Mechanism and non-mechanism based imaging biomarkers for assessing biological response to treatment in non-small cell lung cancer

Application of Noninvasive Imaging to Combined Immune Checkpoint Inhibitors for Breast Cancer: Facts and Future

With the application of mono-immunotherapy in cancer, particularly immune checkpoint inhibitors, improved outcomes have been achieved. However, there are several limitations to immunotherapy, such as a poor response to the drugs, immune resistance, and immune-related adverse events. In recent years, studies of preclinical animal models and clinical trials have demonstrated that immune checkpoint inhibitors for breast cancer can significantly prolong the overall survival and quality of patients' lives. Meanwhile, combined immune checkpoint inhibitor treatment has attracted researchers' attention and showed great potential in the comprehensive treatment of breast cancer patients. Additionally, noninvasive imaging enables physicians to predict response to combined immunotherapeutic drugs, achieve treatment efficacy, and lead to better clinical management. Herein, we review the background of combined immune checkpoint inhibitor therapy and summarize its targeted imaging as well as progress in noninvasive imaging aimed at evaluating therapeutic outcomes. Finally, we describe several factors that may influence the outcome of this combined immunotherapy, the future direction of medical imaging, and the potential application of artificial intelligence in breast cancer. With further development of noninvasive imaging for the guidance of combined immune checkpoint inhibitors, cures for this disease may be achieved.

PET/CT and the Response to Immunotherapy in Lung Cancer

Objective

In recent years, the introduction of immune checkpoint inhibitors has significantly changed the outcome of patients affected by lung cancer and cutaneous melanoma. Although the clinical advantages, the selection of patients and the evaluation of response to immunotherapy remain unclear, the immune-related Response Evaluation Criteria in Solid Tumor (irRECIST) was proposed as an update of the RECIST criteria for the assessment of response to immunotherapy. However, morphological images cannot predict early response to therapy that represents a challenge in clinical practice. 18F-FDG PET/CT before and after immunotherapy has an indeterminate role, demonstrating ambiguous results due to inflammatory effects secondary to activation of the immune system. The aim of the present review was to analyze the role of PET/CT as a guide for immunotherapy, by analyzing the current status and future perspectives.

Methods

A literature search was conducted in order to select all papers that discussed the role of PET/CT with FDG or other tracers in the evaluation or prediction of response to immunotherapy in lung cancer patients.

Results

Many papers are now available. Many clinical trials have demonstrated the efficacy of immunotherapy in lung cancer patients. FDG PET/CT can be used for the prediction of response to immunotherapy, while its utility for the evaluation of response is not still clearly reported. Moreover, the standardization of FDG PET/CT interpretation is missing and different criteria, such as information, have been investigated until now.

Conclusion

The utility of FDG PET/CT for patients with lung cancer undergoing immunotherapies is still preliminary and not well addressed. New agents for PET are promising, but large clinical trials are mandatory.

The dynamics and prognostic value of FDG PET-metrics in weekly monitoring of (chemo)radiotherapy for NSCLC

PURPOSE

To test if the relative change in FDG-PET SUV_max over the course of treatment was associated with disease progression and overall survival. Additionally, the prognostic values of other first-order PET-metric changes were investigated.

METHODS

The study included 38 patients with stage II-III NSCLC, who underwent concurrent chemoradiotherapy. Patients received two pre-treatment FDG-PET scans and four during-treatment scans at weekly intervals. SUV_max was normalized to the start of treatment and analyzed using linear regression. Linear regression coefficients of other first order PET-metrics were grouped according to dissimilarity. Associations to patient outcome were analyzed using Cox hazard ratio.

RESULTS

Twenty-eight patients satisfied the criteria for analysis. All PET-metrics demonstrated a strong linear correlation with time during treatment [median R-range: -0.87: -0.97]. No strong associations (p > 0.10) were found for the relative slope of SUV_max to patient outcomes. Other first-order metrics did correlate with outcome but the single imaging time-point maximizing the association of PET response with outcome varied per PET metric and outcome parameter.

CONCLUSION

All investigated FDG PET metrics linearly decreased during treatment. Relative change in SUV_max was not associated to patient outcome while several other first order PET-metrics were related to patient outcome. A single optimal imaging time-point could not be identified.

Monitoring Physiological Changes in Neutron-Exposed Normal Mouse Brain Using FDG-PET and DW-MRI

We monitored a physiological response in a neutron-exposed normal mouse brain using two imaging tools, [¹⁸F]fluro-deoxy-D-glucose positron emission tomography ([¹⁸F]FDG-PET) and diffusion weighted-magnetic resonance imaging (DW-MRI), as an imaging biomarker. We measured the apparent diffusion coefficient (ADC) of DW-MRI and standardized uptake value (SUV) of [¹⁸F]FDG-PET, which indicated changes in the cellular environment for neutron irradiation. This approach was sensitive enough to detect cell changes that were not confirmed in hematoxylin and eosin (H&E) results. Glucose transporters (GLUT) 1 and 3, indicators of the GLUT capacity of the brain, were significantly decreased after neutron irradiation, demonstrating that the change in blood-brain-barrier (BBB) permeability affects the GLUT, with changes in both SUV and ADC values. These results demonstrate that combined imaging of the same object can be used as a quantitative indicator for in vivo pathological changes. In particular, the radiation exposure assessment of combined imaging, with specific integrated functions of [¹⁸F]FDG-PET and MRI, can be employed repeatedly for noninvasive analysis performed in clinical practice. Additionally, this study demonstrated a novel approach to assess the extent of damage to normal tissues as well as therapeutic effects on tumors.

PET-detected pneumonitis following curative-intent chemoradiation in non-small cell lung cancer (NSCLC): recognizing patterns and assessing the impact on the predictive ability of FDG-PET/CT response assessment

PURPOSE

Inflammatory FDG uptake in the lung (PET-pneumonitis) following curative-intent radiotherapy (RT)/chemo-RT (CRT) in non-small cell lung cancer (NSCLC) can pose a challenge in FDG-PET/CT response assessment. The aim of this study is to describe different patterns of PET-pneumonitis to guide the interpretation of FDG-PET/CT and investigate its association with tumor response and overall survival (OS).

METHODS

Retrospective analysis was performed on 87 NSCLC patients in three prospective trials who were treated with radical RT (n = 7) or CRT (n = 80), with baseline and post-treatment FDG-PET/CT. Visual criteria were performed for post-treatment FDG-PET/CT response assessment. The grading of PET-pneumonitis was based on relative lung uptake intensity compared to organs of reference and classified as per Deauville score from grade 1-5. Distribution patterns of PET-pneumonitis were defined as follows: A) patchy/sub-pleural; B) diffuse (involving more than a segment); and C) peripheral (diffusely surrounding a photopenic region).

RESULTS

Follow-up FDG-PET/CT scans were performed approximately 3 months (median, 89 days; interquartile range, 79-93) after RT. Overall, PET-pneumonitis was present in 62/87 (71%) of patients, with Deauville 2 or 3 in 12/62 (19%) and 4 or 5 in 50/62 (81%) of patients. The frequency of patterns A, B and C of PET-pneumonitis was 19/62 (31%), 20/62 (32%) and 23/62 (37%), respectively. No association was found between grade or pattern of PET-pneumonitis and overall response at follow-up PET/CT (p = 0.27 and p = 0.56, respectively). There was also no significant association between PET-pneumonitis and OS (hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.6-2.5; p = 0.45). Early FDG-PET/CT response assessment, however, was prognostic for OS (HR, 1.7; 95% CI, 1.2-2.2; p < 0.001).

CONCLUSION

PET-pneumonitis is common in early post-CRT/RT, but pattern recognition may assist in response assessment by FDG-PET/CT. While FDG-PET/CT is a powerful tool for response assessment and prognostication, PET-pneumonitis does not appear to confound early response assessment or to independently predict OS.

Ubiquitin specific peptidase 49 inhibits non-small cell lung cancer cell growth by suppressing PI3K/AKT signaling

Ubiquitin specific peptidase 49 (USP49) has been reported as a tumor suppressor in several tumors, but its function and molecular mechanism in non-small cell lung cancer (NSCLC) are still unknown. In this study, USP49 was found downregulated in NSCLC primary tissues and cell lines, and high USP49 predicted a positive index for the overall survival of NSCLC patients. Overexpression of USP49 downregulated the expression levels of Cyclin D1, and upregulated p53 expression. Further flow cytometry analysis showed that overexpressed USP49 induced cell cycle arrest at G0/G1 phase. As a result, overexpression of USP49 significantly inhibited cell growth of NSCLC cells. In mechanism, overexpression of USP49 inhibited PI3K/AKT signaling, but knockdown of USP49 enhanced this signaling. Further studies indicated that USP49 deubiquitinated PTEN and stabilized PTEN protein, which suggested that USP49 inhibited PI3K/AKT signaling by stabilizing PTEN in NSCLC cells. In conclusion, we demonstrated that USP49 was functional in NSCLC cells, and inhibited NSCLC cell growth by suppressing PI3K/AKT signaling, suggesting that USP49 could be as a novel target for NSCLC therapy.

A prospective study of the feasibility of FDG-PET/CT imaging to quantify radiation-induced lung inflammation in locally advanced non-small cell lung cancer patients receiving proton or photon radiotherapy

PURPOSE

This prospective study assessed the feasibility of ¹⁸F-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) to quantify radiation-induced lung inflammation in patients with locally advanced non-small cell lung cancer (NSCLC) who received radiotherapy (RT), and compared the differences in inflammation in the ipsilateral and contralateral lungs following proton and photon RT.

METHODS

Thirty-nine consecutive patients with NSCLC underwent FDG-PET/CT imaging before and after RT on a prospective study. A novel quantitative approach utilized regions of interest placed around the anatomical boundaries of the lung parenchyma and provided lung mean standardized uptake value (SUVmean), global lung glycolysis (GLG), global lung parenchymal glycolysis (GLPG) and total lung volume (LV). To quantify primary tumor metabolic response to RT, an adaptive contrast-oriented thresholding algorithm was applied to measure metabolically active tumor volume (MTV), tumor uncorrected SUVmean, tumor partial volume corrected SUVmean (tumor-PVC-SUVmean), and total lesion glycolysis (TLG). Parameters of FDG-PET/CT scans before and after RT were compared using two-tailed paired t-tests.

RESULTS

All tumor parameters after either proton or photon RT decreased significantly (p < 0.001). Among the 21 patients treated exclusively with proton RT, no significant increase in PVC-SUVmean or PVC-GLPG was observed in ipsilateral lungs after the PVC parameters of primary tumor were subtracted (p = 0.114 and p = 0.453, respectively). Also, there were no significant increases in SUVmean or GLG of contralateral lungs of patients who received proton RT (p = 0.841, p = 0.241, respectively). In contrast, among the nine patients who received photon RT, there was a statistically significant increase in PVC-GLPG of ipsilateral lung (p < 0.001) and in GLG of contralateral (p = 0.036) lung. In the subset of nine patients who received a combined proton and photon RT, there was a statistically significant increase in PVC-GLPG of ipsilateral lung (p < 0.001).

CONCLUSION

Our data suggest less induction of inflammatory response in both the ipsilateral and contralateral lungs of patients treated with proton compared to photon or combined proton-photon RT.

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.

Implementing diffusion-weighted MRI for body imaging in prospective multicentre trials: current considerations and future perspectives

For body imaging, diffusion-weighted MRI may be used for tumour detection, staging, prognostic information, assessing response and follow-up. Disease detection and staging involve qualitative, subjective assessment of images, whereas for prognosis, progression or response, quantitative evaluation of the apparent diffusion coefficient (ADC) is required. Validation and qualification of ADC in multicentre trials involves examination of i) technical performance to determine biomarker bias and reproducibility and ii) biological performance to interrogate a specific aspect of biology or to forecast outcome. Unfortunately, the variety of acquisition and analysis methodologies employed at different centres make ADC values non-comparable between them. This invalidates implementation in multicentre trials and limits utility of ADC as a biomarker. This article reviews the factors contributing to ADC variability in terms of data acquisition and analysis. Hardware and software considerations are discussed when implementing standardised protocols across multi-vendor platforms together with methods for quality assurance and quality control. Processes of data collection, archiving, curation, analysis, central reading and handling incidental findings are considered in the conduct of multicentre trials. Data protection and good clinical practice are essential prerequisites. Developing international consensus of procedures is critical to successful validation if ADC is to become a useful biomarker in oncology.

KEY POINTS

• Standardised acquisition/analysis allows quantification of imaging biomarkers in multicentre trials. • Establishing "precision" of the measurement in the multicentre context is essential. • A repository with traceable data of known provenance promotes further research.

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.

Contrast-enhanced computerized tomography combined with a targeted nanoparticle contrast agent for screening for early-phase non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is a major cause of morbidity and mortality, and patients with NSCLC are frequently diagnosed at an advanced stage. This is primarily due to a lack of advanced and sensitive protocols for the detection of early stage NSCLC. Therefore, methods for the accurate diagnosis of early stage NSCLC are urgently required to improve survival rates. The present study investigated the use of contrast-enhanced computerized tomography (CECT) combined with a targeted nanoparticle contrast agent (TNCA) to diagnose early-stage NSCLC in a mice xenograft model. The TNCA used was lenvatinib, a multi-target tyrosine kinase inhibitor that inhibits vascular endothelial growth factor receptor 1-3, fibroblast growth factor receptor 1-4, platelet-derived growth factor receptor β, proto-oncogene tyrosine-protein kinase receptor Ret and mast/stem cell growth factor receptor Kit. Xenograft NSCLC mice were established and used to analyze the efficacy of CECT-TNCA compared with CT scanning alone. The TNCA was inhaled with the use of an atomizer. The results demonstrated that CECT-TNCA improved the sensitivity of the diagnosis of early stage NSCLC. In addition, imaging using the TNCA enabled the visualization of nodules in the lung in mice with early stage NSCLC. In addition, lung nodule signal enhancement was increased in CECT-TNCA compared with CT, suggesting a high accurate accumulation of the TNCA in tumor nodules. Mice diagnosed with early stage NSCLC exhibited a higher eradication rate of NSCLC after treatment with cisplatin compared with mice with advanced stage NSCLC. These data indicate that the sensitivity and accuracy of CT imaging for the diagnosis of early stage NSCLC was improved through combination with the liposome-encapsulated TNCA.

Expression of Rab1A is upregulated in human lung cancer and associated with tumor size and T stage

Rab1A expression is associated with malignant phenotypes in several human tumors; however, the role of Rab1A in lung cancer is still unclear. In this study, we attempted to establish the role of Rab1A in major human lung cancer subtypes. Rab1A expression in different histological types of human lung cancer was analyzed in lung cancer tissues with paired adjacent noncancerous tissues and a large panel of lung cancer cell lines. The effect of Rab1A expression on multiple cancer-associated signaling pathways was also examined. The results demonstrated that Rab1A was significantly overexpressed in the different histological types of lung cancer as compared to non-cancerous tissues, and Rab1A expression was correlated with tumor volume and stage. In a large panel of lung cancer cell lines, high Rab1A expression was observed as compared to a normal lung/bronchus epithelial cell line. However, Rab1A protein levels were not correlated with mTORC1 (P-S6K1), mTORC2 (P-AKT), MEK (P-ERK), JNK (P-c-Jun) or p38MAPK (P-MK2) signaling. Rab1A knockdown had no effect on mTOR signaling or cell growth. These data suggested that Rab1A may be involved in the pathogenesis of human lung cancer in an mTOR- and MAPK-independent manner.

Diffusion-weighted (DW) MRI in lung cancers: ADC test-retest repeatability

PURPOSE

To determine the test-retest repeatability of Apparent Diffusion Coefficient (ADC) measurements across institutions and MRI vendors, plus investigate the effect of post-processing methodology on measurement precision.

METHODS

Thirty malignant lung lesions >2 cm in size (23 patients) were scanned on two occasions, using echo-planar-Diffusion-Weighted (DW)-MRI to derive whole-tumour ADC (b = 100, 500 and 800smm-2). Scanning was performed at 4 institutions (3 MRI vendors). Whole-tumour volumes-of-interest were copied from first visit onto second visit images and from one post-processing platform to an open-source platform, to assess ADC repeatability and cross-platform reproducibility.

RESULTS

Whole-tumour ADC values ranged from 0.66-1.94x10-3mm2s-1 (mean = 1.14). Within-patient coefficient-of-variation (wCV) was 7.1% (95% CI 5.7-9.6%), limits-of-agreement (LoA) -18.0 to 21.9%. Lesions >3 cm had improved repeatability: wCV 3.9% (95% CI 2.9-5.9%); and LoA -10.2 to 11.4%. Variability for lesions <3 cm was 2.46 times higher. ADC reproducibility across different post-processing platforms was excellent: Pearson's R2 = 0.99; CoV 2.8% (95% CI 2.3-3.4%); and LoA -7.4 to 8.0%.

CONCLUSION

A free-breathing DW-MRI protocol for imaging malignant lung tumours achieved satisfactory within-patient repeatability and was robust to changes in post-processing software, justifying its use in multi-centre trials. For response evaluation in individual patients, a change in ADC >21.9% will reflect treatment-related change.

KEY POINTS

• In lung cancer, free-breathing DWI-MRI produces acceptable images with evaluable ADC measurement. • ADC repeatability coefficient-of-variation is 7.1% for lung tumours >2 cm. • ADC repeatability coefficient-of-variation is 3.9% for lung tumours >3 cm. • ADC measurement precision is unaffected by the post-processing software used. • In multicentre trials, 22% increase in ADC indicates positive treatment response.

Feasibility of free breathing Lung MRI for Radiotherapy using non-Cartesian k-space acquisition schemes

OBJECTIVE

To test a free-breathing MRI protocol for anatomical and functional assessment during lung cancer radiotherapy by assessing two non-Cartesian acquisition schemes based on T₁ weighted 3D gradient recall echo sequence: (i) stack-of stars (StarVIBE) and (ii) spiral (SpiralVIBE) trajectories.

METHODS

MR images on five healthy volunteers were acquired on a wide bore 3T scanner (MAGNETOM Skyra, Siemens Healthcare, Erlangen, Germany). Anatomical image quality was assessed on: (1) free breathing (StarVIBE), (2) the standard clinical sequence (volumetric interpolated breath-hold examination, VIBE) acquired in a 20 second (s) compliant breath-hold and (3) 20 s non-compliant breath-hold. For functional assessment, StarVIBE and the current standard breath-hold time-resolved angiography with stochastic trajectories (TWIST) sequence were run as multiphase acquisitions to replicate dynamic contrast enhancement (DCE) in one healthy volunteer. The potential application of the SpiralVIBE sequence for lung parenchymal imaging was assessed on one healthy volunteer. Ten patients with lung cancer were subsequently imaged with the StarVIBE and SpiralVIBE sequences for anatomical and structural assessment. For functional assessment, free-breathing StarVIBE DCE protocol was compared with breath-hold TWIST sequences on four prior lung cancer patients with similar tumour locations. Image quality was evaluated independently and blinded to sequence information by an experienced thoracic radiologist.

RESULTS

For anatomical assessment, the compliant breath-hold VIBE sequence was better than free-breathing StarVIBE. However, in the presence of a non-compliant breath-hold, StarVIBE was superior. For functional assessment, StarVIBE outperformed the standard sequence and was shown to provide robust DCE data in the presence of motion. The ultrashort echo of the SpiralVIBE sequence enabled visualisation of lung parenchyma.

CONCLUSION

The two non-Cartesian acquisition sequences, StarVIBE and SpiralVIBE, provide a free-breathing imaging protocol of the lung with sufficient image quality to permit anatomical, structural and functional assessment during radiotherapy. Advances in knowledge: Novel application of non-Cartesian MRI sequences for lung cancer imaging for radiotherapy. Illustration of SpiralVIBE UTE sequence as a promising sequence for lung structural imaging during lung radiotherapy.

Automated Generation of Reliable Blood Velocity Parameter Maps from Contrast-Enhanced Ultrasound Data

Objectives

The purpose of this study was the automated generation and validation of parametric blood flow velocity maps, based on contrast-enhanced ultrasound (CEUS) scans.

Materials and Methods

Ethical approval for animal experiments was obtained. CEUS destruction-replenishment sequences were recorded in phantoms and three different tumor xenograft mouse models. Systematic pixel binning and intensity averaging was performed to generate parameter maps of blood flow velocities with different pixel resolution. The 95% confidence interval of the mean velocity, calculated on the basis of the whole tumor segmentation, served as ground truth for the different parameter maps.

Results

In flow phantoms the measured mean velocity values were only weakly influenced by the pixel resolution and correlated with real velocities (r² ≥ 0.94, p < 0.01). In tumor xenografts, however, calculated mean velocities varied significantly (p < 0.0001), depending on the parameter maps' resolution. Pixel binning was required for all in vivo measurements to obtain reliable parameter maps and its degree depended on the tumor model.

Conclusion

Systematic pixel binning allows the automated identification of optimal pixel resolutions for parametric maps, supporting textural analysis of CEUS data. This approach is independent from the ultrasound setup and can be implemented in the software of other (clinical) ultrasound devices.

DCE-MRI, DW-MRI, and MRS in Cancer: Challenges and Advantages of Implementing Qualitative and Quantitative Multi-parametric Imaging in the Clinic

Multi-parametric magnetic resonance imaging (mpMRI) offers a unique insight into tumor biology by combining functional MRI techniques that inform on cellularity (diffusion-weighted MRI), vascular properties (dynamic contrast-enhanced MRI), and metabolites (magnetic resonance spectroscopy) and has scope to provide valuable information for prognostication and response assessment. Challenges in the application of mpMRI in the clinic include the technical considerations in acquiring good quality functional MRI data, development of robust techniques for analysis, and clinical interpretation of the results. This article summarizes the technical challenges in acquisition and analysis of multi-parametric MRI data before reviewing the key applications of multi-parametric MRI in clinical research and practice.

Radiotherapy and Immunotherapy Combinations in Non-small Cell Lung Cancer: A Promising Future?

The goal of re-programming the host immune system to target malignancy with durable anti-tumour clinical responses has been speculated for decades. In the last decade such speculation has been transformed into reality with unprecedented and durable responses to immune checkpoint inhibitors seen in solid tumours. This mini-review considers the mechanism of action of immune modulating agents and the potential for combination with radiotherapy in the treatment of non-small cell lung cancer.

Oncolytic vaccine virus harbouring the IL-24 gene suppresses the growth of lung cancer by inducing apoptosis

Lung cancer has an especially high incidence rate worldwide, and its resistance to cell death and chemotherapeutic drugs increases its intractability. The vaccinia virus has been shown to destroy neoplasm within a short time and disseminate rapidly and extensively as an enveloped virion throughout the circulatory system, and this virus has also demonstrated a strong ability to overexpress exogenous genes. Interleukin-24 (IL-24/mda-7) is an important cytokine that belongs to the activating caspase family and facilitates the inhibition of STAT3 when a cell enters the apoptosis pathway. In this study, we constructed a cancer-targeted vaccinia virus carrying the IL-24 gene knocked in the region of the viral thymidine kinase (TK) gene (VV-IL-24). Our results showed that VV-IL-24 efficiently infected and destroyed lung cancer cells via caspase-dependent apoptosis and decreased the expression of STAT3. In vivo, VV-IL-24 expressed IL-24 at a high level in the transplanted tumour, reduced STAT3 activity, and eventually led to apoptosis. In conclusion, we demonstrated that vv-IL-24 has the potential for use as a new human lung cancer treatment.