Adjuvant Therapy in Patients With Completely Resected Non–small-cell Lung Cancer: Current Status and Perspectives

Fibrinogen-to-albumin ratio (FAR) is the best biomarker for the overall survival of patients with non-small-cell lung cancer

Objective

The inflammatory response and the nutritional status are associated with overall survival (OS) in patients with non-small cell lung cancer (NSCLC), but it is unclear which biomarkers are better suited to predict prognosis. This study sought to determine which of the commonly existing inflammatory and nutritional indicators best predicted the OS.

Methods

This study included 15 compound indicators based on inflammation or nutrition, with cutoff points obtained through the receiver operating characteristic (ROC) curve. Univariate and multivariate Cox proportional risk models were used to evaluate the relationship between these predictors and OS. Kaplan-Meier curves were used for survival analysis, and log-rank tests were used to compare differences between groups. The C-index was calculated to evaluate the predictive ability of the different indicators.

Results

The study included 899 patients with NSCLC. In the univariate analysis, all 15 measures were significantly associated with the OS of patients (all p < 0.05). The results of the C-index analysis showed that the fibrinogen-to-albumin ratio (FAR), the systemic immune-inflammation index (SII), and the albumin-to-alkaline phosphatase ratio (AAPR) were the three indices with the best predictive performance. Among them, FAR (C-index = 0.639) had the best predictive power for OS in patients with NSCLC. In the different subgroups, FAR had the highest C-index in male, non-smoking, adenocarcinoma, and stage II patients. The C-index of the platelet-to-lymphocyte ratio (PLR) in female patients was the highest. SII was the highest in smokers, in those aged <65 and ≥65 years, and in stage III patients. The C-index of AAPR was the highest in non-adenocarcinomas. The C-index of the pan-immune-inflammation value (PIV) was the highest in stage I patients. In the multivariate Cox regression analysis, among FAR, SII, and AAPR, only FAR was an independent predictor of OS in patients with NSCLC. A high FAR was associated with a higher risk of death in patients with NSCLC (HR = 1.601, 95% CI = 1.028-2.495). In order to further evaluate the potential prognostic value of FAR, SII, and AAPR in patients with different stages, Cox regression analysis was performed for those with stage I-II and stage III NSCLC. The results showed that FAR was an independent prognostic factor for OS in patients with stage I-II NSCLC.

Conclusion

For all patients with NSCLC, the prognostic power of FAR was superior to that of other inflammatory and nutritional indicators.

Association between immune-related adverse events and prognosis in patients with advanced non-small cell lung cancer: a systematic review and meta-analysis

Background

The emergence of immune checkpoint inhibitors (ICIs) provides a variety of options for patients with advanced non-small-cell lung cancer (NSCLC). After the application of ICIs, the immune system of patients was highly activated, and immune-related adverse events (irAEs) could occur in some organ systems, and irAEs seemed to be associated with the survival prognosis of patients. Therefore, we evaluated the association between survival outcomes and irAEs in NSCLC patients and conducted a systematic review and meta-analysis.

Methods

We conducted systematic reviews of PubMed, Embase, Cochrane, and Web of Science databases until December 2021. The forest map was constructed by combining the hazard ratio (HR) and 95% confidence interval (CI). I2 estimated the heterogeneity between studies. A meta-analysis was performed using R 4.2.1 software.

Results

Eighteen studies included 4808 patients with advanced NSCLC. In pooled analysis, the occurrence of irAEs was found to be a favorable factor for improved prognosis (PFS: HR: 0.48, 95% CI: 0.41-0.55, P <0.01; OS: HR: 0.46, 95% CI: 0.42-0.52, P <0.01). In subgroup analyses, cutaneous irAE, gastrointestinal irAE, endocrine irAE and grade ≥3 irAEs were associated with improvements in PFS and OS, but pulmonary and hepatic irAEs were not.

Conclusion

Existing evidence suggests that the occurrence of irAEs may be a prognostic biomarker for advanced NSCLC. However, further research is needed to explore the prospect of irAEs as a prognostic biomarker in patients undergoing immunotherapy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPEROFILES/405333_STRATEGY_20240502.pdf, identifier CRD42023405333.

From standard therapies to monoclonal antibodies and immune checkpoint inhibitors - an update for reconstructive surgeons on common oncological cases

Malignancies represent a persisting worldwide health burden. Tumor treatment is commonly based on surgical and/or non-surgical therapies. In the recent decade, novel non-surgical treatment strategies involving monoclonal antibodies (mAB) and immune checkpoint inhibitors (ICI) have been successfully incorporated into standard treatment algorithms. Such emerging therapy concepts have demonstrated improved complete remission rates and prolonged progression-free survival compared to conventional chemotherapies. However, the in-toto surgical tumor resection followed by reconstructive surgery oftentimes remains the only curative therapy. Breast cancer (BC), skin cancer (SC), head and neck cancer (HNC), and sarcoma amongst other cancer entities commonly require reconstructive surgery to restore form, aesthetics, and functionality. Understanding the basic principles, strengths, and limitations of mAB and ICI as (neo-) adjuvant therapies and treatment alternatives for resectable or unresectable tumors is paramount for optimized surgical therapy planning. Yet, there is a scarcity of studies that condense the current body of literature on mAB and ICI for BC, SC, HNC, and sarcoma. This knowledge gap may result in suboptimal treatment planning, ultimately impairing patient outcomes. Herein, we aim to summarize the current translational endeavors focusing on mAB and ICI. This line of research may serve as an evidence-based fundament to guide targeted therapy and optimize interdisciplinary anti-cancer strategies.

The prognostic value of the preoperative albumin/globulin and monocyte ratio in resected early-stage non-small cell lung cancer

OBJECTIVE

This study investigated the prognostic value of the preoperative albumin/globulin to monocyte ratio (AGMR) in patients with resected non-small cell lung cancer (NSCLC).

METHODS

The study retrospectively enrolled patients with resected NSCLC from the Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University from January 2016 to December 2017. Baseline demographic and clinicopathological data were collected. The preoperative AGMR was calculated. Propensity score matching (PSM) analysis was applied. The receiver operating characteristic curve was used to determine the optimal AGMR cut-off value. The Kaplan-Meier method was used to calculate the overall survival (OS) and disease-free survival (DFS). The Cox proportional hazards regression model was used to evaluate the prognostic value of the AGMR.

RESULTS

A total of 305 NSCLC patients were included. The optimal AGMR value was 2.80. Before PSM. The high AGMR (>2.80) group had a significantly longer OS (41.34 + 11.32 vs. 32.03 + 17.01 months; P < 0.01) and DFS (39.00 + 14.49 vs. 28.78 + 19.13 months; P < 0.01) compared with the low AGMR (≤2.80) group. Multivariate analyses showed that AGMR (P < 0.01) in addition to sex (P < 0.05), body mass index (P < 0.01), history of respiratory diseases (P < 0.01), lymph node metastasis (P < 0.01), and tumor size (P < 0.01) were associated with OS and DFS. After PSM, AGMR remained as an independent prognostic factor for OS (hazard ratio [HR] 2.572, 95% confidence interval [CI]: 1.470-4.502; P = 0.001) and DFS (HR 2.110, 95% CI: 1.228-3.626; P = 0.007).

CONCLUSION

The preoperative AGMR is a potential prognostic indicator for OS and DFS in resected early-stage NSCLC.

Immune checkpoint inhibitors as adjuvant therapy in patients with completely resected nonsmall cell lung cancer

PURPOSE OF REVIEW

The purpose of the review is to summarize the current status of immune checkpoint inhibitors as adjuvant therapy in patients with resected nonsmall cell lung cancer (NSCLC).

RECENT FINDINGS

The IMpower010 phase 3 trial demonstrated improved disease-free survival and, in case of PD-L1 at least 50%, also improved overall survival for atezolizumab compared to best supportive care among patients with completely resected stage II-IIIA NSCLC. The PEARLS/KEYNOTE-091 trial showed increased disease-free survival for pembrolizumab among patients with stage IB-IIIA NSCLC. Trials with nivolumab and durvalumab are ongoing.

SUMMARY

Atezolizumab or pembrolizumab have become options for adjuvant therapy in patients with completely resected NSCLC.

Prognostic Significance of Tumor Mutation Burden among Patients with Non-small Cell Lung Cancer Who Received Platinum-based Adjuvant Chemotherapy: An Exploratory Study

This study aimed to investigate the prognostic significance of tumor mutation burden (TMB) among patients with non-small cell lung cancer (NSCLC) who received platinum-based adjuvant chemotherapy. Tumor tissue specimens after surgical resection were collected for DNA extraction. Somatic mutation detection and TMB analysis were conducted using next-generation sequencing (NGS). Recurrence status of the patients was assessed in the hospital during the adjuvant chemotherapy period, and long-term survival data of patients were obtained by telephone follow-up. Univariate analysis between TMB status and prognosis was carried out by survival analysis. A retrospective review of 78 patients with non-squamous NSCLC who received platinum-based adjuvant chemotherapy showed a median disease-free survival of 3.6 years and median overall survival (OS) of 5.3 years. NGS analysis exhibited that the most common mutated somatic genes among the 78 patients were tumor suppressor protein p53 (TP53), epidermal growth factor receptor, low-density lipoprotein receptor related protein 1B, DNA methyltransferase 3 alpha and FAT atypical cadherin 3, and their prevalence was 56.4%, 48.7%, 37.2%, 30.7%, and 25.6%, respectively. TMB status was divided into TMB-L (≤ 4.5/Mb) and TMB-H (> 4.5/Mb) based on the median TMB threshold. Relevance of TMB to prognosis suggested that the median OS of patients with TMB-L was significantly longer than that of patients with TMB-H (NR vs. 4.6, P = 0.014). Higher TMB status conferred a worse implication on OS among patients with non-squamous NSCLC who received platinum-based adjuvant chemotherapy.

CRTAC1 enhances the chemosensitivity of non-small cell lung cancer to cisplatin by eliciting RyR-mediated calcium release and inhibiting Akt1 expression

Sensitivity to platinum-based combination chemotherapy is associated with a favorable prognosis in patients with non-small cell lung cancer (NSCLC). Here, our results obtained from analyses of the Gene Expression Omnibus database of NSCLC patients showed that cartilage acidic protein 1 (CRTAC1) plays a role in the response to platinum-based chemotherapy. Overexpression of CRTAC1 increased sensitivity to cisplatin in vitro, whereas knockdown of CRTAC1 decreased chemosensitivity of NSCLC cells. In vivo mouse experiments showed that CRTAC1 overexpression increased the antitumor effects of cisplatin. CRTAC1 overexpression promoted NFAT transcriptional activation by increasing intracellular Ca2+ levels, thereby inducing its regulated STUB1 mRNA transcription and protein expression, accelerating Akt1 protein degradation and, in turn, enhancing cisplatin-induced apoptosis. Taken together, the present results indicate that CRTAC1 overexpression increases the chemosensitivity of NSCLC to cisplatin treatment by inducing Ca2+-dependent Akt1 degradation and apoptosis, suggesting the potential of CRTAC1 as a biomarker for predicting cisplatin chemosensitivity. Our results further reveal that modulating the expression of CRTAC1 could be a new strategy for increasing the efficacy of cisplatin in chemotherapy of NSCLC patients.

Adjuvant EGFR-TKI therapy in resected EGFR-mutation positive non-small cell lung cancer: A real-world study

Background

Although several clinical studies have laid the foundation for the adjuvant application of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), some questions remain unresolved. This real-world study aimed to address questions such as the effect of adjuvant chemotherapy prior to adjuvant EGFR-TKI therapy on survival outcomes, and the duration of adjuvant EGFR-TKI therapy, etc.

Methods

Between October 2005 and October 2020, 227 consecutive patients with non-small cell lung cancer (NSCLC) who underwent complete pulmonary resections were included in this retrospective study. Patients received postoperative adjuvant chemotherapy followed by EGFR-TKI or adjuvant EGFR-TKI monotherapy. The disease-free survival (DFS) and overall survival (OS) were evaluated.

Results

Of the total 227 patients, 55 (24.2%) patients underwent 3-4 cycles of chemotherapy prior to receiving adjuvant EGFR-TKI therapy. The 5-year DFS rate was 67.8%, while the 5-year OS rate was 76.4%. The stages were significantly associated with both DFS (P&lt;0.001) and OS (P&lt;0.001), while no significant differences were observed in the DFS (P=0.093) and OS (P=0.399) between the adjuvant chemotherapy followed by EGFR-TKI and adjuvant EGFR-TKI monotherapy groups. A longer duration of EGFR-TKI therapy was associated with better DFS (P&lt;0.001) and OS (P&lt;0.001) benefit. Additionally, pTNM stage and duration of EGFR-TKI therapy were considered independent prognostic factors for long-term survival (All P&lt;0.05).

Conclusions

This study supports the use of EGFR-TKI as a postoperative adjuvant treatment for patients with stage II-IIIA EGFR-mutation positive NSCLC. Additionally, patients with stage I who had pathological risk factors were also suitable for receiving adjuvant EGFR-TKI therapy. Postoperative EGFR-TKI based, chemotherapy-free adjuvant regimen may be a potential therapeutic option for patients with EGFR-mutation positive NSCLC.

The radiological appearances of lung cancer treated with immunotherapy

Therapy and prognosis of several solid and hematologic malignancies, including non-small cell lung cancer (NSCLC), have been favourably impacted by the introduction of immune checkpoint inhibitors (ICIs). Their mechanism of action relies on the principle that some cancers can evade immune surveillance by expressing surface inhibitor molecules, known as "immune checkpoints". ICIs aim to conceal tumoural checkpoints on the cell surface and reinvigorate the ability of the host immune system to recognize tumour cells, triggering an antitumoural immune response.In this review, we will focus on the imaging patterns of different responses occurring in patients treated by ICIs. We will also discuss imaging findings of immune-related adverse events (irAEs), along with current and future perspectives of metabolic imaging. Finally, we will explore the role of radiomics in the setting of ICI-treated patients.

Non-small cell lung cancer: Emerging molecular targeted and immunotherapeutic agents

Non-small cell lung cancer (NSCLC) represents the most common and fatal type of primary lung malignancies. NSCLC is often diagnosed at later stages and requires systemic therapies. Despite recent advances in surgery, chemotherapy, and targeted molecular therapies the outcomes of NSCLC remain disproportionately poor. Immunotherapy is a rapidly developing area in NSCLC management and presents opportunities for potential improvements in clinical outcomes. Indeed, different immunotherapeutics have been approved for clinical use in various settings for NSCLC. Their promise is especially poignant in light of improved survival and quality of life outcomes. Herein, we comprehensively review emerging NSCLC therapeutics. We discuss the limitations of such strategies and summarize the present status of various immunotherapeutic agents in key patient populations. We also examine the data from ongoing studies in immunotherapy and consider future areas of study, including novel inhibition targets, therapeutic vaccination, tumor genome modification, and improvements to drug delivery systems.

Updated long-term outcomes of salvage surgery after stereotactic body radiotherapy for early-stage non-small-cell lung cancer

There is dearth of data regarding the long-term survival outcomes of salvage surgery after stereotactic body radiotherapy for early-stage non-small-cell lung cancer, as previous studies have included a short follow-up period. There is also scarce information on the management of re-relapse in previous studies. This study examined the long-term survival outcomes of patients who underwent salvage surgery for isolated local relapse (LR). We reviewed consecutive patients who underwent salvage surgery for isolated LR after stereotactic body radiotherapy for early-stage non-small-cell lung cancer between 1999 and 2015. All patients were followed up until death or at least 5 years from salvage surgery. Twelve patients were included for analysis. The median follow-up from isolated LR was 62.4 (range: 14.3-152.1) months. The 5-year overall survival rate was 58.3%, updated from 79.5% in our previous report. During the interim, new re-relapses did not occur, whereas there were 5 additional deaths. The median survival after re-relapse was 32.6 months. Our follow-up report confirmed that our patient selection for salvage surgery appeared to be appropriate and that long-term follow-up is required to assess the outcomes of patients undergoing salvage surgery. Long-term follow-up would provide detailed information on late re-relapses, treatment and outcomes of re-relapses and mortality from any causes.

Immunotherapy and Vaccination in Surgically Resectable Non-Small Cell Lung Cancer (NSCLC)

Early-stage NSCLC (stages I and II, and some IIIA diseases) accounts for approximately 30% of non-small cell lung cancer (NSCLC) cases, with surgery being its main treatment modality. The risk of disease recurrence and cancer-related death, however, remains high among NSCLC patients after complete surgical resection. In previous studies on the long-term follow-up of post-operative NSCLC, the results showed that the five-year survival rate was about 65% for stage IB and about 35% for stage IIIA diseases. Platinum-based chemotherapy with or without radiation therapy has been used as a neoadjuvant therapy or post-operative adjuvant therapy in NSCLC, but the improvement of survival is limited. Immune checkpoint inhibitors (ICIs) have effectively improved the 5-year survival of advanced NSCLC patients. Cancer vaccination has also been explored and used in the prevention of cancer or reducing disease recurrence in resected NSCLC. Here, we review studies that have focused on the use of immunotherapies (i.e., ICIs and vaccination) in surgically resectable NSCLC. We present the results of completed clinical trials that have used ICIs as neoadjuvant therapies in pre-operative NSCLC. Ongoing clinical trials investigating ICIs as neoadjuvant and adjuvant therapies are also summarized.

Pattern of recurrence of pN2 non-small-cell lung cancer: should postoperative radiotherapy be reconsidered?

OBJECTIVES

The prognosis of patients with mediastinal lymph node (LN) metastasis (pN2 stage III disease) is still unsatisfactory. Both systemic and local recurrence should be prevented after curative surgery. The aim of this study was to explore the pattern of recurrence in patients with completely resected pN2 non-small-cell lung cancer (NSCLC) in the era of adjuvant chemotherapy.

METHODS

We investigated 337 patients with completely resected cN0-1 and pN2 NSCLC from 2005 to 2016 at National Cancer Center Hospital, Japan. The patterns of recurrence were compared between patients who were managed by observation alone and those with adjuvant chemotherapy. In patients with regional LN recurrence, the pattern and site of recurrence were also explored.

RESULTS

There were 195 (58.5%) men and 142 (41.5%) women with a mean age of 63.2 years. Fifty-five (16.3%) patients developed only regional LN recurrence, 116 (32.6%) patients developed only distant recurrence and 65 (19.3%) patients developed both regional LN recurrence and distant recurrence. The difference in the pattern of recurrence between patients with observation alone and those with adjuvant chemotherapy was not statistically significant (P = 0.145). As for the pattern of regional LN recurrence, 68 (20.2%) patients had LN recurrence inside the systematic nodal dissection area.

CONCLUSIONS

Regional LN recurrence was observed in >30% of patients with completely resected pN2 NSCLC. About 20% of patients had recurrence inside the systematic nodal dissection area. Postoperative radiotherapy might be considered as an additional treatment strategy for these patients.

Prognostic factors related to postoperative survival in the newly classified clinical T4 lung cancer

OBJECTIVES

T4 lung cancer has become a more heterogeneous group since the 8th edition of tumour, node, metastasis classification. The aim of this study was to identify predictive factors related to post-surgical survival in patients with clinical T4 non-small-cell lung cancer (NSCLC), based on the 8th edition of the classification.

METHODS

We retrospectively reviewed consecutive patients with clinical T4 NSCLC who underwent resection between January 2006 and December 2016, to identify factors associated with overall survival.

RESULTS

Ninety-three patients were identified. The criteria for clinical T4 disease included tumours larger than 7 cm (n = 54), great vessels or left atrial invasion (n = 22), mediastinal invasion (n = 11), vertebral invasion (n = 3), tracheal or carina invasion (n = 3), diaphragm invasion (n = 1) and ipsilateral different lobe pulmonary metastasis (n = 2). The postoperative nodal status was 0, 1, 2 and 3 in 59, 18, 15 and 1 patient, respectively. R0 resection was achieved in 80 patients, and the 30-day mortality was 0%. The median follow-up time was 37.6 months, and the 5-year overall survival rate was 56.3%. The multivariable analysis revealed that nodal status and R-status were significant prognostic factors for postoperative survival [hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.20-5.72, P = 0.016 and HR 3.29, 95% CI 1.45-7.44, P = 0.004].

CONCLUSIONS

Surgery provided encouraging survival outcomes for clinical T4 NSCLC based on the 8th edition of classification. The nodal status and R-status were significant prognostic factors for postoperative survival.

Prognostic Impact of PD-L1 Expression in pN1 NSCLC: A Retrospective Single-Center Analysis

Simple Summary

The analysis of prognostic biomarkers (e.g., PD-L1) helps to define treatment for lung cancer patients. To date, these markers have only been examined in metastatic or inoperable situations. We analyzed the PD-L1 expression-levels of tumors from 277 lung cancer patients that underwent curative intent surgery. PD-L1 was identified as a prognostic factor, depending on histologic subtype.

Abstract

The programmed death-ligand 1 (PD-L1) plays a crucial role in immunomodulatory treatment concepts for end-stage non-small cell lung cancer (NSCLC). To date, its prognostic significance in patients with curative surgical treatment but regional nodal metastases, reflecting tumor spread beyond the primary site, is unclear. We evaluated the prognostic impact of PD-L1 expression in a surgical cohort of 277 consecutive patients with pN1 NSCLC on a tissue microarray. Patients with PD-L1 staining (clone SP263) on >1% of tumor cells were defined as PD-L1 positive. Tumor-specific survival (TSS) of the entire cohort was 64% at five years. Low tumor stage (p < 0.0001) and adjuvant therapy (p = 0.036) were identified as independent positive prognostic factors in multivariate analysis for TSS. PD-L1 negative patients had a significantly better survival following adjuvant chemotherapy than PD-L1 positive patients. The benefit of adjuvant therapy diminished in patients with PD-L1 expression in more than 10% of tumor cells. Stratification towards histologic subtype identified PD-L1 as a significant positive predictive factor for TSS after adjuvant therapy in patients with adenocarcinoma, but not squamous cell carcinoma. Routine PD-L1 assessment in curative intent treatment may help to identify patients with a better prognosis. Further research is needed to elucidate the predictive value of PD-L1 in an adjuvant setting.

Preoperative systemic immune-inflammation index predicts prognosis and guides clinical treatment in patients with non-small cell lung cancer

Objectives: The purpose of the present study was to evaluate the prognostic value of a systemic immune-inflammation index (SII) and the relationship between SII and the effectiveness of postoperative treatment in patients with non-small cell lung cancer (NSCLC).

Methods: A total of 538 patients diagnosed with NSCLC who had undergone curative surgery were retrospectively enrolled in the study. Clinicopathologic and laboratory variables were collected. SII was defined as neutrophil × platelet/lymphocyte counts. Both univariate and multivariate analyses were performed to analyze the prognostic value of these factors.

Results: The preoperative SII level was associated with sex, smoking history, histological type, lesion type, resection type, pathological stage, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), fibrinogen and bone metastasis (P<0.05). The univariate and multivariate analyses revealed that SII was an independent prognostic factor for disease-free survival (DFS, P=0.033) and overall survival (OS, P=0.020). Furthermore, the prognostic value of SII was also verified regardless of the histological type and pathological stage. The subgroup analysis demonstrated that patients with a high SII may benefit from adjuvant therapy (P=0.024 for DFS and P=0.012 for OS).

Conclusion: An increased preoperative SII may independently predict the poor DFS and OS in patients with resectable NSCLC. SII may help select NSCLC patients who might benefit from adjuvant chemotherapy.

Adjuvant chemotherapy as a risk factor for chronic postoperative pain after video-assisted thoracoscopic surgery: a 10-year single-centre retrospective study

OBJECTIVES

The association between adjuvant chemotherapy (AC) and chronic postoperative pain (CPP) after video-assisted thoracoscopic surgery (VATS) for lung cancer resection has not yet been reported. We, therefore, investigated the association between AC and the long-term incidence of CPP after VATS.

METHODS

We retrospectively reviewed 3015 consecutive patients who underwent VATS for lung cancer between 2007 and 2016. The patients were divided into 2 groups: those who received (AC group) and those who did not receive (non-AC group) AC within 3 months after VATS. Propensity score analysis was performed to adjust for baseline differences between the 2 groups. The cumulative incidence of CPP at the intervals of 3 months, over 36 months, was compared before and after matching. A Cox proportional hazards regression analysis was used to investigate the predictors of CPP after VATS.

RESULTS

We included and assessed 2222 patients in this study. Of these, 320 patients (14.4%) received AC within 3 months post-VATS. The cumulative incidence of CPP during 36 months post-surgery was significantly higher in the AC group than in the non-AC group, before and after matching (log-rank test; P = 0.002 and 0.027, respectively). Cox proportional hazards regression analysis also showed that AC was a significant risk factor for CPP (hazard ratio 1.62, 95% confidence interval 1.16-2.28; P = 0.005).

CONCLUSIONS

Our results indicate that AC is an important risk factor for CPP after VATS. Further understanding of the risk factors for CPP may facilitate its prediction and treatment.

Influence of adjuvant chemotherapy on survival for patients with stage IB and IIA non-small cell lung cancer

Background

The role of adjuvant chemotherapy (ACT) for patients with stage IB–IIA non‐small cell lung cancer (NSCLC) according to the eighth edition of the AJCC TNM staging system remains controversial.

Methods

Data were collected from patients with NSCLC stage IB–IIA according to the eighth edition of the AJCC TNM staging system who underwent surgical resection from 2008 to 2015. The relationship between ACT and overall survival (OS) or disease‐free survival (DFS) was analyzed using the Kaplan–Meier method and Cox proportional hazards model.

Results

The study included 648 patients with completely resected NSCLC stage IB–IIA; 312 underwent ACT after surgical resection and 336 were placed under observation. After propensity score matching, 247 pairs of patients were matched and the five‐year OS was 88.08% and 83.12% (P = 0.13) in ACT and non‐ACT settings, respectively. Subgroup analyses demonstrated that ACT treatment was correlated with an improved five‐year OS in patients with visceral pleural invasion (VPI) in the 3 < tumor ≤ 4 cm subgroup (93.98% and 68.93%, P < 0.01).

Conclusions

ACT was not significantly associated with improved five‐year OS in stage IB–IIA NSCLC patients. However, further subgroup analysis showed that patients with VPI in the 3 < tumor ≤ 4 cm (T2aN0M0, stage IB) subgroup might benefit more from ACT. Further studies are required to validate the findings and better systemic strategies need to be developed in these patients.

Key points

Significant findings of the study

For patients with stage IB–IIA NSCLC according to the eighth edition of the AJCC TNM staging system, the effect of ACT remains unclear.

ACT was not significantly associated with improved five‐year OS in stage IB–IIA NSCLC patients. However, it was correlated with better DFS before or after PSM.

Patients with VPI in the 3 < tumor ≤ 4 cm subgroup may benefit from ACT.

What this study adds

ACT was not significantly associated with improved five‐year OS in stage IB–IIA NSCLC patients. However, it was correlated with better DFS before or after PSM.

Patients with VPI in the 3 < tumor ≤ 4 cm subgroup may benefit from ACT.

Neoadjuvant and Adjuvant Immunotherapy: Opening New Horizons for Patients With Early-Stage Non-small Cell Lung Cancer

Lung cancer is the most common malignant tumor with the highest mortality, and about 84% are non-small cell lung cancer (NSCLC). However, only a small proportion of patients with newly diagnosed lung tumors can receive curative surgery and have a high risk of postoperative recurrence. At present, there are many perioperative treatment methods being continuously explored, such as chemotherapy and targeted therapy, continuously enriching the content of neoadjuvant and adjuvant therapy in early-stage NSCLC. But disappointingly, for patients with driver gene mutation, the significant disease-free survival (DFS) benefit of targeted drugs failed to translate into overall survival (OS) benefit, and for negative patients, chemotherapy has reached a plateau in improving efficacy and survival. Immunotherapy represented by immune checkpoint inhibitors (ICIs) has been researched in more and more clinical trials in patients with early-stage operable disease, gradually enriching the existing treatments. This review focuses on the research progress of clinical trials of neoadjuvant and adjuvant therapy with ICIs in early-stage NSCLC, the exploration of response evaluation and predictive biomarkers, and the urgent problems to be solved in the future.

Genetic Polymorphisms and the Efficacy of Platinum-Based Chemotherapy: Review

Previous studies have indicated that genetic variations in individuals may result in changes in gene expression and amino acids. The effect of these changes may lead to different responses to platinum-based chemotherapy. A vast response rate interval and a short survival rate indicate that the efficacy and efficiency of the selection of chemotherapy have not been optimized. This article aims to illustrate the potential relationship of various genetic polymorphisms in response to platinum-based chemotherapy for several types of cancer. This review was conducted using articles from the last three- and five-year periods (2014-2019) that use gene polymorphism and its relationship to the efficacy of platinum-based chemotherapy as their theme. A total of 26 out of 488 relevant articles were included based on specific criteria. Through various mechanisms, genes, including ERCC1, ERCC2/XPD, XPC, XPA, XRCC1, APE-1, PARP1, OGG1, ABCC2, MRP, GSTP1, GSTM1, GSTT1, MATE1, and OCT2, have been associated with patient response to platinum-based chemotherapy. We conclude that genetic polymorphism analysis is recommended for the management of cancer so that each patient can be administered therapy based on his or her genetic profile to achieve an effective and efficient outcome.

Chemotherapy remains a cornerstone in the treatment of nonsmall cell lung cancer

PURPOSE OF REVIEW

The purpose of the review is to summarize the current and future role of chemotherapy in the treatment of patients with nonsmall cell lung cancer (NSCLC).

RECENT FINDINGS

Chemotherapy has been established in early-stage, locally advanced and metastatic NSCLC. Patients with driver mutation-positive NSCLC receive tyrosine kinase inhibitors as first-line therapy and chemotherapy later during the course of their disease. Immune checkpoint inhibitors have entered clinical practice as single agents or in combination with chemotherapy. These novel treatments will supplement chemotherapy in all tumor stages of NSCLC.

SUMMARY

Targeted drugs and immune checkpoint inhibitors are gaining increasing importance in the treatment of NSCLC. They will supplement but not replace chemotherapy in the future.

Influence of Programmed Death Ligand-1-Gene Polymorphism rs822336 on the Prognosis and Safety of Postoperative Patients with NSCLC Who Received Platinum-Based Adjuvant Chemotherapy

Purpose

This study was done to investigate the influence of PDL1-gene polymorphism on the prognosis and safety of postoperative patients with non–small cell lung cancer (NSCLC) who had received platinum-based adjuvant chemotherapy.

Methods

A total of 289 postoperative patients with NSCLC who had received platinum-based adjuvant chemotherapy from January 2012 to June 2019 participated in this study. Recurrence status and adverse reactions were documented during adjuvant chemotherapy. Overall survival (OS) data were obtained through telephone follow-up. DNA extracted from hematologic specimens was genotyped for PDL1-gene polymorphism. Associations between genotype status and prognosis were assessed using Kaplan–Meier survival analysis, and multivariate adjustment was performed using Cox regression analysis.

Results

Median disease-free survival of the 289 patients with NSCLC was 3.3 years and median OS 4.9 years. With regard to the PDL1 gene polymorphism, only rs822336 was of clinical significance in the subsequent analysis. The minor-allele frequency of rs822336 was 0.21, and distribution of the three genotypes was in accordance with the Hardy–Weinberg equilibrium (P=0.807). Survival analysis according to genotype status suggested that median disease-free survival of patients with GG and GC/CC genotypes was 2.8 and 4.1 years, respectively (P=0.01). Median OS of patients with GG and GC/CC genotypes was 4.1 and 5.4 years, respectively (P=0.008). However, the safety analysis failed to find a significant association between the polymorphism and adverse reactions. Interestingly, expression analysis of RNA extracted from peripheral blood mononuclear cells indicated that PDL1-mRNA expression of patients with the GG genotype was significantly higher than for the GC/CC genotype (P<0.001).

Conclusion

The prognosis of postoperative patients with NSCLC who have received platinum-based adjuvant chemotherapy may be influenced by the rs822336 polymorphism through mediation of the mRNA expression of PDL1.

Neoadjuvant chemotherapy combined with intraoperative radiotherapy is effective to prevent recurrence in high-risk non-small cell lung cancer (NSCLC) patients

Background

Basal cell hyperplasia (BCH) and squamous metaplasia (SM) in the small bronchi distant from the tumor is associated with a high risk of non-small cell lung cancer (NSCLC) recurrence. Here, we assessed whether neoadjuvant chemotherapy (NAC), intraoperative radiotherapy (IORT), or adjuvant chemotherapy (AC) is effective to prevent recurrence in NSCLC patients (n=171) with different premalignant lesions in the small bronchi

Methods

BCH, SM, and dysplasia (D) were identified in the samples of lung tissue distant from the tumor. NSCLC patients were treated by surgery, different combinations of NAC and IORT, and AC.

Results

Based on the type of bronchial lesions, NSCLC patients were classified into four groups: BCH⁺SM⁻D⁻ (55.6%, 95/171), BCH⁺SM⁺D⁻ (26.3%; 45/171), BCH⁻SM⁺D⁺ (6.4%, 11/171), and BCH⁻SM⁻D⁻ (11.7%, 20/171). During 5 years, recurrent carcinoma was found in 13.4% (23/171) of patients and represented by metachronous metastases in the thoracic lymph nodes (82.6%, 19/23) and by a relapse in the bronchial stump (17.4%, 4/23). Recurrence was frequent in BCH⁺SM⁺D⁻ patients (87.0%, 20/23), rare in BCH⁺SM⁻D⁻ and BCH⁻SM⁻D⁻ patients (13.0%, 3/23), and absent in BCH⁻SM⁺D⁺ patients (0/23). The 5-year recurrence-free survival was also shorter in BCH⁺SM⁺D⁻ patients (HR 27.35; 95% CI: 6.31−118.48; P<0.0001). In the high-risk (BCH⁺SM⁺D⁻) group, recurrence occurred mainly in cases without NAC and IORT (88.2%, 15/17) and was absent (0/15) when these therapies were combined. NAC- and IORT-negative patients also showed poor overall survival (HR 4.35; 95% CI: 1.96−9.66; P<0.0001) and tended to have decreased recurrence-free survival (P=0.075). Importantly, the recurrence rate was not different between AC-treated and AC-naïve BCH⁺SM⁺D⁻ patients.

Conclusions

The combination of NAC and IORT is an effective strategy to prevent recurrence in high-risk NSCLC patients.

Integrated CT imaging and tissue immune features disclose a radio-immune signature with high prognostic impact on surgically resected NSCLC

OBJECTIVES

Qualitative and quantitative CT imaging features might intercept the multifaceted tumor immune microenvironment (TIME), providing a non-invasive approach to design new prognostic models in NSCLC patients.

MATERIALS AND METHODS

Our study population consisted of 100 surgically resected NSCLC patients among which 31 served as a validation cohort for quantitative image analysis. TIME was classified according to PD-L1 expression and the magnitude of Tumor Infiltrating Lymphocytes (TILs) and further defined as hot or cold by the tissue analysis of effector (CD8-to-CD3^high/PD-1-to-CD8^low) or inert (CD8-to-CD3^low/PD-1-to-CD8^high) phenotypes. CT datasets acted as source for qualitative (semantic, CT-SFs) and quantitative (radiomic, CT-RFs) features which were correlated with clinico-pathological and TIME profiles to determine their impact on survival outcome.

RESULTS

Specific CT-SFs (texture [TXT], effect [EFC] and margins [MRG]) strongly correlated to PD-L1 and TILs status and showed significant impact on survival outcome (TXT, HR:3.39, 95 % CI 1.12-10-27, P < 0.05; EFC, HR:0.41, 95 % CI 0.18-0.93, P < 0.05; MRG, HR:1.93, 95 % CI 0.88-4.25, P = 0.09). Seven CT derived radiomic features were able to sharply discriminate cases with hot (inflamed) vs cold (desert) TIME, which also exhibited opposite OS (long vs short, HR:0.09, 95 % CI 0.04-0.23, P < 0.001) and DFS (long vs short, HR:0.31, 95 % CI 0.16-0.58, P < 0.001). Moreover, we identified 6 prognostic radiomic features among which ClusterProminence displayed the highest statistical significance (HR:0.13, 95 % CI 0.06-0.31, P < 0.001). These findings were independently validated in an additional cohort of NSCLC (HR:0.11, 95 % CI 0.03-0.40, P = 0.001). Finally, in our training cohort we developed a multiparametric prognostic model, interlacing TIME and clinico-pathological characteristics with CT-SFs (ROC curve AUC:0.83, 95 % CI 0.71-0.92, P < 0.001) or CT-RFs (AUC: 0.91, 95 % CI 0.83-0.99, P < 0.001), which appeared to outperform pTNM staging (AUC: 0.66, 95 % CI 0.51-0.80, P < 0.05) in the risk assessment of NSCLC.

CONCLUSION

Higher order CT extracted features associated with specific TIME profiles may reveal a radio-immune signature with prognostic impact on resected NSCLC.

Conquering lung cancer: current status and prospects for the future

Lung cancer is a major global health problem. Several strategies are required to conquer this cancer. Stricter implementations of tobacco control measures are necessary. Early detection programs should be implemented to decrease lung cancer mortality. Although chemotherapy remains a cornerstone of treatment, targeted therapies and immune checkpoint inhibitors improved treatment of metastatic cancers and are hoped to improve outcome of adjuvant and induction therapies. Novel immunotherapy approaches hold great promise. Better understanding of the molecular biology of lung cancer should lead to rational drug design.

Perioperative chemoimmunotherapy in a patient with stage IIIB non-small cell lung cancer

We present a case of a 56-year-old male patient with stage IIIB (T3N2M0) poorly differentiated squamous cell carcinoma of the lung. Four cycles of chemotherapy were first applied, and the patient had stable disease. However, the patient refused to receive radiotherapy, therefore second-line treatment chemotherapy combined with anti-PD-1 immunotherapy was applied. Partial response was reached at the 4^th cycle of chemotherapy combined with anti-PD-1 immunotherapy. The neoadjuvant strategy was prolonged to 10 cycles but no significant change was observed on tumor size. The patient then underwent video-assisted thoracoscopic left lower lobectomy. Eight cycles of adjuvant PD-1 immunotherapy were applied postoperatively. Perioperative immunotherapy demonstrated good curative effect in this patient and no recurrence was observed at the clinic 40 months following surgery. Here we intend to explore the concept of immunotherapy combined with chemotherapy and surgery in neoadjuvant and adjuvant setting, and to investigate the possibility of extending this strategy in patients with stage IIIB non-small cell lung cancer (NSCLC).

The emerging use of immune checkpoint blockade in the adjuvant setting for solid tumors: a review

The use of immune checkpoint inhibitors has been approved in the advanced and metastatic setting for many types of solid tumors. Nonetheless, their role in the adjuvant setting is limited to the treatment of surgically resected melanoma. Ipilimumab was the first immune checkpoint inhibitor approved for this indication, followed by nivolumab and pembrolizumab. Many ongoing trials are evaluating these molecules in the postoperative setting, alone or in combination with other therapies. Preliminary results are promising regarding the treatment of other cutaneous tumors, lung cancers, head and neck squamous cell carcinomas, bladder cancer and renal cell carcinomas. Some data assessing their use for the adjuvant treatment of esophageal, colorectal, ovarian cancer and other solid tumors are similarly emerging.

Exploration of estrogen receptor-associated hub genes and potential molecular mechanisms in non-smoking females with lung adenocarcinoma using integrated bioinformatics analysis

The present study aimed to explore important estrogen receptor-associated genes and to determine the potential pathogenic and prognostic factors for lung adenocarcinoma in non-smoking females. The gene expression profiles of the two datasets (GSE32863 and GSE75037) were downloaded from the Gene Expression Omnibus (GEO) database. Data for non-smoking female patients with lung adenocarcinoma from The Cancer Genome Atlas (TCGA) database were also downloaded. The Linear Models for Microarray Data package in R was used to explore the differentially expressed genes (DEGs) between samples from non-smoking female patients with lung adenocarcinoma and samples of adjacent non-cancerous lung tissue. The Database for Annotation, Visualization and Integrated Discovery was used for functional enrichment of the DEGs. The Search Tool for the Retrieval of Interacting Genes/Proteins and Cytoscape software were used to obtain a protein-protein interaction (PPI) network and to identify the hub genes. In addition, the network between the estrogen receptor and the DEGs was constructed. A Kaplan-Meier survival plot was used to analyze the overall survival (OS). In total, 248 DEGs were identified in the GEO database, and 2,362 DEGs were identified in TCGA database. The intersection of the two datasets (DEGs in GEO and TCGA) revealed 170 DEGs, and these were selected for further investigation. Gene Ontology was used to group the 170 DEGs into biological process, molecular function and cellular component categories. Kyoto Encyclopedia of Genes and Genomes pathway analysis was subsequently performed. A total of 27 hub genes, including caveolin 1 (CAV1), matrix metallopeptidase 9 (MMP9), secreted phosphoprotein 1 (SPP1) and collagen type I α 1 chain (COL1A1), were closely associated with the estrogen receptor. CAV1 and SPP1 were associated with the OS. However, MMP9 and COL1A1 did not have any significant effect on OS. In summary, the identification of CAV1, MMP9, SPP1 and COL1A1 may provide novel insights into the molecular mechanism of lung adenocarcinoma in non-smoking female patients, and the results obtained in the current study may guide future clinical studies.