The association between hospitalisation for pneumonia and the diagnosis of lung cancer

Development of a predictive score to discriminate community acquired pneumonia with underlying lung cancer: A retrospective case - control study

BACKGROUND

A pneumonic infiltrate might hide an occult lung cancer (LC). This awareness depends on each clinician personal experience, turning definitive LC diagnosis challenging and possibly delayed. In this study we aimed to develop a clinical score to better identify those cases.

MATERIALS AND METHODS

We conducted a retrospective case-control study, including previously undiagnosed LC patients admitted in our institution, with a presumptive suspicious of community acquired pneumonia (CAP). Cases were compared with random CAP inpatient controls, using a matched 2:1 ratio. Demographic, clinical, and laboratorial variables were assessed for a possible association with the presence of a CAP with underlying LC (CAP-uLC).

RESULTS

Among 535 hospitalized LC patients, 43 cases had a presentation compatible with CAP and were compared with 86 CAP controls. A scoring system was built using 6 independent variables, which positively correlated with CAP-uLC: smoking history (OR: 8.3 [1.9-36.2]; p = 0.005); absence of fever (6.5 [2.0-21.5]; p = 0.002); sputum with blood (5.9 [1.2-29.9]; p = 0.033); platelet count ≥ 232x103/μL (5.8 [1.6-20.6]; p = 0.006); putative alternative diagnosis than CAP (4.6 [1.5-14.7]; p = 0.009); and duration of symptoms ≥ 10 days (3.7 [1.1-13.0]; p = 0.037). Our score presented an AUC of 0.910 (95 % CI, 0.852-0.967; p < 0.001), a sensitivity of 88.1 % and specificity of 84.7 %, in predicting the risk of presenting a CAP-uLC, when set to a cutoff of 18.

CONCLUSION

We propose a novel risk score aimed to aid clinicians identifying patients with CAP-uLC in the acute setting, possibly prompting early LC diagnosis.

Features of post-obstructive pneumonia in advanced lung cancer patients, a large retrospective cohort

BACKGROUND

Post-obstructive pneumonia refers to an infection of the lung parenchyma distal to a bronchial obstruction. Previous experience-based studies reported a high prevalence of this infection among patients with a medical history of advanced lung neoplasia, up to 40-55%.

OBJECTIVES

The current study was designed to investigate the features of post-obstructive pneumonia in lung cancer, including its predictors and the discriminants for 30-day mortality.

METHOD

Data from medical records at the tertiary University centre, UZ Brussel, were collected retrospectively between January 2016 and January 2021. Patients affected by lung cancer stages III and IV were included. A multidisciplinary team, composed of a pulmonologist, an infectious disease specialist and a chest radiologist, identified patients affected by post-obstructive pneumonia.

RESULTS

A total of 408 patients were included, of which 46 (11%) were diagnosed with post-obstructive pneumonia. Multivariable logistic regression for predictors of disease onset found significant differences for squamous cell carcinoma (OR:2.46 p-value: .014) and hilar location of the tumour (OR:2.72 p-value: .021). However, no significant differences were identified with regards to age or comorbidities. Furthermore, 30-day mortality among post-obstructive pneumonia patients was 30%. Multivariable logistic regression for prediction of 30-day mortality found significant differences in CURB-65 score (OR:73.20 p-value: .001) and smoking status (OR:0.009 p-value: .015).

CONCLUSIONS

Within this cohort, the prevalence of post-obstructive pneumonia in advanced lung cancer patients was lower than previously reported. Squamous cell carcinoma and a hilar tumour location were two variables associated with disease development, independent of age and comorbidities. Furthermore, a higher CURB-65 score at post-obstructive pneumonia diagnosis was correlated with mortality.

Efficacy and safety of 3 mg pegylated recombinant human granulocyte colony-stimulating factor as support to chemotherapy for lung cancer

Background

NCCN guidelines recommend a dose of 100 μg/kg or a fixed dose of 6 mg pegylated recombinant human granulocyte colony‐stimulating factor (PEG rhG‐CSF) for chemotherapy‐induced neutropenia. However, a single dose of 60 μg/kg or 100 μg/kg produced a similar neutrophil response among patients with chemotherapy‐induced neutropenia (CIN). Thus, this prospective randomized study was designed to investigate the efficacy of 3 mg PEG rhG‐CSF in preventing acute lower respiratory tract infection (ALRTI) after chemotherapy.

Methods

Patients with stage IIIB/IVA lung cancer who underwent chemotherapy were randomly divided into a (i) control group, and (ii) treatment group subject to 3 mg PEG rhG‐CSF after chemotherapy. Patients in the control group were administered rhG‐CSF (5 μg/kg) when decreased absolute neutrophil count (ANC) reached grade 3 of adverse events. The primary outcome was incidence of ALRTI, and the secondary outcomes included ANC, febrile neutropenia (FN), incidence of delayed chemotherapy, infection‐related medical expenses and adverse reactions.

Results

Compared with the control group, there was a significant decrease in the incidence of ALRTI (9.6% vs. 24.6%, p < 0.01), FN (1.7% vs. 7.3%, p < 0.001) and neutropenia (8.3% vs. 23.3%, p < 0.01) in the PEG‐rhG‐CSF group. The incidence of ALRTI was significantly correlated with the grade of CTCAE on ANC. The main adverse reactions of PEG‐rhG‐CSF were pain and fatigue, among which three cases showed pain of ≥ grade 3. The cost of infection‐associated medical expenditure in the treatment group was greatly reduced compared with the control group (p < 0.001).

Conclusions

ALRTI could well be prevented after prophylactic application of PEG‐rhG‐CSF (3 mg), and was related to the reduced neutropenia.

Serum Procalcitonin in Patients With Combined Lung Cancer and Idiopathic Pulmonary Fibrosis (LC-IPF)

Background

Procalcitonin (PCT) is a potential biomarker for sepsis and acts as a guide to antibiotic administration. Previous studies showed that lung cancer (LC) may increase serum PCT levels. However, no studies addressed serum PCT in patients with combined LC and idiopathic pulmonary fibrosis (IPF): LC-IPF. We aimed to evaluate the significance of serum PCT in patients with LC-IPF.

Methods

A total of 137 patients with IPF who had complete follow-up data were reviewed. They were categorized into two groups: 30 patients with LC and IPF (LC-IPF) and 82 patients with IPF only (IPF). PCT assays in the two groups were done using the enzyme-linked immunosorbent assay (ELISA) technique.

Results

Median serum PCT (IQR) was significantly higher in patients with LC-IPF in comparison to those with IPF only (0.655± 3.60 vs 0.07 ± 0.11 ng/ml, p=0.016), respectively. LC-IPF patients with neuroendocrine (NE) component, stage IV disease, and with >2 metastatic sites had a significantly higher PCT in comparison to those with non-NE, stages I-III, and <2 metastatic sites, respectively. The presence of the NE component was the only independent risk factor predictive for PCT positivity in patients with LC-IPF; OR1.8 (95% confidence interval (CI) 0.042-2.145; p = 0.042).

Conclusion

Patients with LC-IPF have higher serum PCT levels than those with IPF alone. These levels are related to the presence of NE component, advanced cancer stage, and the presence of multiple metastases. The presence of the NE component is the only independent risk factor predictive for PCT positivity in patients with LC-IPF. Further studies are warranted.

Premalignant lesions of squamous cell carcinoma of the lung: The molecular make-up and factors affecting their progression

Squamous cell carcinoma (SCC), one of the most common forms of lung cancer, shows accelerated progression and aggressive growth and usually is observed at advanced stages. SCC originates from morphological changes in the bronchial epithelium that occur during chronic inflammation: basal cell hyperplasia, squamous metaplasia, and dysplasia I-III. However, the process is not inevitable; it can be stopped at any stage, remain in the stable state indefinitely and either progress or regress. The reasons and mechanisms of different scenarios of the evolution of premalignant lesions in the respiratory epithelium are not fully understood. In this review, we summarized the literature data (including our own data) regarding genetic, epigenetic, transcriptomic and proteomic profiles of the premalignant lesions and highlighted factors (environmental causes, inflammation, and gene polymorphism) that may govern their progression or regression. In conclusion, we reviewed strategies for lung cancer prevention and proposed new models and research directions for studying premalignant lesions and developing new tools to predict the risk of their malignant transformation.

Post-Obstructive Pneumonia in Patients with Cancer: A Review

Published literature on post-obstructive pneumonia is difficult to find and consists mainly of case reports or small case series. This entity is encountered most often in patients with advanced lung malignancy but is also occasionally seen in patients with community-acquired pneumonia (CAP). There are substantial differences in the manifestations, treatment, and outcomes of post-obstructive pneumonia in these two settings. When obstruction is present in patients with CAP, it is almost always secondary to an underlying pulmonary malignancy. In fact, the observation of an obstructive component in patients with CAP leads to the detection of primary or metastatic lung cancer in more than 50% of such individuals. Post-obstructive pneumonia in patients with advanced lung malignancy is far more common (~ 50% of patients) and is associated with substantial morbidity and mortality. The management of these patients is very challenging and involves multiple disciplines including medical oncology, pulmonary medicine, infectious diseases, intervention radiology, surgery, and intensive care teams. The administration of broad-spectrum antibiotic regimens is generally required. Refractory or recurrent infections despite the administration of appropriate antimicrobial therapy are the norm. Frequent and prolonged antibiotic administration leads to the development of resistant microflora. Complications such as lung abscess, empyema, and local fistula formation develop often. Relief of obstruction generally produces only temporary symptomatic improvement.

High Lung Cancer Incidence in Heavy Smokers Following Hospitalization due to Pneumonia

INTRODUCTION

The rate of lung cancer incidence following pneumonia in heavy smokers is unknown. Heavy smokers hospitalized due to community-acquired pneumonia might be at high risk for subsequent lung cancer. The primary objective of this study was to determine lung cancer incidence in this high-risk population.

PATIENTS AND METHODS

This was a single-center, retrospective cohort study that included heavy smokers hospitalized due to community-acquired pneumonia between January 1, 2007 and December 31, 2011 in Beilinson hospital, a large community hospital and tertiary center. Patients were identified by International Classification of Diseases, Ninth Revision coding from the hospital's registry. Two physicians reviewed every patient's medical file for patient demographics, smoking history, lung cancer risk factors, and anatomical location of pneumonia. Data were cross-checked with the database at the national cancer registry for new diagnoses of cancer.

RESULTS

There were 381 admissions for community-acquired pneumonia included in the final analysis. Thirty-one cases (8.14%; 95% confidence interval [CI], 5.9%-11.2%) of lung cancer were diagnosed during the first year after hospitalization. Lung cancer incidence was significantly higher in patients who had upper-lobe pneumonia (23.8%; 95% CI, 14.9%-40%). Lung cancer was located within the lobe involved by the pneumonia in 75.8% of patients.

CONCLUSIONS

A high lung cancer rate was found in heavy smokers admitted due to community-acquired pneumonia. The association was especially strong for patients with upper-lobe pneumonia. Screening with chest computed tomography should be strongly considered for these patients.

Pneumonia and the incidence of cancer: a Danish nationwide cohort study

OBJECTIVES

To examine the risk of a subsequent pulmonary or extra-pulmonary cancer diagnosis following a first-time hospital-based diagnosis of pneumonia.

DESIGN

Population-based cohort study using Danish medical registries.

SETTING

All hospitals in Denmark.

SUBJECTS

A total of 342,609 patients with a first-time hospital-based (inpatient, emergency room or outpatient clinic) diagnosis of pneumonia between 1995 and 2011.

MAIN OUTCOME MEASURES

We quantified the excess risk of various cancers amongst pneumonia patients compared to the expected risk in the general population, using relative [standardised incidence ratios (SIRs)] and absolute risk calculations. Follow-up started 1 month after a hospital-based diagnosis of pneumonia and ended on 31 December 2011.

RESULTS

A total of 28,496 cancers were observed, compared with 21,625 expected, amongst 342,609 pneumonia patients followed for a median of 4.2 years. The absolute risk of a cancer diagnosis 1 to <6 months following a pneumonia diagnosis was 1.4%, with a corresponding SIR of 2.48 [95% confidence interval (CI) 2.41-2.55]. This was mainly due to an increased risk of lung cancer (eightfold) and haematological cancers (fourfold). The SIR for any cancer remained increased at 1.35 (95% CI 1.30-1.40) during 6-12 months of follow-up, and 1.20 (95% CI 1.18-1.22) during 1-5 years of follow-up. Beyond 5 years, an increased risk was maintained for lung, oesophageal, liver and bladder cancers, squamous cell carcinoma of the skin, lymphoma and multiple myeloma.

CONCLUSIONS

A hospital-based pneumonia diagnosis was associated with an increased risk of a cancer diagnosis, especially in the ensuing months, but the absolute risk was small.

The microbiology of postobstructive pneumonia in lung cancer patients

Recurrent pneumonias often occur in the setting of an airway obstruction and can be the presenting symptom of an undiagnosed malignancy. Little is known regarding the microbiology of these pneumonias making antibiotic therapy difficult to direct; however, the few studies available show these pneumonias to be polymicrobial. Examining the colonization patterns of at-risk populations such as patients with chronic obstructive pulmonary disease and using techniques such as ultrasound and computed tomography-guided biopsies may help in the treatment of these pneumonias. The following review is presented to highlight the current medical knowledge as well as suggest areas for future evaluation.

Serum C-reactive protein and procalcitonin levels in non-small cell lung cancer patients

Aim of the study

The basic uses of C-reactive protein (CRP) and procalcitonin (PCT) in clinical practice are in the diagnosis and follow-up of infectious disease. The fact that CRP already achieves high levels in cases with lung cancer, however, limits its diagnostic specificity. Procalcitonin may be an important marker in the differential diagnosis of lung cancer patients who have fever and high CRP levels. Our objective in this study was to determine the levels of CRP and PCT in patients with newly diagnosed non-infectious non-small cell lung cancer (NSCLC) and to relate these results to patient and disease characteristics.

Material and methods

Serum CRP and PCT levels were measured in 79 histopathologically proven NSCLC patients and 20 healthy controls. Results were compared with demographic and clinical variables in patients with NSCLC.

Results

Serum CRP concentrations were significantly higher in NSCLC patients compared to the control group [38.30 (7.79–185) mg/dl vs. 7.79 (3.36–26.10) mg/dl; p < 0.001]. There was no significant difference between the two groups in PCT levels (p > 0.05). A mild, positive correlation was found between CRP level and tumor diameter. When comparing CRP levels in the lung cancer patients grouped according to age, sex, smoking status, clinical TNM staging and performance status (PS), the only significant difference found was that for PS score.

Conclusions

High serum CRP levels in non-infectious NSCLC patients are mainly related to PS status and weakly to tumor size. Adding serum PCT measurement may contribute to exclusion of infections in patients with NSCLC.

Diagnostic value and prognostic significance of pleural C-reactive protein in lung cancer patients with malignant pleural effusions

PURPOSE

C-reactive protein (CRP) has been implicated in various inflammatory and advanced malignant states. Increased serum CRP (s-CRP) levels have been shown to be associated with independent prognostic factors for survival in patients with advanced lung cancer. However, only few studies have focused on the role of CRP in pleural effusions. This study aimed to evaluate the diagnostic and prognostic value of pleural CRP (p-CRP) in lung cancer patients with malignant pleural effusion (MPE).

MATERIALS AND METHODS

Pleural effusion (PE) samples were collected from patients with MPE (68 lung cancers; 12 extrathoracic tumors), and from 68 patients with various benign conditions (31 with pneumonia; 37 with tuberculosis). Concentrations of p- and s-CRP were measured by enzyme-linked immunosorbent assay. CRP level in pleural fluid and its association with survival were examined.

RESULTS

p-CRP levels correlated with s-CRP levels (r=0.82, p<0.0001). For the differential diagnosis of MPE and benign PE, the area under the receiver operating characteristic curve was greater for p-CRP (0.86) than for s-CRP (0.77). High p-CRP expression significantly correlated with shorter overall survival (p=0.006). P-CRP was independent prognostic factor significantly associated with overall survival on multivariated analysis (p=0.0001). The relative risk of death for lung cancer patients with high p-CRP levels was 3.909 (95% confidence interval, 2.000-7.639).

CONCLUSION

P-CRP is superior to s-CRP in determining pleural fluid etiology. Quantitative measurement of p-CRP might be a useful complementary diagnostic and prognostic test for lung cancer patients with MPE.

The effects of radiation and dose-fractionation on cancer and non-tumor disease development

The Janus series of radiation experiments, conducted from 1970 to 1992, explored the effects of gamma and neutron radiation on animal lifespan and disease development. Data from these experiments presents an opportunity to conduct a large scale analysis of both tumor and non-tumor disease development. This work was focused on a subset of animals from the Janus series of experiments, comparing acute or fractionated exposures of gamma or neutron radiation on the hazards associated with the development of tumor and non-tumor diseases of the liver, lung, kidney or vascular system. This study also examines how the co-occurrence of non-tumor diseases may affect tumor-associated hazards. While exposure to radiation increases the hazard of dying with tumor and non-tumor diseases, dose fractionation modulates these hazards, which varies across different organ systems. Finally, the effect that concurrent non-cancer diseases have on the hazard of dying with a tumor also differs by organ system. These results highlight the complexity in the effects of radiation on the liver, lung, kidney and vascular system.

Improving Detection Accuracy of Lung Cancer Serum Proteomic Profiling via Two-Stage Training Process

Background

Surface-Enhanced Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (SELDI-TOF-MS) is a frequently used technique for cancer biomarker research. The specificity of biomarkers detected by SELDI can be influenced by concomitant inflammation. This study aimed to increase detection accuracy using a two-stage analysis process.

Methods

Sera from 118 lung cancer patients, 72 healthy individuals, and 31 patients with inflammatory disease were randomly divided into training and testing groups by 3:2 ratio. In the training group, the traditional method of using SELDI profile analysis to directly distinguish lung cancer patients from sera was used. The two-stage analysis of distinguishing the healthy people and non-healthy patients (1^st-stage) and then differentiating cancer patients from inflammatory disease patients (2^nd-stage) to minimize the influence of inflammation was validated in the test group.

Results

In the test group, the one-stage method had 87.2% sensitivity, 37.5% specificity, and 64.4% accuracy. The two-stage method had lower sensitivity (> 70.1%) but statistically higher specificity (80%) and accuracy (74.7%). The predominantly expressed protein peak at 11480 Da was the primary splitter regardless of one- or two-stage analysis. This peak was suspected to be SAA (Serum Amyloid A) due to the similar m/z countered around this area. This hypothesis was further tested using an SAA ELISA assay.

Conclusions

Inflammatory disease can severely interfere with the detection accuracy of SELDI profiles for lung cancer. Using a two-stage training process will improve the specificity and accuracy of detecting lung cancer.

Impact of respiratory symptoms on lung cancer: 30-year follow-up of an urban population

We investigated the relationship between respiratory symptoms reported at one time and incidence of lung cancer the subsequent 30 years in an urban Norwegian population. A cohort of 19,998 persons, aged 15-70 years living in Oslo, was randomly selected for a respiratory survey in 1972. The response-rate was 89% and 17,670 respondents were followed up. The relationship between respiratory symptoms and lung cancer incidence was investigated separately for each symptom group, symptom score and sex, with adjustment for age, smoking habits and occupational exposure. Lung cancer developed in 352 persons (228 men and 124 women) during follow up. We found a significant positive association between the incidence of lung cancer and cough symptoms in both sexes, asthma-like symptoms among women and dyspnoea when walking uphill among men. The relative risk for lung cancer increased with the number of symptoms reported at baseline and was strongest the first decade and decreased with duration of follow up. This association was more pronounced for non-small cell lung cancer than for small cell lung cancer.