invasion, whereas lower expression of SRPK‑1 suppressed growth, migration and invasion of the NSCLC cells. Animal experiments demonstrated that ChanSRPK‑1 inhibited the β‑catenin/T‑cell factor complex. ChanSRPK‑1 treatment also downregulated the phosphorylation levels of glycogen synthase kinase 3-β and prolonged the survival of tumor‑bearing mice. Taken together, SRPK‑1 may offer potential as a therapeutic target oncogenic molecular in NSCLC, and ChanSRPK‑1 may be a therapeutic agent with functions as a target and for oncolytic therapy in the treatment of NSCLC.

The Value of FDG PET/CT in Treatment Response Assessment, Follow-Up, and Surveillance of Lung Cancer

OBJECTIVE

The purpose of this article is to summarize the evidence regarding the role of FDG PET/CT in treatment response assessment and surveillance of lung cancer and to provide suggested best practices.

CONCLUSION

FDG PET/CT is a valuable imaging tool for assessing treatment response for patients with lung cancer, though evidence for its comparative effectiveness with chest CT is still evolving. FDG PET/CT is most useful when there is clinical suspicion or other evidence for disease recurrence or metastases. The sequencing, cost analysis, and comparative effectiveness of FDG PET/CT and conventional imaging modalities in the follow-up setting need to be investigated.