Risk factors for local and regional recurrence in patients with resected N0-N1 non-small-cell lung cancer, with implications for patient selection for adjuvant radiation therapy

Nomogram using intratumoral and peritumoral radiomics for the preoperative prediction of visceral pleural invasion in clinical stage IA lung adenocarcinoma

BACKGROUND

Accurate prediction of visceral pleural invasion (VPI) in lung adenocarcinoma before operation can provide guidance and help for surgical operation and postoperative treatment. We investigate the value of intratumoral and peritumoral radiomics nomograms for preoperatively predicting the status of VPI in patients diagnosed with clinical stage IA lung adenocarcinoma.

METHODS

A total of 404 patients from our hospital were randomly assigned to a training set (n = 283) and an internal validation set (n = 121) using a 7:3 ratio, while 81 patients from two other hospitals constituted the external validation set. We extracted 1218 CT-based radiomics features from the gross tumor volume (GTV) as well as the gross peritumoral tumor volume (GPTV5, 10, 15), respectively, and constructed radiomic models. Additionally, we developed a nomogram based on relevant CT features and the radscore derived from the optimal radiomics model.

RESULTS

The GPTV10 radiomics model exhibited superior predictive performance compared to GTV, GPTV5, and GPTV15, with area under the curve (AUC) values of 0.855, 0.842, and 0.842 in the three respective sets. In the clinical model, the solid component size, pleural indentation, solid attachment, and vascular convergence sign were identified as independent risk factors among the CT features. The predictive performance of the nomogram, which incorporated relevant CT features and the GPTV10-radscore, outperformed both the radiomics model and clinical model alone, with AUC values of 0.894, 0.828, and 0.876 in the three respective sets.

CONCLUSIONS

The nomogram, integrating radiomics features and CT morphological features, exhibits good performance in predicting VPI status in lung adenocarcinoma.

Exploring non-invasive precision treatment in non-small cell lung cancer patients through deep learning radiomics across imaging features and molecular phenotypes

BACKGROUND

Accurate prediction of tumor molecular alterations is vital for optimizing cancer treatment. Traditional tissue-based approaches encounter limitations due to invasiveness, heterogeneity, and molecular dynamic changes. We aim to develop and validate a deep learning radiomics framework to obtain imaging features that reflect various molecular changes, aiding first-line treatment decisions for cancer patients.

METHODS

We conducted a retrospective study involving 508 NSCLC patients from three institutions, incorporating CT images and clinicopathologic data. Two radiomic scores and a deep network feature were constructed on three data sources in the 3D tumor region. Using these features, we developed and validated the 'Deep-RadScore,' a deep learning radiomics model to predict prognostic factors, gene mutations, and immune molecule expression levels.

FINDINGS

The Deep-RadScore exhibits strong discrimination for tumor molecular features. In the independent test cohort, it achieved impressive AUCs: 0.889 for lymphovascular invasion, 0.903 for pleural invasion, 0.894 for T staging; 0.884 for EGFR and ALK, 0.896 for KRAS and PIK3CA, 0.889 for TP53, 0.895 for ROS1; and 0.893 for PD-1/PD-L1. Fusing features yielded optimal predictive power, surpassing any single imaging feature. Correlation and interpretability analyses confirmed the effectiveness of customized deep network features in capturing additional imaging phenotypes beyond known radiomic features.

INTERPRETATION

This proof-of-concept framework demonstrates that new biomarkers across imaging features and molecular phenotypes can be provided by fusing radiomic features and deep network features from multiple data sources. This holds the potential to offer valuable insights for radiological phenotyping in characterizing diverse tumor molecular alterations, thereby advancing the pursuit of non-invasive personalized treatment for NSCLC patients.

Development and validation of 18F-FDG PET/CT radiomics-based nomogram to predict visceral pleural invasion in solid lung adenocarcinoma

OBJECTIVES

This study aimed to establish a radiomics model based on 18F-FDG PET/CT images to predict visceral pleural invasion (VPI) of solid lung adenocarcinoma preoperatively.

METHODS

We retrospectively enrolled 165 solid lung adenocarcinoma patients confirmed by histopathology with 18F-FDG PET/CT images. Patients were divided into training and validation at a ratio of 0.7. To find significant VPI predictors, we collected clinicopathological information and metabolic parameters measured from PET/CT images. Three-dimensional (3D) radiomics features were extracted from each PET and CT volume of interest (VOI). Receiver operating characteristic (ROC) curve was performed to determine the performance of the model. Accuracy, sensitivity, specificity and area under curve (AUC) were calculated. Finally, their performance was evaluated by concordance index (C-index) and decision curve analysis (DCA) in training and validation cohorts.

RESULTS

165 patients were divided into training cohort (n = 116) and validation cohort (n = 49). Multivariate analysis showed that histology grade, maximum standardized uptake value (SUVmax), distance from the lesion to the pleura (DLP) and the radiomics features had statistically significant differences between patients with and without VPI (P < 0.05). A nomogram was developed based on the logistic regression method. The accuracy of ROC curve analysis of this model was 75.86% in the training cohort (AUC: 0.867; C-index: 0.867; sensitivity: 0.694; specificity: 0.889) and the accuracy rate in validation cohort was 71.55% (AUC: 0.889; C-index: 0.819; sensitivity: 0.654; specificity: 0.739).

CONCLUSIONS

A PET/CT-based radiomics model was developed with SUVmax, histology grade, DLP, and radiomics features. It can be easily used for individualized VPI prediction.

Segmentectomy versus lobectomy. Which factors are decisive for an optimal oncological outcome?

Low-dose computed tomography is being used for lung cancer screening in high-risk groups. Detecting lung cancer at an early stage improves the chance of optimal treatment and increases overall survival. This article compares segmentectomy vs. lobectomy as surgical options, in the case of stage I non-small cell lung carcinoma, ideally IA. To compare the 2 previously referred strategies, data were collected from articles (40 studies were reviewed), reviews, and systematic analyses in PubMed Central, as well as reviewing recent literature. Segmentectomy could be an equal alternative to lobectomy in early-stage NSCLC (tumour < 2 cm). It could be preferred for patients with a low cardiopulmonary reserve, who struggle to survive a lobectomy. As far as early-stage NSCLC is concerned, anatomic segmentectomy is an acceptable procedure in a selective group of patients. For better tumour and stage classification, a systematic lymph node dissection should be performed.

Clinical and economic impact of recurrence in early-stage non-small-cell lung cancer following complete resection

Aim: Real-world data on outcomes for early-stage non-small-cell lung cancer (NSCLC) are needed to better understand the benefits of new therapies. Methods: In this retrospective study using the ConcertAI Patient360™ database, overall survival and healthcare resource utilization were compared among patients with recurrent and non-recurrent completely resected stage IB-IIIA NSCLC. Results: Recurrence was associated with a shorter median overall survival compared with non-recurrence (31.5 months vs 75.6 months, respectively), lower survival probability 5-years post-resection, and higher healthcare resource utilization. Patients with late recurrence had a longer restricted mean survival time versus patients with early recurrence. Conclusion: Results from this real-world study highlight the potential value of preventing or delaying recurrence in patients with early-stage NSCLC.

Deep Learning with Multimodal Integration for Predicting Recurrence in Patients with Non-Small Cell Lung Cancer

Due to high recurrence rates in patients with non-small cell lung cancer (NSCLC), medical professionals need extremely accurate diagnostic methods to prevent bleak prognoses. However, even the most commonly used diagnostic method, the TNM staging system, which describes the tumor-size, nodal-involvement, and presence of metastasis, is often inaccurate in predicting NSCLC recurrence. These limitations make it difficult for clinicians to tailor treatments to individual patients. Here, we propose a novel approach, which applies deep learning to an ensemble-based method that exploits patient-derived, multi-modal data. This will aid clinicians in successfully identifying patients at high risk of recurrence and improve treatment planning.

Update on Image-Guided Thermal Lung Ablation: Society Guidelines, Therapeutic Alternatives, and Postablation Imaging Findings

Percutaneous image-guided thermal ablation (IGTA) has been endorsed by multiple societies as a safe and effective lung-preserving treatment for primary lung cancer and metastases involving the lung and chest wall. This article reviews the role of IGTA in the care continuum of patients with thoracic neoplasms and discusses strategies to identify the optimal local therapy considering patient and tumor characteristics. The advantages and disadvantages of percutaneous thermal ablation compared to surgical resection and stereotactic body radiotherapy are summarized. Principles of radiofrequency ablation, microwave ablation, and cryoablation, as well as the emerging use of transbronchial thermal ablation, are described. Specific considerations are presented regarding the role of thermal ablation for early-stage non-small cell lung cancer (NSCLC), multifocal primary NSCLC, pulmonary metastases, salvage of recurrent NSCLC after surgery or radiation, and pain palliation for tumors involving the chest wall. Recent changes to professional society guidelines regarding the role of thermal ablation in the lung, including for treatment of oligometastatic disease, are highlighted. Finally, recommendations are provided for imaging follow-up after thermal ablation of lung tumors, accompanied by examples of expected postoperative findings and patterns of disease recurrence.

SUVmax to tumor perimeter distance: a robust radiomics prognostic biomarker in resectable non-small cell lung cancer patients

OBJECTIVE

The purpose of this study was to evaluate the prognostic value of novel geometric variables obtained from pre-treatment [¹⁸F]FDG PET/CT with respect to classical ones in patients with non-small cell lung cancer (NSCLC).

METHODS

Retrospective study including stage I-III NSCLC patients with baseline [¹⁸F]FDG PET/CT. Clinical, histopathologic, and metabolic parameters were obtained. After tumor segmentation, SUV and volume-based variables, global texture, sphericity, and two novel parameters, normalized SUVpeak to centroid distance (nSCD) and normalized SUVmax to perimeter distance (nSPD), were obtained. Early recurrence (ER) and short-term mortality (STM) were used as end points. Univariate logistic regression and multivariate logistic regression with respect to ER and STM were performed.

RESULTS

A cohort of 173 patients was selected. ER was detected in 49/104 of patients with recurrent disease. Additionally, 100 patients died and 53 had STM. Age, pathologic lymphovascular invasion, lymph nodal infiltration, TNM stage, nSCD, and nSPD were associated with ER, although only age (aOR = 1.06, p = 0.002), pathologic lymphovascular invasion (aOR = 3.40, p = 0.022), and nSPD (aOR = 0.02, p = 0.018) were significant independent predictors of ER in multivariate analysis. Age, lymph nodal infiltration, TNM stage, nSCD, and nSPD were predictors of STM. Age (aOR = 1.05, p = 0.006), lymph nodal infiltration (aOR = 2.72, p = 0.005), and nSPD (aOR = 0.03, p = 0.022) were significantly associated with STM in multivariate analysis. Coefficient of variation (COV) and SUVmean/SUVmax ratio did not show significant predictive value with respect to ER or STM.

CONCLUSION

The geometric variables, nSCD and nSPD, are robust biomarkers of the poorest outcome prediction of patients with NSCLC with respect to classical PET variables.

KEY POINTS

• In NSCLC patients, it is crucial to find prognostic parameters since TNM system alone cannot explain the variation in lung cancer survival. • Age, lymphovascular invasion, lymph nodal infiltration, and metabolic geometrical parameters were useful as prognostic parameters. • The displacement grade of the highest point of metabolic activity towards the periphery assessed by geometric variables obtained from [¹⁸F]FDG PET/CT was a robust biomarker of the poorest outcome prediction of patients with NSCLC.

Multimodal analysis suggests differential immuno-metabolic crosstalk in lung squamous cell carcinoma and adenocarcinoma

Immunometabolism within the tumor microenvironment is an appealing target for precision therapy approaches in lung cancer. Interestingly, obesity confers an improved response to immune checkpoint inhibition in non-small cell lung cancer (NSCLC), suggesting intriguing relationships between systemic metabolism and the immunometabolic environment in lung tumors. We hypothesized that visceral fat and ¹⁸F-Fluorodeoxyglucose uptake influenced the tumor immunometabolic environment and that these bidirectional relationships differ in NSCLC subtypes, lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC). By integrating ¹⁸F-FDG PET/CT imaging, bulk and single-cell RNA-sequencing, and histology, we observed that LUSC had a greater dependence on glucose than LUAD. In LUAD tumors with high glucose uptake, glutaminase was downregulated, suggesting a tradeoff between glucose and glutamine metabolism, while in LUSC tumors with high glucose uptake, genes related to fatty acid and amino acid metabolism were also increased. We found that tumor-infiltrating T cells had the highest expression of glutaminase, ribosomal protein 37, and cystathionine gamma-lyase in NSCLC, highlighting the metabolic flexibility of this cell type. Further, we demonstrate that visceral adiposity, but not body mass index (BMI), was positively associated with tumor glucose uptake in LUAD and that patients with high BMI had favorable prognostic transcriptional profiles, while tumors of patients with high visceral fat had poor prognostic gene expression. We posit that metabolic adjunct therapy may be more successful in LUSC rather than LUAD due to LUAD's metabolic flexibility and that visceral adiposity, not BMI alone, should be considered when developing precision medicine approaches for the treatment of NSCLC.

Prognostic factors for treatment response and survival outcomes after first-line management of Stage 4 non-small cell lung cancer: A real-world Indian perspective

Background:

Indian data on treatment outcomes and survival in advanced non-small cell lung cancer (NSCLC) remain scarce.

Materials and Methods:

A retrospective review of 537 advanced NSCLC patients treated at a tertiary care facility in North India from January 2008 to March 2018 was done to assess treatment response and survival in terms of objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS).

Results:

Median age of enrolled patients was 60 years (range: 26–89 years). The majority were males (78.2%) and smokers (66.5%). Adenocarcinoma (51.2%) was the most common pathological type. Most patients had good performance status (PS) (the Eastern Cooperative Oncology Group [ECOG] 0 or 1 in 55.7%) and received conventional chemotherapy (86.6%). ORR and DCR after 3–4 months of first-line treatment were 55.2% and 71.75%, respectively (n = 223). Never smokers had better ORR as well as DCR compared to chronic smokers whereas treatment with tyrosine kinase inhibitors achieved significantly better ORR, and patients with good PS had better DCR compared to those with poor PS. Median PFS (n = 455) was 7.0 months (95% confidence interval [CI]: 3.7–14.0) and median OS was 11.7 months (95% CI: 5.5–29.9 months). Good PS and nonsmoking status were independent predictors of better PFS on multivariate analysis. For OS, good PS, nonsmoking behavior, and treatment with epidermal growth factor receptor inhibitors were independent predictors.

Conclusion:

In advanced NSCLC, never-smokers, and patients with good baseline ECOG have favorable treatment and survival outcomes. Treatment with targeted therapy results in better ORR and OS but did not affect PFS.

[Predicting the risk of tumor progression in patients with early stages of adenocarcinoma and squamous cell lung carcinoma based on laboratory parameters]

Non-small cell carcinoma (NSCLC) prevails in the structure of the incidence of lung cancer. In patients with I stage NSCLC, only 60-70% overcome the 5-year survival barrier, and at II stage it decreases to 35-40%. The reason for such a high mortality rate is almost always a relapse of the disease. The main histological forms of NSCLC - adenocarcinoma (AC) and squamous cell carcinoma (SCLC) - differ in the course, protocols and effectiveness of the treatment. Comparative survival data for AK and PCLC are controversial, and reliable biomarkers for determining the risk of tumor progression are lacking. In thus study we have investigated the possibility of using laboratory parameters characterizing the level of some blood proteins involved in carcinogenesis in patients with early stages of AC and SCLC to determine the risk of disease progression. We retrospectively analyzed the duration of the relapse-free period after surgical treatment for one year in 1250 patients (816 with stages I and II of adenocarcinoma, G1-3 and 434 with early stages of SCLC, G1-3). In 81 patients with AC and 36 - with SCLC (stages I-II, G1-3) the level of CYFRA 21-1 and SCC by electrochemiluminescent method, chemokines CXCL5, CXCL8, TPA, pyruvate kinase M2, HIF-1α and hyaluronic acid by enzyme immunoassay, receptors CXCR1, CXCR2, CD44v6 by flow cytometry were determined. Using the Kaplan-Meier graphical analysis, groups of low (stage I G1-2 + stage II G1) and high (stage I G3 + stage II G2-3) risk of tumor progression were identified. In the case of the one-year survival rate of patients with AC was higher than with SCLC. In patients with AC and a high risk of tumor recurrence, compared with a low one, the level of CYFRA 21-1, the mean intensity of fluorescence (MFI) of the CXCR1 receptor in granulocytes, and the relative content of the CXCR2 receptor in lymphocytes were higher. In the case of rapid progression of SCLC in patients, the relative content of the CXCR2 receptor in lymphocytes, the proportion of monocytes equipped with the CD44v6 receptor, and the SCC level were higher than with slow progression. Regression equations, including combinations of the above parameters (threshold value for AC - 0,512, for SCLC - 0,409, sensitivity - 91,9% and 90,0%, specificity - 90,0% and 87,5%, respectively), allow to predict the probability of tumor recurrence.

Postoperative radiotherapy in resected non-small cell lung cancer: The never-ending story

This manuscript collects in a joint and orderly manner the existing evidence at the present time about postoperative treatment with radiotherapy in non-small cell lung cancer. It also systematically reviews the current evidence, the international recommendations in the most relevant guidelines, the most controversial aspects in clinical and pathological staging, the specific technical aspects of radiotherapy treatment, and also collects all the potential risk factors that have been postulated as significant in the prognosis of these patients, evaluating the possibility of segmenting a particularly sensitive subpopulation with a high risk of relapse on which an adjuvant treatment with radiotherapy could have an impact on their clinical evolution. Finally, currently active trials that aspire to provide more evidence on this topic are reviewed.

PD-L1 expression as a predictor of postoperative recurrence and the association between the PD-L1 expression and EGFR mutations in NSCLC

Although information on the PD-L1 expression and EGFR mutations in non-small cell lung cancer (NSCLC) is important for therapeutic strategies, the effect of these factors on postoperative recurrence and the association between each factor have remained unclear. We retrospectively assessed the PD-L1 expression and EGFR mutations in 280 NSCLC patients, and analyzed the associations by multivariate analyses. The hazard ratio (HR) of postoperative recurrence in cases with high (≥ 50%) PD-L1 expression regarding negative expression was 4.83 (95% confidence interval [CI] 1.51-15.5). The HR for the PD-L1 expression, considered a continuous variable, was 1.016 (95% CI 1.01-1.03). The HRs in cases with EGFR major and minor mutations were 0.42 (95% CI 0.14-1.25) and 0.63 (95% CI 0.18-2.15), respectively. The high PD-L1 (≥ 50%) expression was significantly associated with exon 21 L858R mutation (Ex21) of EGFR (odds ratio, 0.10; 95% CI 0.01-0.87). The risk of postoperative recurrence increased 1.016-fold for every 1% increase in the PD-L1 expression, and a marked increase in risk was observed for expression levels of ≥ 50%. Whereas EGFR mutations were not an independent risk factor. The high PD-L1 (≥ 50%) expression was negatively associated with Ex21. These findings may help identify NSCLC patients with an increased risk of postoperative recurrence.

Nonoperative Treatment of Large (5-7 cm), Node-Negative Non-Small Cell Lung Cancer Commonly Deviates From NCCN Guidelines

BACKGROUND

Optimal treatment of nonoperative patients with large, node-negative non-small cell lung cancer (NSCLC) is poorly defined. Current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) recommend definitive radiotherapy (RT) with or without sequential chemotherapy and do not include concurrent chemoradiotherapy (chemoRT) as a treatment option. In this study, we identified factors that predict nonadherence to NCCN Guidelines.

PATIENTS AND METHODS

Patients who received definitive RT for nonmetastatic, node-negative NSCLC with tumor size of 5 to 7 cm were identified in the National Cancer Database from 2004 through 2016. Patients were evaluated by RT type (stereotactic body RT [SBRT], hypofractionated RT [HFRT], or conventionally fractionated RT [CFRT]) and chemotherapy use (none, sequential, or concurrent with RT). Patients were classified as receiving NCCN-adherent (RT with or without sequential chemotherapy) or NCCN-nonadherent (concurrent chemoRT) treatment. Demographic and clinical factors were assessed with logistic regression modeling. Overall survival was evaluated with Kaplan-Meier, log-rank, and univariable/multivariable Cox proportional hazards regression analyses.

RESULTS

Among 2,020 patients in our cohort, 32% received NCCN-nonadherent concurrent chemoRT, whereas others received NCCN-adherent RT alone (51%) or sequential RT and chemotherapy (17%). CFRT was most widely used (64% CFRT vs 22% SBRT vs 14% HFRT). Multivariable analysis revealed multiple factors to be associated with NCCN-nonadherent chemoRT: age ≤70 versus >70 years (odds ratio [OR] , 2.72; P<.001), treatment at a nonacademic facility (OR, 1.65; P<.001), and tumor size 6 to 7 cm versus 5 to 6 cm (OR, 1.27; P=.026). Survival was similar between the NCCN-nonadherent chemoRT and NCCN-adherent groups (hazard ratio, 1.00; P=.992) in multivariable analysis.

CONCLUSIONS

A substantial proportion of inoperable patients with large, node-negative NSCLC are not treated according to NCCN Guidelines and receive concurrent chemoRT. Younger patients with larger tumors receiving treatment at nonacademic medical centers were more likely to receive NCCN-nonadherent therapy, but adherence to NCCN Guidelines was not associated with differences in overall survival.

Society of Interventional Radiology Multidisciplinary Position Statement on Percutaneous Ablation of Non-small Cell Lung Cancer and Metastatic Disease to the Lungs: Endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology

PURPOSE

To state the Society of Interventional Radiology's position on the use of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease to the lung.

MATERIALS AND METHODS

A multidisciplinary writing group, with expertise in treating lung cancer, conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 63 studies, including existing systematic reviews and meta-analysis, retrospective cohort studies, and single-arm trials were identified. The expert writing group developed and agreed on 7 recommendations on the use of image-guided thermal ablation in the lung.

CONCLUSION

SIR considers image-guided thermal ablation to be an acceptable treatment option for patients with inoperable Stage I NSCLC, those with recurrent NSCLC, as well as patients with metastatic lung disease.

Diversity of lymphatic flow in patients with lung cancer revealed by computed tomography lymphography

OBJECTIVES

This study was conducted to verify the optimal extent of lymph node dissection or sampling during lung cancer surgery based on the sentinel node (SN) map created by computed tomography (CT) lymphography.

METHODS

From April 2010 to January 2015, patients with clinical stage I non-small-cell lung cancer, who were candidates for lobectomy or segmentectomy with standard hilar and mediastinal lymph node dissection, and in whom bronchus reached the tumour, were enrolled. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. CT images of the chest were obtained 30 s after 2.5 ml of iopamidol was injected. SNs were identified when the maximum CT attenuation value of the lymph nodes on postcontrast CT images increased by 30 Hounsfield units or more compared with the precontrast images. Patients underwent lobectomy with standard lymph node dissection.

RESULTS

SNs were identified in 36 (87.8%) of the 41 patients. The average number of SNs was 1.6 (range, 1-4). There was 1 false negative case; therefore, the accuracy of SN identification was 97.2% (35/36). In 5 (13.9%) of 36 patients, SNs were outside the lobe-specific lymph node station range (#11i from right S1, #7 from right S1, #4R from right S8, #12u from right S8, #7 and #12l from left S1 + 2).

CONCLUSIONS

CT lymphography demonstrated the diversity of lymphatic spreading patterns and there were cases in which lymph flows are found outside the lymph node dissection range.

Multi-disciplinary approach for the management of non-metastatic non-small cell lung cancer in the Middle East and Africa: Expert panel recommendations

The Middle East and Africa (MEA) region, a large geographical area, lies at the confluence of Asian, Caucasian and African races and comprises of a population with several distinct ethnicities. The course of management of non-small cell lung cancer (NSCLC) differs as per patients' performance status as well as stage of disease, requiring personalized therapy decisions. Although management of NSCLC has received a significant impetus in the form of molecularly targeted therapies and immune therapies in last few years, surgery remains gold standard for patients with early-stage disease. In case of unresectable disease, radiotherapy and chemotherapy are the primary management modalities. With newer therapies being approved for treatment of early stage disease, use of multi-disciplinary team (MDT) for comprehensive management of NSCLC is of prime importance. A group of experts with interest in thoracic oncology, deliberated and arrived at a consensus statement for the community oncologists treating patients with NSCLC in the MEA region. The deliberation was based on the review of the published evidence including literature and global and local guidelines, subject expertise of the participating panellists and experience in real-life management of patients with NSCLC. We present the proposed regional adaptations of international guidelines and recommends the MDT approach for management of NSCLC in MEA.

Completion Pneumonectomy for Second Primary/Primary Lung Cancer and Local Recurrence Lung Cancer

BACKGROUND

Completion pneumonectomy (CP) for second primary/primary lung cancer (SPLC) and local recurrence lung cancer (LRLC) is still controversial. Although several case series on such a practice exist, the oncological benefit is under debate. The purpose of this study was to review available literatures on CP for SPLC and LRLC and evaluate postoperative and long-term outcomes.

METHODS

MEDLINE, SCOPUS and Web of Science were reviewed for eligible studies in January 2021. Studies were included if they indicated outcomes of patients with lung cancer undergoing CP. Overall survival (OS) was defined as the primary end point; secondary end points included operative morbidity and 30-day mortality. Random-effects meta-analysis based on a binomial distribution was used to create pooled estimates.

RESULTS

Thirty-two eligible studies including 1,157 patients were identified. These studies were uniformly retrospective reports. Pooled estimates for 3- and 5-year OS were 50.6% [95% confidence interval (CI) 34.7-66.5] and 38.9% [95% CI 32.2-46.1] in SPLC patients. When the SPLC was a stage I tumor, pooled 5-year OS was favorable with 60.7% [95% CI 43.2-75.9]. In LRLC, pooled 3- and 5-year OS were 47.6% [95% CI 36.1-59.4] and 33.8% (95% CI 26.8-41.5). Pooled morbidity and 30-day mortality was reported in 38.2% (95% CI 32.0-44.9), and 10.0% (95% CI 8.1-12.3).

CONCLUSIONS

CP for SPLC and LRLC is a challenging procedure with significant perioperative morbimortality. However, published evidence indicates good long-term survival for selected patients. Further studies are needed to identify patient subgroups which benefit most from CP.

Postoperative Radiotherapy for Locally Advanced NSCLC: Implications for Shifting to Conformal, High-Risk Fields

BACKGROUND

To examine the effect of radiotherapy field size on survival outcomes and patterns of recurrence in patients treated with postoperative radiotherapy (PORT) for non-small-cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed the records of 216 patients with T1-4 N1-2 NSCLC following surgery and PORT using whole mediastinum (WM) or high-risk (HR) nodal fields from 1998 to 2015. Survival rates were calculated using the Kaplan-Meier method. Univariate and multivariable analyses were conducted using Cox proportional hazards modeling for outcomes and logistic regression analysis for treatment toxicities.

RESULTS

Median follow-up was 28 months (interquartile range [IQR] 13-75 months) and 38 months (IQR 19-73 months) for WM (n = 131) and HR (n = 84) groups, respectively. Overall survival (OS) was not significantly different between groups (median OS: HR 49 vs. WM 32 months; P = .08). There was no difference in progression-free survival (PFS), freedom from locoregional recurrence (LRR), or freedom from distant metastasis (P > .2 for all). Field size was not associated with OS, PFS, or LRR (P > .40 for all). LRR rates were 20% for HR and 26% for WM groups (P = .30). There was no significant difference in patterns of initial site of LRR between groups (P > .1). WM fields (OR 3.73, P = .001) and concurrent chemotherapy (odds ratio 3.62, P = .001) were associated with grade ≥2 toxicity.

CONCLUSIONS

Locoregional control and survival rates were similar between PORT groups; an improved toxicity profile was observed in the HR group. Results from an ongoing prospective randomized clinical trial will provide further insight into the consequences of HR PORT fields.

Adjuvant treatment in lung cancer

BACKGROUND

Adjuvant treatment for both small-cell and non-small-cell lung cancer is a controversial topic. There are no published results from prospective studies that either confirm or reject the benefit of adjuvant radiotherapy, although the presentation of recent studies at a number of conferences questions whether there should be a change in the paradigm of adjuvant RT for lung cancer.

AIM

The main goal of this study is to review the most relevant publications on the topic, updating the state of the matter regarding adjuvant radiotherapy following lung surgery, and analyzing the role of chemotherapy in the process.

RELEVANCE FOR PATIENTS

This review aims to assess the potential benefit of PORT in NSCLC and SCLC patients by looking at recent research. In doing so, it will be possible to determine which patients might benefit from it as adjuvant treatment after pulmonary resection.

Inflammatory Risk Factors for Early Recurrence of Non-Small Cell Lung Cancer Within One Year Following Curative Resection

BACKGROUND

Several inflammation-based scoring systems and nutritional indicators have been shown to have relevance to survival of patients with non-small cell lung cancer (NSCLC).The present study examined preoperative and pathological factors in patients who underwent curative resection for non-small cell lung cancer, with the aim to elucidate risk factors for early recurrence within 1 year of surgery.

METHODS

Patients with NSCLC who underwent surgery from January 2009 to December 2014 were retrospectively investigated. Routine laboratory measurements including carcinoembryonic antigen were performed before surgery, and pathological information was collected after surgery. Patients with recurrence within 1 year after surgery were considered as early recurrence group (ERG), those with recurrence after 1 year were as late recurrence group (LRG), and those without recurrence were as no recurrence group (NRG).

RESULTS

Multivariate analysis between ERG and LRG revealed Glasgow prognostic score (GPS) and CRP-to-albumin ratio (CAR) as independent risk factors for early recurrence. Multivariate analysis between ERG and LRG + NRG confirmed CAR, vascular invasion, and pathological stage as risk factors for early recurrence.

CONCLUSION

These findings indicated that CAR and GPS were confirmed to be risk factors for early recurrence, in addition to pathological factors.

Prediction of visceral pleural invasion in lung cancer on CT: deep learning model achieves a radiologist-level performance with adaptive sensitivity and specificity to clinical needs

OBJECTIVES

To develop and validate a preoperative CT-based deep learning model for the prediction of visceral pleural invasion (VPI) in early-stage lung cancer.

METHODS

In this retrospective study, dataset 1 (for training, tuning, and internal validation) included 676 patients with clinical stage IA lung adenocarcinomas resected between 2009 and 2015. Dataset 2 (for temporal validation) included 141 patients with clinical stage I adenocarcinomas resected between 2017 and 2018. A CT-based deep learning model was developed for the prediction of VPI and validated in terms of discrimination and calibration. An observer performance study and a multivariable regression analysis were performed.

RESULTS

The area under the receiver operating characteristic curve (AUC) of the model was 0.75 (95% CI, 0.67-0.84), which was comparable to those of board-certified radiologists (AUC, 0.73-0.79; all p > 0.05). The model had a higher standardized partial AUC for a specificity range of 90 to 100% than the radiologists (all p < 0.05). The high sensitivity cutoff (0.245) yielded a sensitivity of 93.8% and a specificity of 31.2%, and the high specificity cutoff (0.448) resulted in a sensitivity of 47.9% and a specificity of 86.0%. Two of the three radiologists provided highly sensitive (93.8% and 97.9%) but not specific (48.4% and 40.9%) diagnoses. The model showed good calibration (p > 0.05), and its output was an independent predictor for VPI (adjusted odds ratio, 1.07; 95% CI, 1.03-1.11; p < 0.001).

CONCLUSIONS

The deep learning model demonstrated a radiologist-level performance. The model could achieve either highly sensitive or highly specific diagnoses depending on clinical needs.

KEY POINTS

• The preoperative CT-based deep learning model demonstrated an expert-level diagnostic performance for the presence of visceral pleural invasion in early-stage lung cancer. • Radiologists had a tendency toward highly sensitive, but not specific diagnoses for the visceral pleural invasion.

Clinicoradiopathological features and prognosis according to genomic alterations in patients with resected lung adenocarcinoma

Background

We investigated the clinicoradiopathological features and prognosis according to genomic alterations in patients with surgically resected lung adenocarcinoma.

Methods

Patients who underwent surgical resection for pathologic stage I, II, or IIIA lung adenocarcinoma between 2009 and 2016 and for whom results regarding EGFR mutation, ALK immunohistochemistry (IHC), and KRAS mutation were available were included. Clinicoradiopathological characteristics, genomic alterations, and disease-free survival were analyzed retrospectively.

Results

Of 164 patients, 86 (52.4%) were female and 94 (57.3%) were never-smokers. The most common imaging patterns were part-solid lesion (67.7%) followed by solid (26.2%) and non-solid (6.1%) lesions. EGFR mutation, ALK IHC, and KRAS mutation were positive in 95 (57.9%), 9 (5.5%), and 11 (6.7%) patients, respectively. EGFR mutation positivity was associated with female sex, never-smoker, subsolid pattern on radiological examination, and acinar or papillary predominant histologic subtype. ALK IHC positivity was associated with longer maximal diameter, advanced stage, solid pattern on radiological examination, solid predominant histologic subtype, and distant metastasis during follow-up. KRAS mutation positivity was associated with male sex, smoker, solid pattern on radiological examination, and invasive mucinous adenocarcinoma on histologic analysis. In multivariable analysis, ALK IHC positivity and lymph node involvement were independently associated with recurrence. However, solidity was not an independent risk factor for recurrence.

Conclusions

Genomic alterations are associated with clinicoradiopathologic features in patients with resected lung adenocarcinoma. Identifying genomic alterations could help to predict the prognosis of early-stage lung adenocarcinoma.

The prognostic value of a Methylome-based Malignancy Density Scoring System to predict recurrence risk in early-stage Lung Adenocarcinoma

Current NCCN guidelines do not recommend the use of adjuvant chemotherapy for stage IA lung adenocarcinoma patients with R0 surgery. However, 25% to 40% of patients with stage IA disease experience recurrence. Stratifying patients according to the recurrence risk may tailor adjuvant therapy and surveillance imaging for those with a higher risk. However, prognostic markers are often identified by comparing high-risk and low-risk cases which might introduce bias due to the widespread interpatient heterogeneity. Here, we developed a scoring system quantifying the degree of field cancerization in adjacent normal tissues and revealed its association with disease-free survival (DFS).

Methods: We recruited a cohort of 44 patients with resected stage IA lung adenocarcinoma who did not receive adjuvant therapy. Both tumor and adjacent normal tissues were obtained from each patient and subjected to capture-based targeted genomic and epigenomic profiling. A novel methylome-based scoring system namely malignancy density ratio (MD ratio) was developed based on 39 patients by comparing tumor and corresponding adjacent normal tissues of each patient. A MD score was then obtained by Wald statistics. The correlations of MD ratio, MD score, and genomic features with clinical outcome were investigated.

Results: Patients with a high-risk MD ratio showed a significantly shorter postsurgical DFS compared with those with a low-risk MD ratio (HR=4.47, P=0.01). The MD ratio was not associated with T stage (P=1), tumor cell fraction (P=0.748) nor inflammatory status (p=0.548). Patients with a high-risk MD score also demonstrated an inferior DFS (HR=4.69, P=0.039). In addition, multivariate analysis revealed EGFR 19 del (HR=5.39, P=0.012) and MD score (HR= 7.90, P=0.01) were independent prognostic markers.

Conclusion: The novel methylome-based scoring system, developed by comparing the signatures between tumor and corresponding adjacent normal tissues of individual patients, largely minimizes the bias of interpatient heterogeneity and reveals a robust prognostic value in patients with resected lung adenocarcinoma.

Clinical outcomes of microscopic residual disease after bronchial sleeve resection for non-small cell lung cancer

OBJECTIVES

To evaluate the significance of microscopic residual disease (MRD) at the bronchial resection margin after bronchial sleeve resection in non-small cell lung cancer.

METHODS

We retrospectively reviewed 536 consecutive patients who underwent bronchial sleeve resection between 1995 and 2015. Clinical outcomes, including recurrence and long-term survival, were analyzed according to the bronchial resection margin status (R0 = complete resection and R1 = microscopic residual tumor).

RESULTS

Forty patients (7.5%) were identified to have MRD. During a 52.4-month follow-up (range, 0.1-261.0 months), there was no significant difference in 5-year overall survival (61.8% vs 61.5%; P = .550) and 5-year recurrence-free survival (53.7% vs 59.0%; P = .390) between groups R1 and R0. Multivariable cox regression analysis demonstrated that the margin status (group R1) was not associated with significantly decreased overall survival and recurrence-free survival. In group R1, 3 patients (7.5%) showed locoregional recurrence, including 1 patient (2.5%) with anastomotic recurrence. There were no significant differences between both groups in anastomotic recurrence (2.5% vs 2.6%; P = 1.000), locoregional recurrence (7.5% vs 12.7%; P = .476), and distant recurrence (25.0% vs 23.2%; P = .947) rates. Subgroup analysis of group R1 revealed a significant trend toward an increasing recurrence rate as the pathological extent of MRD advanced toward invasive extramucosal carcinoma (P for trend = .015).

CONCLUSIONS

In our experience of bronchial sleeve resection, the oncologic outcome of MRD was not jeopardized. Furthermore, the pathological extent of MRD might be helpful for recurrence prediction and treatment planning.

Severe symptoms persist for Up to one year after diagnosis of stage I-III lung cancer: An analysis of province-wide patient reported outcomes

OBJECTIVES

Lung cancer is associated with significant disease- and treatment-related morbidity. The Edmonton Symptom Assessment System (ESAS) is a tool developed to elicit patients' own assessment of the severity of common cancer-associated symptoms. The objective of this study was to examine symptom severity in the 12 months following diagnosis of lung cancer, and to identify predictors of high symptom burden.

MATERIALS AND METHODS

This was a retrospective population-based cohort study, including patients with stage I-III lung cancer diagnosed between 2007-2016, and who had symptom screening in the 12 months following diagnosis. The proportion of patients reporting severe symptoms (ESAS ≥ 7) in the year following diagnosis was plotted over time. Multivariable regression models were constructed to identify factors associated with severe symptoms.

RESULTS

69,440 unique symptom assessments were reported by 11,075 lung cancer patients. Tiredness was the most prevalent severe symptom (47.3 %), followed by shortness of breath (39.4 %) and poor wellbeing (36.5 %) among all disease stages. Patients diagnosed with higher stage disease reported more severe symptoms, but symptom trajectories were similar for all stages in the year following diagnosis. Disease stage (RR 1.10-2.01), comorbidity burden (RR 1.17-1.51), degree of socioeconomic marginalization (RR1.15-1.45), and female sex (RR 1.15-1.50) were associated with reporting severe symptoms in the year following diagnosis.

CONCLUSION

Severe physical and psychological symptoms persist throughout the first year following lung cancer diagnosis, regardless of disease stage. Those at risk of experiencing high symptom burden may benefit from targeted supportive care interventions, including psychosocial support aimed at improving health-related quality of life.

The comparison between adenocarcinoma and squamous cell carcinoma in lung cancer patients

BACKGROUND

There are several studies comparing the difference between adenocarcinoma (AC) and squamous cell carcinoma (SqCC) of lung cancer. However, seldom studies compare the different overall survival (OS) between AC and SqCC at same clinical or pathological stage. The aim of the study was to investigate the 5-year OS between AC and SqCC groups.

METHODS

Data were obtained from the Taiwan Society of Cancer Registry. There were 48,296 non-small cell lung cancer (NSCLC) patients analyzed between 2009 and 2014 in this retrospective study. We analyzed both the AC and SqCC groups by age, gender, smoking status, Charlson co-morbidity index (CCI) score, clinical TNM stage, pathological stage, tumor location, histologic grade, pleura invasion, performance status, treatment, stage-specific 5-year OS rate in each clinical stage I-IV and causes of death. We used propensity score matching to reduce the bias.

RESULTS

The AC and SqCC groups are significantly different in age, gender, smoking status, CCI score, clinical TNM stage, pathological stage, tumor location, histologic grade, pleura invasion, performance status, treatment, stage-specific 5-year OS rate in each clinical stage and causes of death (p < 0.0001). The stage-specific 5-year OS rates between AC and SqCC were 79% vs. 47% in stage I; 50% vs. 32% in stage II; 27% vs. 13% in stage III; 6% vs. 2% in stage IV, respectively (all p values < 0.0001).

CONCLUSIONS

AC and SqCC have significantly different outcomes in lung cancer. We suggest that these two different cancers should be analyzed separately to provide more precise outcomes in the future.

[Survival in Lung Cancer among Female Never-smokers in Rural Xuanwei and Fuyuan Counties in Eastern Yunnan Province, China]

背景与目的

云南东部农村地区宣威市、富源县女性居民主要从事农业生产和家务工作，基本不吸烟，但肺癌死亡率却是世界上最高的，而且发病、死亡年龄提前。本研究对宣威、富源非吸烟女性肺癌生存状况及其影响因素进行分析。

方法

以2006年-2010年被当地省、市、县9家医院新诊断、并纳入“非吸烟女性肺癌病例对照研究项目”的常住户籍女性肺癌病例为研究对象随访至2016年末。通过Life-table法进行全部病例生存分析，评估人群相对生存率和年龄别标化相对生存率。应用Kaplan-Meier法和Cox比例风险模型分别进行单因素生存分析、分层分析和多因素分析。

结果

随访的1, 250例病例中，死亡1, 075例，删失175例，随访中位时间为69个月(95%CI: 61.9-76.0)。病例平均年龄(54.8±10.9)岁，Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期和未知分期分别占3.5%、8.7%、20.7%、29.7%和37.4%；手术、非手术治疗和未治疗分别占17.2%、39.0%和43.8%，组织学、细胞学诊断占51.6%。中位生存时间13.2个月，5年观察生存率、相对生存率、年龄标化相对生存率分别为8.9%(95%CI: 7.0-10.6)、9.4%(95%CI: 7.6-11.5)和10.1%(95%CI: 3.7-20.5)。Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期、未分期5年生存率分别为41.1%、22.4%、5.3%、1.3%、11.2%；手术治疗、非手术治疗、未治疗分别为34.8%和3.2%、4.7%；腺癌、鳞癌分别为17.9%和5.6%。省级医院治疗、X线胸部筛查、非农民职业、城镇居住、65岁以下年龄等因素有利于提高生存率，而市县级医院治疗、农民职业、乡村居住、65岁以上年龄等则生存率较低。分层分析显示，任意原发灶-淋巴结-远处转移(tumor-node-metastasis, TNM)分期，无论腺癌或鳞癌患者，行手术治疗的生存率明显高于非手术治疗；与未治疗病例相比非手术治疗仅在Ⅲ期显示差异；腺癌生存率大于鳞癌不仅仅因为早期和手术病例较多，在Ⅲ期、未分期也显示明显生存优势。不同级别医院治疗疗效有明显差异，省级医院治疗的Ⅳ期、鳞癌的生存预后明显优于市、县级医院。Cox分析显示治疗方法、TNM分期、治疗医院级别、X线胸部筛查是独立预后因素，其中TNM分期、手术治疗对肺癌患者生存影响较大，而治疗医院级别、X胸部筛查相对较弱。

结论

宣威、富源非吸烟女性肺癌生存率较低，主要与其诊断时早期病例和手术、综合治疗较少、而未治疗病例较多有关，其次较差的农村社会经济、健康保障等也是生存预后的不利因素。

Distinct Prognostic Factors in Patients with Stage I Non-Small Cell Lung Cancer with Radiologic Part-Solid or Solid Lesions

INTRODUCTION

Recent studies have indicated that the presence of ground-glass opacity (GGO) components is associated with favorable survival. The purpose of this study was to reveal the prognostic value of GGO components and differences in prognostic factors for part-solid and solid lesions in invasive stage I NSCLC.

METHODS

The cases of 2010 patients with completely resected invasive pathological stage I NSCLC were reviewed according to the eighth edition of the TNM classification. Patients were categorized into the pure-GGO, part-solid, and solid groups based on consolidation-to-tumor ratio. Cox multivariate proportional hazard analyses were conducted to identify independent prognostic factors in each group.

RESULTS

Of the 2010 patients, 146 (7.3%) were in the pure-GGO group, 732 (36.4%) were in the part-solid group, and 1132 (56.3%) were in the solid group. Cox multivariate analyses revealed that GGO absence was a strong independent risk factor for worse recurrence-free survival (p < 0.001). For the pure-GGO group, there was no recurrence in spite of the invasive stage. For the part-solid group, visceral pleural invasion could not predict recurrence-free survival in general (p = 0.514) or in each tumor size group (for tumors size ≤1 cm, p = 0.664; for tumors size >1 to 2 cm, p = 0.456; for tumors size >2 to 3 cm, p = 0.900; and for tumors size >3 to 4 cm, p = 0.397). For the solid group, adenocarcinoma subtype was not a prognostic factor for recurrence-free survival in general (p = 0.162) or in each tumor size group (for tumors size ≤ 2 cm, p = 0.092; for tumors size >2 to 3 cm, p = 0.330; and for tumors size >3 to 4 cm, p = 0.885).

CONCLUSIONS

The presence of GGO components was a strong predictor in patients with invasive pathological stage I NSCLC. Risk factors were distinct in the part-solid and solid groups. There was no prognostic value of visceral pleural invasion in the part-solid group. Adenocarcinoma subtype did not have prognostic value in the solid group.

Visceral Pleural Invasion in Pulmonary Adenocarcinoma: Differences in CT Patterns between Solid and Subsolid Cancers

PURPOSE

To analyze the incidence and CT patterns of visceral pleural invasion (VPI) in adenocarcinomas on the basis of their CT presentation as solid or subsolid nodules.

MATERIALS AND METHODS

A total of 286 adenocarcinomas in direct contact with a pleural surface, resected at an institution between 2005 and 2016, were included in this retrospective, institutional review board-approved study. CT size and longest contact length with a pleural surface were measured and their ratios computed. Pleural deviation, pleural thickening, spiculations, different pleural tag types, pleural effusion, and the CT appearance of transgression into an adjacent lobe or infiltration of surrounding tissue were evaluated. Fisher exact tests and simple and multiple logistic regression models were used.

RESULTS

Of the 286 nodules, 179 of 286 (62.6%) were solid and 107 of 286 (37.4%) were subsolid. VPI was present in 49 of 286 (17.1%) nodules and was significantly more frequent in solid (44 of 179; 24.6%) than in subsolid nodules (five of 107; 4.7%; P < .001). In solid nodules, multiple regression analysis showed an association of higher contact length-to-size ratio (adjusted odds ratio [OR], 1.02; P = .007) and the presence of multiple pleural tag types (adjusted OR, 5.88; P = .002) with VPI. In subsolid nodules, longer pleural contact length of the solid nodular component (adjusted OR, 1.27; P = .017) and the CT appearance of transgression or infiltration (adjusted OR, 10.75; P = .037) were associated with VPI.

CONCLUSION

During preoperative evaluation of adenocarcinomas for the likelihood of VPI, whether a tumor manifests as a solid or a subsolid nodule is important to consider because the incidence of VPI is significantly higher in solid than in subsolid nodules. In addition, this study showed that the CT patterns associated with VPI differ between solid and subsolid nodules.© RSNA, 2019Supplemental material is available for this article.See also the commentary by Elicker in this issue.

Questionnaire survey comparing surgery and stereotactic body radiotherapy for lung cancer: lessons from patients with experience of both modalities

Background

Currently, there is some controversy regarding indications for stereotactic body radiotherapy (SBRT) for lung cancer patients. We investigated the treatment preferences of patients with experience of both surgery and SBRT using a questionnaire survey.

Methods

Of lung cancer patients treated with SBRT between 2005 and 2017, we identified those who also previously underwent surgery for lung cancer. These patients were asked about their experiences of surgery and SBRT including perceived condition, distress, stress, convenience, adverse effects, and satisfaction during and after treatment. Participants were also asked about treatment decision-making for hypothetical scenarios.

Results

Of 653 lung cancer patients treated with SBRT, 149 also underwent surgery for lung cancer, 52 of whom participated in this questionnaire. The median age at the time of this survey was 76 years (range, 59-91 years). Significantly more participants had a favorable impression of SBRT during and after treatment (all question items; P<0.01). In terms of overall satisfaction, 27 patients preferred SBRT and three patients preferred surgery. In a hypothetical scenario (equivalent treatment outcomes) aged 70 years and faced with decision-making for first-time lung cancer treatment, significantly more patients selected SBRT (P<0.01): 38 patients selected SBRT. In a scenario with 20% better survivals for surgical resection, 14 patients selected SBRT, 12 selected surgery, and 26 were indecisive (P=0.47). In a scenario at age 80 years, significantly more patients selected SBRT (P<0.01).

Conclusions

Most patients with experience of both surgery and SBRT for lung cancer prefer SBRT. This information would be helpful at treatment decision-making.

Contact of a tumour with the pleura is not associated with regional recurrence following stereotactic ablative radiotherapy for early stage non-small cell lung cancer

BACKGROUND AND PURPOSE

The aim was to investigate the incidence of isolated regional failure following stereotactic ablative radiotherapy (SABR) and risk factors for recurrence.

MATERIALS AND METHODS

Early stage non-small cell lung cancer (NSCLC) patients treated with SABR were included in this retrospective cohort study, with isolated regional recurrence (IRR) as primary endpoint, distant recurrence (DR) and overall survival (OS) as secondary endpoints. Survival analyses were performed using the cumulative incidence function (IRR and DR) or the Kaplan-Meier method (OS) and Cox proportional hazards modelling for univariate and multivariate analyses. The prognostic effect of contact between the tumour and the pleura was investigated using the CT scans used for SABR planning.

RESULTS

A total of 554 patients were included, of whom 494 could be analysed for IRR. The median follow-up for surviving patients was 48.1 months. Twenty-one patients developed an IRR (4%). The cumulative incidence of IRR and DR after 1-, 2-, and 5 years was 2%, 3%, 7% and 8%, 15% and 21%, respectively. Two year OS was 71%. The presence and type of pleural contact was not associated with any of the studied outcomes.

CONCLUSION

The presence, type and length of pleural contact as surrogate for visceral pleural invasion were not predictive for outcome. Further studies focussing on risk factors for occult nodal involvement, (I)RR, distant metastases and mortality in early stage NSCLC are warranted for the development of risk adapted diagnostic, treatment and follow-up strategies as more younger, operable and fitter patients receive SABR.

Challenges in Predicting Recurrence After Resection of Node-Negative Non-Small Cell Lung Cancer

BACKGROUND

One in 5 patients with completely resected early-stage non-small cell lung cancer will recur within 2 years. Risk stratification may facilitate a personalized approach to the use of adjuvant therapy and surveillance imaging. We developed a prediction model for recurrence based on five clinical variables (tumor size and grade, visceral pleural and lymphovascular invasion, and sublobar resection), and tested the hypothesis that the addition of several new molecular markers of poor long-term outcome (vascular endothelial growth factor C; microRNA precursors 486 and 30d) would enhance prediction.

METHODS

We performed a retrospective cohort study of patients with completely resected, node-negative non-small cell lung cancer from 2011 to 2014 (follow-up through 2016) using the Lung Cancer Biospecimen Resource Network. Cox regression was used to estimate the 2-year risk of recurrence. Our primary measure of model performance was the optimism-corrected C statistic.

RESULTS

Among 173 patients (mean tumor size, 3.6 cm; 12% sublobar resection, 32% poorly differentiated, 16% lymphovascular invasion, 26% visceral pleural invasion), the 2-year recurrence rate was 23% (95% confidence interval, 17% to 31%). A prediction model using five known risk factors for recurrence performed only slightly better than chance in predicting recurrence (optimism-corrected C statistic, 0.54; 95% confidence interval, 0.51 to 0.68). The addition of biomarkers did not improve the model's ability to predict recurrence (corrected C statistic, 0.55; 95% confidence interval, 0.52 to 0.71).

CONCLUSIONS

We were unable to predict lung cancer recurrence using a risk-prediction model based on five well-known clinical risk factors and several biomarkers. Further research should consider novel predictors of recurrence to stratify patients with completely resected early-stage non-small cell lung cancer according to their risk of recurrence.

Risk factors for local recurrence after lobectomy and lymph node dissection in patients with non-small cell lung cancer: Implications for adjuvant therapy

OBJECTIVES

The objective of this study was to investigate clinicopathological risk factors for local recurrence in patients who underwent either complete resection with lobectomy or more extensive resection with hilar and mediastinal lymph node dissection for non-small cell lung cancer (NSCLC). The role of adjuvant therapy was also explored.

MATERIALS AND METHODS

We reviewed the records of 1012 consecutive stage I-III NSCLC patients who underwent complete resection. The median follow-up time was 59 months. The risk factors for local recurrence were investigated by multivariate analysis using Cox's proportional hazards regression model.

RESULTS

Local recurrence was identified in 9.4% of the patients. The most significant risk factor for local recurrence was lymph node metastasis (N1: hazard ratio [HR]=2.27, p=0.009; N2: HR=6.85, p<0.0001). For the subgroup of patients with lymph node metastasis (n=289), the independent risk factors for local recurrence were N2 disease with N1 metastasis (N2 with N1; HR=3.46, p<0.0001) and non-receipt of adjuvant platinum-based chemotherapy (HR=1.91, p=0.018). The 5-year freedom from local recurrence rates were 96.1%, 84.1%, 85.0%, and 53.5% for N0, N1, skip N2, and N2 with N1 stages (p<0.0001).

CONCLUSION

Local recurrence is significantly associated with poor overall survival. Therefore, local control is essential for radical cure of NSCLC. N2 with N1 status was the primary risk factor for local recurrence, while adjuvant chemotherapy improved local control. These data have important implications for postoperative radiotherapy and highlight the need to devise more effective eligibility criteria for this modality in patients with lymph node metastasis.

Nodal recurrence after stereotactic body radiotherapy for early stage non-small cell lung cancer: Incidence and proposed risk factors

Stereotactic body radiotherapy (SBRT) is an alternative to surgery for patients with early stage non-small cell lung cancer (NSCLC) who are inoperable due to comorbid disease or who refuse surgery. SBRT results in an excellent local control rate of more than 90%, which is comparable to surgery, while short and long-term overall toxicity is low. Surgically treated patients are often more extensively staged pre-operatively, e.g. with endobronchial ultrasound and/or mediastinoscopy, and typically undergo intra-operative lymph node dissection or sampling. Occult nodal metastases (ONM), detected by lymph node dissection, have been shown to increase the incidence of regional recurrence (RR) after surgery, which is associated with poor outcome. In patients undergoing SBRT, however, definite pathological nodal staging is lacking and so other ways to identify patients at high risk for ONM and RR are desirable. The aim of this systematic review is to summarize the incidence of, and risk factors for, RR after SBRT and compare these to those after surgery. The available evidence shows the incidence of RR after SBRT or surgery to be comparable, despite more elaborate pre- and intra-operative lymph node evaluation in surgical patients. However, the fact that this finding is based on mostly retrospective studies in which the majority of patients treated with SBRT were inoperable, needs to be taken into consideration. For now, there is no evidence that inoperable clinical stage I patients with no indication of pathological lymph nodes on PET/CT will benefit from more invasive lymph node staging prior to SBRT.

The predictive and prognostic values of factors associated with visceral pleural involvement in resected lung adenocarcinomas

Background

The predictive and prognostic impact of factors associated with visceral pleural invasion (VPI) on survival and recurrence in patients with resected lung adenocarcinomas is not clearly defined.

Patients and methods

A total of 505 consecutive patients with stage Ia–IIIa lung adenocarcinomas treated with radical resection were included. The predominant growth pattern was classified according to the new classification system for lung adenocarcinoma proposed by the International Association for the Study of Lung Cancer, the American Thoracic Society, and the European Respiratory Society. The correlations of VPI with clinical and pathologic parameters were analyzed.

Results

The incidence of VPI was significantly lower in lepidic predominant group (15.5% vs 4.5%, P<0.001) and higher in solid and micropapillary predominant group (28.6% vs 17.6%, P=0.004 and 14.7% vs 4.2%, P<0.001, respectively). VPI correlated with higher risk in regional postoperative recurrence (hazard ratio, 2.341; 95% confidence interval, 1.564–3.504) and distant recurrence (hazard ratio, 2.193; 95% confidence interval, 1.665–2.89) in surgically resected lung adenocarcinomas. However, when growth patterns of adenocarcinoma were lumped into multivariate analysis, VPI was not a significant independent predictive factor for survival (P=0.854 for overall survival [OS] and P=0.575 for disease-free survival [DFS]) and recurrence (P=0.38 for regional recurrence and P=0.089 for distant recurrence). Of the 95 patients with stage Ib, those who received adjuvant chemotherapy had longer DFS and OS than the patients who received no chemotherapy after surgery. However, these differences in DFS and OS did not reach statistical significance (P=0.063 for DFS, P=0.85 for OS).

Conclusion

VPI was associated with solid and micropapillary histology. In addition, stage Ib patients with solid histologic subtype tumor showed longer DFS and OS, highlighting a potential benefit in this subgroup of patients and necessitating the need for larger clinical trials.

Prognostic Impact of Multiple Clinicopathologic Risk Factors and c-MET Overexpression in Patients Who Have Undergone Resection of Stage IB Non-Small-Cell Lung Cancer

BACKGROUND

Several studies have suggested risk factors for poor survival in stage IB non-small-cell lung cancer (NSCLC) patients. However, these factors are not definite indicators of adjuvant chemotherapy for stage IB cancer, and most of them can be used to consider adjuvant chemotherapy. We aimed to determine the clinicopathologic factors and assess whether c-MET is a prognostic factor in stage IB NSCLC patients who have undergone surgery. Additionally, we determined the relevance of the factors and the recurrence pattern in these patients.

PATIENTS AND METHODS

This study included 115 patients who underwent resection of pathologic stage IB NSCLC between January 2005 and December 2013. We retrospectively reviewed the clinicopathologic data and performed immunohistochemical analysis for c-MET. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were evaluated according to clinicopathologic factors and c-MET expression.

RESULTS

Lymphovascular invasion (LVI) and c-MET overexpression were significantly associated with poor RFS. A large tumor with visceral pleural invasion (VPI) or LVI, moderate/poor differentiation with LVI, and VPI with LVI were negative prognostic factors for RFS and CSS. c-MET overexpression with a large tumor, VPI, or LVI was an independent prognostic factor for poor RFS and CSS, and LVI was a significant factor for distant recurrence.

CONCLUSION

LVI and c-MET overexpression might be associated with poor prognosis in stage IB NSCLC patients. Additionally, survival might be poor in stage IB patients with multiple pathologic risk factors. Moreover, there is a high possibility of distant recurrence in patients with LVI.

Recurrence of squamous cell lung carcinoma is associated with the co-presence of reactive lesions in tumor-adjacent bronchial epithelium

Recurrences occur in 30 % of lung cancer patients after radical therapy; however, known prognostic factors are not always effective. In this study, we investigated whether the frequency of squamous non-small cell lung cancer (NSCLC) recurrence depends on the presence of reactive lesions in tumor-adjacent bronchial epithelium. Specimens of adjacent lung tissue from 104 patients with squamous NSCLC were used for the determination of basal cell hyperplasia (BCH) and squamous metaplasia (SM) and for the analysis of the expression of Ki-67, p53, Bcl-2, and CD138. We found that recurrence was observed in 36.7 % of patients with BCH combined with SM (BCH + SM+) in the same bronchus, compared with 1.8 % in patients with isolated BCH (BCH + SM-; odds ratio (OR) 31.26, 95 % confidence interval (CI) 3.77-258.60; p = 0.00002). The percentage of Ki-67-positive cells was significantly higher in BCH + SM+ than in BCH + SM- (34.9 vs. 18.3 %; effect size 2.86, 95 % CI 2.23-3.47; p = 0.003). P53 expression was also more significant in BCH + SM+ than in BCH + SM- (14.4 vs. 9.6 %; effect size 1.22, 95 % CI 0.69-1.76; p = 0.0008). In contrast, CD138 expression was lower in BCH + SM+ than in BCH + SM- (21.8 vs. 38.5 %; effect size -6.26, 95 % CI -7.31 to -5.22; p = 0.003). Based on our results, we concluded that the co-presence of reactive bronchial lesions is associated with the development of recurrent squamous NSCLC and may be a negative prognostic indicator. In addition, significant differences in Ki-67, p53, and CD138 expression exist between isolated BCH and BCH combined with SM that probably reflect part of biological differences, which could relate to the mechanism of lung cancer recurrence.

Evidence-based recommendations of postoperative radiotherapy in lung cancer from Oncologic Group for the Study of Lung Cancer (Spanish Radiation Oncology Society)

Locally advanced non-small cell lung cancer (NSCLC) is a diversified illness in which postoperative radiation therapy (PORT) for complete resection with positive hiliar (pN1) and/or mediastinal (pN2) lymph nodes is controversial. Although several studies have shown that PORT has beneficial effects, randomized trials are needed to demonstrate its impact on overall survival. In this review, the Spanish Radiation Oncology Group for Lung Cancer describes the most relevant literature on PORT in NSCLC patients stage pN1-2. In addition, we have outlined the current recommendations of different national and international clinical guidelines and have also specified practical issues regarding treatment volume definition, doses and fractionation.

Synergistic Effects between mTOR Complex 1/2 and Glycolysis Inhibitors in Non-Small-Cell Lung Carcinoma Cells

Cancer metabolism has greatly interested researchers. Mammalian target of rapamycin (mTOR) is dysregulated in a variety of cancers and considered to be an appealing therapeutic target. It has been proven that growth factor signal, mediated by mTOR complex 1 (mTORC1), drives cancer metabolism by regulating key enzymes in metabolic pathways. However, the role of mTORC2 in cancer metabolism has not been thoroughly investigated. In this study, by employing automated spectrophotometry, we found the level of glucose uptake was decreased in non-small-cell lung carcinoma (NSCLC) A549, PC-9 and SK-MES-1 cells treated with rapamycin or siRNA against Raptor, indicating that the inhibition of mTORC1 attenuated glycolytic metabolism in NSCLC cells. Moreover, the inhibition of AKT reduced glucose uptake in the cells as well, suggesting the involvement of AKT pathway in mTORC1 mediated glycolytic metabolism. Furthermore, our results showed a significant decrease in glucose uptake in rictor down-regulated NSCLC cells, implying a critical role of mTORC2 in NSCLC cell glycolysis. In addition, the experiments for MTT, ATP, and clonogenic assays demonstrated a reduction in cell proliferation, cell viability, and colony forming ability in mTOR inhibiting NSCLC cells. Interestingly, the combined application of mTORC1/2 inhibitors and glycolysis inhibitor not only suppressed the cell proliferation and colony formation, but also induced cell apoptosis, and such an effect of the combined application was stronger than that caused by mTORC1/2 inhibitors alone. In conclusion, this study reports a novel effect of mTORC2 on NSCLC cell metabolism, and reveals the synergistic effects between mTOR complex 1/2 and glycolysis inhibitors, suggesting that the combined application of mTORC1/2 and glycolysis inhibitors may be a new promising approach to treat NSCLC.

Accelerated radiotherapy and concurrent chemotherapy for patients with contralateral central or mediastinal lung cancer relapse after pneumonectomy

BACKGROUND

Treatment options are very limited for patients with lung cancer who experience contralateral central or mediastinal relapse following pneumonectomy. We present results of an accelerated salvage chemoradiotherapy regimen.

METHODS

Patients with localized contralateral central intrapulmonary or mediastinal relapse after pneumonectomy were offered combined chemoradiotherapy including concurrent weekly cisplatin (25 mg/m(2)) and accelerated radiotherapy [accelerated fractionated (AF), 60 Gy, 8×2 Gy per week] to reduce time for repopulation. Based on 4D-CT-planning, patients were irradiated using multifield intensity-modulated radiotherapy (IMRT) or helical tomotherapy.

RESULTS

Between 10/2011 and 12/2012, seven patients were treated. Initial stages were IIB/IIIA/IIIB: 3/1/3; histopathological subtypes scc/adeno/large cell: 4/1/2. Tumour relapses were located in mediastinal nodal stations in five patients with endobronchial tumour in three patients. The remaining patients had contralateral central tumour relapses. All patients received 60 Gy (AF), six patients received concurrent chemotherapy. Median dose to the remaining contralateral lung, esophagus, and spinal cord was 6.8 (3.3-11.4), 8.0 (5.1-15.5), and 7.6 (2.8-31.2) Gy, respectively. With a median follow-up of 29 [17-32] months, no esophageal or pulmonary toxicity exceeding grade 2 [Common terminology criteria for adverse events (CTC-AE) v. 3] was observed. Median survival was 17.2 months, local in-field control at 12 months 80%. Only two local recurrences were observed, both in combination with out-field metastases.

CONCLUSIONS

This intensified accelerated chemoradiotherapy schedule was safely applicable and offers a curative chance in these pretreated frail lung cancer patients.

Prognostic performance of inflammation-based prognostic indices in primary operable non-small cell lung cancer

BACKGROUND

At least 30% of patients with primary resectable non-small cell lung cancer (NSCLC) will experience a relapse in their disease within 5 years following definitive treatment. Clinicopathological predictors have proved to be suboptimal in identifying high-risk patients. We aimed to establish whether inflammation-based scores offer an improved prognostic ability in terms of estimating overall (OS) and recurrence-free survival (RFS) in a cohort of operable, early-stage NSCLC patients.

METHODS

Clinicopathological, demographic and treatment data were collected prospectively for 220 patients operated for primary NSCLC at the Hammersmith Hospital from 2004 to 2011. Pretreatment modified Glasgow Prognostic Score (mGPS), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were tested together with established prognostic factors in uni- and multivariate Cox regression analyses of OS and RFS.

RESULTS

Half of the patients were male, with a median age of 65. A total of 57% were classified as stage I with adenocarcinoma being the most prevalent subtype (60%). Univariate analyses of survival revealed stage (P<0.001), grade (P=0.02), lymphovascular (LVI, P=0.001), visceral pleural invasion (VPI, P=0.003), mGPS (P=0.02) and NLR (P=0.04) as predictors of OS, with stage (P<0.001), VPI (P=0.02) and NLR (P=0.002) being confirmed as independent prognostic factors on multivariate analyses. Patients with more advanced stage (P<0.001) and LVI (P=0.008) had significantly shorter RFS.

CONCLUSIONS

An elevated NLR identifies operable NSCLC patients with a poor prognostic outlook and an OS difference of almost 2 years compared to those with a normal score at diagnosis. Our study validates the clinical utility of the NLR in early-stage NSCLC.

How and when to use genetic markers for nonsmall cell lung cancer

PURPOSE OF REVIEW

Many driver mutations that determine the malignant behavior of lung cancer have been identified in recent years. The promise of therapies targeted to the specific molecular pathways altered by such mutations has made genetic testing in nonsmall cell lung cancer (NSCLC) attractive to clinicians. We reviewed recent research on clinically relevant genetic and molecular tests for patients with NSCLC, with an emphasis on the tests linked to actionable mutations that influence therapy and improve outcomes.

RECENT FINDINGS

Mutations in the epidermal growth factor receptor gene (EGFR) and translocations involving the anaplastic lymphoma kinase (ALK) gene have been shown to be common driver mutations in lung adenocarcinoma. The presence or absence of these mutations has been demonstrated to predict response to targeted therapy in many recent studies. Targeted therapies for patients with mutations in the EGFR domain or the echinoderm microtubule-associated protein-like 4 anaplastic lymphoma kinase translocation have been shown to be effective and are approved for use. Ongoing studies continue to define the extent of their utility and may continue to expand their indications. Sufficient tissue for genetic analysis can be obtained from cytologic samples, including those obtained from endobronchial ultrasound-guided transbronchial needle aspiration.

SUMMARY

Genetic testing for driver mutations is useful in identifying patients with NSCLC who are likely to respond to targeted therapy. These tests are best used in patients with adenocarcinoma who have advanced-stage cancer.

Lung cancer and prognosis in taiwan: a population-based cancer registry

INTRODUCTION

Lung cancer is the leading cause of cancer death in Taiwan. This study investigated the prognostic factors affecting survival of patients with lung cancer in Taiwan.

METHODS

Data were obtained from the National Health Insurance Research Database published in Taiwan. Clinicopathologic profiles and prognostic factors of 33,919 lung cancer patients were analyzed between 2002 and 2008 in this retrospective review. The impact of the clinicopathologic factors on overall survival was assessed.

RESULTS

Nearly two thirds of the patients were men. The 5-year survival rate was 15.9%, with a median survival of 13.2 months. The clinical staging of the patients included stage I (n = 4254; 12.5%), stage II (n = 1140; 3.4%), stage III (n = 10,161; 30.0%), and stage IV (n = 18,364; 54.1%). In the multivariate analysis, age more than 65 years, sex, cell type, histologic grade, and primary tumor location were identified as independent prognostic factors.

CONCLUSION

In additional to tumor-nodes-metastasis (TNM) staging system, patient sex and age, tumor location, cell type, and differentiation were independent prognostic factors. We recommend incorporation of these factors to subclassify lung cancer patients.

Risk factors for locoregional recurrence in patients with resected N1 non-small cell lung cancer: a retrospective study to identify patterns of failure and implications for adjuvant radiotherapy

Background

Meta-analysis of randomized trials has shown that postoperative radiotherapy (PORT) had a detrimental effect on overall survival (OS) in patients with resected N1 non–small cell lung cancer (NSCLC). Conversely, the locoregional recurrence (LR) rate is reported to be high without adjuvant PORT in these patients. We have evaluated the pattern of failure, actuarial risk and risk factors for LR in order to identify the subset of N1 NSCLC patients with the highest risk of LR. These patients could potentially benefit from PORT.

Methods

We conducted a retrospective study on 199 patients with pathologically confirmed T1–3N1M0 NSCLC who underwent surgery. None of the patients had positive surgical margins or received preoperative therapy or PORT. The median follow-up was 53.8 months. Complete mediastinal lymph node (MLN) dissection and examination was defined as ≥3 dissected and examined MLN stations; incomplete MLN dissection or examination (IMD) was defined as <3 dissected or examined MLN stations. The primary end point of this study was freedom from LR (FFLR). Differences between patient groups were compared and risk factors for LR were identified by univariate and multivariate analyses.

Results

LR was identified in 41 (20.6%) patients, distant metastasis (DM) was identified in 79 (39.7%) patients and concurrent LR and DM was identified in 25 (12.6%) patients. The 3- and 5-year OS rates in patients with resected N1 NSCLC were 78.4% and 65.6%, respectively. The corresponding FFLR rates were 80.8% and 77.3%, respectively. Univariate analyses identified that nonsmokers, ≤23 dissected lymph nodes, visceral pleural invasion and lymph node ratio >10% were significantly associated with lower FFLR rates (P < 0.05). Multivariate analyses further confirmed positive lymph nodes at station 10 and IMD as risk factors for LR (P < 0.05). The 5-year LR rate was highest in patients with both these risk factors (48%).

Conclusions

The incidence of LR in patients with surgically resected T1–3N1M0 NSCLC is high. Patients with IMD and positive lymph nodes at station 10 have the highest risk of LR, and may therefore benefit from adjuvant PORT. Further investigations of PORT in this subset of patients are warranted.