Predictive value of a prognostic model based on pathologic features in lung invasive adenocarcinoma

A Population-Based Study on the Prognostic factors and Efficacy of Adjuvant Chemotherapy in the Postoperative Stage for Patients with Stage IIA Non-Small Cell Lung Cancer

Objective

This study aimed to design a nomogram survival prediction by means of the figures retrieved from the Surveillance, Epidemiology, and End Results (SEER) source bank, and to predict the overall survival (OS) of patients with stage IIA non-small cell lung cancer (NSCLC) after surgery.

Methods

Data for 4511 patients who had been diagnosed with postoperative stage IIA NSCLC were collected from the SEER databank, while information on 528 patients was acquired from the Chongqing University Cancer Hospital for the external validation cohort. The independent risk factors that affected the prognosis were identified using a multivariate Cox proportional hazards regression model (also used to conduct a nomogram). A survival analysis between the low- and the high-risk groups was performed using the Kaplan-Meier method. Furthermore, a subgroup analysis was conducted of the two groups using the Kaplan-Meier method to determine whether the patients had received adjuvant chemotherapy.

Results

The following five variables were integrated into the nomogram: sex (female: HR 1.73, 95% CI 0.64-0.83), age (≥60: HR 1.61, 95% CI 1.39-1.87), differentiation grade (grade II: HR 2.19, 95% CI 1.66-2.88; grade III: HR 2.65, 95% CI 2.00-3.51; grade IV: HR 3.17, 95% CI 1.99-5.03), surgery (lobectomy: HR 0.72, 95% CI 0.59-0.86), and lymph node resection (>12: HR 0.82, 95% CI 0.70-0.96). Furthermore, the patients selected were categorized into high- and low-risk groups. The OS rate was significantly lower in the high-risk group than in the low-risk group (P < 0.001). Finally, adjuvant chemotherapy was highly correlated with OS in the high-risk set (P = 0.035); however, adjuvant chemotherapy was not related to OS in the low-risk set.

Conclusion

A nomogram was created as a reliable, convenient scheme that could predict OS, and it was determined that the high-risk feature patients identified by the nomogram gained benefits from adjuvant chemotherapy.

Clinicopathological Impact of the Spread through Air Space in Non-Small Cell Lung Cancer: A Meta-Analysis

This study aimed to elucidate the clinicopathological significance of spread through air space (STAS) in non-small cell lung cancer (NSCLC) through a meta-analysis. Using 47 eligible studies, we obtained the estimated rates of STAS in various histological subtypes of NSCLC and compared the clinicopathological characteristics and prognosis between NSCLC with and without STAS. The estimated STAS rate was 0.368 (95% confidence interval [CI], 0.336–0.0.401) in patients with NSCLC. Furthermore, the STAS rates for squamous cell carcinoma and adenocarcinoma were 0.338 (95% CI, 0.273–0.411) and 0.374 (95% CI, 0.340–0.409), respectively. Among the histological subtypes of adenocarcinoma, micropapillary-predominant tumors had the highest rate of STAS (0.719; 95% CI, 0.652–0.778). The STAS rates of solid- and papillary-predominant adenocarcinoma were 0.567 (95% CI, 0.478–0.652) and 0.446 (95% CI, 0.392–0.501), respectively. NSCLCs with STAS showed a higher visceral pleural, venous, and lymphatic invasion than those without STAS. In addition, anaplastic lymphoma kinase mutations and ROS1 rearrangements were significantly more frequent in NSCLCs with STAS than in those without STAS. The presence of STAS was significantly correlated with worse overall and recurrence-free survival (hazard ratio, 2.119; 95% CI, 1.811–2.480 and 2.372; 95% CI, 2.018–2.788, respectively). Taken together, the presence of STAS is useful in predicting the clinicopathological significance and prognosis of patients with NSCLC.

A Novel Immune-Related Gene Signature Predicts Prognosis of Lung Adenocarcinoma

Background

Lung adenocarcinoma (LUAD) is the most common form of lung cancer, accounting for 30% of all cases and 40% of all non-small-cell lung cancer cases. Immune-related genes play a significant role in predicting the overall survival and monitoring the status of the cancer immune microenvironment. The present study was aimed at finding an immune-related gene signature for predicting LUAD patient outcomes.

Methods

First, we chose the TCGA-LUAD project in the TCGA database as the training cohort for model training. For model validating, we found the datasets of GSE72094 and GSE68465 in the GEO database and took them as the candidate cohorts. We obtained 1793 immune-related genes from the ImmPort database and put them into a univariate Cox proportional hazard model to initially look for the genes with potential prognostic ability using the data of the training cohort. These identified genes then entered into a random survival forests-variable hunting algorithm for the best combination of genes for prognosis. In addition, the LASSO Cox regression model tested whether the gene combination can be further shrinkage, thereby constructing a gene signature. The Kaplan-Meier, Cox model, and ROC curve were deployed to examine the gene signature's prognosis in both cohorts. We conducted GSEA analysis to study further the mechanisms and pathways that involved the gene signature. Finally, we performed integrating analyses about the 22 TICs, fully interpreted the relationship between our signature and each TIC, and highlighted some TICs playing vital roles in the signature's prognostic ability.

Results

A nine-gene signature was produced from the data of the training cohort. The Kaplan-Meier estimator, Cox proportional hazard model, and ROC curve confirmed the independence and predictive ability of the signature, using the data from the validation cohort. The GSEA analysis results illustrated the gene signature's mechanism and emphasized the importance of immune-related pathways for the gene signature. 22 TICs immune infiltration analysis revealed resting mast cells' key roles in contributing to gene signature's prognostic ability.

Conclusions

This study discovered a novel immune-related nine-gene signature (BTK, CCR6, S100A10, SEMA3C, GPI, SCG2, TNFRSF11A, CCL20, and DKK1) that predicts LUAD prognosis precisely and associates with resting mast cells strongly.

Prognostic implication of tumor spread through air spaces in patients with pathologic N0 lung adenocarcinoma

OBJECTIVES

Tumor spread through air spaces (STAS) has been identified as an invasive pattern in lung adenocarcinoma (ADC), but the prognostic implication of STAS has not been well studied in patients with pathologic N0 lung ADC. The purpose of this study was to evaluate the prognostic implication of STAS in pathologic N0 lung ADC patients after radical surgery.

MATERIALS AND METHODS

Between January 2017 and December 2018, 796 patients with completely resected pathologic N0 lung ADC were reviewed. Pearson's chi-square test or Fisher exact test was used for comparing the relationship between STAS and clinicopathological features. The log-rank test and multivariate Cox regression models were used to explore prognostic factors.

RESULTS

Among the 796 patients, STAS was positive in 201 patients (25.3%). The presence of STAS was significantly associated with patients with solid nodules (P < 0.001), micropapillary pattern-predominant adenocarcinoma/solid pattern-predominant adenocarcinoma (P < 0.001), larger tumor size (P < 0.001), visceral pleural invasion (P < 0.001) and lymphovascular invasion (P < 0.001). Multivariable analysis showed that STAS was an independent prognostic factor for recurrence-free survival (RFS) in pathologic N0 lung ADC patients (P = 0.014). For patients with acinar pattern-predominant adenocarcinoma (APA) / papillary pattern-predominant adenocarcinoma (PPA) / invasive mucinous adenocarcinoma (IMA) and patients who underwent lobectomy, STAS was an independent prognostic factor for RFS (P = 0.015, P = 0.011; respectively) and overall survival (OS) (P = 0.038, P = 0.020; respectively).

CONCLUSION

In this study, STAS was an independent prognostic factor for RFS in pathologic N0 lung adenocarcinomas, and it was also an independent prognostic factor for RFS and OS in patients with APA/PPA/IMA and those who received lobectomy.

GAS6-AS1 Overexpression Increases GIMAP6 Expression and Inhibits Lung Adenocarcinoma Progression by Sponging miR-24-3p

GAS6 antisense RNA 1 (GAS6-AS1) is a long non-coding RNA involved in hepatocellular carcinoma and gastric cancer. However, the functional role of GAS6-AS1 in lung adenocarcinoma (LUAD) remains unclear. In the present study, qRT-PCR was used to measure the levels of GAS6-AS1, GIMAP6 and miR-24-3p expression in LUAD samples and cell lines. CCK-8 and colony formation assays were used to determine cell proliferation. Cell migration and invasion were evaluated using wound healing and transwell assays, respectively. The potential interactions between molecules were assessed using RNA immunoprecipitation and luciferase reporter assays. Western blot analysis was used to quantify protein expression. The anti-tumor effect of over-expressed GAS6-AS1 on LUAD was also examined in vivo in xenograft tumor experiments. The expression of GAS6-AS1 was notably downregulated in LUAD samples and cell lines and associated with a poor prognosis. GAS6-AS1 overexpression inhibited the migration and invasion of A549 and H1650 cells. Down-expressed GAS6-AS1 acted as a sponge for miR-24-3p and down-regulated the expression of its target, GTPase IMAP Family Member 6. These findings suggested that GAS6-AS1 might represent a potential diagnostic biomarker for LUAD.

A prognostic model for elderly patients with squamous non-small cell lung cancer: a population-based study

Background

Squamous cell carcinoma (SCC) is a main pathological type of non-small cell lung cancer. It is common among elderly patients with poor prognosis. We aimed to establish an accurate nomogram to predict survival for elderly patients (≥ 60 years old) with SCC based on the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

The gerontal patients diagnosed with SCC from 2010 to 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The independent prognostic factors were identified using multivariate Cox proportional hazards regression analysis, which were utilized to conduct a nomogram for predicting survival. The novel nomogram was evaluated by Concordance index (C-index), calibration curves, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA).

Results

32,474 elderly SCC patients were included in the analysis, who were randomly assigned to training cohort (n = 22,732) and validation cohort (n = 9742). The following factors were contained in the final prognostic model: age, sex, race, marital status, tumor site, AJCC stage, surgery, radiation and chemotherapy. Compared to AJCC stage, the novel nomogram exhibited better performance: C-index (training group: 0.789 vs. 0.730, validation group: 0.791 vs. 0.733), the areas under the receiver operating characteristic curve of the training set (1-year AUC: 0.846 vs. 0.791, 3-year AUC: 0.860 vs. 0.801, 5-year AUC: 0.859 vs. 0.794) and the validation set (1-year AUC: 0.846 vs. 0.793, 3-year AUC: 0.863 vs. 0.806, 5-year AUC: 0.866 vs. 0.801), and the 1-, 3- and 5-year calibration plots. Additionally, the NRI and IDI and 1-, 3- and 5-year DCA curves all confirmed that the nomogram was a great prognosis tool.

Conclusions

We constructed a novel nomogram that could be practical and helpful for precise evaluation of elderly SCC patient prognosis, thus helping clinicians in determining the appropriate therapy strategies for individual SCC patients.

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.

Significance of tumor spread through air spaces (STAS) in lung cancer from the pathologist perspective

Airspace invasion in lung cancer has been known over the last 30 years, but it was only recently that WHO 2015 formally recognized it as a mechanism of invasion with the terminology of tumor spread through air spaces (STAS). Multiple studies have shown the association of STAS with lower survival and suggest that STAS is an independent prognostic factor across lung adenocarcinoma of all stages and in other histologic subtypes of lung cancer as well. Consequently, STAS is designated as an exclusion criterion of adenocarcinoma in situ and minimally invasive adenocarcinoma; thus, the presence of STAS impacts the diagnosis and staging of lung adenocarcinoma. Further, wedge resection and segmentectomy have been increasingly applied for small node negative tumors and the presence of STAS in those specimens may indicate the requirement of completion lobectomy. Given these significant clinical implications, we, pathologists, need to recognize and appropriately report STAS (possibly including at the time of intraoperative consultation). However, emerging data suggests that more work should be done to improve consensus and identification of STAS, including at frozen section. In this review, the evolution of our understanding of airspace invasion over the past decade, the clinical significance of STAS, and controversies and practical issues associated with the diagnosis of STAS are discussed.

The role of spread through air spaces (STAS) in lung adenocarcinoma prognosis and therapeutic decision making

Spread through air spaces (STAS) was included as a novel pattern of invasion in lung adenocarcinoma by the World Health Organization in 2015. Since then, multiple studies have investigated the association of STAS with clinicopathological and molecular features and its implication in the prognosis of early stage lung cancer patients undergoing different surgery types. The aim of this comprehensive review is to present current data on the role of STAS and its perspective in lung adenocarcinoma management.

Relevance and prognostic ability of Twist, Slug and tumor spread through air spaces in lung adenocarcinoma

BACKGROUND

Tumor spread through air spaces (STAS) is a novel pathologic characteristic in lung adenocarcinomas that indicates invasive tumor behavior. We aimed to explore the relationship between Twist, Slug and STAS in lung adenocarcinoma and to investigate the potential relationship between epithelial-mesenchymal transition (EMT) and STAS.

MATERIALS AND METHODS

Our study retrospectively analyzed 115 patients with resected lung adenocarcinomas to evaluate the relationship between Twist, Slug and STAS. STAS was diagnosed using hematoxylin-eosin (H&E) staining. Immunohistochemistry was used to evaluate the expression levels of Slug and Twist.

RESULTS

In this study, 56 (48.7%) patients had STAS, 40 (34.8%) patients had Slug overexpression, and 28 (24.3%) patients had Twist overexpression. Patients with either STAS or Slug and Twist overexpression experienced poor recurrence-free survival (RFS) and overall survival (OS). There were significant associations between Twist overexpression, Slug overexpression and the presence of STAS. The logistic model further revealed that pathological stage, Twist overexpression and Slug overexpression were independent risk factors for STAS. A multivariate analysis that contained Twist, Slug, pathologic stage and STAS, showed that pathologic stage and STAS were independent prognostic factors for poor RFS and OS. Another multivariate model that contained Twist, Slug and pathologic stage, showed that pathologic stage, Twist overexpression and Slug overexpression were independent risk factors for poor RFS and OS. In the cohort with STAS, the multivariate analysis showed that pathologic stage and Twist overexpression were independent risk factors for poor survival. The subgroup analysis showed that patients with both Slug overexpression and Twist overexpression with STAS received a poor prognosis.

CONCLUSIONS

STAS, Slug and Twist were correlated with poor RFS and OS in resected lung adenocarcinomas. Additionally, STAS was correlated with the overexpression of Twist and Slug, which could potentially provide information on the mechanism of STAS.

Prognostic model based on circular RNA circPDK1 for resected lung squamous cell carcinoma

Background

Circular RNA has been revealed as a potential biomarker in multiple malignancies. However, few studies have focused on its potential to be prognostic markers in lung squamous cell carcinoma (LSCC). In this work, we aimed to build a prognostic model of resected LSCC based on circular RNA pyruvate dehydrogenase kinase 1 (circPDK1) and other clinicopathological factors.

Methods

circPDK1 was identified via next-generation sequencing. Three hundred two cases of LSCC tissue and their adjacent normal lung tissues were obtained from multiple medical centers and divided into study cohort (n=232) and validation cohort (n=70). The expression of circPDK1 was detected for analyzing its potential prognostic value for recurrence-free survival (RFS) and overall survival (OS) in LSCC. Finally, combined with circPDK1, T staging, lymph nodes (LN) metastasis status, age, and serum squamous cell Carcinoma Antigen (SCCAg), we built a prognostic model by nomograms method and confirmed it in the validation cohort.

Results

CircPDK1 was identified to be overexpressed (P<0.01) in LSCC. Through analysis in study cohort, circPDK1^low patients (less than the mean expression, n=124) showed more lymph nodes metastasis (P=0.025), more vascular invasion (VI) (P=0.047), more visceral pleural invasion (VPI) (P=0.015) and poorer prognosis (P=0.003) than circPDK1^high ones (n=108). Univariate and multivariate analysis showed that circPDK1, T staging, LN status, age, and SCCAg were significant prognostic factors for RFS and OS. The prognostic model based on these factors showed the concordance index (C-index) of 0.8214 and 0.8359 for predicting 5-year RFS and OS, respectively. Finally, the calibration curves were performed in the study cohort and a validation cohort to evaluate the model's efficiency.

Conclusions

circPDK1 was identified as a potential biomarker of resected LSCC. The prognostic model including circPDK1, T staging, LN status, age, and SCCAg could effectively predict prognosis of resected LSCC.

Spread Through Air Spaces (STAS) Is Prognostic in Atypical Carcinoid, Large Cell Neuroendocrine Carcinoma, and Small Cell Carcinoma of the Lung

INTRODUCTION

Tumor spread through air spaces (STAS) has prognostic significance in lung adenocarcinoma and squamous cell carcinoma. We sought to investigate the prognostic importance of STAS in lung neuroendocrine tumors (NETs).

METHODS

All tumor slides from patients with resected pathologic stage I to III lung NETs (N = 487) (299 with typical carcinoid [TC], 38 with atypical carcinoid [AC], 93 with large cell neuroendocrine carcinoma [LCNEC], and 57 with SCLC) treated between 1992 and 2012 were evaluated for presence of STAS. Cumulative incidence of recurrence (CIR) and lung cancer-specific cumulative incidence of death (LC-CID) were analyzed by using a competing-risks approach.

RESULTS

STAS was identified in 26% of NETs (16% of TCs, 37% of ACs, 43% of LCNECs, and 46% of SCLCs). STAS was associated with distant metastasis, as well as with higher CIR and LC-CID in the overall cohort and in the AC, LCNEC, and SCLC cohorts (owing to a small number of recurrences and deaths [<5], prognostic analysis was not performed in the TC cohort). In multivariable analysis stratified by stage, STAS was significantly associated with higher CIR (subhazard ratio = 2.85, 95% confidence interval: 1.73-4.68, p < 0.001) and LC-CID (subhazard ratio = 2.72, 95% confidence interval: 1.57-4.70, p < 0.001), independent of histologic subtype. STAS was independently associated with CIR and LC-CID in the LCNEC cohort and LC-CID in the SCLC cohort.

CONCLUSIONS

In patients with lung NETs, STAS is associated with early distant metastasis and worse LC-CID. In patients with LCNEC or SCLC, STAS is an independent poor prognostic factor.