Whole transcriptome targeted gene quantification provides new insights on pulmonary sarcomatoid carcinomas

Case Report: Intestinal metastasis from ALK-rearranged pulmonary pleomorphic carcinomas mimicking inflammatory myofibroblastic tumors

Lung carcinomas usually spread to the liver, lungs, pleura, pericardium, adrenal glands, brain, and bones. Anaplastic lymphoma kinase gene (ALK) fusion occurs in approximately 5% of non-small cell lung cancer (NSCLC) cases and most frequently in adenocarcinoma. Here, we report a rare case of intestinal metastasis originating from pulmonary pleomorphic carcinoma in a 49-year-old male heavy smoker. At the local hospital, the patient was initially considered to have an ALK-positive intestinal tumor, leading to a differential diagnosis of inflammatory myofibroblastic tumor (IMT). Due to the tumor's peculiar morphology (including epithelioid and spindle cell components), pathologists of the local hospital sent slides of the case to our hospital for further consultation. Immunohistochemical analysis revealed that the epithelioid and spindle neoplastic cells were positive for CK7, TTF1, and ALK-V. Fluorescence in situ hybridization (FISH) confirmed the presence of the echinoderm microtubule-associated protein-like 4 (EML4):: ALK fusion. Based on these findings, we established the final diagnosis as intestinal metastasis of ALK-positive pulmonary pleomorphic carcinoma. A subsequent enhanced CT scan of the chest revealed a 3.0 cm solid mass in the right upper lung, further supporting the diagnosis of intestinal metastasis originating from pulmonary pleomorphic carcinoma. In conclusion, this case exhibited highly unusual clinicopathological features that could easily lead to misdiagnosis as primary intestinal tumors with ALK rearrangement. Pathologists must know this possibility to ensure accurate diagnosis and appropriate management.

Real-world treatment patterns and outcomes among patients with advanced non-small-cell lung cancer with spindle cell and/or giant cell carcinoma

Objectives

A definitive diagnosis of pulmonary sarcomatoid carcinoma cannot be made with small biopsies. In clinical practice, a diagnosis of advanced non-small-cell lung cancer with spindle cell and/or giant cell carcinoma (NSCLCsg), or possible sarcomatoid carcinoma, is acceptable. Therefore, we aimed to investigate the treatment patterns and outcomes of advanced NSCLCsg.

Materials and methods

Between 01 January 2012 and 01 April 2021, patients with pathologically proven advanced NSCLCsg were enrolled. The choice of treatment was based on clinician discretion.

Results

In all, 101 patients with advanced NSCLCsg were enrolled. In total, 77 (76.2%) patients received at least one line of systemic therapy; 44 patients (43.1%) had received platinum doublet chemotherapy; 27 (26.7%) patients had been treated with targeted therapies; and 23 patients (22.8%) had been given an immune checkpoint inhibitor (ICI). The median overall survival (OS) was 6.3 months [95% confidence interval (CI): 3.6-9.0 months]. Excluding patients without systemic therapy, patients who had received an ICI had better OS (median: 18.2 months) than those who had not (median 3.8 months, log-rank test p = 0.002). No significant difference in OS was detected between patients who had or had not received platinum doublet chemotherapy (log-rank test p = 0.279), or targeted therapy (log-rank test p = 0.416). Having received any systemic therapy [hazard ratio (HR): 0.33, 95% CI: 0.18-0.61, p < 0.0001) and ICI (HR: 0.38, 95% CI: 0.19-0.78, p = 0.008) were independent factors for better OS. Patients with programmed death ligand-1 (PD-L1) expression ⩾50% had better OS than those with PD-L1 expression <50% (HR: 0.51, 95%: 0.30-0.86, p = 0.012).

Conclusion

Although advanced NSCLCsg has a poor survival outcome, our results showed that ICI may prolong OS in patients with advanced NSCLCsg. Further prospective studies are warranted to gain more understanding of the role of ICI in this specific patient population.

Clinical characteristics and prognostic factors of pulmonary sarcomatoid carcinoma

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is a kind of rare lung cancer. We aim to analyze the clinical characteristics and prognostic factors of patients with PSC.

METHODS

From January 1, 2006 to December 31, 2015, 119 patients in the Cancer Hospital Chinese Academy of Medical Sciences were diagnosed with PSC, and they received treatment. We retrospectively collected information on gender, age, body mass index (BMI), symptoms, family history, smoking history, tumor size, tumor location, tumor diameter, tumor-node-metastasis (TNM), pathological type, and other factors to analyze the relationship between these factors and 1-, 3-, 5-year, and overall survival (OS).

RESULTS

Male patients who had a smoking history (n=76) comprised the main group of PSC. Median patient age was 60.67±10.50 years (range, 26-89 years). The majority of these patients (n=82) presented with respiratory symptoms. The median survival of patients who died of PSC was 11.87 months (6.38-21.48 months). The 1-, 3-, and 5-year survival rates were 61.3%, 34.5%, and 31.9%, respectively. Patients with a lower T stage and without lymph node metastasis and distant metastasis had a better OS (P<0.05). Other clinical characteristics and the difference in treatments did not influence the prognosis significantly (P>0.05).

CONCLUSIONS

PSC is a rare malignant neoplasm of the lung with poor prognosis. Surgery is a major therapeutic method for this disease entity. TNM-stage is the main factors affecting prognosis.

Integrative analysis of non-small cell lung cancer patient-derived xenografts identifies distinct proteotypes associated with patient outcomes

Non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths worldwide. Only a fraction of NSCLC harbor actionable driver mutations and there is an urgent need for patient-derived model systems that will enable the development of new targeted therapies. NSCLC and other cancers display profound proteome remodeling compared to normal tissue that is not predicted by DNA or RNA analyses. Here, we generate 137 NSCLC patient-derived xenografts (PDXs) that recapitulate the histology and molecular features of primary NSCLC. Proteome analysis of the PDX models reveals 3 adenocarcinoma and 2 squamous cell carcinoma proteotypes that are associated with different patient outcomes, protein-phosphotyrosine profiles, signatures of activated pathways and candidate targets, and in adenocarcinoma, stromal immune features. These findings portend proteome-based NSCLC classification and treatment and support the PDX resource as a viable model for the development of new targeted therapies.

With non-small cell lung cancer (NSCLC) being the leading cause of cancer deaths worldwide, the development of targeted therapies remains crucial. Here, the generation and multi-omics characterization of 137 NSCLC patient-derived xenografts provides a resource for potential classifications and targets.

A seven-gene prognostic signature predicts overall survival of patients with lung adenocarcinoma (LUAD)

Background

Lung adenocarcinoma (LUAD) is one of the most common types in the world with a high mortality rate. Despite advances in treatment strategies, the overall survival (OS) remains short. Our study aims to establish a reliable prognostic signature closely related to the survival of LUAD patients that can better predict prognosis and possibly help with individual monitoring of LUAD patients.

Methods

Raw RNA-sequencing data were obtained from Fudan University and used as a training group. Differentially expressed genes (DEGs) for the training group were screened. The univariate, least absolute shrinkage and selection operator (LASSO), and multivariate cox regression analysis were conducted to identify the candidate prognostic genes and construct the risk score model. Kaplan–Meier analysis, time-dependent receiver operating characteristic (ROC) curve were used to evaluate the prognostic power and performance of the signature. Moreover, The Cancer Genome Atlas (TCGA-LUAD) dataset was further used to validate the predictive ability of prognostic signature.

Results

A prognostic signature consisting of seven prognostic-related genes was constructed using the training group. The 7-gene prognostic signature significantly grouped patients in high and low-risk groups in terms of overall survival in the training cohort [hazard ratio, HR = 8.94, 95% confidence interval (95% CI)] [2.041–39.2]; P = 0.0004), and in the validation cohort (HR = 2.41, 95% CI [1.779–3.276]; P < 0.0001). Cox regression analysis (univariate and multivariate) demonstrated that the seven-gene signature is an independent prognostic biomarker for predicting the survival of LUAD patients. ROC curves revealed that the 7-gene prognostic signature achieved a good performance in training and validation groups (AUC = 0.91, AUC = 0.7 respectively) in predicting OS for LUAD patients. Furthermore, the stratified analysis of the signature showed another classification to predict the prognosis.

Conclusion

Our study suggested a new and reliable prognostic signature that has a significant implication in predicting overall survival for LUAD patients and may help with early diagnosis and making effective clinical decisions regarding potential individual treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-021-01975-z.

Survival Analysis and Prediction Model for Pulmonary Sarcomatoid Carcinoma Based on SEER Database

Objective

This study aimed to investigate the incidence of the pulmonary sarcomatoid carcinoma (PSC), to compare the clinical characteristics and overall survival (OS) of patients with PSC and those with other non-small-cell lung cancer (oNSCLC), so as to analyze the factors affecting the OS of patients with PSC and construct a nomogram prediction model.

Methods

Data of patients with PSC and those with oNSCLC diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results database were collected. The age-adjusted incidence of PSC was calculated. The characteristics of patients with PSC and those with oNSCLC were compared, then the patients were matched 1:2 for further survival analysis. Patients with PSC were randomly divided into training set and testing set with a ratio of 7:3. The Cox proportional hazards model was used to identify the covariates associated with the OS. Significant covariates were used to construct the nomogram, and the C-index was calculated to measure the discrimination ability. The accuracy of the nomogram was compared with the tumor–node–metastasis (TNM) clinical stage, and the corresponding area under the curve was achieved.

Results

A total of 1049 patients with PSC were enrolled, the incidence of PSC was slowly decreased from 0.120/100,000 in 2004 to 0.092/100,000 in 2015. Before PSM, 793 PSC patients and 191356 oNSCLC patients were identified, the proportion of male, younger patients (<65 years), grade IV, TNM clinical stage IV was higher in the PSC. The patients with PSC had significantly poorer OS compared with those with oNSCLC. After PSM, PSC still had an extremely inferior prognosis. Age, sex, TNM clinical stage, chemotherapy, radiotherapy, and surgery were independent factors for OS. Next, a nomogram was established based on these factors, and the C-indexs were 0.775 and 0.790 for the training and testing set, respectively. Moreover, the nomogram model indicated a more comprehensive and accurate prediction than the TNM clinical stage.

Conclusions

The incidence of PSC was slowly decreased. PSC had a significantly poor prognosis compared with oNSCLC. The nomogram constructed in this study accurately predicted the prognosis of PSC, performed better than the TNM clinical stage.

Transformation of Two Cases of Lung Adenocarcinoma into Pulmonary Sarcomatoid Carcinoma following Treatment

Accumulating evidence shows that histologic transformation is involved in the drug resistance of lung cancer. Moreover, it is common for lung adenocarcinoma to transform into small-cell lung cancer or squamous cell carcinoma; however, clinical cases with sarcomatoid transformation have been rarely reported. Thus, both the diagnosis and treatment of lung adenocarcinoma with sarcomatoid transformation remain difficult. Here, we discuss two patients with lung adenocarcinoma with sarcomatoid transformation—analyzing the diagnosis, clinical features, immunohistochemical characteristics, therapy, and prognosis—with the hope that this report will be used as a reference for future treatment of these patients.

Significant benefits of pembrolizumab in treating refractory advanced pulmonary sarcomatoid carcinoma: A case report

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC), a rare subtype of non-small cell lung cancer (NSCLC), is poorly differentiated and highly aggressive. Treatment is limited, and the prognosis is poor. Pembrolizumab is an anti-programmed death (PD)-1 antibody with good efficacy in NSCLC. Recent studies have demonstrated that PD-ligand 1 (PD-L1) overexpression is common in PSCs, which suggests that anti-PD-L1 treatment is an ideal option. However, the response to pembrolizumab in PSC has not been studied.

CASE SUMMARY

We present a PSC case with PD-L1 overexpression that significantly benefited from pembrolizumab. A 73-year-old Chinese male was detected with a right lung lesion. Pathological analysis of the right upper lobectomy confirmed PSC. The PD-L1 test revealed overexpression (TPS: 90%). Multiple metastases occurred 1 mo after surgery, representing stage IV PSC. Neither first-line chemotherapy nor second-line antiangiogenic agents showed any benefit. Radiotherapy (1200 cGy) was administered to relieve chest wall pain. The patient received the PD-1 inhibitor pembrolizumab (100 mg) as third-line therapy; however, because of fever and severe infection, he refused to receive immunotherapy any longer. Thus, only one dose of pembrolizumab was administered. Deep sustained remission of most of the metastases was achieved except for lesions in the right adrenal gland, which first shrank and then progressed. The patient died because of disease progression in the right adrenal gland. He achieved a progression-free survival time of 8 mo and an overall survival time of 9 mo with third-line pembrolizumab.

CONCLUSION

Our findings highlight and offer direct evidence of the efficacy of pembrolizumab in PD-L1-overexpressing PSCs. Combined radiotherapy and immunotherapy may enhance treatment efficacy.

The EMT transcription factor, Twist1, as a novel therapeutic target for pulmonary sarcomatoid carcinomas

Pulmonary sarcomatoid carcinomas (PSCs) are a rare subtype of non‑small‑cell lung cancer and are typically biphasic neoplasms. No effective treatment for PSCs is currently available in clinical practice. The expression of the epithelial‑mesenchymal transition (EMT) transcription factors, Twist1, Slug and Snail, as well as the EMT phenotype and vasculogenic mimicry (VM) were analysed in 41 PSC and 79 pulmonary squamous carcinoma (PSCC) samples. Compared with the PSCCs, the PSCs exhibited an EMT phenotype and VM, and they also exhibited an increased expression of the Twist1, Slug, Snail and VM markers. Twist1 expression was associated with metastasis and TNM stage. Twist1‑positive patients exhibited a poorer prognosis for overall survival (OS) than those with Twist1‑negative PSCs. Transforming growth factor β1 (TGFβ1) was used to induce an EMT transition in a PSCC cell line. SK‑MES‑1 cells treated with TGFβ1 exhibited an increased expression of Twist1. The EMT phenotype, VM and increased migratory and invasive abilities were induced following TGFβ1 treatment. Importantly, in cells treated with TGFβ1, the EMT phenotype was reversed, VM marker expression was decreased, and the migratory and invasive ability of the PSCC cell line was decreased following Twist1 knockdown. Collectively, this study provides a new perspective of Twist1 in the aggressiveness of PSCs. The identification of Twist1 as an independent marker of poor prognoses may lead to the development of novel strategies for improving the treatment of patients with PSC.

Approaches to Tumor Classification in Pulmonary Sarcomatoid Carcinoma

Pulmonary sarcomatoid carcinoma (PSC) is a heterogeneous category of primary lung cancer accounting from 0.3% to 3% of all primary lung malignancies. According to the most recent 2015 World Health Organization (WHO) classification, PSC includes several different variants of malignant epithelial tumors (carcinomas) histologically mimicking sarcomas showing or entirely lacking a conventional component of non-small cell lung cancer (NSCLC). Thus, this rare subheading of lung neoplasms includes pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, pulmonary blastoma, and carcinosarcoma. A diagnosis of PSC may be suspected on small biopsy or cytology, but commonly requires a surgical resection to reach a conclusive definition. The majority of patients with PSC consists of elderly, smoking men with a large, peripheral mass characterized by well-defined margins. However, presentation with a central, polypoid endobronchial lesion is well-documented, particularly in pleomorphic carcinoma and carcinosarcoma showing a squamous cell carcinoma component. As expected, PSC may pose diagnostic problems and immunohistochemistry is largely used when pathologists deal these tumors in routine practice. Indeed, PSC tends to overexpress molecules associated with the epithelial-to-mesenchymal transition, such as vimentin, but the panel of immunostains also includes epithelial markers (cytokeratins, EMA), TTF-1, p40 and negative markers (e.g., melanocytic, mesothelial and sarcoma-related primary antibodies). Although rare, PSC has increased their interest among oncologist community for different reasons: a. identification of the epithelial-to-mesenchymal phenomenon as a major mechanism of secondary resistance to tyrosine kinase inhibitors; b. over-expression of PD-L1 and effective treatment with immunotherapy; c. identification of c-MET exon 14 skipping mutation representing an effective target to crizotinib and other specific inhibitors. In this review, the feasibility of the diagnosis of PSC, its differential diagnosis and novel molecular findings characterizing this group of lung tumor are discussed.

Induction of Acquired Resistance towards EGFR Inhibitor Gefitinib in a Patient-Derived Xenograft Model of Non-Small Cell Lung Cancer and Subsequent Molecular Characterization

In up to 30% of non-small cell lung cancer (NSCLC) patients, the oncogenic driver of tumor growth is a constitutively activated epidermal growth factor receptor (EGFR). Although these patients gain great benefit from treatment with EGFR tyrosine kinase inhibitors, the development of resistance is inevitable. To model the emergence of drug resistance, an EGFR-driven, patient-derived xenograft (PDX) NSCLC model was treated continuously with Gefitinib in vivo. Over a period of more than three months, three separate clones developed and were subsequently analyzed: Whole exome sequencing and reverse phase protein arrays (RPPAs) were performed to identify the mechanism of resistance. In total, 13 genes were identified, which were mutated in all three resistant lines. Amongst them the mutations in NOMO2, ARHGEF5 and SMTNL2 were predicted as deleterious. The 53 mutated genes specific for at least two of the resistant lines were mainly involved in cell cycle activities or the Fanconi anemia pathway. On a protein level, total EGFR, total Axl, phospho-NFκB, and phospho-Stat1 were upregulated. Stat1, Stat3, MEK1/2, and NFκB displayed enhanced activation in the resistant clones determined by the phosphorylated vs. total protein ratio. In summary, we developed an NSCLC PDX line modelling possible escape mechanism under EGFR treatment. We identified three genes that have not been described before to be involved in an acquired EGFR resistance. Further functional studies are needed to decipher the underlying pathway regulation.