Lung cancer

Unusual presentation of lepidic adenocarcinoma in a healthy female

Background

Lepidic adenocarcinoma represents a histologic pattern of non-small cell lung cancer that characteristically arises in the lung periphery with tracking alongside pre-existing alveolar walls. Noninvasive and invasive variants of lepidic adenocarcinoma are dependent on parenchymal destruction, vascular, or pleural invasion. The lepidic-predominant lung malignancies are collectively recognized as slow growing with rare metastasis and excellent prognosis. The World Health Organization classification of lung malignancies depends on molecular and histopathological findings. CT findings most commonly include ground-glass characteristics, commonly mistaken for inflammatory or infectious etiology. These tumors are generally surgically resectable and associated with better survival given infrequent nodal and extrathoracic involvement. Rarely these tumors present with diffuse pneumonic-type involvement associated with worse outcomes despite lack of nodal and distant metastases.

Case presentation

A 63-year-old Caucasian athletic immunocompetent female presented with 2 months of progressive shortness of breath, fatigue, loss of appetite and 15 pound weight loss. History was only notable for well controlled essential hypertension and hypothyroidism. Contrast computed tomography angiogram and positron emission tomography revealed diffuse hypermetabolic interstitial and airspace abnormalities of the lungs without lymphadenopathy (or distant involvement) in addition to right hydropneumothorax and left pleural effusion. Baseline laboratory testing was unremarkable, and extensive bacterial and fungal testing returned negative. Bronchoscopy and video-assisted thoracoscopic surgery was subsequently performed with pleural fluid cytology, lung and pleural biopsies returning positive for lepidic adenocarcinoma with 2% programmed death ligand 1 expression and genomic testing positive for PTEN gene deletion. Prior to treatment, the patient perished on day 15 of admission.

Conclusion

We present a rare case of lepidic predominant adenocarcinoma with extensive bilateral aerogenous spread in the context of no lymphovascular invasion in a healthy, low risk patient. This case presentation may add to the body of knowledge regarding the different behavior patterns of lepidic predominant adenocarcinomas.

Targeting STAT3 signaling overcomes gefitinib resistance in non-small cell lung cancer

Lung cancer is one of the most aggressive cancers with poor prognosis and high resistance rate. The family of signal transducer and activator of transcriptions (STATs) appears to modulate resistance in non-small cell lung cancer (NSCLC). In this work, we demonstrated that STAT3/ZEB1 is a critical axis in gefitinib resistance. STAT3-targeted inhibition therefore is a new potential therapeutic strategy for gefitinib resistance in lung cancer. Our small molecule screening identified a relatively specific STAT3-targeted inhibitor, LL1. Pharmacological and biochemical studies indicated that LL1 block the activation of STAT3 via inhibiting its phosphorylation. Further in vitro and in vivo studies elucidated that LL1 sensitizes the resistance cells to gefitinib through depleting STAT3 activity and blocking STAT3/ZEB1 signaling pathways. Little toxicity of LL1 was observed in animal models. All these favorable results indicated that LL1 is a chemotherapeutic adjuvant for gefitinib resistance in NSCLC.

Circ_0000376, a Novel circRNA, Promotes the Progression of Non-Small Cell Lung Cancer Through Regulating the miR-1182/NOVA2 Network

Background

Hypoxia has been shown to induce the malignant progression of cancer, including non-small cell lung cancer (NSCLC). Circular RNA (circRNA) is considered to be an important regulator of cancer progression. However, the role of a newly discovered circRNA, circ_0000376, in the progression of NSCLC is unclear.

Methods

The relative expression levels of circ_0000376, miR-1182 and neuro-oncological ventral antigen 2 (NOVA2) were detected via quantitative real-time polymerase chain reaction (qRT-PCR). Glucose consumption and lactate production were determined using Glucose Assay Kit and Lactate Assay Kit, respectively. Moreover, the protein levels of glycolysis markers and NOVA2 were measured using Western blot (WB) analysis. Furthermore, 3-(4, 5-dimethyl-2 thiazolyl)-2, 5-diphenyl-2-H-tetrazolium bromide (MTT) assay was performed to assess cell viability, and transwell assay was employed to evaluate cell migration and invasion. The interaction between miR-1182 and circ_0000376 or NOVA2 was confirmed by dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay. In addition, animal experiments were conducted to assess the influence of circ_0000376 silencing on NSCLC tumor growth in vivo.

Results

Circ_0000376 was upregulated in NSCLC, and its high expression was related to the poor overall survival of NSCLC patients. Hypoxia could enhance circ_0000376 expression and promote the glycolysis, viability, migration, and invasion of NSCLC cells. However, silencing of circ_0000376 could inhibit the glycolysis, viability, migration, and invasion of hypoxia-induced NSCLC cells. Additionally, circ_0000376 could sponge miR-1182, and miR-1182 could target NOVA2. MiR-1182 silencing could reverse the inhibitory effect of circ_0000376 knockdown on NSCLC progression, and NOVA2 overexpression also could reverse the suppressive effect of miR-1182 overexpression on NSCLC progression. Meanwhile, miR-1182 inhibitor could invert the negative regulation effect of circ_0000376 silencing on NOVA2 expression. In addition, circ_0000376 knockdown inhibited the NSCLC tumor growth via regulating the miR-1182 and NOVA2 expression in vivo.

Conclusion

Circ_0000376 promoted NSCLC progression by regulating the miR-1182/NOVA2 axis, suggesting that circ_0000376 might be a potential biomarker for NSCLC treatment.

Gene Expression Classification of Lung Adenocarcinoma into Molecular Subtypes

As one of the most common malignancies in the world, lung adenocarcinoma (LUAD) is currently difficult to cure. However, the advent of precision medicine provides an opportunity to improve the treatment of lung cancer. Subtyping lung cancer plays an important role in performing a specific treatment. Here, we developed a framework that combines k-means clustering, t-test, sensitivity analysis, self-organizing map (SOM) neural network, and hierarchical clustering methods to classify LUAD into four subtypes. We determined that 24 differentially expressed genes could be used as therapeutic targets, and five genes (i.e., RTKN2, ADAM6, SPINK1, COL3A1, and COL1A2) could be potential novel markers for LUAD. Multivariate analysis showed that the four subtypes could serve as prognostic subtypes. Representative genes of each subtype were also identified, which could be potentially targetable markers for the different subtypes. The function and pathway enrichment analyses of these representative genes showed that the four subtypes have different pathological mechanisms. Mutations associated with the subtypes, e.g., epidermal growth factor receptor (EGFR) mutations in subtype 4 and tumor protein p53 (TP53) mutations in subtypes 1 and 2, could serve as potential markers for drug development. The four subtypes provide a foundation for subtype-specific therapy of LUAD.

Safety evaluation of durvalumab for the treatment of non-small-cell lung cancer

INTRODUCTION

The development of immune checkpoint inhibitors (ICIs), such as anti-programmed death 1/programmed death ligand 1 (PD-1/PD-L1) inhibitors, has been a breakthrough in the treatment of non-small-cell lung cancer (NSCLC). Durvalumab, a PD-L1 inhibitor, has shown survival benefit as a maintenance therapy for patients with unresectable stage III NSCLC following definitive chemoradiotherapy, and is approved by the U.S. Food and Drug Administration and the European Medicines Agency.

AREAS COVERED

In this article, we review the development of durvalumab, its pharmacology, and its safety profile as a monotherapy and in combination with other agents, including epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), ICIs such as cytotoxic T-lymphocyte antigen 4 (CTLA-4) blockers, and cytotoxic chemotherapy.

EXPERT OPINION

ICIs, including durvalumab, cause unique side effects, known as immune-mediated adverse events, which are commonly manageable with standard treatment algorithms. The safety profile of durvalumab monotherapy is similar to those of other PD-1/PD-L1 inhibitors. In the PACIFIC trial, durvalumab after radiotherapy resulted in a slight increase in pulmonary toxicity, but most cases were mild. The enhanced effect of ICIs when used in combination therapies is accompanied by an increased risk of side effects. Therefore, the authors evaluated the safety profile and risk-benefit balance of durvalumab combined with various agents.

The clinical significance of CXCL16 in the treatment of advanced non-small cell lung cancer

BACKGROUND

Bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF)-A, has shown efficacy in patients with advanced nonsquamous non-small cell lung cancer (NSCLC). There are no identified or clinically validated biomarkers to determine the efficacy of bevacizumab. In this study, we assessed the adequacy of chemokine (C-X-C motif) ligand 16 (CXCL16) as a biomarker for patients treated with bevacizumab-containing chemotherapy regimen.

METHODS

Patients diagnosed histologically with NSCLC were enrolled. Serial serum CXCL16 levels during treatment were measured by enzyme-linked immunosorbent assay. The relationship between serum CXCL16 levels before and after treatment, progression-free survival, and overall survival were analyzed. CXCL16 and VEGF-A expressions in lung cancer tissue were also evaluated by immunohistochemical tests.

RESULTS

The median serum level of CXCL16 in these patients was 3.4 ng/mL, which was significantly higher than that in age-matched healthy adults (2.2 ng/mL). Immunohistochemistry results showed that CXCL16 was predominantly localized in the tumor stroma, whereas VEGF was expressed in tumor cells. Including bevacizumab with chemotherapy led to lower CXCL16 levels post-chemotherapy, which correlated with better response rates. In addition, evaluation of differences in serum CXCL16 levels before and after the first-line chemotherapy showed that longer overall survival was achieved in patients who showed a larger decrease in serum CXCL16 levels.

CONCLUSIONS

According to our findings, serum CXCL16 level was identified as a potential biomarker for the efficacy of therapy, including anti-VEGF.

KEY POINTS

Significant findings of the study Patients with NSCLC whose serum CXCL16 levels decreased below 0.07 ng/mL after chemotherapy, showed longer overall survival than those without this decrease. Moreover, low CXCL16 levels corresponded to better response rates among patients with advanced NSCLC treated with bevacizumab-containing chemotherapy. What this study adds Previously there were no identifiable predictive biomarkers to determine the efficacy of bevacizumab. Data from our findings identified serum CXCL16 level as a potential biomarker for the efficacy of bevacizumab-containing chemotherapy.

Delineation of cell death mechanisms induced by synergistic effects of statins and erlotinib in non-small cell lung cancer cell (NSCLC) lines

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) have been shown to overcome tyrosine kinase inhibitor (TKI) resistance in epithelial growth factor receptor (EGFR) mutated non-small cell lung cancer (NSCLC) cells in vivo and in vitro. However, little is known about the putative induction of non-apoptotic cell death pathways by statins. We investigated the effects of pitavastatin and fluvastatin alone or in combination with erlotinib in three NSCLC cell lines and examined the activation of different cell death pathways. We assessed apoptosis via fluorometric caspase assay and poly (ADP-ribose) polymerase 1 (PARP) cleavage. Furthermore, annexinV/propidium iodide (PI) flow cytometry was performed. Small molecule inhibitors benzyloxycarbonyl-Val-Ala-Asp-fluoromethyl ketone (zVAD), necrostatin 1 (Nec1), ferrostatin 1 (Fer1), Ac-Lys-Lys-Norleucinal (Calp1) were used to characterise cell death pathway(s) putatively (co-)activated by pitavastatin/erlotinib co-treatment. Synergism was calculated by additivity and isobolographic analyses. Pitavastatin and fluvastatin induced cell death in EGFR TKI resistant NSCLC cells lines A549, Calu6 and H1993 as shown by caspase 3 activation and PARP cleavage. Co-treatment of cells with pitavastatin and the EGFR TKI erlotinib resulted in synergistically enhanced cytotoxicity compared to pitavastatin monotherapy. Flow cytometry indicated the induction of alternative regulated cell death pathways. However, only co-treatment with mevalonic acid (Mev) or the pan-caspase inhibitor zVAD could restore cell viability. The results show that cytotoxicity mediated by statin/erlotinib co-treatment is synergistic and can overcome erlotinib resistance in K-ras mutated NSCLC and relies only on apoptosis.

Surfactant Expression Defines an Inflamed Subtype of Lung Adenocarcinoma Brain Metastases that Correlates with Prolonged Survival

PURPOSE

To provide a better understanding of the interplay between the immune system and brain metastases to advance therapeutic options for this life-threatening disease.

EXPERIMENTAL DESIGN

Tumor-infiltrating lymphocytes (TIL) were quantified by semiautomated whole-slide analysis in brain metastases from 81 lung adenocarcinomas. Multi-color staining enabled phenotyping of TILs (CD3, CD8, and FOXP3) on a single-cell resolution. Molecular determinants of the extent of TILs in brain metastases were analyzed by transcriptomics in a subset of 63 patients. Findings in lung adenocarcinoma brain metastases were related to published multi-omic primary lung adenocarcinoma The Cancer Genome Atlas data (n = 230) and single-cell RNA-sequencing (scRNA-seq) data (n = 52,698).

RESULTS

TIL numbers within tumor islands was an independent prognostic marker in patients with lung adenocarcinoma brain metastases. Comparative transcriptomics revealed that expression of three surfactant metabolism-related genes (SFTPA1, SFTPB, and NAPSA) was closely associated with TIL numbers. Their expression was not only prognostic in brain metastasis but also in primary lung adenocarcinoma. Correlation with scRNA-seq data revealed that brain metastases with high expression of surfactant genes might originate from tumor cells resembling alveolar type 2 cells. Methylome-based estimation of immune cell fractions in primary lung adenocarcinoma confirmed a positive association between lymphocyte infiltration and surfactant expression. Tumors with a high surfactant expression displayed a transcriptomic profile of an inflammatory microenvironment.

CONCLUSIONS

The expression of surfactant metabolism-related genes (SFTPA1, SFTPB, and NAPSA) defines an inflamed subtype of lung adenocarcinoma brain metastases characterized by high abundance of TILs in close vicinity to tumor cells, a prolonged survival, and a tumor microenvironment which might be more accessible to immunotherapeutic approaches.

Invasive Pulmonary Adenocarcinoma with Lepidic Growth Pattern in a Pregnant Patient

Among the differential diagnoses that should be considered in acute respiratory failure (ARF) are infectious processes, autoimmune diseases, interstitial pulmonary fibrosis, and pulmonary neoplasia. Timely diagnosis of lung neoplasia is complicated in the early stages. An opportune diagnosis, as well as the specific treatment, decrease mortality. ARF occurs 1 in 500 pregnancies and is most common during the postpartum period. Among the specific etiologies that cause ARF during pregnancy that must be considered are: (1) preeclampsia; (2) embolism of amniotic fluid; (3) peripartum cardiomyopathy; and (4) trophoblastic embolism. The case of a 36-year-old patient with a 33-week pregnancy and ARF is presented. The patient presented dyspnea while exerting moderate effort that progressed to orthopnea and type 1 respiratory insufficiency. Imaging studies showed bilateral alveolar infiltrates and predominantly right areas of consolidation. Blood cultures, a galactomannan assay and IgG antibodies against mycoplasma pneumoniae, were reported as negative. Autoimmune etiology was ruled out through an immunoassay. A percutaneous pulmonary biopsy was performed and an invasive pulmonary adenocarcinoma with lepidic growth pattern (i.e. lepidic pulmonary adenocarcinoma, LPA) result was reported. This etiology is rare and very difficult to recognize in acute respiratory failure cases. After infectious, autoimmune and interstitial lung fibrosis have been excluded the clinician must suspect of lung cancer in a patient with acute respiratory failure and chest imaging compatible with the presence of ground-glass nodular opacities, a solitary nodule or mass with bronchogram, and lung consolidation. In the presence of acute respiratory failure, the suspicion of pulmonary neoplasia in an adult of reproductive age must be timely. Failure to recognize this etiology can lead to fatal results.

In vivo imaging characterization and anticancer efficacy of a novel HER2 affibody and pemetrexed conjugate in lung cancer model

INTRODUCTION

In this study, a new agent consisting of HER2-specific affibody Z_HER2:V2 and chemotherapy drug pemetrexed was synthesized to develop a new targeted drug. Its biological characteristics and anticancer efficacy were assessed in cells level and xenografts models by radiolabeling with technetium-99m.

METHODS

After the Z_HER2:V2-pemetrexed conjugate was synthesized, radiolabeling of the conjugate was performed using its C-terminal 4 amino acids (Gly-Gly-Gly-Cys) as the chelating moiety. The radiochemical yield of the [^99mTc]Tc-Z_HER2:V2-pemetrexed was identified by instant thin-layer chromatography (ITLC). Stability of the radiolabeled conjugate was investigated both in vitro and in vivo. In vitro binding affinity and cell internalization study of the probe were performed in A549 cells (HER2-positive). Tumor uptake was evaluated by in vitro uptake assay in A549 cells and H23 cells (HER2-negative), and by in vivo biodistribution and SPECT imaging in A549 and H23 tumor-bearing mice. The antitumor efficacy of the Z_HER2:V2-pemetrexed conjugate was evaluated in cells and xenograft models.

RESULTS

The Z_HER2:V2-pemetrexed was successfully synthesized and conjugated with technetium-99 m, and acquired the radiochemical yield of 97.0 ± 0.3%. The stability of [^99mTc]Tc-Z_HER2:V2-pemetrexed was good in both physiological saline and human serum. The radiolabeled agent displayed excellent HER2-binding specificity and affinity in vitro, and was gradually internalized into the cells. Biodistribution study revealed obvious tumor uptake in A549 xenografts (percentage injected dose per gram, 2.6 ± 1.0%ID/g at 4 h postinjection), while the uptake in HER2-negative H23 tumors was much lower (0.2 ± 0.1%ID/g at 4 h postinjection, P < 0.01). SPECT imaging exhibited an intensity in the A549 xenograft which could be blocked by excess Z_HER2:V2-pemetrexed. Treatment with Z_HER2:V2-pemetrexed significantly impaired the tumor growth (P < 0.05), with less weight loss than pemetrexed.

CONCLUSION

[^99mTc]Tc-Z_HER2:V2-pemetrexed showed desirable property and HER2-specificity. The Z_HER2:V2-pemetrexed conjugate could inhibit tumor growth of HER2-positive lung adenocarcinoma and may have the potential to become a targeted drug for lung cancer.

ADVANCES IN KNOWLEDGE AND IMPLICATIONS FOR PATIENT CARE

The compound described herein performs HER2-targeting with favorable anticancer efficacy and offers the potential of novel targeting strategies for further tumor therapy.

Short- and long-term outcomes in elderly patients with locally advanced non-small-cell lung cancer treated using video-assisted thoracic surgery lobectomy

BACKGROUND

In recent years, video-assisted thoracic surgery (VATS) lobectomy has been used to treat locally advanced non-small-cell lung cancer (LA-NSCLC). However, VATS has not been reported in elderly patients (≥70 years) with LA-NSCLC. The purpose of this study was to compare short- and long-term outcomes of patients with LA-NSCLC aged ≥70 years and 55-69 years treated with VATS.

PATIENTS AND METHODS

From January 2012 to January 2018, a total of 83 patients with LA-NSCLC who were ≥55 years of age underwent VATS. Patients were divided into ≥70 years group (37 cases) and 55-69 years group (46 cases), based on their age at the time of VATS. Short- and long-term outcomes of these two groups of patients were compared.

RESULTS

American Society of Anesthesiologists scores of ≥70 years patients were higher than those of 55-69 years patients. No significant differences were observed when comparing the general preoperative data. For short-term outcomes, there was no significant difference between the two groups of patients in length of surgery, intraoperative blood loss, conversion to thoracotomy, postoperative 30-day complication rate and severity, postoperative 30-day mortality, pathological results, compliance with adjuvant chemotherapy, or other factors. Long-term follow-up results showed that recurrence, overall survival, and disease-free survival were similar in both groups. Furthermore, multivariate analysis showed that age was not an independent predictor of overall and disease-free survival.

CONCLUSIONS

VATS in elderly patients (≥70 years) with LA-NSCLC can result in short- and long-term outcomes similar to those of 55-69 years patients with LA-NSCLC.

A review of metabolism-associated biomarkers in lung cancer diagnosis and treatment

INTRODUCTION

Lung cancer continues to be the leading cause of cancer-related mortality worldwide. Early detection has proven essential to extend survival. Genomic and proteomic advances have provided impetus to the effort dedicated to detect and diagnose the disease at an earlier stage. Recently, the study of metabolites associated with tumor formation and progression has inaugurated the era of cancer metabolomics to aid in this effort.

OBJECTIVES

This review summarizes recent work regarding novel metabolites with the potential to serve as biomarkers for early lung tumor detection, evaluation of disease progression, and prediction of patient outcomes.

METHOD

We compare the metabolite profiling of cancer patients with that of healthy individuals, and the metabolites identified in tissue and biofluid samples and their usefulness as lung cancer biomarkers. We discuss metabolite alterations in tumor versus paired non-tumor lung tissues, as well as metabolite alterations in different stages of lung cancers and their usefulness as indicators of disease progression and overall survival. We evaluate metabolite dysregulation in different types of lung cancers, and those associated with lung cancer versus other lung diseases. We also examine metabolite differences between lung cancer patients and smokers/risk-factor individuals.

RESULT

Although an extensive list of metabolites has been evaluated to distinguish between these cases, refinement of methods is further required for adequate patient diagnosis.

CONCLUSION

We conclude that with technological advancement, metabolomics may be able to replace more invasive and costly diagnostic procedures while also providing the means to more effectively tailor treatment to patient-specific tumors.

Systematic review of CYFRA 21-1 as a prognostic indicator and its predictive correlation with clinicopathological features in Non-small Cell Lung Cancer: A meta-analysis

AIM

To evaluate the value of Cytokeratin 19 fragment for its survival prognostic indicator and predictive correlation with clinicopathological features in Non-small Cell Lung Cancer.

METHODS

Eligible studies or databases for articles were retrieved via search systematically. Pooled effect was calculated to evaluate the association between Cytokeratin 19 fragment level and long-term overall survival, as well as the tumor clinicopathological features in Non-small Cell Lung Cancer patients. A fixed-effects or random-effects model was used to calculate the Pooled risk ratios (RRs) and corresponding 95 % confidence intervals (CIs).

RESULTS

Six studies were up to the selection criteria. This meta-analysis indicated that Cytokeratin 19 fragment high level expression correlated with lower 2-year overall survival (RR =0.47; 95%CI: 0.28-0.79), higher Tumor Node Metastasis stage (II+III+IV) (RR =1.43; 95%CI: 1.15-1.76) in Non-small Cell Lung Cancer. The pooled RR estimates indicated that there is no statistical significance of Cytokeratin 19 fragment level expression in the advanced Non-small Cell Lung Cancer (IIIB+IV) (RR =1.43, 95% CI: 0.85-2.43).

CONCLUSION

Cytokeratin 19 fragment is a negative prognosis indicator and its high level expression indicates higher Tumor Node Metastasis pathological stage (II+III+IV) in Non-small Cell Lung Cancer. In advanced Non-small Cell Lung Cancer, the level of serum Cytokeratin 19 fragment appears to provide more prognostic information than it does for clinical Tumor Node Metastasis stage information. Further studies are required to confirm our results.

Current and Prospective Protein Biomarkers of Lung Cancer

Lung cancer is a malignant lung tumor with various histological variants that arise from different cell types, such as bronchial epithelium, bronchioles, alveoli, or bronchial mucous glands. The clinical course and treatment efficacy of lung cancer depends on the histological variant of the tumor. Therefore, accurate identification of the histological type of cancer and respective protein biomarkers is crucial for adequate therapy. Due to the great diversity in the molecular-biological features of lung cancer histological types, detection is impossible without knowledge of the nature and origin of malignant cells, which release certain protein biomarkers into the bloodstream. To date, different panels of biomarkers are used for screening. Unfortunately, a uniform serum biomarker composition capable of distinguishing lung cancer types is yet to be discovered. As such, histological analyses of tumor biopsies and immunohistochemistry are the most frequently used methods for establishing correct diagnoses. Here, we discuss the recent advances in conventional and prospective aptamer based strategies for biomarker discovery. Aptamers like artificial antibodies can serve as molecular recognition elements for isolation detection and search of novel tumor-associated markers. Here we will describe how these small synthetic single stranded oligonucleotides can be used for lung cancer biomarker discovery and utilized for accurate diagnosis and targeted therapy. Furthermore, we describe the most frequently used in-clinic and novel lung cancer biomarkers, which suggest to have the ability of differentiating between histological types of lung cancer and defining metastasis rate.

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

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

Circulating microRNA-34 family low expression correlates with poor prognosis in patients with non-small cell lung cancer

Background

To evaluate the association of plasma miR-34a/b/c expressions with the clinicopathological properties and the prognosis in non-small cell lung cancer (NSCLC) patients.

Methods

A total of 196 NSCLC patients were recruited in the study. Plasma sample and tumor tissue sample were collected. Total RNA was extracted from plasma and tissue samples, and microR-34a/b/c expression was evaluated by real-time polymerase chain reaction (PCR).

Results

MiR-34a and miR-34c in plasma were positively associated with that in tumor tissue (P<0.001 and P=0.001, respectively). Plasma miR-34a expression was negatively correlated with lymph node metastasis (P=0.002), also tissue miR-34a expression was negatively associated with lymph node metastasis (P=0.018). Furthermore, plasma miR-34a high expression was correlated with prolonged disease-free survival (DFS) (P=0.011) and overall survival (OS) (P=0.011) compared to low expression, and plasma miR-34c high expression could predict longer DFS (P=0.038) than low expression, while no correlation of plasma miR-34b with DFS and OS was discovered. In terms of tissue sample, worse DFS was associated with miR-34a (P=0.002) and miR-34c (P=0.032) low expressions compared with high expressions, and miR-34a (P<0.001), as well as miR-34c (P=0.003) high expressions were associated with longer OS than low expressions. Plasma miR-34a was correlated with prolonged DFS and OS in univariate Cox model, while it could not independently predict DFS and OS of NSCLC patients in multivariate Cox model.

Conclusions

In conclusion, circulating miR-34a and miR-34c might be served as novel prognostic biomarkers in NSCLC patients.

Topoisomerase I expression is associated with prognosis in postoperative non-small cell lung cancer patients

Background

Biomarkers may help to improve non‐small cell lung cancer (NSCLC) prognosis. However, the prognostic effect of topoisomerase I (Topo I) on NSCLC is unknown. We evaluated the clinicopathologic and prognostic significance of tumor Topo I and thymidylate synthase (TS) protein expression in postoperative NSCLC patients.

Methods

One hundred and fifteen patients with postoperative NSCLC were enrolled. Topo I and TS protein were detected in removed tumors by immunohistochemistry. The correlations between Topo I/TS protein expression and clinicopathologic characters and outcomes of patients were analyzed.

Results

Increased expression of Topo I was found in 57 (49.6%) tumors. The largest diameter of the tumor was significantly different between patients with high and low Topo I expression (P = 0.035). TS staining showed that 35 (30.4%) carcinomas were TS positive. The level of TS expression was correlated with tumor differentiation (P = 0.037). Patients with low Topo I expression had significantly longer overall survival (OS) than those with high expression (P = 0.004). The correlation between Topo I expression and OS was demonstrated among patients with squamous cell carcinoma (P = 0.030) and patients in pathological tumor node metastasis stage I (P = 0.027). Topo I expression was positively correlated with TS expression in tumor tissue (R = 0.251, P = 0.007).

Conclusions

Low Topo I expression is an independent favorable prognostic factor for longer OS in postoperative NSCLC patients, especially in squamous cell carcinoma. There is a correlation between the expression of TS and Topo I in removed tumor tissue.

New development of inhibitors targeting the PI3K/AKT/mTOR pathway in personalized treatment of non-small-cell lung cancer

Lung cancer is the leading cause of cancer-related death worldwide. Non-small-cell lung cancer (NSCLC) is the most common pathological type of lung cancer, divided into squamous cell carcinoma and adenocarcinoma. Despite better techniques of surgery and improvement in adjuvant and neoadjuvant therapy, the median survival of advanced NSCLC is only 8-10 months. With increased understanding of molecular alternations in NSCLC, considerable efforts have focused on the development of personalized molecular-targeted therapies. The PI3K/AKT/mTOR pathway regulates tumor development, growth, and proliferation of NSCLC. Various novel inhibitors targeting this pathway have been identified in preclinical studies or clinical trials. Some genetic alternations may be considered sensitive or resistant biomarkers to these inhibitors. Sometimes, upregulation of RTK and the downstream PI3K pathway or upregulation of the ERK pathway by compensatory feedback reactivation in response to these inhibitors also lead to drug resistance. Therefore, combination therapy of these inhibitors and other targeted inhibitors such as EGFR-TKI or MEK inhibitors according to genetic status and categories of inhibitors is required to enhance the efficacy of these inhibitors. Here, we reviewed the genetic status of the PI3K/AKT/mTOR pathway in NSCLC and the novel inhibitors targeting this pathway in preclinical or clinical studies, exploring the possible genetic alternations related to different inhibitors and the means to enhance the antitumor effect in NSCLC.

Roles of immunohistochemical staining in diagnosing pulmonary squamous cell carcinoma

BACKGROUND

Differentiating morphologic features based on hematoxylin-eosin (HE) staining is the most common method to classify pathological subtypes of non-small-cell lung cancer (NSCLC). However, its accuracy and inter-observer reproducibility in pathological diagnosis of poorly differentiated NSCLC remained to be improved.

MATERIALS AND METHODS

We attempted to explore the role of immunohistochemistry (IHC) staining in diagnosing pulmonary squamous cell carcinoma (SQCC) with poorly differentiated features by HE staining or with elevated serum adenocarcinoma-specific tumor markers (AD-TMs). We also compared the difference of epidermal growth factor receptor (EGFR) mutation rate between patients with confirmed SQCC and those with revised pathological subtype. Logistic regression analyses were used to test the association between different factors and diagnostic accuracy.

RESULTS

A total of 132 patients who met the eligible criteria and had adequate specimens for IHC confirmation were included. Pathological revised cases in poor differentiated subgroup, biopsy samples and high-level AD-TMs cases were more than those with high/moderate differentiation, surgical specimens and normal-level AD-TMs. Moreover, biopsy sample was a significant factor decreasing diagnostic accuracy of pathological subtype (OR, 4.037; 95% CI 1.446-11.267, p=0.008). Additionally, EGFR mutation rate was higher in patients with pathological diagnostic changes than those with confirmed SQCC (16.7% vs 4.4%, p=0.157).

CONCLUSIONS

Diagnosis based on HE staining only might cause pathological misinterpretation in NSCLC patients with poor differentiation or high-level AD-TMs, especially those with biopsy samples. HE staining and IHC should be combined as pathological diagnostic standard. The occurrence of EGFR mutations in pulmonary SQCC might be overestimated.

Advanced squamous lung carcinoma in a patient experiencing long-term survival following repeated responses to gemcitabine and cisplatin chemotherapy: A case report

The cisplatin and gemcitabine regimen is one of the most effective regimens against advanced non-small-cell lung cancer. However, tumors that are initially sensitive to chemotherapy treatment may acquire drug resistance. Excision repair cross complementation 1 gene (ERCC1) is involved in the repair of DNA damage caused by cisplatin, and ribonucleotide reductase M1 subunit (RRM1) is associated with gemcitabine resistance in tumor cells. The current study reports the case of a patient with advanced squamous cell lung carcinoma exhibiting low ERCC1 and RRM1 expression levels, who experienced long-term survival following repeated responses to gemcitabine and cisplatin chemotherapy. This case indicates that selected patients may benefit from multiple courses of gemcitabine and cisplatin chemotherapy, and the sustained clinical benefits suggest that further investigation into individualized therapy is merited.

Addressing the unmet need in lung cancer: The potential of immuno-oncology

Chemotherapy is currently the standard of care for non-oncogene-driven advanced non-small cell lung cancer (NSCLC). Due to improvements in chemotherapeutic choices and supportive care, patients currently typically undergo multiple lines of chemotherapy as their disease progresses. Although treatments have improved over recent years, limited benefits are seen, especially in patients receiving later-line chemotherapy, as response rates can be low, response duration short and survival poor. Furthermore, only a small percentage of patients derive benefit from later-line therapy, with most experiencing deteriorating quality of life and significant toxicities. More recently, molecular targeted therapies have provided improvements in outcomes. However, these treatments only offer a clear benefit in subsets of tumours harbouring the appropriate genomic alteration (mutation, amplification, translocation). Most of the genomic abnormalities susceptible to therapeutic intervention are detected in adenocarcinoma, mainly in never smokers, while alterations in the genome of other histological subtypes are known but specific agents targeting these alterations have yet to be developed. Thus, the therapeutic management of these subtypes represents an ongoing challenge. Recent advances in immunotherapy have highlighted the potential of immuno-oncology based treatments for NSCLC, offering the potential to provide durable responses and outcomes regardless of histology or mutation status. This review discusses the current unmet medical needs in NSCLC, the limits of current first-line and later-line chemotherapy and targeted agents, and the emergence of new therapeutic strategies.

Molecular histology of lung cancer: from targets to treatments

Lung cancer is the leading cause of cancer-related death worldwide with a 5-year survival rate of less than 15%, despite significant advances in both diagnostic and therapeutic approaches. Combined genomic and transcriptomic sequencing studies have identified numerous genetic driver mutations that are responsible for the development of lung cancer. In addition, molecular profiling studies identify gene products and their mutations which predict tumour responses to targeted therapies such as protein tyrosine kinase inhibitors and also can offer explanation for drug resistance mechanisms. The profiling of circulating micro-RNAs has also provided an ability to discriminate patients in terms of prognosis/diagnosis and high-throughput DNA sequencing strategies are beginning to elucidate cell signalling pathway mutations associated with oncogenesis, including potential stem cell associated pathways, offering the promise that future therapies may target this sub-population, preventing disease relapse post treatment and improving patient survival. This review provides an assessment of molecular profiling within lung cancer concerning molecular mechanisms, treatment options and disease-progression. Current areas of development within lung cancer profiling are discussed (i.e. profiling of circulating tumour cells) and future challenges for lung cancer treatment addressed such as detection of micro-metastases and cancer stem cells.

Clinicopathological analysis of PD-L1 and PD-L2 expression in pulmonary squamous cell carcinoma: Comparison with tumor-infiltrating T cells and the status of oncogenic drivers

PURPOSE

Programmed cell death-1 (PD-1)/programmed cell death-ligand-1 (PD-L1) pathway-targeted immunotherapy has beneficial therapeutic effects in pulmonary squamous cell carcinoma (SqCC) patients. However, the expression patterns of PD-1 and PD-1 ligands (PD-Ls) in pulmonary SqCC remain unclear. Moreover, the association between the PD-1/PD-Ls pathway and the status of oncogenic drivers in pulmonary SqCC is unknown.

METHODS

PD-L1 and PD-L2 expression in tumor cells and the numbers of PD-1(+) and CD8(+) tumor-infiltrating lymphocytes (TILs) were examined in 331 resected SqCC tumors along with matched lymph node metastases from 77 cases using immunohistochemistry. EGFR and FGFR1 and MET expression and genetic status were also examined.

RESULTS

PD-L1 and PD-L2 expression was detected in 26.9% and 23.9% of the pulmonary SqCC samples, respectively. PD-L1 and PD-L2 expression was maintained or increased in the metastatic lymph node tumors in 81.1% and 93.5% of the 77 cases, respectively. The numbers of PD-1(+) and CD8(+) TILs were significantly positively correlated (P<0.001). Cases displaying high PD-L1 expression exhibited consistently high CD8(+) T cell infiltration (P<0.001), even in subgroup analyses according to age, smoking status, tumor size, lymph node metastasis, stage, and the EGFR, MET and FGFR1 status. Moreover, MET expression in the tumors was significantly correlated with high PD-L2 expression and increased PD-1(+) TILs (P=0.001 for both). Increased numbers of CD8(+) or PD-1(+) TILs were significantly associated with prolonged disease-free survival of these patients, whereas PD-L1 and PD-L2 expression had no significant prognostic implications.

CONCLUSION

PD-L1 and PD-L2 expression in pulmonary SqCC is associated with an increased number of CD8(+) TILs and increased MET expression, which might provide therapeutic insight into targeting the PD-1/PD-Ls pathway in pulmonary SqCC.

Integrative genomic analysis reveals a high frequency of LKB1 genetic alteration in Chinese lung adenocarcinomas

Liver kinase B1 (LKB1) genetic alteration in lung cancer involves not only point mutations and small deletion of several base pairs but also exonic loss. However, most of recent studies in LKB1 gene status only focus on point mutations and small deletion, and thus may underestimate the actual frequency of LKB1 genetic alteration in lung cancer. Thus, an integrative analysis of LKB1 genetic alteration is timely and important for providing a better estimate for the incidence of genetic alterations in this important tumor suppressor gene. One hundred and seven lung adenocarcinomas with more than 70% tumor have been analyzed for mutation of LKB1 as well as LKB1 large deletions detection by using multiplex ligation-dependent probe amplification analysis. These samples were also analyzed for EGFR, KRAS, HER2, BRAF, ALK, ROS1, and RET status in stepwise method. Among 107 lung adenocarcinomas analyzed, 29 (27.1%) harbored LKB1 genetic alteration. Twenty-three (21.5%) harbored LKB1 large exonic deletions and eight (7.48%) had LKB1 points mutations, two samples harbored both LKB1 large exonic deletions and point mutations. Eighty-seven samples (81.31%) harbored known driver mutations and 20 samples (18.69%) had no identifiable driver mutations. A high rate of LKB1 genetic alteration in Chinese lung adenocarcinomas is revealed by the integrative analysis of point mutation and exonic deletion. Moreover, LKB1 genetic alterations are concurrent with EGFR, KRAS, HER2, and CD74-ROS fusions.

CP-673451, a platelet-derived growth-factor receptor inhibitor, suppresses lung cancer cell proliferation and migration

Lung cancer is the leading cause of cancer mortality in the world. Although some advances in lung cancer therapy have been made, patient survival is still poor. The platelet-derived growth factor receptors (PDGFRs) and their ligands play critical roles in the regulation of many cancer cell processes, including cell survival and cell motility. Herein, we investigate the anticancer activities of CP-673451, a potent selective inhibitor of PDGFR kinase, in non-small-cell lung cancer (NSCLC) therapy. We found that CP-673451 is effective at suppressing cell viability, inducing cell apoptosis, and inhibiting cell migration and invasion by suppressing the PDGFR downstream signaling pathway in NSCLC cells. Furthermore, CP-673451 is effective at suppressing NSCLC tumor growth in vivo. In summary, our studies suggest that CP-673451 might be a promising therapeutic compound for NSCLC.

Bladder metastasis from lung adenocarcinoma: a difficult differential diagnosis with primary bladder adenocarcinoma

BACKGROUND

Bladder metastases from lung adenocarcinoma are extremely rare; in the seven previously reported cases, the finding of an intact epithelium overlying the bladder tumour was considered suggestive of a secondary lesion. We describe the first case of bladder metastasis from lung adenocarcinoma whereby endoscopic appearance was strongly consistent with primary bladder cancer, thus complicating the differential diagnosis with primary bladder adenocarcinoma.

CASE REPORT

A 65-year-old woman with a 13-year history of clean intermittent catheterization was diagnosed with a right lung adenocarcinoma metastatic to mediastinal and right supraclavicular nodes, as well as to the left lung, and treated with six cycles of cisplatin/pemetrexed, followed by six cycles of pemetrexed only. The 18-month follow-up computed tomography revealed several solid lesions of the bladder wall and she was scheduled for transurethral resection of bladder tumours. Endoscopic appearance was strongly consistent with primary bladder cancer but a thorough pathologic evaluation allowed the diagnosis of bladder metastasis from lung adenocarcinoma.

CONCLUSIONS

Differentiating primary bladder adenocarcinoma from metastatic adenocarcinoma lesions can be difficult. An endoscopic appearance consistent with primary bladder cancer further complicates the differential diagnosis, which heavily relies on pathologic evaluation and specific immunohistochemical staining.

Efficacy of epidermal growth factor receptor-tyrosine kinase inhibitors for Chinese patients with squamous cell carcinoma of lung harboring EGFR mutation

OBJECTIVE

Epidermal growth factor receptor (EGFR) mutation mostly occurred in lung adenocarcinoma, rarely in squamous cell carcinoma (SQCC). EGFR mutation rate in SQCC varied in previous reports, and the efficacy of EGFR tyrosine kinase inhibitors (TKIs) in SQCC harboring EGFR mutation has not yet been fully evaluated. The aim of this study was to investigate the efficacy EGFR-TKIs for Chinese patients with SQCC of lung harboring EGFR mutation.

PATIENTS AND METHODS

Two cohorts of patients were analyzed. The first cohort included 146 consecutive post-operation SQCC patients from January 2008 to October 2012. The second cohort included 63 patients with advanced SQCC receiving EGFR-TKIs treatment. EGFR mutation analysis was performed with Real-time PCR method. The pathologic diagnosis was validated with immunohistochemistry (IHC) for patients harboring activated EGFR mutation. And the efficacy of EGFR-TKIs in squamous cell carcinoma of lung (SQCC) was evaluated in patients with activated EGFR mutations.

RESULTS

In the first cohort, 146 resected patients, EGFR mutations were detected in 3 patients, with the mutation rate of 2.0%. In cohort two, 63 patients treated with EGFR-TKIs, 15 patients possessed activated EGFR mutations. The response rate and disease control rate in these patients was 26.7% and 66.7% respectively. 5 patients had disease control over 6 months. The progression free survival (PFS) in EGFR-mutated patients was 3.9 months.

CONCLUSIONS

In Chinese SQCC patients, EGFR mutation rate was extremely low. EGFR-TKIs seemed to be less effective in EGFR-mutated SQCC patients, but some patients could still obtain benefit from EGFR-TKIs. To identify this part of patients, further study was warranted in the future.

Advances in oncologic imaging: update on 5 common cancers

Imaging has become a pivotal component throughout a patient's encounter with cancer, from initial disease detection and characterization through treatment response assessment and posttreatment follow-up. Recent progress in imaging technology has presented new opportunities for improving clinical care. This article provides updates on the latest approaches to imaging of 5 common cancers: breast, lung, prostate, and colorectal cancers, and lymphoma.

Lung cancers diagnosed at annual CT screening: volume doubling times

PURPOSE

To empirically address the distribution of the volume doubling time (VDT) of lung cancers diagnosed in repeat annual rounds of computed tomographic (CT) screening in the International Early Lung Cancer Action Program (I-ELCAP), first and foremost with respect to rates of tumor growth but also in terms of cell types.

MATERIALS AND METHODS

All CT screenings in I-ELCAP from 1993 to 2009 were performed according to HIPAA-compliant protocols approved by the institutional review boards of the collaborating institutions. All instances of first diagnosis of primary lung cancer after a negative screening result 7-18 months earlier were identified, with symptom-prompted diagnoses included. Lesion diameter was calculated by using the measured length and width of each cancer at the time when the nodule was first identified for further work-up and at the time of the most recent prior screening, 7-18 months earlier. The length and width were measured a second time for each cancer, and the geometric mean of the two calculated diameters was used to calculate the VDT. The χ(2) statistic was used to compare the VDT distributions.

RESULTS

The median VDT for 111 cancers was 98 days (interquartile range, 108). For 56 (50%) cancers it was less than 100 days, and for three (3%) cancers it was more than 400 days. Adenocarcinoma was the most frequent cell type (50%), followed by squamous cell carcinoma (19%), small cell carcinoma (19%), and others (12%). Lung cancers manifesting as subsolid nodules had significantly longer VDTs than those manifesting as solid nodules (P < .0001).

CONCLUSION

Lung cancers diagnosed in annual repeat rounds of CT screening, as manifest by the VDT and cell-type distributions, are similar to those diagnosed in the absence of screening.

Squamous cell carcinoma of the lung: molecular subtypes and therapeutic opportunities

Lung cancer is the leading cause of cancer-related deaths worldwide. Next to adenocarcinoma, squamous cell carcinoma (SCC) of the lung is the most frequent histologic subtype in non-small cell lung cancer. Encouraging new treatments (i.e., bevacizumab, EGFR tyrosine kinase inhibitors, and ALK inhibitors) have afforded benefits to patients with adenocarcinoma, but unfortunately the same is not true for SCC. However, many genomic abnormalities are present in SCC, and there is growing evidence of their biologic significance. Thus, in the short term, the molecular characterization of patients with SCC in modern profiling platforms will probably be as important as deciphering the molecular genetics of adenocarcinoma. Patients with SCC of the lung harboring specific molecular defects that are actionable (e.g., fibroblast growth factor receptor 1 amplification, discoidin domain receptor 2 mutation, and phosphoinositide 3-kinase amplification) should be enrolled in prospective clinical trials targeting such molecular defects.

Lung cancer serum biomarker discovery using label-free liquid chromatography-tandem mass spectrometry

INTRODUCTION

Lung cancer remains the leading cause of cancer-related death with poor survival due to the late stage at which lung cancer is typically diagnosed. Given the clinical burden from lung cancer and the relatively favorable survival associated with early-stage lung cancer, biomarkers for early detection of lung cancer are of important potential clinical benefit.

METHODS

We performed a global lung cancer serum biomarker discovery study using liquid chromatography-tandem mass spectrometry in a set of pooled non-small cell lung cancer case sera and matched controls. Immunoaffinity subtraction was used to deplete the top most abundant serum proteins; the remaining serum proteins were subjected to trypsin digestion and analyzed in triplicate by liquid chromatography-tandem mass spectrometry. The tandem mass spectrum data were searched against the human proteome database, and the resultant spectral counting data were used to estimate the relative abundance of proteins across the case/control serum pools. The spectral counting-derived abundances of some candidate biomarker proteins were confirmed with multiple reaction monitoring mass spectrometry assays.

RESULTS

A list of 49 differentially abundant candidate proteins was compiled by applying a negative binomial regression model to the spectral counting data (p < 0.01). Functional analysis with Ingenuity Pathway Analysis tools showed significant enrichment of inflammatory response proteins, key molecules in cell-cell signaling and interaction network, and differential physiological responses for the two common non-small cell lung cancer subtypes.

CONCLUSIONS

We identified a set of candidate serum biomarkers with statistically significant differential abundance across the lung cancer case/control pools, which, when validated, could improve lung cancer early detection.

Epstein-Barr virus microRNAs and lung cancer

Background:

We conducted the first analysis of viral microRNAs (miRNAs) in lung cancer, with a focus on Epstein–Barr virus (EBV).

Methods:

We evaluated viral miRs with a two-channel oligo-array targeting mature, anti-sense miRNAs in 290 cases. In 48 cases, we compared microarray and real-time quantitative PCR (qPCR) expression for three EBV miRNAs. We tested for EBV DNA, RNA, and protein in tumour tissue from six cases with and six cases without strong qPCR-based evidence of EBV miRNAs.

Results:

The EBV miRNAs strongly differentiated between adenocarcinoma and squamous cell carcinoma using the microarray (P<0.01 for 9 out of 16 EBV miRNAs). However, microarray and qPCR measurements of BART1, BART2, and BHRF1–3 expression were not significantly correlated (P=0.53, 0.94, and 0.47, respectively). Although qPCR provided substantial evidence of EBV miRNAs in 7 out of 48 cases, only 1 of these 7 cases had detectable EBV DNA in tumour tissue. None had detectable EBV RNA or protein by histochemical stains.

Conclusion:

In a comprehensive evaluation of EBV miRNA, DNA, RNA, and protein in lung cancer, we found little evidence of EBV in lung tumour tissue. Discrepancies between microarray- and qPCR-based strategies highlight the difficulty of validating molecular markers of disease. Our results do not support a role of EBV in lung cancer.

PET/CT imaging in different types of lung cancer: an overview

Lung cancer (LC) still represents one of the most common tumours in both women and men. PET/CT is a whole-body non-invasive imaging procedure that has been increasingly used for the assessment of LC patients. In particular, PET/CT added value to CT is mainly related to a more accurate staging of nodal and metastatic sites and to the evaluation of the response to therapy. Although the most common PET tracer for LC evaluation is 18F-FDG, new tracers have been proposed for the evaluation of lung neuroendocrine tumours (68Ga-DOTA-peptides, 18F-DOPA) and for the assessment of central nervous system metastasis (11C-methionine). This review focuses on the main clinical applications and accuracy of PET/CT for the detection of non-small cells lung cancer (NSCLC), broncho-alveolar carcinoma (BAC), small cells lung cancer (SCLC), lung neuroendocrine tumours (NET) and solitary pulmonary nodules (SPN).

Spectrum of LKB1, EGFR, and KRAS mutations in chinese lung adenocarcinomas

INTRODUCTION

Somatic LKB1 mutations are found in lung adenocarcinomas at different frequencies in Caucasian and East Asian (Japanese and Korean) populations. This study was designed to characterize the frequency of LKB1 mutations, their relationship to EGFR and KRAS mutations, and their associated clinicopathologic characteristics in Chinese patients.

METHODS

Two hundred thirty-nine lung adenocarcinomas consecutively collected from October 2007 to July 2009 were dissected into 3 to 4 small (3 mm) pieces for histopathological analyses of tumor content. Genomic DNA and/or cDNA from 86 samples with more than 70% tumor content were used for sequencing of LKB1 (exons 1-9), EGFR (exons 18-21), and KRAS (exon 2). LKB1 germline mutation status was determined by sequencing of genomic DNA from matched histologically distant lung tissues that are histologically normal.

RESULTS

6.9% of lung adenocarcinomas harbored LKB1 somatic mutations. A total of 10.5% of patients had an LKB1 germline polymorphism, F354L. Interestingly, in two of these patients, tumors displayed loss of heterozygosity at this allele. EGFR kinase domain and KRAS mutations were found in 66.3% and 2.3% of Chinese lung adenocarcinomas, respectively. Concurrent LKB1 and EGFR somatic mutations were observed in one patient. Both KRAS-mutant tumors harbored LKB1 mutations.

CONCLUSIONS

These data provide important clinical and molecular characteristics of lung adenocarcinomas from Chinese patients.

The evolving role of histology in the management of advanced non-small-cell lung cancer

Until recently, non-small-cell lung cancer (NSCLC) was treated as a single disease despite recognition of its histologic and molecular heterogeneity. Recent clinical trials, however, demonstrate that histology is an important factor for individualizing treatment, based on either safety or efficacy outcomes. For example, the labeling of the licensed agents bevacizumab and pemetrexed is restricted to patients with nonsquamous cell NSCLC. For bevacizumab, this restriction is due to an apparent association between squamous cell histology and severe pulmonary hemorrhage, whereas for pemetrexed, superior treatment effects have been observed in patients with nonsquamous cell histology. Given fewer agents are both active and tolerable in patients with squamous cell carcinoma compared with adenocarcinoma, and the nature of this particular phenotype of NSCLC, new drugs are needed for this histology. In this new histology-based treatment era, questions persist. Can pathology accurately distinguish the histologic subtypes of NSCLC? Can we use cytologic diagnosis? In the future, will molecular profiling of tumors trump histologic analysis? Herein we describe how therapy for NSCLC is evolving on the basis of a better understanding of molecular mechanisms underlying NSCLC histologic heterogeneity and tumorigenesis.

Metastasis to the occipitocervical junction: A case report and review of the literature

Background

The management of metastatic spinal disease is generally considered palliative, as the progression of systemic disease is likely to hinder survival. Although the occurrence of C1-C2 instability due to metastatic disease is not uncommon and thus treatment options have been well-defined, craniocervical instability due to lesions occurring at the junction of the occiput and atlas is more rare, and treatment for metastasis to this region is less well-defined.

Case Description

We present a patient with non-small-cell lung cancer metastatic to the atlanto-occipital facet joint complex. A drastic improvement in the presenting debilitating mechanical neck pain was noted following an occipitocervical fusion. A literature review of published cases of metastases to the occipitocervical junction was conducted along with treatment options.

Conclusions

The atlanto-occipital facet joint is a rare site of metastatic disease. Destruction of this joint can lead to significant neck pain secondary to instability. Spinal fusion may afford significant and rapid resolution of these symptoms, and should be considered in the management of patients—even those with end-stage oncologic disease.

Targeting angiogenesis with multitargeted tyrosine kinase inhibitors in the treatment of non-small cell lung cancer

It has been >35 years since the link between angiogenesis and the growth of tumors was first reported. Targeting angiogenesis became feasible with the availability of bevacizumab, an anti-vascular endothelial growth factor monoclonal antibody. Initial studies revealed that the combination of bevacizumab and chemotherapy led to longer overall survival times than with chemotherapy alone in patients with advanced colorectal cancer. Since then, drug development strategies have added small molecule tyrosine kinase inhibitors to the panel of antiangiogenic agents under evaluation; data from numerous trials are now available. The challenge now is to identify the optimal antiangiogenic agent for specific patient groups and to understand not only the mechanistic differences between agents, but also the variability in their antitumor activity across different tumor types and their differing side-effect profiles. As in other solid tumors, angiogenesis contributes to the development of non-small cell lung cancer (NSCLC), and this review summarizes the role of angiogenesis in this disease. We review the current developmental status of antiangiogenic tyrosine kinase inhibitors (including vandetanib, sunitinib, axitinib, sorafenib, vatalanib, and pazopanib) in NSCLC and conclude by briefly discussing the need for optimal patient selection and potential future directions.

Diagnosing cancer in the symptomatic patient

Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.

Clinical overview on Lipoplatin: a successful liposomal formulation of cisplatin

Nanoparticle formulations for packaging existing drugs have been used to treat cancer. Lipoplatin is a liposomal cisplatin encapsulated into liposome nanoparticles of an average diameter of 110 nm. Lipoplatin has substantially reduced the renal toxicity, peripheral neuropathy, ototoxicity, myelotoxicity as well as nausea/vomiting and asthenia of cisplatin in Phase I, II and III clinical studies with enhanced or similar efficacy to cisplatin. During clinical development, 10- to 200-fold higher accumulation of Lipoplatin in solid tumors compared to adjacent normal tissue was found in patients. Targeting of tumor vasculature by Lipoplatin in animals suggested its antiangiogenesis potential and Lipoplatin was proposed to act like a double-sword: as chemotherapy and an antiangiogenesis drug. Lipoplatin has finished successfully one Phase III non-inferiority clinical study as first-line against NSCLC in its combination with paclitaxel showing statistically significant reduction in nephrotoxicity; two more Phase III studies are in progress, one in NSCLC with gemcitabine also showing noninferiority with reduced toxicity and another in squamous cell carcinoma of the head and neck with 5-fluorouracil. A registrational Phase II/III study against pancreatic cancer is in progress under the orphan drug status granted to Lipoplatin by the European Medicines Agency. Phase II studies are continuing in advanced breast cancer with vinorelbine and gastrointestinal cancers with radiotherapy and 5-fluorouracil. The highlights of the clinical development of Lipoplatin are reviewed.

Microvessel density and expression of thrombospondin-1 in non-small cell lung cancer and their correlation with clinicopathological features

Microvessel density and thrombospondin-1 (TSP-1) expression were analysed in 42 non-small cell lung cancer (NSCLC) specimens and 40 normal lung tissue specimens using immunohistochemistry. Microvessel density was significantly higher and TSP-1 expression significantly lower in NSCLC tissue compared with normal tissue. Significantly lower levels of TSP-1 expression and higher microvessel densities were found in late-stage NSCLC compared with early-stage NSCLC, and in those with lymph node metastasis compared with those without metastasis. A statistically significant inverse correlation was observed between TSP-1 expression and microvessel density in squamous cell carcinoma but not in adenocarcinoma. These results suggest a close relationship between microvessel density and NSCLC tumour progress, and that a high expression of TSP-1 may play an important role in inhibiting tumour occurrence and development. The lack of correlation between microvessel density and TSP-1 expression in adenocarcinoma suggests that the mechanism of tumour inhibition by TSP-1 varies according to histological type.

Symptom Severity 1 to 4 Months After Thoracotomy for Lung Cancer

Background Information about the severity of symptoms during recovery from surgery for lung cancer can be useful in planning and anticipating needs for recovery.

Objectives To describe symptom severity during the first 4 months after thoracotomy for non–small cell lung cancer and factors associated with overall symptom severity at 1 and 4 months.

Methods Ninety-four patients were assessed at 1, 2, and 4 months after thoracotomy by using the Lung Cancer Symptom Scale, Brief Pain Inventory, Schwartz Fatigue Scale, Dyspnea Index, and Center for Epidemiology Studies–Depression Scale (CES-D). Clinically meaningful changes, decrease in the proportion of patients with severe symptoms, and relationships among symptoms were determined. Mixed effects models for repeated measures were used to evaluate changes in severity. Multiple regression models were used to examine correlates of overall symptoms.

Results Mean symptom severity significantly decreased over time for most symptoms. Only disrupted appetite, pain, and dyspnea had clinically meaningful improvement at 4 months. Severe symptoms included fatigue (57%), dyspnea (49%), cough (29%), and pain (20%). Prevalence of depressed mood decreased at 4 months. Most patients (77%) had comorbid conditions. Number of comorbid conditions and CES-D explained 54% of the variance in symptom severity at 1 month; comorbid conditions, male sex, neoadjuvant treatment, and CES-D score explained 50% of the variance at 4 months.

Conclusions Severe symptoms continued 4 months after surgery for some patients, indicating the need for support during recovery, especially for patients with multiple comorbid conditions and depressed mood.

Valor do FDG[18F]-PET/TC como preditor de câncer em nódulo pulmonar solitário

OBJETIVO: Determinar a acurácia diagnóstica da positron emission tomography (tomografia por emissão de pósitrons)/tomografia computadorizada (PET/TC) com deoxiglicose marcada com flúor-18, conhecida como fluorodeoxiglicose (FDG[18F]), na avaliação de nódulo pulmonar solitário (NPS). MÉTODOS: Análise prospectiva de 53 pacientes consecutivos que realizaram PET/TC para avaliação de NPS, entre março de 2005 e maio de 2007. Destes 32 preencheram os critérios de inclusão. As lesões foram avaliadas quanto a sua localização e tamanho, grau de captação do radiofármaco e o standardized uptake value (SUV, valor padronizado de captação) máximo das lesões. Os achados dos estudos de FDG-PET/TC foram correlacionados com outros preditores de malignidade (idade, sexo, tabagismo, tamanho e localização do nódulo). O diagnóstico definitivo foi estabelecido por confirmação histopatológica ou acompanhamento clínico-radiológico por um período mínimo de um ano. RESULTADOS: Encontrados 14 NPS malignos. Após análise da curva ROC, o SUV de 2,5 foi considerado o melhor ponto de corte que identificou corretamente 13 dos 14 NPS malignos. Os resultados abaixo deste ponto de corte mostraram um exame falso positivo para neoplasia num total de 14. O método semiquantitativo apresentou sensibilidade de 92,9%, especificidade de 72,2%, valor preditivo positivo de 72,2%, valor preditivo negativo de 92,9% e acurácia de 81,2%. Na análise multivariada, apenas a localização do nódulo nos lobos superiores (p = 0,048) e o SUV (p = 0,007) demonstraram significância estatística para malignidade no NPS. CONCLUSÕES: Os dados do estudo mostram que o SUV da FDG[18F] é um bom preditor de neoplasia em nódulos pulmonares e com alto valor preditivo negativo, o que oferece grande segurança em afastar presença de malignidade, indicando sua importância na abordagem diagnóstica do nódulo pulmonar.