Updates in the molecular pathology of non-small cell lung cancer

Investigating the anti-lung cancer properties of Zhuang medicine Cycas revoluta Thunb. leaves targeting ion channels and transporters through a comprehensive strategy

BACKGROUND

Cycas revoluta Thunb., known for its ornamental, economic, and medicinal value, has leaves often discarded as waste. However, in ethnic regions of China, the leaves (CRL) are used in folk medicine for anti-tumor properties, particularly for regulating pathways related to cancer. Recent studies on ion channels and transporters (ICTs) highlight their therapeutic potential against cancer, making it vital to identify CRL's active constituents targeting ICTs in lung cancer.

PURPOSE

This study aims to uncover bioactive substances in CRL and their mechanisms in regulating ICTs for lung cancer treatment using network pharmacology, bioinformatics, molecular docking, molecular dynamics (MD) simulations, in vitro cell assays and HPLC.

METHODS

We analyzed 62 CRL compounds, predicted targets using PubChem and SwissTargetPrediction, identified lung cancer and ICT targets via GeneCards, and visualized overlaps with R software. Interaction networks were constructed using Cytoscape and STRING. Gene expression, GO, and KEGG analyses were performed using R software. TCGA data provided insights into differential, correlation, survival, and immune analyses. Key interactions were validated through molecular docking and MD simulations. Main biflavonoids were quantified using HPLC, and in vitro cell viability assays were conducted for key biflavonoids.

RESULTS

Venn diagram analysis identified 52 intersecting targets and ten active CRL compounds. The PPI network highlighted seven key targets. GO and KEGG analysis showed CRL-targeted ICTs involved in synaptic transmission, GABAergic synapse, and proteoglycans in cancer. Differential expression and correlation analysis revealed significant differences in five core targets in lung cancer tissues. Survival analysis linked EGFR and GABRG2 with overall survival, and immune infiltration analysis associated the core targets with most immune cell types. Molecular docking indicated strong binding of CRL ingredients to core targets. HPLC revealed amentoflavone as the most abundant biflavonoid, followed by hinokiflavone, sciadopitysin, and podocarpusflavone A. MD simulations showed that podocarpusflavone A and amentoflavone had better binding stability with GABRG2, and the cell viability assay also proved that they had better anti-lung cancer potential.

CONCLUSIONS

This study identified potential active components, targets, and pathways of CRL-targeted ICTs for lung cancer treatment, suggesting CRL's utility in drug development and its potential beyond industrial waste.

Application of the 5th WHO Guidelines for the Diagnosis of Lung Carcinoma in Small Lung Biopsies in a Tertiary Care Center: Is Insecurity of Pathologists for the Accurate Diagnosis Justified?

BACKGROUND/OBJECTIVES

The diagnosis of lung carcinoma (LC) is currently performed in small biopsies and according to the WHO classification by using limited stains to spare tissue for molecular testing. This procedure, however, often causes diagnostic uncertainty among pathologists.

METHODS

In this retrospective analysis, we compared the diagnosis made by these guidelines in 288 lung biopsies with that using more stains, as retrieved from our archive. We also compared the results of p63 and p40 immunoexpression and investigated the diagnostic role of p53/Rb1.

RESULTS

In our investigation, we reached a definite diagnosis with a mean number of one stain compared with six stains in the original diagnostic procedure, with a 97.3% concordance rate. Only in the case of metastases, a clear advantage is proven in the use of more stains, especially in the absence of clinical information. We also found a comparable utility of p40 and p63 for the diagnosis of squamous cell carcinoma, despite the higher p63 expression in other histological types. Moreover, normal p53/Rb1 expression could be utilized for the exclusion of small-cell LC.

CONCLUSIONS

Our study confirms the diagnostic certainty achieved by the suggestions of the WHO classification and justifies the potential insecurity in the absence of adequate communication with the treating clinician.

Transbronchial lung cryobiopsy for peripheral pulmonary lesions. A narrative review

An increasing number of peripheral pulmonary lesions (PPLs) requiring tissue verification to establish a definite diagnosis for further individualized management are detected due to the growing adoption of lung cancer screening by chest computed tomography (CT), especially low-dose CT. However, the morphological diagnosis of PPLs remains challenging. Transbronchial lung cryobiopsy (TBLC) that can retrieve larger specimens with more preserved cellular architecture and fewer crush artifacts in comparison with conventional transbronchial forceps biopsy (TBFB), as an emerging technology for diagnosing PPLs, has been demonstrated to have the potential to resolve the clinical dilemma pertaining to currently available sampling devices (e.g., forceps, needle and brush) and become a diagnostic cornerstone for PPLs. Of note, with the introduction of the 1.1 mm cryoprobe that will be more compatible with advanced bronchoscopic navigation techniques, such as radial endobronchial ultrasound (r-EBUS), virtual bronchoscopic navigation (VBN) and electromagnetic navigation bronchoscopy (ENB), the use of TBLC is expected to gain more popularity in the diagnosis of PPLs. While much remains for exploration using the TBLC technique for diagnosing PPLs, it can be envisaged that the emergence of additional studies with larger data accrual will hopefully add to the body of evidence in this field.

Dual Oncological Challenges: Management of Simultaneous Lung Adenocarcinoma and Primary Cardiac Lymphoma

Adenocarcinoma of the lung and primary cardiac lymphoma are both significant malignancies with serious health impacts. This case involves a 67-year-old woman who presented with progressive shortness of breath and fatigue. Initial computed tomography (CT) imaging identified possible cardiac and pulmonary masses, leading to her transfer to a specialized care center. Subsequent analysis confirmed adenocarcinoma of the lung, and further imaging and biopsy of the cardiac mass revealed diffuse large B-cell lymphoma. The patient received treatments targeted to each cancer, including chemotherapy and immunotherapy. This concurrence of malignancies highlights the importance of comprehensive diagnostic evaluations and personalized therapeutic strategies. Further research is needed to improve the management of patients with concurrent primary cancers.

A retrospective, descriptive analysis identifying non‑small cell lung cancer molecular markers

Non-small-cell lung cancer (NSCLC) remains one of the leading causes of cancer mortality worldwide. The aim of the present study was to review the histologic patterns and molecular drivers of NSCLC in patients with lung cancer. The electronic health records (EHR) of all patients diagnosed with lung cancer between April 2015 and September 2022 were obtained from a tertiary care hospital and retrospectively analysed. A total of 224 patients were identified of which 192 (138 males and 54 females) were included in the final analysis. Adenocarcinoma was the most common type of lung cancer identified, and accounted for 134 patients (70%), followed by squamous cell carcinoma in 47 (24%) patients, while large cell lung cancer was noted in only 5 (3%) patients. The most common mutations were EGFR mutations and were detected in 29 (15%) patients, followed by PD-L1 expression which was present in 56 (24.7%) patients, KRAS in 16 (8.3%) patients, ALK1 in 8 (4.2%) patients and BRAF, ROS1 and MET were present in 3 (1.6%), 2 (1%) and 1 (0.5%), respectively. The findings from the present study offer important insights into the epidemiological, clinical and molecular characteristics of NSCLC. Further research is warranted to explore the clinical implications of these findings.

Practical challenges in lung cancer pathology: bedside care to treatment decisions

PURPOSE OF REVIEW

Lung cancer is one of the most common malignancies in the whole world, and the pulmonologist is generally the first medical professional to meet the patient and decide what method of tumour sampling is preferable in each specific case. It is imperative for pulmonary physicians to be aware of the intricacies of the diagnostic process, and understand the multiple challenges that are encountered, from the moment the tissue specimen leaves their offices and is sent to the pathology laboratory, until the diagnosis reaches the patient and treating physician.

RECENT FINDINGS

The new 2021 WHO classification of thoracic tumours recommended a minimum immunohistochemical (IHC) diagnostic panel for nonsmall cell lung cancer (NSCLC), and following publications of different institutional and country-based guidelines, advocated basic molecular testing for epithelial growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK) and programmed cell death ligand 1 (PD-L1) to be initiated by the diagnosing pathologist in all cases of biopsy or resection specimens. In general, sequential testing for molecular biomarkers was not recommended due to tissue wastage, instead next generation sequencing (NGS) diagnostic panel was supported.

SUMMARY

The lung cancer specimen has to undergo histologic diagnosis through a panel of IHC studies, and -preferably, a reflex molecular study by NGS including several targetable genes. Adequate communication and clinical information preclude the pathologist from "overusing" the tissue for additional studies, while focusing on preservation of material for molecular testing.

Potential biomarkers for predicting immune response and outcomes in lung cancer patients undergoing thermal ablation

Thermal ablation is a promising alternative treatment for lung cancer. It disintegrates cancer cells and releases antigens, followed by the remodeling of local tumor immune microenvironment and the activation of anti-tumor immune responses, enhancing the overall effectiveness of the treatment. Biomarkers can offer insights into the patient's immune response and outcomes, such as local tumor control, recurrence, overall survival, and progression-free survival. Identifying and validating such biomarkers can significantly impact clinical decision-making, leading to personalized treatment strategies and improved patient outcomes. This review provides a comprehensive overview of the current state of research on potential biomarkers for predicting immune response and outcomes in lung cancer patients undergoing thermal ablation, including their potential role in lung cancer management, and the challenges and future directions.

Tyrosine kinase alterations in colorectal cancer with emphasis on the distinct clinicopathological characteristics

AIMS

Tyrosine kinase (TK) alterations, such as anaplastic lymphoma kinase (ALK) fusion, neurotrophic tyrosine receptor kinase (NTRK) fusion, c-ros oncogene 1 (ROS1) fusion and mesenchymal-epithelial transition factor (MET) exon 14 skipping, have been reported in colorectal cancers (CRC). We have previously reported CRCs with NTRK fusion among our cohort. However, their clinicopathological features have not been fully elucidated.

METHODS AND RESULTS

Tissue microarray (TMA)-based immunohistochemistry (IHC) was performed on 951 CRC lesions from 944 patients. IHC was evaluated as positive or negative for ALK and ROS1 and 0 to 3+ for c-MET. For ALK and ROS1 IHC-positive cases, RNA-based imbalanced gene expression assays, Archer FusionPlex assays and reverse transcription-polymerase chain reaction (RT-PCR) followed by Sanger sequencing were performed. For c-MET IHC 3+ cases, RT-PCR followed by Sanger sequencing were performed. ALK IHC was positive in three cases (0.2%) and all showed imbalanced ALK gene expression. The following ALK fusions were confirmed: EML4 (exon 21)::ALK (exon 20), EML4 (exon 6)::ALK (exon 19) and HMBOX1 (exon 6)::ALK (exon 20). Two showed microsatellite instability-high/mismatch repair (MMR)-deficient, and all were located in the right colon. ROS1 IHC was positive in one case; however, imbalanced expression and ROS1 fusion was negative. Forty-two cases (4.4%) showed c-MET IHC3+. MET exon 14 skipping was confirmed in nine cases. All cases were microsatellite stable/MMR-proficient, and eight were located in the left colon and rectum.

CONCLUSIONS

CRCs with these TK alterations had distinct clinicopathological features. Together with our previous study, 15 cases (1.6%) harboured targetable TK alterations (three NTRK fusion, three ALK fusion, nine MET exon 14 skipping).

Comprehensive analysis to identify a novel diagnostic marker of lung adenocarcinoma and its immune infiltration landscape

Background

Lung cancer continues to be a problem faced by all of humanity. It is the cancer with the highest morbidity and mortality in the world, and the most common histological type of lung cancer is lung adenocarcinoma (LUAD), accounting for about 40% of lung malignant tumors. This study was conducted to discuss and explore the immune-related biomarkers and pathways during the development and progression of LUAD and their relationship with immunocyte infiltration.

Methods

The cohorts of data used in this study were downloaded from the Gene Expression Complex (GEO) database and the Cancer Genome Atlas Program (TCGA) database. Through the analysis of differential expression analysis, weighted gene co-expression network analysis (WGCNA), and least absolute shrinkage and selection operator(LASSO), selecting the module with the highest correlation with LUAD progression, and then the HUB gene was further determined. The Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Gene Set Enrichment Analysis (GSEA) were then used to study the function of these genes. Single-sample GSEA (ssGSEA) analysis was used to investigate the penetration of 28 immunocytes and their relationship with HUB genes. Finally, the receiver operating characteristic curve (ROC) was used to evaluate these HUB genes accurately to diagnose LUAD. In addition, additional cohorts were used for external validation. Based on the TCGA database, the effect of the HUB genes on the prognosis of LUAD patients was assessed using the Kaplan-Meier curve. The mRNA levels of some HUB genes in cancer cells and normal cells were analyzed by reverse transcription-quantitative polymerase chain reaction (RT-qPCR).

Results

The turquoise module with the highest correlation with LUAD was identified among the seven modules obtained with WGCNA. Three hundred fifty-four differential genes were chosen. After LASSO analysis, 12 HUB genes were chosen as candidate biomarkers for LUAD expression. According to the immune infiltration results, CD4 + T cells, B cells, and NK cells were high in LUAD sample tissue. The ROC curve showed that all 12 HUB genes had a high diagnostic value. Finally, the functional enrichment analysis suggested that the HUB gene is mainly related to inflammatory and immune responses. According to the RT-qPCR study, we found that the expression of DPYSL2, OCIAD2, and FABP4 in A549 was higher than BEAS-2B. The expression content of DPYSL2 was lower in H1299 than in BEAS-2B. However, the expression difference of FABP4 and OCIAD2 genes in H1299 lung cancer cells was insignificant, but both showed a trend of increase.

Conclusions

The mechanism of LUAD pathogenesis and progression is closely linked to T cells, B cells, and monocytes. 12 HUB genes(ADAMTS8, CD36, DPYSL2, FABP4, FGFR4, HBA2, OCIAD2, PARP1, PLEKHH2, STX11, TCF21, TNNC1) may participate in the progression of LUAD via immune-related signaling pathways.

MET alterations in advanced pulmonary sarcomatoid carcinoma

Pulmonary sarcomatoid carcinoma (PSC) is a rare subset of NSCLC that accounts for about 0.5-1% of all primary lung carcinoma, and its malignant biological behavior is more aggressive than other pathological types of lung cancer. Recent studies have reported a variety of gene mutations associated with the occurrence, development and treatment of PSC, especially the mesenchymal-epithelial transition (MET) proto-oncogene alterations, including the exon 14 (METex14) skipping mutations as well as the amplification and overexpression of MET gene, which are associated with molecularly targeted therapy for PSC. METex14 skipping mutation is the most common and well-studied mutation type, occurring in about 22-31.8% of PSC patients, while the prevalence of MET amplification is reported as 4.8-13.6% and MET ovexpression is about 20.2%. Molecular pathology tests, including IHC and NGS, are valuable in determining the prognosis of patients with PSC and helping to determine the treatment. The existing clinical data have confirmed the efficacy of MET-TKI in PSC patients with MET alteration, among which the clinical study of Savolitinib has enrolled the largest proportion of PSC patients and achieved relatively good efficacy, but more clinical researches are still needed. The multi-disciplinary team may maximize the optimal treatment options for patients with the advanced PSC.

NUT Carcinoma: Clinicopathologic Features, Molecular Genetics and Epigenetics

Nuclear protein in testis (NUT) carcinoma is a rare, highly aggressive, poorly differentiated carcinoma occurring mostly in adolescents and young adults. This tumor usually arises from the midline structures of the thorax, head, and neck, and exhibits variable degrees of squamous differentiation. NUT carcinoma is defined by the presence of a NUTM1 (15q14) rearrangement with multiple other genes. In about 70-80% of the cases, NUTM1 is involved in a balanced translocation with the BRD4 gene (19p13.12), leading to a BRD4-NUTM1 fusion oncogene. Other variant rearrangements include BRD3-NUTM1 fusion (~15-20%) and NSD3-NUTM1 fusion (~6%), among others. The diagnosis of NUT carcinoma requires the detection of nuclear expression of the NUT protein by immunohistochemistry. Additional methods for diagnosis include the detection of a NUTM1 rearrangement by fluorescence in situ hybridization or by reverse transcriptase PCR. NUT carcinoma is usually underrecognized due to its rarity and lack of characteristic histological features. Therefore, the goal of this review is to provide relevant recent information regarding the clinicopathologic features of NUT carcinoma, the role of the multiple NUTM1 gene rearrangements in carcinogenesis, and the impact of understanding these underlying molecular mechanisms that may result in the development of possible novel targeted therapies.

Evaluation of lung cancer biomarkers profile for the decision of targeted therapy in EBUS-TBNA cytological samples

BACKGROUND

Guidelines recommend performing biomarker tests for epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), BRAF and ROS proto-oncogene-1(ROS1) genes and protein expression of programmed death ligand-1(PD-L1) in patients with non-small lung cell carcinoma (NSCLC). Studies reported that endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) can provide sufficient material for cancer biomarker analyses, but there are still concerns about the subject.

AIM

The purpose of the study was to assess the adequacy of EBUS-TBNA for testing lung cancer biomarkers.

METHODS

We retrospectively reviewed patients with NSCLC whose EBUS-TBNA was analysed for EGFR, ALK, ROS-1, BRAF and PD-L1 expression between December 2011 and December 2020.

RESULTS

A total of 394 patients were enrolled in the study. EGFR mutation and ALK fusion were the most common studied biomarkers. EBUS-TBNA adequacy rate for biomarker tests was found 99.0% for EGFR, 99.1 for ALK, 97.2% for ROS1, 100% for BRAF and 99.3% for PD-L1 testing. Multivariate analysis revealed the histological type, history of treatment for NSCL, size, or 18-fluorodeoxyglucose uptake of sampled lesion did not show any association with TBNA adequacy for biomarker testing.

CONCLUSION

EBUS-TBNA can provide adequate material for biomarker testing for EGFR, ALK, ROS-1, BRAF and PD-L1 expression.

Potential application of cryobiopsy for histo-molecular characterization of mediastinal lymph nodes in patients with thoracic malignancies: a case presentation series and implications for future developments

Background

The management of non-small cell lung cancer (NSCLC) has become increasingly complex due to the evolution of personalized medicine approaches. Such approaches are characterized by the necessity of adequate tumor samples; hence, improved biopsy techniques are needed. Transbronchial lung cryobiopsy is a novel endoscopic procedure designed to collect peripheral pulmonary tissue, and it is currently employed in interstitial lung diseases. The use of this technique in oncology might result in improved mediastinum staging and molecular characterizations; however, available data involving the use of a cryoprobe on mediastinal lymph nodes are still limited.

Case presentation

Here we present a series of five consecutive patients who underwent endoscopic assessment of mediastinal lymph nodes for oncologic reasons. All patients were subjected both to endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) and cryobiopsy of mediastinal lymph nodes during the same procedure, and no complications were observed. In three of the reported cases, both cryobiopsy and cell block from EBUS TBNA were positive, while in one case cryobiopsy was not diagnostic and EBUS TBNA was negative; moreover, one case showed discordance between the procedures, as cryobiopsy was negative and cell block obtained from multiple stations was diagnostic for small cell lung cancer. In one case involving a patient treated for lymphoma, cryobiopsy provided more complete histologic characterization, and in another case involving a patient affected by NSCLC cryobiopsy provided more material for molecular analyses.

Conclusion

This case presentation series suggests that cryobiopsy, which has been generally used on peripheral lung lesions so far, is a feasible and safe approach for diagnosis and staging of mediastinal lymph nodal involvement, especially when station 7 is involved. Compared to EBUS TBNA, cryobiopsy might provide more adequate histological samples, with a possible impact on molecular characterizations and, therefore, therapeutic decisions. However, the learning curve of the procedure has not to be understated and optimal protocols for implementing this technique are needed. In our opinion, further studies designed to integrate the routine use of cryobiopsy in current practice for solid and eventually hematologic tumors with mediastinal lymph node involvement are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01814-x.