Tumoral cavitation in patients with non-small-cell lung cancer treated with antiangiogenic therapy using bevacizumab

Tumor cavitation in patients with non-small-cell lung cancer receiving anti-angiogenic therapy with apatinib

Background

Cavities have been reported in approximately 20% of lung cancer after anti-angiogenesis treatments. However, the effect of which on treatment outcomes remains unclear. This study sought to investigate the incidence and radiographic patterns of tumor cavitation in patients with non-small cell lung cancer (NSCLC) treated with apatinib, and its associations with patients' clinical characteristics and outcomes.

Methods

A total of 300 patients with NSCLC treated with apatinib were retrospectively identified. Baseline and follow-up chest computed tomography scans were reviewed to identify tumor cavitation, and the subsequent filling-in of the cavitation. A multivariate logistic regression analysis was conducted to identify the factors associated with tumor cavitation. Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test.

Results

Of the 300 patients, 51 (17.0%) developed lung cavitation after initiating apatinib therapy. The results of the multivariate analysis showed that apatinib combination therapy (vs. apatinib monotherapy, odds ratio: 0.593, 95% confidence interval: 0.412-0.854, P=0.005) was significantly associated with tumor cavitation. Patients with tumor cavitation had significantly longer progression-free survival (PFS) than those without cavitation (8.2 vs. 5.2 months, P<0.01). Of the patients, 18 had cavity filling after progression, while 13 had persistent cavities after progression. The corresponding median PFS times were 11.9 and 3.2 months in patients with filled and persistent cavities after disease progression, respectively (P<0.001).

Conclusions

Tumor cavitation occurred in 17% of the NSCLC patients treated with apatinib and was associated with better PFS. Patients who had cavities filled after progression had a better prognosis than those with persistent cavities.

Pitfalls in the surgical treatment of undiagnosed lung lesions and cystic pulmonary hydatidosis

Background

Hydatid cysts can mimic many lung pathologies radiologically, as well as some malignant or benign lung tumors may show hydatid cyst-like radiological features. The aim of our study is to present our clinical experience and recommendations by analyzing the cases that create diagnostic difficulties by presenting a common radiological pattern with a pulmonary hydatid cyst.

Methods

The patients who were operated on with a preliminary diagnosis of hydatid cyst but were diagnosed differently, and who were operated on with different prediagnoses and unexpectedly diagnosed with hydatid cyst were included in the study. The clinical and radiological features of the patients were documented, and the features of the cases that could cause difficulties in diagnosis and treatment for the surgeon were revealed.

Results

A total of 20 patients who were radiologically suggestive of hydatid cyst but were diagnosed differently or unexpectedly diagnosed as hydatid cyst were included in the study. Lung cancer, bronchogenic cyst, or bronchiectasis were detected in 13 patients who were radiologically suggestive of hydatid cyst. There were 7 patients who were diagnosed with hydatid cysts, although they did not have specific radiological findings.

Conclusions

While hydatid cysts can mimic many lung pathologies, many benign or malign parenchymal lung pathologies may exhibit hydatid cyst-like radiological features. Therefore, in regions where a hydatid cyst is endemic, the surgeon should consider all possibilities while managing the cases.

Clinical registration number: Institutional Review Board of the Dr Suat Seren Chest Diseases and Chest Surgery Education and Research Center (No. 49109414-604.02).

Lung cavitation in patients with anaplastic thyroid cancer treated with lenvatinib

BACKGROUND

Anaplastic thyroid cancer (ATC) is a rare malignancy with a poor prognosis. It accounts for 1-2% of all thyroid cancers. Lenvatinib is an orally administered inhibitor of vascular endothelial growth factor receptor (VEGFR)-1, -2, and -3, fibroblast growth factor receptor (FGFR)-1 to -4, platelet-derived growth factor receptor (PDGFR)-α, rearranged during transfection (RET), and KIT. There have been cases of pneumothorax caused by lung cavitation and collapse after administration of lenvatinib in ATC with lung metastasis. In this study, we investigate lung cavitation during treatment with lenvatinib in ATC patients with lung metastasis.

METHODS

All ATC patients with lung metastasis treated at our hospital with lenvatinib between November 2015 and May 2021 were selected from our electronic medical records. The primary objective was to determine the incidence of cavitation of lung metastasis of ATC in patients treated with lenvatinib. The secondary objective was to evaluate prognostic factors in ATC patients with lung metastasis treated with lenvatinib.

RESULTS

We identified 26 patients treated with lenvatinib for ATC with lung metastasis. Of these, 12 (46.2%) had cavitation with lung metastasis during lenvatinib treatment. The median overall survival (OS) was 128 days (79-228 days), and the cavitation (+) group had significantly longer OS than the cavitation (-) group [186 days (117-355 days) vs. 89 days (59-179 days), P=0.033]. Kaplan-Meier survival curves indicated a significant difference in OS was observed between the two groups (P=0.0293). Univariate analysis demonstrated lung cavitation was a significant prognostic factor (hazard ratio: 0.38, 95% CI: 0.16-0.93).

CONCLUSIONS

Lung cavitation occurred in 46.2% of patients treated with lenvatinib for ATC with lung metastasis. Patients who developed lung cavitation had a significantly better prognosis than those who did not.

Pearls and Pitfalls in the Imaging of Targeted Therapy and Immunotherapy in Lung Cancer

Most lung cancers are diagnosed at advanced stage when the cancer has metastasized outside the lung. These patients are not eligible for curative surgery or radiation therapy and treated with systemic therapy. Advances in the understanding of the biology of lung cancer has resulted in the development of targeted therapy aimed at specific genetic mutations identified with non-small cell lung cancer and immunotherapy that helps the immune system recognize tumors as foreign, stimulates the immune system, and removes the inhibition that allows growth and spread of cancer cells. Tumors treated with targeted or immunotherapies respond differently when compared with traditional chemotherapy and not captured by conventional response criteria such as the World Health Organization criteria and Response Evaluation Criteria in Solid Tumors. Therefore, several modified criteria have been developed to appropriately address the treatment response when using these novel agents. Numerous treatment-related side effects have been described that are important to recognize to avoid misinterpretation as worsening tumor and to ensure appropriate management.

Post-chemotherapy and targeted therapy imaging of the chest in lung cancer

Non-small-cell lung cancer (NSCLC) is frequently diagnosed when it is not amenable to local therapies; therefore, systemic agents are the mainstay of therapy for many patients. In recent years, treatment of advanced NSCLC has evolved from a general approach primarily involving chemotherapy to a more personalised strategy in which biomarkers such as the presence of genomic tumour aberrations and the expression of immune proteins such as programmed death-ligand 1 (PD-L1), in combination with other elements of clinical information such as histology and clinical stage, guide management. For instance, pathways resulting in uncontrolled growth and proliferation of tumour cells due to epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements may be targeted by tyrosine kinase inhibitors (TKIs). In this article, we review the current state of medical oncology, imaging characteristics of mutations, pitfalls in response assessments and the imaging of complications.

COVID19 pneumonia with cavitation and cystic lung changes: multi-detector computed tomography spectrum of a gamut of etiologies

The COVID19 pandemic since its beginning in March 2020, continues to wreak havoc causing great morbidity and mortality with each passing day. Ample literature is now available describing the imaging features of COVID19 infection; however, there is still a paucity of knowledge on the various causes of pulmonary cavitation and cystic lesions which can be associated with the virus albeit uncommonly. Cavitation in a COVID19 positive patient could be a consequence of the infection itself or a manifestation of sinister etiologies like coinfection with bacterial, fungal or mycobacterial pathogens, or incidental malignancy/metastasis. It could also be a result of multiple cavitating pulmonary nodules as a manifestation of septic emboli and infarct, Granulomatosis with polyangiitis or rheumatoid arthritis creating a diagnostic dilemma. Similarly, the causes of cystic air spaces on chest CT in COVID19 patient can be varied, either primarily due to the infection itself or secondary to coexistent cystic bronchiectasis, emphysema, interstitial lung disease or mechanical ventilation-associated barotrauma as well as complicated pulmonary cysts. Through this pictorial review, we aim to highlight these uncommon imaging manifestations of COVID19 and educate the reader regarding the various causes, MDCT features and differentials to be considered while approaching a cavity/cystic lesion amidst this pandemic.

Pulmonary cavitation in patients with thyroid cancer receiving antiangiogenic agents

Background

Thyroid malignancies are among the most common endocrine cancers worldwide. Owing to the angiogenic nature of these malignancies, tyrosine kinase inhibitors (TKIs) are an attractive potential treatment. However, TKIs have been associated with an increased risk of tumor cavitation, in turn linked to poor outcomes, in patients with malignancies in the lungs, where thyroid cancer commonly metastasizes.

Method

We performe d a retrospective cohort study of patients with thyroid cancer and evidence of metastatic disease to the lung that were treated with multi-targeted antiangiogenic TKIs. The primary objective of this study was to determine the incidence of pulmonary cavitation. The secondary objective was to evaluate the effect of pulmonary cavitation on survival.

Results

Of the 83 patients with pulmonary nodules, 10 developed cavitation during treatment. Of these 83 patients, two patients had to stop the treatment due to pneumothorax. Additionally, cavitation did not demonstrate any significant effect on survival.

Conclusion

In patients with thyroid cancer and evidence of metastatic disease to the chest, the use of multi-targeted TKIs led to cavitations that were not uncommon but clinical consequences were marginal. Treatment was stopped only in two patients that developed pneumothorax, however the small sample is a strong limitation of our study.

Evolution of cystic airspaces lung lesions on immune checkpoint inhibition in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) can be associated with pulmonary cystic airspaces (pCAs). pCAs are radiologically classified into four types based on whether the nodule or mass extrudes the wall of the pCAs. In most cases, response evaluation of these lesions by Response Evaluation Criteria in Solid Tumors (RECIST) V.1.1 is challenging. Based on the observation of a case of morphological evolution of pCAs associated with NSCLC in a patient receiving immune checkpoint inhibitor (ICI), we reviewed retrospectively imaging scans of 92 consecutive advanced patients with NSCLC treated at our institution. Overall, three cases of pCAs associated with NSCLC obtained a remarkable change following ICI. Of note, these changes were not always seen in the context of a clear radiological objective response. The morphological changes observed may reflect a novel pattern of response to immunotherapy agents that clinicians should be aware of. This pattern of response, not reported before, warrants further investigation and, if confirmed, we believe that it should be considered in future version of immune RECIST.

Multicenter Cohort Study to Assess the Association between Changes on Imaging and Outcome after Regorafenib Treatment (KSCC1603)

<b><i>Background:</i></b> Molecular targeted drugs having angiogenesis-inhibiting properties allow the induction of necrosis inside tumors. We retrospectively investigated the relationship between changes on imaging associated with regorafenib (REGO) and treatment outcomes using real-world data. <b><i>Patients and Methods:</i></b> The eligibility criteria included an ECOG PS of 0–1, a starting dose of 120 or 160 mg/day of REGO, and a duration of treatment of at least 35 days. Regarding changes on imaging, cavitation in lung lesions (CLL), morphologic response of liver lesions (MRL), and change of liver metastasis density (CLD) were evaluated. <b><i>Results:</i></b> We finally screened 671 cases, and 226 cases were eligible. In total, 172 and 145 patients had lung and liver metastases, respectively. Among the patients with lung metastasis, CLL was found in 69 patients (40.0%). The median progression-free survival (PFS) of the patients with and those without CLL was 3.2 and 2.4 months, respectively (hazard ratio [HR] = 0.758; 95% confidence interval [CI]: 0.529–1.087), and the median overall survival (OS) of these groups was 10.5 and 8.9 months, respectively (HR = 0.862; 95% CI: 0.579–1.285). MRL and CLD of liver metastasis were analyzed in 145 and 90 patients, respectively. The median OS with and without MRL was 8.9 and 8.2 months, respectively, whereas the median OS with and without CLD was 11.6 and 7.7 months, respectively (HR = 0.523; 95% CI: 0.275–0.992). <b><i>Conclusion:</i></b> CLL may predict PFS but not OS among patients with lung metastasis. CLD was predictive of favorable outcomes for REGO in patients with liver metastasis.

Imaging of Novel Oncologic Treatments in Lung Cancer Part 1: Systemic Therapies

Thoracic tumors are a leading cause of cancer-related morbidity and mortality. In recent years, developments in oncologic treatments for these tumors have ushered in an era of targeted therapy, and, in many cases, these novel treatments have replaced conventional strategies to become standard therapeutic options, particularly in those with lung cancer. Targeted medical therapies for lung cancer now include angiogenesis inhibitors, tyrosine kinase inhibitors, and immunotherapeutic agents. Several novel ablative therapies have also gained widespread acceptance as alternatives to conventional surgical options in appropriately selected patients. Tumors treated with targeted medical therapies can respond to treatment differently when compared with conventional therapies. For example, pseudoprogression is a well-described phenomenon in patients receiving checkpoint inhibitor immunotherapy in which an initial increase in tumor burden is followed by a decrease in tumor burden and sometimes partial or complete response, while the frequent cavitating responses seen when antiangiogenic agents are used can be difficult to quantify using existing response assessment criteria. In some cases, novel response assessment criteria are needed to adequately capture response. In addition, numerous treatment-related side effects have been described, which are important to recognize, both to ensure appropriate treatment and to avoid misclassification as worsening tumor. Imaging plays a vital role in the assessment of patients receiving targeted medical therapy, and it is essential that thoracic radiologists are familiar with the rationale underpinning these treatments and the expected posttherapy findings.

Remarkable Response of Metastatic Gallbladder Carcinoma to Apatinib After Failed Multiline Chemotherapies: A Case Report and Literature Review

Gallbladder carcinoma (GBC) is a relatively rare and aggressive malignant tumor with a poor prognosis. A systematic review of current clinical studies illustrates an extreme paucity of second-line therapeutic options following the failure of standard-of-care cisplatin-gemcitabine chemotherapy. The efficacy of apatinib, an highly potent and selective oral inhibitor of VEGFR-2 tyrosine kinase, for refractory advanced GBC has not yet been clarified. Herein, we report a case of advanced GBC that presented a durable partial response to apatinib used as monotherapy after the failure of multiline chemotherapies including S-1 monotherapy, capecitabine monotherapy, gemcitabine plus capecitabine, and irinotecan plus oxaliplatin. The patient achieved an efficacy of partial response within 2 months. By September 23, 2019, the duration of treatment had extended for almost 1 year with a satisfactory quality of life, and the administration of apatinib was continued. Dose reduction of apatinib occurred at week four due to grade 2 hypertension and hand-foot skin reaction (HFSR). No fatigue, proteinuria, mucositis, or thrombocytopenia occurred. To the best of our knowledge, this is the first case of a successful use of apatinib monotherapy for heavily pretreated GBC. Further prospective studies are warranted to confirm the efficacy and safety of apatinib in GBC.

Prognostic value of tumor cavitation in extensive-stage small-cell lung cancer patients treated with anlotinib

PURPOSE

Anlotinib is a novel multi-target tyrosine kinase inhibitor (TKI) for tumor angiogenesis and tumor cell proliferation. The efficacy of anlotinib as a third-line or beyond therapy for SCLC was confirmed in the ALTER1202 trial. For lung cancer patients treated with antiangiogenesis agents, the phenomenon of cavitation is commonly seen in the lung target lesions. The impact of tumor cavitation on survival in lung cancer patients treated with vascular-targeted therapy remains controversial. Our retrospective study was to investigate the prognostic value of tumor cavitation in extensive-stage SCLC patients treated with anlotinib.

METHODS

A total of 73 extensive-stage SCLC patients confirmed by histopathology from January 2018 to January 2019 were retrospectively analyzed. All patients received anlotinib therapy at Shanghai Chest Hospital. We defined tumor cavitation of the lung target lesions as that part of solid component was changed to air-filled area according to chest CT. Progression-free survival (PFS) was calculated from the beginning of anlotinib therapy to the disease progression or the last follow-up visit.

RESULTS

Eleven (15.0%) patients had tumor cavitation during anlotinib therapy. The ORR of the 73 patients was 15.1%. Multivariate logistic regression analysis showed that tumor cavitation during anlotinib therapy was not associated with gender (P = 0.630), age (P = 0.190), smoking status (P = 0.165), anatomy type (P = 0.641), and the line of anlotinib therapy (P = 0.302). The median PFS of all patients was 2.6 months (95%CI 2.1-3.2). According to the univariate analysis, the median PFS in patients with and without tumor cavitation was 5.0 months and 2.2 months, respectively, and the difference was statistically significant (P = 0.041). According to the multivariate analysis, tumor cavitation was an independent factor for PFS after adjusting gender, age, smoking status, anatomy type, the line of anlotinib therapy, tumor cavitation, and response to anlotinib (adjusted HR 0.316, 95%CI 0.142-0.702; P = 0.005).

CONCLUSIONS

In 73 extensive-stage SCLC patients treated with anlotinib, no demographic/clinical characteristic was related to tumor cavitation, and tumor cavitation was an independent factor in predicting better PFS.

Efficacy of regorafenib in acute pulmonary carcinomatous lymphangitis as a manifestation of rectal cancer: A case report

Recent therapeutic advancements have prolonged the survival duration of patients with metastatic or recurrent colorectal cancer even during salvage treatment. Although treatment with regorafenib and trifluridine/tipiracil combination has exhibited apparent survival benefits, clear and objective evidence of a response to these drugs is scarce. Herein, the present study reports the case of a patient with rectal cancer refractory to multiple surgical interventions and standard chemotherapy. Treatment with regorafenib resulted in immediate improvement of respiratory failure caused by pulmonary lymphangitic carcinomatosis. This improvement persisted for over 3 months and was confirmed by radiology. Our findings suggest that regorafenib can reduce peritumoral edema via its interaction with the vascular endothelial growth factor receptor. Thus, regorafenib functions as a multityrosine kinase inhibitor to alleviate symptoms of lymphangitic carcinomatosis despite the low potency of the drug.

Computed tomography densitometric study of anti-angiogenic effect of regorafenib in colorectal cancer liver metastasis

Aim: Regorafenib induces radiological changes in liver metastasis among patients with metastatic colorectal cancer (mCRC). The standard criteria used to evaluate solid tumor response (Response Evaluation Criteria in Solid Tumors) may be limited in assessing response to biologic agents with anti-angiogenic action. Patients & methods: A total of 67 hepatic lesions in 32 selected patients were analyzed to evaluate tumor attenuation as measured by Hounsfield unit (HU) and size changes. Results: Following two cycles of regorafenib, tumor HU values decreased in the in 73.1% (49/67) of lesions (average HU changes -25.6%) while tumor size increased in 64.2% (43/67) of them (average size changes +25.4%). Conclusion: The computed tomography density changes evaluation may be an additional tool, in combination with tumor sizing, to evaluate tumor response in patients treated with regorafenib.

Apatinib monotherapy for advanced non-small cell lung cancer after the failure of chemotherapy or other targeted therapy

Background

Apatinib, a small‐molecule inhibitor of vascular endothelial growth factor receptor 2 (VEGFR‐2), has proven to be effective and safe for treating patients with advanced gastric cancer after second‐line chemotherapy failure. As VEGFR‐2 targeted therapy has made encouraging progress for the treatment of a broad range of malignancies, we explored the efficacy and safety of apatinib for the treatment of advanced non‐small cell lung cancer after the failure of chemotherapy or other targeted therapy.

Methods

We retrospectively analyzed the data of 34 patients (11 with squamous carcinoma and 23 with adenocarcinoma) who were treated with apatinib alone in a daily oral dose of 250 mg in the second‐line or third‐line setting from January 2016 to July 2017. The primary endpoint was progression‐free survival (PFS).

Results

EGFR mutation or amplification was detected in 15 patients. The median PFS of the whole group was four months (95% confidence interval 0.3–7.7). A partial response was observed in 2 patients (5.88%) and stable disease in 19 (55.88%). The disease control rate was 61.76%. Common side effects of apatinib were hypertension (n = 12), hand‐foot syndrome (n = 8), and proteinuria (n = 5), which accounted for 35.30%, 23.53%, and 14.71%, respectively, and no grade 3/4 adverse reactions occurred. Apatinib toxicity was controllable and tolerable.

Conclusions

Apatinib appears to be effective and safe for advanced non‐small cell lung cancer after the failure of chemotherapy or other targeted therapy.

Hallmarks of Cancer in the Reading Room: A Guide for Radiologists

OBJECTIVE

The hallmarks of cancer are mechanisms that cells develop to undergo malignant transformation. The targeting of these hallmarks by newer cancer therapies results in new mechanisms of response, toxicity, and resistance. The purpose of this article is to review these hallmarks, their associated targeted therapies, imaging features of responses, and toxicities.

CONCLUSION

Ten hallmarks, among them proliferative signaling, angiogenesis, immune response, and genome instability, are reviewed. Molecular targeted therapies, including antiangiogenic factors and immune checkpoint inhibitors, target these hallmarks.

Tumoral cavitation in colorectal cancer patients with unresectable lung metastasis treated with bevacizumab and chemotherapy

PURPOSE

Efficacy and the frequency of tumor cavitation have not been investigated in patients with metastatic colorectal cancer (mCRC) and lung metastases (LMs) treated with chemotherapy in combination with bevacizumab. This study was aimed to evaluate the efficacy and safety of bevacizumab for unresectable mCRC with LM and to determine the frequency of tumor cavitation, and its correlation with clinical outcomes in patients receiving bevacizumab plus chemotherapy.

METHODS

Patients with mCRC and LMs treated with bevacizumab as first- or second-line therapy at West China Hospital, Sichuan University Cancer Center from September 2010 to November 2016 were included in this retrospective study. Data on clinicopathological characteristic were collected and overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and disease control rate (DCR) were determined.

RESULTS

Among 60 patients included in the study, response rate (RR), stable disease (SD), and DCR were 43.6% (17/39), 51.3% (20/39) and 94.9% (37/39) in patients receiving bevacizumab as first-line treatment. Median OS and PFS of the first-line treatment group were 32.4 and 15.5 months, respectively. Among 60, 12 patients (20%) developed cavitation after bevacizumab therapy initiation. Median OS was longer in patients with cavitation than those without cavitation (42.1 vs 30.8 months; p = 0.042) in the first-line treatment group.

CONCLUSION

Bevacizumab in combination with chemotherapy exhibited promising efficacy in mCRC patients LMs. Moreover, our findings reveal that OS might be affected by new tumor cavitation during antiangiogenic agent treatment.

Imaging on Lung Cancer and Treatment with Targeted Therapy

The identification of genetic mutations known as oncogenic driver mutations that lead to the growth and survival of cancer cells has been an important advance in the field of oncology. Treatment in advanced non-small-cell lung cancer (NSCLC) has transitioned from a more general approach to a more personalized approach based on genetic mutations of the cancer itself. Common mutations detected in patients with advanced NSCLC include mutations of epidermal growth factor receptor and anaplastic lymphoma kinase (ALK). Targeted therapies are aimed at the products of these gene mutations and include erlotinib (used in epidermal growth factor receptor mutant NSCLC) and crizotinib (used in anaplastic lymphoma kinase positive NSCLC). In this review, we discuss common genetic mutations in advanced NSCLC, the role of targeted therapies, and imaging findings that can be associated with various genetic mutations.

Targeted Therapy and Imaging Findings

Non-small cell lung cancer (NSCLC) is usually diagnosed when it is not amenable to curative surgery or radiation. Many of these patients are candidates for systemic therapy. Median survival is only approximately 10 months, and, accordingly, treatment in advanced NSCLC is evolving toward a more personalized approach with the identification of genetic abnormalities based on biomarkers. For example, gene mutations in EGFR (epidermal growth factor receptor) and ALK (anaplastic lymphoma kinase) lead to a cascade of pathways resulting in uncontrolled growth, proliferation, and survival of tumor cells. Targeted therapies are aimed at the products of these mutated genes and include agents such as erlotinib and gefitinib (in EGFR-mutant NSCLC) or crizotinib (in ALK-positive NSCLC). Antiangiogenesis agents such as bevacizumab are another category of targeted therapy that inhibits vascular endothelial growth factors. The imaging characteristics of advanced NSCLC with genetic abnormalities, the evolution of targeted therapies and their imaging manifestations will be discussed.

Targeted Therapy and Immunotherapy in the Treatment of Non-Small Cell Lung Cancer

The treatment strategy in advanced non-small cell lung cancer (NSCLC) has evolved from empirical chemotherapy to a personalized approach based on histology and molecular markers of primary tumors. Targeted therapies are directed at the products of oncogenic driver mutations. Immunotherapy facilitates the recognition of cancer as foreign by the host immune system, stimulates the immune system, and alleviates the inhibition that allows the growth and spread of cancer cells. The authors describes the role of targeted therapy and immunotherapy in the treatment of NSCLC, patterns of disease present on imaging studies, and immune-related adverse events encountered with immunotherapy.

Apatinib for heavily treated patients with non-small cell lung cancer: Report of a case series and literature review

Although many strategies have been developed for non-small cell lung cancer (NSCLC), more secondary and further treatments are needed due to drug resistance or tumor recurrence. Apatinib is a novel oral antiangiogenic agent and in this study, we aim to investigate the clinical value of apatinib in heavily pretreated NSCLC. Here, we reported the characteristics, efficacy and adverse events of three patients treated with apatinib (500 mg/day). We also summarized the currently available evidence and ongoing clinical trials regarding the use of apatinib in NSCLC. Two cases of adenocarcinoma and one case of squamous cell carcinoma were treated with apatinib due to disease progression after previous treatments of chemotherapy and epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI). All patients responded to apatinib rapidly and underwent drug resistance shortly afterwards. The patient with squamous cell carcinoma died of hemoptysis. Other adverse events were acceptable. All previous relevant studies were compared and showed similar results but a longer progression-free survival. Additionally, ongoing clinical trials were systematically searched and listed. In conclusion, apatinib shows some efficacy in heavily treated NSCLC and generally tolerable toxicity in non-squamous NSCLC. More solid evidence will be accessible in near future.

Early morphological change for predicting outcome in metastatic colorectal cancer after regorafenib

Background and Objective

It is unclear whether early morphological change (EMC) is a predictive marker for regorafenib in metastatic colorectal cancer (mCRC). Therefore, the present study investigated whether EMC can predict the outcome of mCRC patients receiving regorafenib.

Results

This study evaluated 68 patients. Among 52 patients with lung metastasis, 16 (31%) had cavity formation (CF). The median progression-free survival (PFS) and overall survival (OS) in patients with/without CF were 4.2/2.4 months (p<0.01) and 9.2/6.5 months (p=0.09), respectively. Among 45 patients with liver metastasis, 14 (31%) had active morphological response (MR). The median PFS and OS in patients with/without active MR were 5.3/2.4 months (p<0.01) and 13.6/6.9 months (p=0.02), respectively. Overall, 25 patients (37%) had EMC. The median PFS and OS in patients with/without EMC were 5.3/2.1 months (p<0.01) and 13.3/6.1 months (p<0.01), respectively.

Materials and Methods

This retrospective study included mCRC patients with lung and/or liver metastases receiving regorafenib. CF in lung metastasis and MR in liver metastasis were evaluated at the first post-treatment computed tomography scan. EMC was determined as CF and/or active MR. We compared PFS and OS between patients with and those without EMC.

Conclusions

EMC could be a useful predictive marker for regorafenib in mCRC.

[Application of Bevacizumab in Non-small Cell Lung Cancer]

At present, non-small cell lung cancer is one of the highest incidence of cancers in the world, and its incidence increased year by year, this situation prompted people to continue to seek a variety of treatment in order to extend the survival of patients and improve the quality of life of patients. This review aims to discuss the progress of bevacizumab in the treatment of non-small cell lung cancer, through the clinical data so far to explore the clinical use of the drug, the choice of patients and the future direction of development.

Radiological imaging markers predicting clinical outcome in patients with metastatic colorectal carcinoma treated with regorafenib: post hoc analysis of the CORRECT phase III trial (RadioCORRECT study)

OBJECTIVE

To identify imaging markers predicting clinical outcomes to regorafenib in metastatic colorectal carcinoma (mCRC).

METHODS

The RadioCORRECT study is a post hoc analysis of a cohort of patients with mCRC treated within the phase III placebo-controlled CORRECT trial of regorafenib. Baseline and week 8 contrast-enhanced CT were used to assess response by RECIST 1.1, changes in the sum of target lesion diameters (ΔSTL), lung metastases cavitation and liver metastases density. Primary and secondary objectives were to develop ex novo univariable and multivariable models to predict overall survival (OS) and progression-free survival (PFS), respectively.

RESULTS

202 patients were enrolled, 134 (66.3%) treated with regorafenib and 68 (33.7%) with placebo. In the univariate analysis, PFS predictors were lung metastases cavitation at baseline (HR 0.50, 95% CI 0.27 to 0.92, p=0.03) and at week 8 (HR 0.58, 95% CI 0.36 to 0.93, p=0.02). Baseline cavitation (HR 0.23, 95% CI 0.08 to 0.66, p=0.007), RECIST 1.1 (HR 0.23, 95% CI 0.14 to 0.4, p <0.0001) and ΔSTL (HR 1.16, 95% CI 1.06 to 1.27, p=0.002) predicted OS. We found an increase of 9% of diameter as the best threshold for discriminating OS (HR 2.64, 95% CI 1.61 to 4.34, p <0.001). In the multivariate analysis, baseline and week 8 cavitation remained significant PFS predictors. Baseline cavitation, RECIST 1.1 and ΔSTL remained predictors of OS in exploratory multivariable models. Assessment of liver metastases density did not predict clinical outcome.

CONCLUSIONS

RECIST 1.1 and ΔSTL predict favourable outcome to regorafenib. In contrast to liver metastases density that failed to be a predictor, lung metastases cavitation represents a novel radiological marker of favourable outcome that deserves consideration.

Personalized chemotherapy of lung cancer: What the radiologist should know

Lung cancer is the leading cause of deaths due to cancer in France. More than half of lung cancers are discovered at an advanced-stage. New anticancer treatment strategies (i.e., the so-called personalized or targeted therapy) have recently been introduced and validated for non-small-cell lung cancer (NSCLC), in addition to or in association with standard chemotherapy. Personalized therapy includes tyrosine kinase inhibitors (TKIs), antiangiogenic treatments and immunotherapy. Because these treatments may be responsible for atypical thoracic adverse effects and responses as compared to standard chemotherapy, RECIST 1.1 criteria may be inadequate to evaluate the responses to these agents. The goal of this article was to review personalized treatment strategies for NSCLC, to consider the therapy-specific responses and thoracic complications induced by these new therapeutic agents and finally to discuss future directions for the personalized assessment of tumor response.

Comparison of CT volumetric measurement with RECIST response in patients with lung cancer

PURPOSE

To examine the correlations between uni-dimensional RECIST and volumetric measurements in patients with lung adenocarcinoma and to assess their association with overall survival (OS) and progression-free survival (PFS).

MATERIALS AND METHODS

In this study of patients receiving chemotherapy for lung cancer in the setting of a clinical trial, response was prospectively evaluated using RECIST 1.0. Retrospectively, volumetric measurements were recorded and response was assessed by two different volumetric methods at each followup CT scan using a semi-automated segmentation algorithm. We subsequently evaluated the correlation between the uni-dimensional RECIST measurements and the volumetric measurements and performed landmark analyses for OS and PFS at the completion of the first and second follow-ups. Kaplan-Meier curves together with log-rank tests were used to evaluate the association between the different response criteria and patient outcome.

RESULTS

Forty-two patients had CT scans at baseline, after the first follow up scan and second followup scan, and then every 8 weeks. The uni-dimensional RECIST measurements and volumetric measurements were strongly correlated, with a Spearman correlation coefficient (ρ) of 0.853 at baseline, ρ=0.861 at the first followup, ρ=0.843 at the 2nd followup, and ρ=0.887 overall between-subject. On first follow-up CT, partial responders and non responders as assessed by an "ellipsoid" volumetric criteria showed a significant difference in OS (p=0.008, 1-year OS of 70% for partial responders and 46% for non responders). There was no difference between the groups when assessed by RECIST criteria on first follow-up CT (p=0.841, 1-year OS rate of 64% for partial responders and 64% for non responders).

CONCLUSION

Volumetric response on first follow-up CT may better predict OS than RECIST response.

CLINICAL RELEVANCE STATEMENT

Assessment of tumor size and response is of utmost importance in clinical trials. Volumetric measurements may help to better predict OS than uni-dimensional RECIST criteria.

Clinical Implication of Anti-Angiogenic Effect of Regorafenib in Metastatic Colorectal Cancer

Background

Regorafenib induces distinct radiological changes that represent its anti-angiogenic effect. However, clinical implication of the changes is unclear.

Methods

Tumor attenuation as measured by Hounsfield units (HU) in contrast-enhanced computed tomography (CT) and cavitary changes of lung metastases were analyzed in association with treatment outcome of metastatic colorectal cancer patients (N = 80) treated with regorafenib in a prospective study.

Results

141 lesions in 72 patients were analyzed with HU. After 2 cycles of regorafenib, 87.5% of patients showed decrease of HU (Median change -23.9%, range -61.5%–20.7%). Lesional attenuation change was modestly associated with metabolic changes of 18-fluoro-deoxyglucose positron emission tomography-CT (Pearson’s r = 0.37, p = 0.002). Among 53 patients with lung metastases, 17 (32.1%) developed cavitary changes. There were no differences in disease control rate, progression-free survival, or overall survival according to the radiological changes. At the time of progressive disease (PD) according to RECIST 1.1, HU was lower than baseline in 86.0% (43/50) and cavitary change of lung metastasis persisted without refilling in 84.6% (11/13).

Conclusion

Regorafenib showed prominent anti-angiogenic effect in colorectal cancer, but the changes were not associated with treatment outcome. However, the anti-angiogenic effects persisted at the time of PD, which suggests that we may need to develop new treatment strategies.

Early tumor cavitation with regorafenib in metastatic colorectal cancer: A case report

Tumoral cavity formation is a characteristic phenomenon reported in anti-angiogenic therapy in lung lesions. A 57-year-old male with multiple pulmonary metastases from colorectal cancer treated with an oral tyrosine kinase inhibitor, regorafenib, exhibited a characteristic cavity formation after the first two cycles. The decrease in the size of tumors was calculated as 38%, and there were associated decreases in the serum concentrations of the tumor markers carcinoembryonic antigen and CA19-9. After eight cycles of treatment, the cavity gradually disappeared through filling-in. This unique morphological response is not only reported in lung cancer but also in liver metastasis in colorectal cancer. However, the association between morphological changes including cavity formation and clinical benefit remains controversial. Pulmonary hemorrhage and pneumothorax are well-known consequences of cavitation, as reported with the other anti-angiogenic inhibitors. Early tumor cavitation in lung metastasis may demonstrate the predictive potential of regorafenib in colorectal cancer, although it is necessary to be mindful of toxicity.

Imaging Tumor Response and Tumoral Heterogeneity in Non-Small Cell Lung Cancer Treated With Antiangiogenic Therapy: Comparison of the Prognostic Ability of RECIST 1.1, an Alternate Method (Crabb), and Image Heterogeneity Analysis

PURPOSE

We aimed to assess computed tomography (CT) intratumoral heterogeneity changes, and compared the prognostic ability of the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, an alternate response method (Crabb), and CT heterogeneity in non-small cell lung cancer treated with chemotherapy with and without bevacizumab.

MATERIALS AND METHODS

Forty patients treated with chemotherapy (group C) or chemotherapy and bevacizumab (group BC) underwent contrast-enhanced CT at baseline and after 1, 3, and 6 cycles of chemotherapy. Radiologic response was assessed using RECIST 1.1 and an alternate method. CT heterogeneity analysis generating global and locoregional parameters depicting tumor image spatial intensity characteristics was performed. Heterogeneity parameters between the 2 groups were compared using the Mann-Whitney U test. Associations between heterogeneity parameters and radiologic response with overall survival were assessed using Cox regression.

RESULTS

Global and locoregional heterogeneity parameters changed with treatment, with increased tumor heterogeneity in group BC. Entropy [group C: median -0.2% (interquartile range -2.2, 1.7) vs. group BC: 0.7% (-0.7, 3.5), P=0.10] and busyness [-27.7% (-62.2, -5.0) vs. -11.5% (-29.1, 92.4), P=0.10] showed a greater reduction in group C, whereas uniformity [1.9% (-8.0, 9.8) vs. -5.0% (-13.9, 5.6), P=0.10] showed a relative increase after 1 cycle but did not reach statistical significance. Two (9%) and 1 (6%) additional responders were identified using the alternate method compared with RECIST in group C and group BC, respectively. Heterogeneity parameters were not significant prognostic factors.

CONCLUSIONS

The alternate response method described by Crabb identified more responders compared with RECIST. However, both criteria and baseline imaging heterogeneity parameters were not prognostic of survival.

Associations between deepness of response and clinical outcomes among Japanese patients with metastatic colorectal cancer treated with second-line FOLFIRI plus cetuximab

BACKGROUND

In the FIRE-3 trial, overall survival (OS) was significantly longer in patients treated with FOLFIRI plus cetuximab (C-mab) than in those treated with FOLFIRI plus bevacizumab (Bev), but progression-free survival (PFS) was not significantly different. This may be associated with the deepness of response (DpR) in patients treated with FOLFIRI plus C-mab. We aimed to evaluate the relationship between clinical outcome and DpR in metastatic colorectal cancer (mCRC) patients treated with second-line FOLFIRI plus C-mab.

METHODS

A total of 112 patients with histopathologically confirmed mCRC treated with second-line FOLFIRI in combination with C-mab (N=42) or Bev (N=70) were retrospectively enrolled between October 2008 and June 2013. The relationship between DpR and clinical outcome in patients treated with FOLFIRI plus C-mab or Bev was determined.

RESULTS

Forty-two patients treated with FOLFIRI plus C-mab had a mean DpR of 6.1% (inter-quartile range: -13.7%, 20.8%) and a minimum DpR of -62.7%. On the other hand, 70 patients treated with FOLFIRI plus Bev had a mean DpR of 0% (interquartile range: -16%, 10%) and a minimum DpR of -111%. DpR ≥30% was associated with significantly longer OS and PFS when compared with DpR ≤30% in patients given FOLFIRI plus C-mab. DpR (≥30%) was independently associated with prolongation of OS and PFS. In patients treated with FOLFIRI plus C-mab, there was a moderate positive correlation between DpR and clinical outcomes (OS: r=0.51, P<0.001; PFS: r=0.54, P<0.001).

CONCLUSION

FOLFIRI plus C-mab yielded a stronger correlation between DpR and clinical outcomes. These results indicate the potential of DpR as a new measure of efficacy in mCRC patients treated with second-line chemotherapy plus C-mab.

Hapten-enhanced therapeutic effect in advanced stages of lung cancer by ultra-minimum incision personalized intratumoral chemoimmunotherapy therapy

Aim

The objective of the study reported here was to evaluate the therapeutic effects of hapten-enhanced chemoimmunotherapy in the treatment of advanced lung cancer by ultra-minimum incision personalized intratumoral chemoimmunotherapy (UMIPIC) and to analyze the effect of this immune booster.

Materials and methods

A total of 97 patients with advanced lung cancer were treated with UMIPIC or intratumoral chemotherapy (ITCT). UMIPIC was delivered intratumorally in combination with a proprietary therapeutic regimen composed of three components – an oxidant, a cytotoxic drug, and hapten. ITCT applied using the same procedures and regimen, only without hapten. All data from the two groups were reviewed and analyzed. A total of 55 patients were treated with UMIPIC and 42 with ITCT. Patient responses were assessed with computed tomography scan 4–6 weeks after treatment, and all of the patients were followed until their deaths.

Results

Median overall survival was 11.23 months in the UMIPIC (test) group and 5.62 months in the ITCT (control) group (P<0.01). The 6-month and 1-year survival rates of the UMIPIC and ITCT groups were 76.36% versus 45.23% (P<0.01) and 45.45% versus 23.81% (P<0.05), respectively. Two cycles of UMIPIC treatment (n=19) conferred a significant survival benefit compared with two cycles of ITCT (n=29); significant benefits in survival time were also found with UMIPIC (n=20) compared with ITCT (n=13) when both were utilized without adjuvant treatment.

Conclusion

The hapten-enhanced clinical effect of UMIPIC conferred a superior survival time in patients with advanced lung cancer compared with ITCT. The addition of the hapten in UMIPIC demonstrates a significant advantage in terms of prolonged survival time.

Pulmonary hilar lymph node metastasis of breast cancer induced bronchopleural fistula and superior vena cava syndrome

Patient: Female, 56

Final Diagnosis: Broncho-pleural fistula • empyema • supra-vena cava syndrome

Symptoms: Dyspnea • fever • facial edema

Medication: —

Clinical Procedure: —

Specialty: Oncology and Pulmonology

Anti-angiogenic agents in the treatment of non-small cell lung cancer

Lung cancer is the most common malignant neoplasm diagnosed worldwide. In Poland, in 2011, lung cancer was diagnosed in 14,522 men and 6,283 women. Morbidity and mortality are nearly equal, and lung cancer is still the most common cause of cancer-related death among men as well as among women. Approximately 80% of lung cancer cases are non-small-cell lung cancer. The most commonly applied chemotherapy regimens do not produce satisfactory effects. Oncological research is now focused on molecular targeted therapies; immunotherapy is also under evaluation. The formation of abnormal blood vessels has an enormous impact on the development and progression of a tumor. Bevacizumab is a monoclonal antibody which binds VEGF (vascular endothelial growth factor). A different group of drugs is constituted by small-molecule antiangiogenic tyrosine kinase inhibitors. These agents represent a different profile of side effects in comparison to chemotherapy. The mode of action, differing from cytotoxic drugs, requires renewed analysis as well as standardization of radiological response assessment criteria.

State of the art: Response assessment in lung cancer in the era of genomic medicine

Tumor response assessment has been a foundation for advances in cancer therapy. Recent discoveries of effective targeted therapy for specific genomic abnormalities in lung cancer and their clinical application have brought revolutionary advances in lung cancer therapy and transformed the oncologist's approach to patients with lung cancer. Because imaging is a major method of response assessment in lung cancer both in clinical trials and practice, radiologists must understand the genomic alterations in lung cancer and the rapidly evolving therapeutic approaches to effectively communicate with oncology colleagues and maintain the key role in lung cancer care. This article describes the origin and importance of tumor response assessment, presents the recent genomic discoveries in lung cancer and therapies directed against these genomic changes, and describes how these discoveries affect the radiology community. The authors then summarize the conventional Response Evaluation Criteria in Solid Tumors and World Health Organization guidelines, which continue to be the major determinants of trial endpoints, and describe their limitations particularly in an era of genomic-based therapy. More advanced imaging techniques for lung cancer response assessment are presented, including computed tomography tumor volume and perfusion, dynamic contrast material-enhanced and diffusion-weighted magnetic resonance imaging, and positron emission tomography with fluorine 18 fluorodeoxyglucose and novel tracers. State-of-art knowledge of lung cancer biology, treatment, and imaging will help the radiology community to remain effective contributors to the personalized care of lung cancer patients.

Practical management of NSCLC patients with long-term bevacizumab treatment: a report of four cases

INTRODUCTION

Previous research showed that the addition of bevacizumab (a monoclonal antibody against vascular endothelial growth factor [VEGF]) to chemotherapy resulted in a significant efficacy benefit in the treatment of selected patients with advanced nonsquamous non-small cell lung cancer (NSCLC). However, the occurrence and management of adverse events (AEs) during long-term maintenance treatment with bevacizumab is not well known.

METHODS

This report presents a descriptive analysis, including the management of AEs, of four patients with advanced NSCLC, who received a relatively long period of bevacizumab maintenance treatment.

RESULTS

In patient 1, a 72-year-old retired man with stage cT2N2M1b NSCLC, the only AE related to bevacizumab was a grade 1 rhinorrhea. Treatment resulted in a stable disease, with duration of response of 38 months. Patient 2 had NSCLC stage cT4N3M1b and developed a cavitation and infection after the first cycle of chemotherapy and bevacizumab, which caused a temporary decrease of her quality of life. Bevacizumab therapy resulted in a partial response, with duration of response of 15 months. A 52-year-old female (patient 3) with stage T2bN2M1a NSCLC is currently under treatment and has so far received 42 cycles of maintenance bevacizumab, with stabilized response (duration of response of 29 months) and no noteworthy AEs. The last patient is a 74-year-old male farmer with NSCLC T1N0M1, whose response has lasted for more than 3 years, with until now, no AEs.

CONCLUSION

Our retrospective findings of these four patients show the long-term efficacy and safety of bevacizumab treatment in a real-life setting.

[Bevacizumab combined with chemotherapy for advanced non-small cell lung cancer: a meta-analysis]

BACKGROUND AND OBJECTIVE

Bevacizumab is a recombinant, humanised, monoclonal antibody against the vascular endothelial growth factor receptor (VEGFR), the aim of this meta-analysis is to evaluate the clinical efficacy and safety of bevacizumab combined with chemotherapy for non-small cell lung cancer (NSCLC).

METHODS

The CBM, CNKI, VIP, WanFang, The Cochrane Library, PubMed, Ovid, EMBASE and SCI etc were retrieved by computer, the randomized controlled trials (randomized control trial, RCT) of bevacizumab combined with chemotherapy in the treatment of NSCLC were collected by us. The outcomes included overall survival (OS), progression-free survival (PFS), response rate (RR), toxicities and treatment related mortality. Relative risk (RR) and hazard ratios (HR) were used for the meta-analysis and were expressed with 95% confidence intervals (95%CI), and the software Stata 12.0 was used for meta-analyses.

RESULTS

Six trials and 2,338 advanced NSCLC patients were included. Meta analysis indicated that compared with chemotherapy alone, the bevacizumab (7.5 mg/kg or 15 mg/kg) combination with chemotherapy could increase overall survival rate (RR=1.68, P<0.01, 95%CI: 1.31-2.15; RR= 1.79, P<0.01, 95%CI: 1.53-2.08), and could decrease the progression of the disease risk (HR=0.75, P<0.01, 95%CI: 0.61-0.89; HR=0.69, P<0.01, 95%CI: 0.62-0.77) and the risk of disease death (HR=0.94, P<0.01, 95%CI: 0.77-1.10; HR=0.87, P<0.01, 95%CI: 0.78-0.97). The high dose of bevacizumab (15 mg/kg) combination with chemotherapy could increase the treatment related mortality (RR=1.88, P=0.010, 95%CI: 1.16-3.05) and the rates of other toxic reaction.

CONCLUSIONS

Whether first-line or second-line treatment, the addition of bevacizumab to chemotherapy in patients with advanced NSCLC prolongs RR, OS and PFS.

Imaging beyond RECIST: CT and MRI in molecular therapies

Until recently, almost all systemic antineoplastic therapies in cancer patients aimed at destruction of tumor cells, i.e. they were cytotoxic. The effect of therapy was assessed by measuring the tumor size with a decrease in size suggesting response to therapy and an increase suggesting progression. Modern molecular therapies, however, are mostly not cytotoxic but aim to reduce tumor perfusion or metabolism by blocking specific cell functions without causing cell death. Assessment of tumor size alone may, therefore, not be appropriate in this setting and can even lead to false conclusions. This presentation gives examples of changes at computed tomography (CT) and magnetic resonance imaging (MRI) of tumors undergoing therapy with molecular therapies, highlights potential pitfalls und suggests criteria for response assessment. The presentation focuses on CT and MRI of chest and abdominal tumors and specifically excludes positron emission tomography/CT and brain tumors.