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Jiang Y, Lin Y, Fu W, He Q, Liang H, Zhong R, Cheng R, Li B, Wen Y, Wang H, Li J, Li C, Xiong S, Chen S, Xiang J, Mann MJ, He J, Liang W. The impact of adjuvant EGFR-TKIs and 14-gene molecular assay on stage I non-small cell lung cancer with sensitive EGFR mutations. EClinicalMedicine 2023; 64:102205. [PMID: 37745018 PMCID: PMC10511786 DOI: 10.1016/j.eclinm.2023.102205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background Currently, the role of EGFR-TKIs as adjuvant therapy for stage I, especially IA NSCLC, after surgical resection remains unclear. We aimed to compare the effect of adjuvant EGFR-TKIs with observation in such patients by incorporating an established 14-gene molecular assay for risk stratification. Methods This retrospective cohort study was conducted at the First Affiliated Hospital of Guangzhou Medical University (Study ID: ChNCRCRD-2022-GZ01). From March 2013 to February 2019, completely resected stage I NSCLC (8th TNM staging) patients with sensitive EGFR mutation were included. Patients with eligible samples for molecular risk stratification were subjected to the 14-gene prognostic assay. Inverse probability of treatment weighting (IPTW) was employed to minimize imbalances in baseline characteristics. Findings A total of 227 stage I NSCLC patients were enrolled, with 55 in EGFR-TKI group and 172 in the observation group. The median duration of follow-up was 78.4 months. After IPTW, the 5-year DFS (HR = 0.30, 95% CI, 0.14-0.67; P = 0.003) and OS (HR = 0.26, 95% CI, 0.07-0.96; P = 0.044) of the EGFR-TKI group were significantly better than the observation group. For subgroup analyses, adjuvant EGFR-TKIs were associated with favorable 5-year DFS rates in both IA (100.0% vs. 84.5%; P = 0.007), and IB group (98.8% vs. 75.3%; P = 0.008). The 14-gene assay was performed in 180 patients. Among intermediate-high-risk patients, EGFR-TKIs were associated with a significant improvement in 5-year DFS rates compared to observation (96.0% vs. 70.5%; P = 0.012), while no difference was found in low-risk patients (100.0% vs. 94.9%; P = 0.360). Interpretation Our study suggested that adjuvant EGFR-TKI might improve DFS and OS of stage IA and IB EGFR-mutated NSCLC, and the 14-gene molecular assay could help patients that would benefit the most from treatment. Funding This work was supported by China National Science Foundation (82022048, 82373121).
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Affiliation(s)
- Yu Jiang
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuechun Lin
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenhai Fu
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qihua He
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hengrui Liang
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ran Zhong
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ran Cheng
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bingliang Li
- Department of Cardiac Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yaokai Wen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Huiting Wang
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianfu Li
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Caichen Li
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shan Xiong
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | | | - Michael J. Mann
- Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jianxing He
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenhua Liang
- National Clinical Research Center for Respiratory Disease, Guangzhou, China
- Departments of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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2
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Wan Y, Qian Y, Wang Y, Fang F, Wu G. Prognostic value of Beclin 1, EGFR and ALK in non-squamous non-small cell lung cancer. Discov Oncol 2022; 13:127. [PMID: 36401689 PMCID: PMC9675885 DOI: 10.1007/s12672-022-00586-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is one of the most malignant tumors. The study was carried out to investigate the prognostic value of Beclin 1, EGFR and ALK for this cancer. Patients diagnosed with non-squamous NSCLC and admitted to our hospital from January 2011 to September 2016 were analyzed. Expression of Beclin 1 and mutation of EGFR and ALK were assessed using polymerase chain reaction (PCR) and fluorescent in situ hybridization (FISH) and analyzed for their relationship with demographic and clinical characteristics of the patients. Multivariate Cox regression models were applied to analyze the risk factors associated with survival and receiver response curves (ROC) were plotted to determine the prognostic value of Beclin 1, EGFR and ALK for patients with non-squamous NSCLC. Compared with adjacent normal tissue, Beclin 1 expression was elevated in the cancer tissue significantly; assessments of EGFR and ALK mutations showed that out of the 480 patients, 233 (48.5%) and 75 (12.6%) patients had EGFR and ALK mutations. Univariate analysis revealed that Beclin 1 level, EGFR and ALK mutations were associated with lymph node metastasis, TNM stage, tumor differentiation and prognosis, but not with gender, age and smoking status. The Kaplan-Meier survival analysis indicated that low Beclin 1 expression and positive EGFR and ALK rearrangements were associated with higher survival rate and longer progress-free survival (PFS). Multivariate Cox regression analysis showed that Beclin 1, EGFR, ALK mutations, tumor differentiation grade, TNM stage and lymph node metastasis were independently associated with PFS. ROC analysis showed that Beclin 1, EGFR and ALK were significant predictors for PFS; the areas under curve (AUC) for Beclin 1, EGFR and ALK were 0.812 (P = 0.018, cut-off value: 1.2), 0.781 (P = 0.011, cut-off value: 15%) and 0.722 (P = 0.010, cut-off value: 11%), respectively, suggesting that they have significant prognostic value for lung cancer patients. Our data indicate that Beclin 1, EGFR and ALK genes are associated with the prognosis of patients with non-squamous NSCLC. High Beclin 1 expression and negative EGFR and ALK mutations predict a poor prognosis with PFS.
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Affiliation(s)
- Yanhui Wan
- Department of Thoracic Surgery, the First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, 3002 Futian Road , Shenzhen, 518000, China.
| | - Youhui Qian
- Department of Thoracic Surgery, the First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, 3002 Futian Road , Shenzhen, 518000, China
| | - Youyu Wang
- Department of Thoracic Surgery, the First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, 3002 Futian Road , Shenzhen, 518000, China
| | - Fuyuan Fang
- Department of Thoracic Surgery, the First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, 3002 Futian Road , Shenzhen, 518000, China
| | - Guodong Wu
- Department of Thoracic Surgery, the First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, 3002 Futian Road , Shenzhen, 518000, China
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3
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Padinharayil H, Varghese J, John MC, Rajanikant GK, Wilson CM, Al-Yozbaki M, Renu K, Dewanjee S, Sanyal R, Dey A, Mukherjee AG, Wanjari UR, Gopalakrishnan AV, George A. Non-small cell lung carcinoma (NSCLC): Implications on molecular pathology and advances in early diagnostics and therapeutics. Genes Dis 2022. [DOI: 10.1016/j.gendis.2022.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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4
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Genetic and immunologic features of recurrent stage I lung adenocarcinoma. Sci Rep 2021; 11:23690. [PMID: 34880292 PMCID: PMC8654957 DOI: 10.1038/s41598-021-02946-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022] Open
Abstract
Although surgery for early-stage lung cancer offers the best chance of cure, recurrence still occurs between 30 and 50% of the time. Why patients frequently recur after complete resection of early-stage lung cancer remains unclear. Using a large cohort of stage I lung adenocarcinoma patients, distinct genetic, genomic, epigenetic, and immunologic profiles of recurrent tumors were analyzed using a novel recurrence classifier. To characterize the tumor immune microenvironment of recurrent stage I tumors, unique tumor-infiltrating immune population markers were identified using single cell RNA-seq on a separate cohort of patients undergoing stage I lung adenocarcinoma resection and applied to a large study cohort using digital cytometry. Recurrent stage I lung adenocarcinomas demonstrated higher mutation and lower methylation burden than non-recurrent tumors, as well as widespread activation of known cancer and cell cycle pathways. Simultaneously, recurrent tumors displayed downregulation of immune response pathways including antigen presentation and Th1/Th2 activation. Recurrent tumors were depleted in adaptive immune populations, and depletion of adaptive immune populations and low cytolytic activity were prognostic of stage I recurrence. Genomic instability and impaired adaptive immune responses are key features of stage I lung adenocarcinoma immunosurveillance escape and recurrence after surgery.
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5
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Gupta AR, Woodard GA, Jablons DM, Mann MJ, Kratz JR. Improved outcomes and staging in non-small-cell lung cancer guided by a molecular assay. Future Oncol 2021; 17:4785-4795. [PMID: 34435876 PMCID: PMC9039775 DOI: 10.2217/fon-2021-0517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/13/2021] [Indexed: 01/02/2023] Open
Abstract
There remains a critical need for improved staging of non-small-cell lung cancer, as recurrence and mortality due to undetectable metastases at the time of surgery remain high even after complete resection of tumors currently categorized as 'early stage.' A 14-gene quantitative PCR-based expression profile has been extensively validated to better identify patients at high-risk of 5-year mortality after surgical resection than conventional staging - mortality that almost always results from previously undetectable metastases. Furthermore, prospective studies now suggest a predictive benefit in disease-free survival when the assay is used to guide adjuvant chemotherapy decisions in early-stage non-small-cell lung cancer patients.
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MESH Headings
- Biomarkers, Tumor/genetics
- Carcinogenesis/genetics
- Carcinoma, Non-Small-Cell Lung/diagnosis
- Carcinoma, Non-Small-Cell Lung/genetics
- Carcinoma, Non-Small-Cell Lung/mortality
- Carcinoma, Non-Small-Cell Lung/therapy
- Chemotherapy, Adjuvant/statistics & numerical data
- Clinical Decision-Making
- Datasets as Topic
- Disease-Free Survival
- Gene Expression Profiling
- Gene Expression Regulation, Neoplastic
- Humans
- Lung Neoplasms/diagnosis
- Lung Neoplasms/genetics
- Lung Neoplasms/mortality
- Lung Neoplasms/therapy
- Molecular Diagnostic Techniques/methods
- Molecular Diagnostic Techniques/statistics & numerical data
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging/methods
- Pneumonectomy/statistics & numerical data
- Prospective Studies
- Real-Time Polymerase Chain Reaction
- Risk Assessment/methods
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Affiliation(s)
- Alexander R Gupta
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Gavitt A Woodard
- Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - David M Jablons
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Michael J Mann
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Johannes R Kratz
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
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6
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Woodard GA, Kratz JR, Haro G, Gubens MA, Blakely CM, Jones KD, Mann MJ, Jablons DM. Molecular Risk Stratification is Independent of EGFR Mutation Status in Identifying Early-Stage Non-Squamous Non-Small Cell Lung Cancer Patients at Risk for Recurrence and Likely to Benefit From Adjuvant Chemotherapy. Clin Lung Cancer 2021; 22:587-595. [PMID: 34544620 DOI: 10.1016/j.cllc.2021.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND A clinically-certified gene expression profile improved survival in a cohort of stage I-IIA NSCLC patients by identifying those likely to benefit from adjuvant intervention. EGFR mutation status has not provided this type of predictive risk discrimination in stage IA NSCLC, and overtreatment of low-risk stage IB patients may have limited the overall benefit seen recently in the adjuvant application of a third-generation TKI. We compared EGFR mutation data to molecular risk stratification in a prospective, early-stage cohort. MATERIALS AND METHODS Two hundred fifty eligible stage I-IIA non-squamous NSCLC patients underwent prospective molecular risk stratification by the 14-gene prognostic assay. Platinum doublet adjuvant chemotherapy (AC) was recommended for molecular high-risk (MHR). Differences in freedom from recurrence (FFR) and disease-free survival (DFS) were evaluated. RESULTS At 29 months, prospective molecular testing yielded an estimated FFR of 94.6% and 72.4% in low-risk and untreated MHR patients, respectively, and 97.0% among MHR patients receiving AC (P < .001). In contrast, there was no association between EGFR status and recurrence, while molecular risk predicted survival and response to AC within both the EGFR mutation(+) and mutation(-) populations. Sixty-seven percent of EGFR(+) and 49% of EGFR(-) patients were molecular low-risk. CONCLUSION This prospective study demonstrates the utility of the 14-gene assay independent of EGFR mutation. Basing adjuvant intervention in early-stage NSCLC on EGFR status alone may undertreat up to 51% of EGFR(-) patients likely to benefit from adjuvant intervention, and overtreat as many as 67% of EGFR(+) patients more likely to be free of residual disease.
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Affiliation(s)
- Gavitt A Woodard
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA.
| | - Johannes R Kratz
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA
| | - Greg Haro
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA
| | - Matthew A Gubens
- Division of Hematology and Oncology, University of California, San Francisco, CA
| | - Collin M Blakely
- Division of Hematology and Oncology, University of California, San Francisco, CA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, CA
| | - Michael J Mann
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA
| | - David M Jablons
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA
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7
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Rodríguez M, Ajona D, Seijo LM, Sanz J, Valencia K, Corral J, Mesa-Guzmán M, Pío R, Calvo A, Lozano MD, Zulueta JJ, Montuenga LM. Molecular biomarkers in early stage lung cancer. Transl Lung Cancer Res 2021; 10:1165-1185. [PMID: 33718054 PMCID: PMC7947407 DOI: 10.21037/tlcr-20-750] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Low dose computed tomography (LDCT) screening, together with the recent advances in targeted and immunotherapies, have shown to improve non-small cell lung cancer (NSCLC) survival. Furthermore, screening has increased the number of early stage-detected tumors, allowing for surgical resection and multimodality treatments when needed. The need for improved sensitivity and specificity of NSCLC screening has led to increased interest in combining clinical and radiological data with molecular data. The development of biomarkers is poised to refine inclusion criteria for LDCT screening programs. Biomarkers may also be useful to better characterize the risk of indeterminate nodules found in the course of screening or to refine prognosis and help in the management of screening detected tumors. The clinical implications of these biomarkers are still being investigated and whether or not biomarkers will be included in further decision-making algorithms in the context of screening and early lung cancer management still needs to be determined. However, it seems clear that there is much room for improvement even in early stage lung cancer disease-free survival (DFS) rates; thus, biomarkers may be the key to refine risk-stratification and treatment of these patients. Clinicians’ capacity to register, integrate, and analyze all the available data in both high risk individuals and early stage NSCLC patients will lead to a better understanding of the disease’s mechanisms, and will have a direct impact in diagnosis, treatment, and follow up of these patients. In this review, we aim to summarize all the available data regarding the role of biomarkers in LDCT screening and early stage NSCLC from a multidisciplinary perspective. We have highlighted clinical implications, the need to combine risk stratification, clinical data, radiomics, molecular information and artificial intelligence in order to improve clinical decision-making, especially regarding early diagnostics and adjuvant therapy. We also discuss current and future perspectives for biomarker implementation in routine clinical practice.
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Affiliation(s)
- María Rodríguez
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Daniel Ajona
- Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
| | - Luis M Seijo
- Department of Pulmonology, Clínica Universidad de Navarra, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Julián Sanz
- Department of Pathology, Clínica Universidad de Navarra, Madrid, Spain
| | - Karmele Valencia
- Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
| | - Jesús Corral
- Department of Oncology, Clínica Universidad de Navarra, Madrid, Spain
| | - Miguel Mesa-Guzmán
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Pamplona, Spain
| | - Rubén Pío
- Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
| | - Alfonso Calvo
- Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Pathology, Anatomy and Physiology, Schools of Medicine and Sciences, University of Navarra, Pamplona, Spain
| | - María D Lozano
- Navarra Institute for Health Research (IdISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Pathology, Anatomy and Physiology, Schools of Medicine and Sciences, University of Navarra, Pamplona, Spain.,Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Javier J Zulueta
- Navarra Institute for Health Research (IdISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Pulmonology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Luis M Montuenga
- Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Pathology, Anatomy and Physiology, Schools of Medicine and Sciences, University of Navarra, Pamplona, Spain
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8
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Haro GJ, Sheu B, Cook NR, Woodard GA, Mann MJ, Kratz JR. Comparison of Conventional TNM and Novel TNMB Staging Systems for Non-Small Cell Lung Cancer. JAMA Netw Open 2019; 2:e1917062. [PMID: 31808928 PMCID: PMC6902768 DOI: 10.1001/jamanetworkopen.2019.17062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Improved staging for non-small cell lung cancer (NSCLC) represents a critical unmet need. External validations of the eighth edition of the TNM staging system have yielded disappointing results, with persistently high mortality observed in early-stage disease. OBJECTIVE To determine whether incorporation of a molecular prognostic classifier into conventional TNM staging for NSCLC improves estimation of disease-free survival. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted at an academic, quaternary care medical center from 2012 to 2018. A consecutive series of 238 patients underwent surgical resection of stage I to IIIC nonsquamous NSCLC and had molecular prognostic classifier testing performed. Data analysis was conducted in May 2019. EXPOSURES Patients were restaged according to the seventh and eighth editions of the TNM staging system and the novel TMMB staging system, which maintains the order and structure of the eighth edition of the TNM but downstages or upstages according to low or high molecular risk, respectively. MAIN OUTCOMES AND MEASURES The primary outcome was disease-free survival 3 years from the time of surgical resection. Reclassification statistics were then used to evaluate performance and improvement measures of the TNM seventh and eighth editions and the TNMB staging system. RESULTS Two hundred thirty-eight patients (144 [60.5%] female; median [interquartile range] age, 70 [63-75] years) were analyzed. The median (interquartile range) follow-up was 25 (14-40) months, and the disease-free survival rate was estimated to be 58.3% (95% CI, 45.7% to 69.0%). One hundred fifty-nine patients (66.8%) were reclassified by the TNMB staging system. Overall model fit remained the same for the seventh and eighth editions of the TNM staging system, whereas the R2 statistic (change from 0.22 to 0.31), concordance index (change from 0.68 to 0.73), and log-rank χ2 (change from 38 to 108) were all associated with improvements after TNMB adoption. The TNMB system, compared with the TNM eighth edition, was associated with enhanced identification of high-risk patients and better differentiation of those without recurrence from those who had recurrence (net reclassification improvement, 0.28; 95% CI, 0.08 to 0.46; P < .001), whereas the eighth edition compared with the seventh edition was not associated with improvement of this measure (net reclassification improvement, 0.02; 95% CI, -0.18 to 0.21; P = .87). CONCLUSIONS AND RELEVANCE The TNMB staging system was associated with improved estimation of disease-free survival compared with conventional TNM staging. Incorporation of a molecular prognostic classifier into staging for NSCLC may lead to better identification of high-risk patients.
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Affiliation(s)
- Greg J. Haro
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco
| | - Bonnie Sheu
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco
| | - Nancy R. Cook
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gavitt A. Woodard
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco
| | - Michael J. Mann
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco
| | - Johannes R. Kratz
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco
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9
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Quintanal-Villalonga Á, Mediano M, Ferrer I, Meléndez R, Carranza-Carranza A, Suárez R, Carnero A, Molina-Pinelo S, Paz-Ares L. Histology-dependent prognostic role of pERK and p53 protein levels in early-stage non-small cell lung cancer. Oncotarget 2018; 9:19945-19960. [PMID: 29731995 PMCID: PMC5929438 DOI: 10.18632/oncotarget.24977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/11/2018] [Indexed: 12/17/2022] Open
Abstract
Lung tumors represent a major health problem. In early stage NSCLC tumors, surgical resection is the preferred treatment, but 30-55% of patients will relapse within 5 years after surgery. Thus, the identification of prognostic biomarkers in early stage NSCLC patients, especially those which are therapeutically addressable, is crucial to enhance survival of these patients. We determined the immunohistochemistry expression of key proteins involved in tumorigenesis and oncogenic signaling, p53, EGFR, pAKT and pERK, and correlated their expression level to clinicopathological characteristics and patient outcome. We found EGFR expression is higher in the squamous cell carcinomas than in adenocarcinomas (p=0.043), and that nuclear p53 staining correlated with lower differentiated squamous tumors (p=0.034). Regarding the prognostic potential of the expression of these proteins, high pERK levels proved to be an independent prognostic factor for overall (p<0.001) and progression-free survival (p<0.001) in adenocarcinoma patients, but not in those from the squamous histology, and high p53 nuclear levels were identified as independent prognostic factor for progression-free survival (p=0.031) only in squamous cell carcinoma patients. We propose a role as early prognostic biomarkers for pERK protein levels in adenocarcinoma, and for nuclear p53 levels in squamous cell lung carcinoma. The determination of these potential biomarkers in the adequate histologic context may predict the outcome of early stage NSCLC patients, and may offer a therapeutic opportunity to enhance survival of these patients.
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Affiliation(s)
- Álvaro Quintanal-Villalonga
- H120-CNIO Lung Cancer Clinical Research Unit, Instituto de Investigación 12 de Octubre and CNIO, Madrid, Spain
| | - Mariló Mediano
- Instituto de Biomedicina de Sevilla (IBIS) (HUVR, CSIC, Universidad de Sevilla), Sevilla, Spain.,Hospital Universitario Virgen del Rocío (HUVR), Sevilla, Spain
| | - Irene Ferrer
- H120-CNIO Lung Cancer Clinical Research Unit, Instituto de Investigación 12 de Octubre and CNIO, Madrid, Spain.,CiberOnc, Madrid, Spain
| | - Ricardo Meléndez
- Instituto de Biomedicina de Sevilla (IBIS) (HUVR, CSIC, Universidad de Sevilla), Sevilla, Spain
| | - Andrés Carranza-Carranza
- Instituto de Biomedicina de Sevilla (IBIS) (HUVR, CSIC, Universidad de Sevilla), Sevilla, Spain.,Hospital Universitario Virgen del Rocío (HUVR), Sevilla, Spain
| | - Rocío Suárez
- H120-CNIO Lung Cancer Clinical Research Unit, Instituto de Investigación 12 de Octubre and CNIO, Madrid, Spain
| | - Amancio Carnero
- Instituto de Biomedicina de Sevilla (IBIS) (HUVR, CSIC, Universidad de Sevilla), Sevilla, Spain
| | - Sonia Molina-Pinelo
- Instituto de Biomedicina de Sevilla (IBIS) (HUVR, CSIC, Universidad de Sevilla), Sevilla, Spain.,CiberOnc, Madrid, Spain
| | - Luis Paz-Ares
- H120-CNIO Lung Cancer Clinical Research Unit, Instituto de Investigación 12 de Octubre and CNIO, Madrid, Spain.,Medical Oncology Department, Hospital Universitario Doce de Octubre & Centro Nacional de Investigaciones Oncológicas (CNIO), Madrid, Spain.,Medical School, Universidad Complutense, Madrid, Spain.,CiberOnc, Madrid, Spain
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10
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Feldman R, Kim ES. Prognostic and predictive biomarkers post curative intent therapy. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:374. [PMID: 29057234 DOI: 10.21037/atm.2017.07.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Large-scale screening trials have demonstrated that early diagnosis of lung cancer results in a significant reduction in lung cancer mortality. Despite improvements in detecting more lung cancers at early stages, the 5-year survival rates of lung cancers diagnosed before widespread disease is only 30-50%. High rates of recurrence, despite early diagnosis, suggest the need to improve treatment strategies based on the likelihood of recurrence in patient subsets, as well as explore the role of predictive markers for therapy selection in the adjuvant setting. In the era of personalized medicine, there have been a wide array of molecular alterations and signatures studied for their potential prognostic and predictive utility, however most have failed to translate into clinical tools. This review will discuss progress made in clinical management of lung cancer, and recent progress in the development of patient selection tools for the refinement of early stage lung cancers.
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Affiliation(s)
- Rebecca Feldman
- Department of Solid Tumor Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Edward S Kim
- Department of Solid Tumor Oncology and Investigational Therapeutics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
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11
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Woodard GA, Wang SX, Kratz JR, Zoon-Besselink CT, Chiang CY, Gubens MA, Jahan TM, Blakely CM, Jones KD, Mann MJ, Jablons DM. Adjuvant Chemotherapy Guided by Molecular Profiling and Improved Outcomes in Early Stage, Non-Small-Cell Lung Cancer. Clin Lung Cancer 2017. [PMID: 28645632 DOI: 10.1016/j.cllc.2017.05.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Many early stage non-small-cell lung cancer (NSCLC) patients who are not considered candidates for adjuvant treatment according to current guidelines do harbor occult metastasis, and have disease recurrence despite complete resection. Although National Comprehensive Cancer Network (NCCN) guidelines suggest clinicopathologic characteristics to identify high-risk patients for adjuvant intervention, molecular profiling more accurately predicts 5-year survival. Early evidence of clinical benefit from application of this molecular-based management strategy, however, has not been reported. PATIENTS AND METHODS An internationally validated, prognostic, 14-gene quantitative polymerase chain reaction expression assay was used to stratify risk prospectively in 100 consecutive patients with stage IA, IB, and IIA nonsquamous NSCLC. Kaplan-Meyer estimates, log rank analysis, and Cox regression were used to compare disease-free survival (DFS) between high-risk patients who did or did not elect adjuvant chemotherapy. RESULTS Forty-eight patients (48%) were deemed high-risk according to molecular testing and 36 (36%) met NCCN high-risk criteria; risk designations were discordant in 34 (34%) of all patients. Estimated 5-year DFS was 48.9% among molecular high-risk patients who did not undertake adjuvant chemotherapy, 93.8% among untreated molecular low-risk patients, and 91.7% in molecular high-risk patients who did undergo chemotherapy (P = .004). In contrast, DFS was only 75.2% in untreated NCCN low-risk patients, and 61.9% in untreated NCCN high-risk patients (P = .183). CONCLUSION This prospective, nonrandomized study provides initial evidence that high-risk designation according to the 14-gene prognostic assay also predicts benefit from adjuvant chemotherapy for very early stage NSCLC, and further supports the superiority of molecular stratification over current NCCN criteria at identifying high-risk patients.
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Affiliation(s)
- Gavitt A Woodard
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Sue X Wang
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Johannes R Kratz
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Clara T Zoon-Besselink
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Matthew A Gubens
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Thierry M Jahan
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Collin M Blakely
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, San Francisco, CA
| | - Michael J Mann
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - David M Jablons
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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12
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Robles AI, Harris CC. Integration of multiple "OMIC" biomarkers: A precision medicine strategy for lung cancer. Lung Cancer 2017; 107:50-58. [PMID: 27344275 PMCID: PMC5156586 DOI: 10.1016/j.lungcan.2016.06.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/07/2016] [Accepted: 06/10/2016] [Indexed: 12/17/2022]
Abstract
More than half of all new lung cancer diagnoses are made in patients with locally advanced or metastatic disease, at which point therapeutic options are scarce. It is anticipated, however, that the widespread use of Low-Dose Computed Tomography (LDCT) screening, will lead to a greater proportion of lung cancers being diagnosed at an early, operable, stage. Still, the overall rate of recurrence for surgically treated Stage I lung cancer patients is up to 30% within 5 years of diagnosis. Thus, the identification and clinical application of biomarkers of early stage lung cancer are a pressing medical need. The integrative analysis of "omic," clinical and epidemiological data for single patients is a core principle of precision medicine. Through rigorous bioinformatics and statistical analyses we have identified biomarkers of early-stage lung cancer based on DNA methylation, expression of mRNA and miRNA, inflammatory cytokines, and urinary metabolites. Beyond a more comprehensive understanding of the molecular taxonomy of lung cancer, these biomarkers can have very practical implications in the context of unmet clinical needs of early stage lung cancer patients: First, current guidelines for LDCT screening broadly include individuals based on age and history of heavy smoking. Tumor-derived circulating biomarkers in the blood and urine associated with lung cancer risk could narrow and prioritize individuals for LDCT screening. Second, a high number of nodules are identified by LDCT, of which fewer than 5% are finally diagnosed as lung cancer. Biomarkers may help discriminate malignant nodules from benign or indolent lesions. Third, the expected rise in the numbers of lung cancer patients diagnosed at an early stage will necessitate new treatment options. Circulating, urinary and tissue-based biomarkers that molecularly categorize Stage I patients after tumor resection can help identify high-risk patients who may benefit from adjuvant chemotherapy or innovative immunotherapy regimens.
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Affiliation(s)
- Ana I Robles
- Laboratory of Human Carcinogenesis, National Cancer Institute, NIH, Bethesda, MD 20892, USA.
| | - Curtis C Harris
- Laboratory of Human Carcinogenesis, National Cancer Institute, NIH, Bethesda, MD 20892, USA
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13
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Zheng Y, Bueno R. Commercially available prognostic molecular models in early-stage lung cancer: a review of the Pervenio Lung RS and Myriad myPlan Lung Cancer tests. Expert Rev Mol Diagn 2016; 15:589-96. [PMID: 25896578 DOI: 10.1586/14737159.2015.1028371] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lung cancer is the most common cause of cancer death in the USA. Patients with early-stage non-small-cell lung cancer have a 5-year survival of approximately 70%. Effective, accurate and clinically relevant prognostic tests are needed to determine which patients are at high risk of disease-specific mortality after surgical resection. Currently, there are two commercially available prognostic tests based on differential gene expression for this purpose: the Myriad myPlan™ Lung Cancer and Pervenio™ Lung RS tests. One stratifies patients into two risk groups and the other into three risk groups. Both have been validated in independent patient cohorts and neither has yet been demonstrated to improve survival. These tests have the potential to risk-stratify which patients with early-stage lung cancer will have a higher likelihood of disease recurrence after surgical resection and may benefit from adjuvant treatment.
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Affiliation(s)
- Yifan Zheng
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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14
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Abstract
The seventh edition of the non-small cell lung cancer (NSCLC) TNM staging system was developed by the International Association for the Staging of Lung Cancer (IASLC) Lung Cancer Staging Project by a coordinated international effort to develop data-derived TNM classifications with significant survival differences. Based on these TNM groupings, current 5-year survival estimates in NSLCC range from 73 % in stage IA disease to 13 % in stage IV disease. TNM stage remains the most important prognostic factor in predicting recurrence rates and survival times, followed by tumor histologic grade, and patient sex, age, and performance status. Molecular prognostication in lung cancer is an exploding area of research where interest has moved beyond TNM stage and into individualized genetic tumor analysis with immunohistochemistry, microarray, and mutation profiles. However, despite intense research efforts and countless publications, no molecular prognostic marker has been adopted into clinical use since most fail in subsequent cross-validation with few exceptions. The recent interest in immunotherapy for NSCLC has identified new biomarkers with early evidence that suggests that PD-L1 is a predictive marker of a good response to new immunotherapy drugs but a poor prognostic indicator of overall survival. Future prognostication of outcomes in NSCLC will likely be based on a combination of TNM stage and molecular tumor profiling and yield more precise, individualized survival estimates and treatment algorithms.
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15
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Combined clinical and genomic signatures for the prognosis of early stage non-small cell lung cancer based on gene copy number alterations. BMC Genomics 2015; 16:752. [PMID: 26444668 PMCID: PMC4595201 DOI: 10.1186/s12864-015-1935-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/21/2015] [Indexed: 11/16/2022] Open
Abstract
Background The development of a more refined prognostic methodology for early non-small cell lung cancer (NSCLC) is an unmet clinical need. An accurate prognostic tool might help to select patients at early stages for adjuvant therapies. Results A new integrated bioinformatics searching strategy, that combines gene copy number alterations and expression, together with clinical parameters was applied to derive two prognostic genomic signatures. The proposed methodology combines data from patients with and without clinical data with a priori information on the ability of a gene to be a prognostic marker. Two initial candidate sets of 513 and 150 genes for lung adenocarcinoma (ADC) and squamous cell carcinoma (SCC), respectively, were generated by identifying genes which have both: a) significant correlation between copy number and gene expression, and b) significant prognostic value at the gene expression level in external databases. From these candidates, two panels of 7 (ADC) and 5 (SCC) genes were further identified via semi-supervised learning. These panels, together with clinical data (stage, age and sex), were used to construct the ADC and SCC hazard scores combining clinical and genomic data. The signatures were validated in two independent datasets (n = 73 for ADC, n = 97 for SCC), confirming that the prognostic value of both clinical-genomic models is robust, statistically significant (P = 0.008 for ADC and P = 0.019 for SCC) and outperforms both the clinical models (P = 0.060 for ADC and P = 0.121 for SCC) and the genomic models applied separately (P = 0.350 for ADC and P = 0.269 for SCC). Conclusion The present work provides a methodology to generate a robust signature using copy number data that can be potentially used to any cancer. Using it, we found new prognostic scores based on tumor DNA that, jointly with clinical information, are able to predict overall survival (OS) in patients with early-stage ADC and SCC. Electronic supplementary material The online version of this article (doi:10.1186/s12864-015-1935-0) contains supplementary material, which is available to authorized users.
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16
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Woodard GA, Jablons DM. The Latest in Surgical Management of Stage IIIA Non-Small Cell Lung Cancer: Video-Assisted Thoracic Surgery and Tumor Molecular Profiling. Am Soc Clin Oncol Educ Book 2015:e435-e441. [PMID: 25993207 DOI: 10.14694/edbook_am.2015.35.e435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Stage IIIA non-small cell lung cancer (NSCLC) remains a treatment challenge and requires a multidisciplinary care team to optimize survival outcomes. Thoracic surgeons play an important role in selecting operative candidates and assisting with pathologic mediastinal staging via cervical mediastinoscopy, endobronchial ultrasound, or esophageal ultrasound with fine needle aspiration. The majority of patients with stage IIIA disease will receive induction therapy followed by repeat staging before undergoing lobectomy or pneumonectomy; occasionally, a patient with an incidentally found, single-station microscopic IIIA tumor will undergo resection as the primary initial therapy. Multiple large clinical trials, including SWOG-8805, EORTC-8941, INT-0139, and ANITA, have shown 5-year overall survival rates of up to 30% to 40% using triple-modality treatments, and the best outcomes repeatedly are seen among patients who respond to induction treatment or who have tumors amenable to lobectomy instead of pneumonectomy. The need for a pneumonectomy is not a reason to deny patients an operation, because current operative mortality and morbidity rates are acceptably low at 5% and 30%, respectively. In select patients with stage IIIA disease, video-assisted thoracic surgery and open resections have been shown to have comparable rates of local recurrence and long-term survival. New developments in genetic profiling and personalized medicine are exciting areas of research, and early data suggest that molecular profiling of stage IIIA NSCLC tumors can accurately stratify patients by risk within this stage and predict survival outcomes. Future advances in treating stage IIIA disease will involve developing better systemic therapies and customizing treatment plans on the basis of an individual tumor's genetic profile.
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Affiliation(s)
- Gavitt A Woodard
- From the Department of Surgery, University of California, San Francisco, CA
| | - David M Jablons
- From the Department of Surgery, University of California, San Francisco, CA
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17
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Prognostic Molecular Assay Might Improve Identification of Patients At Risk for Recurrence in Early-Stage Non–Small-Cell Lung Cancer. Clin Lung Cancer 2014; 15:426-32. [DOI: 10.1016/j.cllc.2014.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/07/2014] [Accepted: 07/09/2014] [Indexed: 11/21/2022]
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