Prognostic impact of micropapillary component in patients with node-negative subcentimeter lung adenocarcinoma: A Chinese cohort study

Prediction of the pathological subtypes by intraoperative frozen section for patients with cT1N0M0 invasive lung adenocarcinoma (ECTOP-1015): a prospective multicenter study

BACKGROUND

This study aims to assess the diagnostic accuracy of the intraoperative frozen section (FS) in determining the pathological subtypes among patients diagnosed with cT1N0M0 invasive lung adenocarcinoma.

MATERIALS AND METHODS

This was a prospective, multicenter (seven centers in China) clinical trial of Eastern Cooperative Thoracic Oncology Projects (ECTOP-1015). Patients with cT1N0M0 invasive lung adenocarcinoma were enrolled in the study. Pathological images obtained from FS and final pathology (FP) were reviewed by at least two pathologists. The primary endpoint was the concordance between FS and FP diagnoses. The interobserver agreement for identifying pathological subtypes on FS was evaluated among three pathologists.

RESULTS

A total of 935 patients were enrolled. The best sensitivity of diagnosing the predominant subtype was 78.2% in the evaluation of the acinar pattern. The presence of an acinar pattern diagnosed by FS was an independent factor for the concordance between FS and FP ( P =0.007, 95% confidence interval: 2.332-4.736). Patients with tumor size >2 cm measured by pathology showed a better concordance rate for the predominant subtype (81.6% vs. 74.6%, P =0.023). The presence of radiological ground glass opacity component did not affect the diagnosis accuracy of FS for the predominant subtype (concordance rate: 76.4% vs. 75.2%, P =0.687). Patients with ground glass opacity component showed better accuracy of the identification in the presence of lepidic pattern-predominant adenocarcinoma (82.1% vs. 71.0%, P =0.026). Substantial agreement between the FS diagnosis from three pathologists for the predominant pathological pattern was revealed with κ=0.846.

CONCLUSIONS

This is the largest prospective trial evaluating FS diagnosing pathological subtype in cT1N0M0 invasive lung adenocarcinoma. A favorable concordance in the assessment of the pathological subtypes between FS and FP was observed, indicating the feasibility of utilizing accurate intraoperative pathological diagnoses from FS in guiding surgical strategies. A combination of radiology could improve the precision of FS.

The clinicopathological features and possible physiological mechanisms of only the EGFR-T790M primary mutation in patients with lung adenocarcinoma

BACKGROUND

The treatment of non-small cell lung cancer (NSCLC) patients can be complicated by the presence of the EGFR-T790M mutation. Although primary or secondary EGFR-T790M mutations have been extensively studied worldwide, there are few reports on the clinicopathological characteristics and physiological mechanisms of lung adenocarcinoma (LUAD) with only the EGFR-T790M primary mutation.

METHODS

The clinical data of all LUAD patients with only the EGFR-T790M primary mutation were collected. Immunohistochemical staining was performed on cell cycle-related proteins, targeted therapy indicators, and prognosis-related proteins in the specimens obtained from puncture biopsies or surgeries.

OBJECTIVES

The aim of this study is to analyze the clinicopathological features and possible physiological mechanisms of only the EGFR-T790M primary mutation in LUAD, and to offer recommendations for clinical management.

RESULTS

Two patients who have only the T790M de novo mutation were both female (2/12,928, 0.02%). β-catenin and Cyclin D1 were both highly expressed. In case 1, IHC results showed a positive Ki67 and mutant P53 and there was a significant increase in serum CYFRA 21-1. Third-generation of EGFR TKIs resulted in a partial response (PR) time of less than 8 months in case 1. In case 2, the patient underwent surgical resection and adjuvant chemotherapy, resulting in a progression-free survival (PFS) time of 25 months.

CONCLUSION

The results suggest that abnormal activation of the Wnt signaling pathway may be specifically associated with the EGFR-T790M primary mutation in LUAD. Furthermore, it has been observed that patients with significant Ki67, mutant P53, and CYFRA 21-1 expression tend to have a poor prognosis.

Whole-lesion iodine map histogram analysis versus single-slice spectral CT parameters for determining novel International Association for the Study of Lung Cancer grade of invasive non-mucinous pulmonary adenocarcinomas

PURPOSE

The purpose of this study was to evaluate and compare the performances of whole-lesion iodine map histogram analysis to those of single-slice spectral computed tomography (CT) parameters in discriminating between low-to-moderate grade invasive non-mucinous pulmonary adenocarcinoma (INMA) and high-grade INMA according to the novel International Association for the Study of Lung Cancer grading system of INMA.

MATERIALS AND METHODS

Sixty-one patients with INMA (34 with low-to-moderate grade [i.e., grade I and grade II] and 27 with high grade [i.e., grade III]) were evaluated with spectral CT. There were 28 men and 33 women, with a mean age of 56.4 ± 10.5 (standard deviation) years (range: 29-78 years). The whole-lesion iodine map histogram parameters (mean, standard deviation, variance, skewness, kurtosis, entropy, and 1st, 10th, 25th, 50th, 75th, 90th, and 99th percentile) were measured for each INMA. In other sessions, by placing regions of interest at representative levels of the tumor and normalizing them, spectral CT parameters (iodine concentration and normalized iodine concentration) were obtained. Discriminating capabilities of spectral CT and histogram parameters were assessed and compared using area under the ROC curve (AUC) and logistic regression models.

RESULTS

The 1st, 10th, and 25th percentiles of the iodine map histogram analysis, and iodine concentration and normalized iodine concentration of single-slice spectral CT parameters were significantly different between high-grade and low-to-moderate grade INMAs (P < 0.001 to P = 0.002). The 1st percentile of histogram parameters (AUC, 0.84; 95% confidence interval [CI]: 0.73-0.92) and iodine concentration (AUC, 0.78; 95% CI: 0.66-0.88) from single-slice spectral CT parameters had the best performance for discriminating between high-grade and low-to-moderate grade INMAs. At ROC curve analysis no significant differences in AUC were found between histogram parameters (AUC = 0.86; 95% CI: 0.74-0.93) and spectral CT parameters (AUC = 0.81; 95% CI: 0.74-0.93) (P = 0.60).

CONCLUSION

Both whole-lesion iodine map histogram analysis and single-slice spectral CT parameters help discriminate between low-to-moderate grade and high-grade INMAs according to the novel International Association for the Study of Lung Cancer grading system, with no differences in diagnostic performances.

EGFR co-mutation is associated with the risk of recurrence in invasive lung adenocarcinoma with the micropapillary component

BACKGROUND

Invasive lung adenocarcinoma (LUAD) patients with the micropapillary (MPP) component tend to have extremely poor prognosis. To optimize clinical outcomes, a better understanding of specific concurrent gene alterations and their impact on the prognosis of patients with the MPP component is necessary.

METHOD

A total of 621 Chinese patients with surgically resected invasive LUAD who underwent genetic testing for lung cancer were enrolled in this retrospective study. The genomic profiling of major lung cancer-related genes based on next-generation sequencing (NGS) was carried out on formalin-fixed paraffin-embedded tumor samples.

RESULT

Among 621 patients with invasive LUAD, 154 (24.8%, 154/621) had the MPP component. We found that PIK3CA (4.5% vs 1.3%), KRAS (9.1% vs 4.7%), and ROS1 (2.6% vs 0.4%) were more frequent in patients with the MPP component than those without the MPP component (P < 0.05). The co-mutation occurred in 66 patients (10.6%, 66/621), of which 19 patients with the MPP component. Most of them were EGFR co-mutations (89.5%, 17/19), including EGFR and PIK3CA, EGFR and ERBB2, and other types. Patients with the MPP component who harbored EGFR co-mutations showed significantly worse recurrence-free survival (RFS) than single EGFR mutation (median RFS 20.1 vs 30.5 months; hazard ratio [HR]: 8.008; 95% confidence interval [CI]: 1.322-48.508).

CONCLUSIONS

Patients with the MPP component harbored the co-mutation of driver genes had a higher risk of recurrence after surgery, especially in patients with EGFR co-mutation. EGFR co-mutation was a significant prognostic factor for RFS in patients with the MPP component.

Optimal resection strategies for small-size lung cancer: Is a wedge enough? Is lobectomy too much?

Recently published large multicenter prospective clinical trials have demonstrated that sublobar resection is noninferior to lobectomy, the traditional treatment of choice, for peripherally located early-stage lung cancer. Most clinical trials and several retrospective studies published to date have used the consolidation-to-tumor ratio to define the indication for sublobar resection, as it is well known that the size of the solid portion seen on high-resolution computed tomography is highly correlated with pathologic invasiveness. However, it is difficult to accurately predict pathologic features that may increase the risk of locoregional recurrence, such as specific adenocarcinoma subtypes or spread through air spaces, based on imaging characteristics alone, and the location of the nodule also should be considered one of the important factors in obtaining an adequate parenchymal resection margin. In this article, we summarize the results of the most recently published clinical trials related to sublobar resection and discuss various factors that should be considered for optimal candidate selection for sublobar resection.

Development of the semi-dry dot-blot method for intraoperative detecting micropapillary component in lung adenocarcinoma based on proteomics analysis

BACKGROUND

Micropapillary (MIP) component was a major concern in determining surgical strategy in lung adenocarcinoma (LUAD). We sought to develop a novel method for detecting MIP component during surgery.

METHODS

Differentially expressed proteins between MIP-positive and MIP-negative LUAD were identified through proteomics analysis. The semi-dry dot-blot (SDB) method which visualises the targeted protein was developed to detect MIP component.

RESULTS

Cellular retinoic acid-binding protein 2 (CRABP2) was significantly upregulated in MIP-positive LUAD (P < 0.001), and the high CRABP2 expression zone showed spatial consistency with MIP component. CRABP2 expression was also associated with decreased recurrence-free survival (P < 0.001). In the prospective cohort, the accuracy and sensitivity of detecting MIP component using SDB method by visualising CRABP2 were 82.2% and 72.7%, which were comparable to these of pathologist. Pathologist with the aid of SDB method would improve greatly in diagnostic accuracy (86.4%) and sensitivity (78.2%). In patients with minor MIP component (≤5%), the sensitivity of SDB method (63.6%) was significantly higher than pathologist (45.4%).

CONCLUSIONS

Intraoperative examination of CRABP2 using SDB method to detect MIP component reached comparable performance to pathologist, and SDB method had notable superiority than pathologist in detecting minor MIP component.

Frozen sections accurately predict the IASLC proposed grading system and prognosis in patients with invasive lung adenocarcinomas

INTRODUCTION

The International Association for the Study of Lung Cancer (IASLC) newly proposed grading system for lung adenocarcinomas (ADC) has been shown to be of prognostic significance. Hence, intraoperative consultation for the grading system was important regarding the surgical decision-making. Here, we evaluated the accuracy and interobserver agreement for IASLC grading system on frozen section (FS), and further investigated the prognostic performance.

METHODS

FS and final pathology (FP) slides were reviewed by three pathologists for tumor grading in 373 stage I lung ADC following surgical resection from January to June 2013 (retrospective cohort). A prospective multicenter cohort (January to June 2021, n = 212) were included to confirm the results.

RESULTS

The overall concordance rates between FS and FP were 79.1% (κ = 0.650) and 89.6% (κ = 0.729) with substantial agreement in retrospective and prospective cohorts, respectively. Presence of complex gland was the only independent predictor of discrepancy between FS and FP (presence versus. absence: odds ratio, 2.193; P = 0.015). The interobserver agreement for IASLC grading system on FS among three pathologists were satisfactory (κ = 0.672 for retrospective cohort; κ = 0.752 for prospective cohort). Moreover, the IASLC grading system by FS diagnosis could well predict recurrence-free survival and overall survival for patients with stage I invasive lung ADC.

CONCLUSIONS

Our results suggest that FS had high diagnostic accuracy and satisfactory interobserver agreement for IASLC grading system. Future prospective studies are merited to validate the feasibility of using FS to match patients into appropriate surgical type.

Minor histological components predict the recurrence of patients with resected stage I acinar- or papillary-predominant lung adenocarcinoma

Objective

Invasive lung adenocarcinoma is composed of five different histological subgroups with diverse biological behavior and heterogeneous morphology, the acinar/papillary-predominant lung adenocarcinomas are the most common subgroups and recognized as an intermediate-grade group. In the real world, clinicians primarily consider predominant patterns and ignore the impact of minor components in the prognosis of lung adenocarcinoma. The study evaluated the clinicopathologic characteristics of the lepidic, solid, and micropapillary patterns as non-predominant components and whether the minimal patterns had prognostic value on acinar/papillary-predominant lung adenocarcinomas.

Methods

A total of 153 acinar/papillary-predominant lung adenocarcinoma patients with tumor size ≤4 cm were classified into four risk subgroups based on the presence of lepidic and micropapillary/solid components: MP/S^-Lep⁺, MP/S⁺Lep⁺, MP/S^-Lep^-, and MP/S⁺Lep^- groups. The Cox-proportional hazard regression model was used to assess disease-free survival (DFS).

Results

The risk subgroups based on the non-predominant patterns were associated with differentiation (P = 0.001), lymphovascular invasion (P = 0.001), and recurrence (P = 0.003). In univariate analysis, DFS was correlated with non-predominant components (P = 0.014), lymphovascular invasion (P = 0.001), carcinoembryonic antigen (CEA) (P = 0.001), and platelet-to-lymphocyte ratio (PLR) (P = 0.012). In the multivariate analysis, non-predominant components (P = 0.043) and PLR (P = 0.032) were independent prognostic factors for DFS. The 5-year survival rates of MP/S^-Lep⁺, MP/S⁺Lep⁺, MP/S^-Lep^- and MP/S⁺Lep^- subgroups were 93.1%,92.9%,73.1%,61.9%, respectively. The MP/S^-Lep⁺ subgroup had the favorable prognosis than MP/S⁺Lep^- subgroup with a statistically significant difference (P = 0.002). As minor components, the lepidic patterns were a protective factor, and the solid and micropapillary components were poor factors. The recurrence was related to the presence of non-predominant patterns rather than their proportion. Adjuvant chemotherapy did not significantly improve the prognosis of the MP/S⁺Lep^- subgroup (P = 0.839).

Conclusions

Regardless of the proportion, the presence of micropapillary/solid components and the absence of lepidic patterns are aggressive factors of DFS in patients with resected stage I acinar- or papillary-predominant lung adenocarcinoma.

The IASLC Proposed Grading System Accurately Predicts Prognosis and Mediastinal Nodal Metastasis in Patients With Clinical Stage I Lung Adenocarcinoma

The International Association for the Study of Lung Cancer (IASLC) recently proposed a new grading system for lung adenocarcinoma (LUAD). We aimed to validate the prognostic performance of the grading system and explore its role in guiding the strategy of lymph node (LN) dissection. We retrospectively reviewed 1029 patients with clinical stage I LUAD who underwent surgery between 2011 and 2013. The association between mediastinal nodal metastasis and grading system was evaluated. To investigate the value of the grading system in guiding LN dissection strategies, 3 pathologists evaluated the feasibility of identifying the grading system using frozen section (FS). The differences in prognosis between all neighboring grades were highly significant based on the grading system ( P <0.001). Notably, almost no grade 1 LUAD (1.4%) had pN2 disease, whereas higher rates were found in grade 2 LUAD (9.6%) and grade 3 LUAD (18.3%) ( P <0.001). Multivariate logistic regression analysis revealed that higher tumor grade was an independent predictor of mediastinal nodal metastasis ( P =0.002). Moreover, limited mediastinal LN dissection had equivalent prognosis in grade 1 LUAD, but significantly worse prognosis in grade 2 and grade 3 LUAD than systematic mediastinal LN dissection. The overall accuracy of using intraoperative FS to identify the IASLC grading system was 85.4% (κ=0.765) with substantial agreement. The IASLC grading system could accurately stratify prognosis and predict mediastinal nodal metastasis in patients with clinical stage I LUAD. FS was feasible for identifying the IASLC grading system.

Genomic and clinicopathological features of lung adenocarcinomas with micropapillary component

BACKGROUND

Lung adenocarcinoma (LA) with a micropapillary component (LAMPC) is a histological subtype of lung cancer that has received increasing attention due to its correlation with poor prognosis, and its tendency to recur and metastasize. At present, comprehensive genomic profiles and clinicopathological features for LAMPC remain unclear and require further investigation.

METHODS

From September 2009 to October 2020, a total of 465 LAMPC patients were recruited and divided into four groups according to MPC proportions, and the correlations between varying proportions of MPCs and clinicopathological characteristics were analyzed. Twenty-nine (29) LAMPC patients and 89 LA patients without MPC (non-MPC) that had undergone NGS testing were selected for further study The comprehensively analyze genomic variations and the difference between LAMPC and MPC were determined. In addition, Gene alterations of LAMPC between Chinese and Western populations were also compared using cBioPortal data.

RESULTS

A higher proportion of MPCs, associated with higher tumor stage, pleural invasion, and vascular tumor thrombus formation, was determined in LA patients. Compared to non-MPC patients, LAMPC patients were determined to have a lower frequency of single nucleotide variants and a higher frequency of insertion-deletion mutations. Mutations in TP53, CTNNB1, and SMAD4, and ALK rearrangements/fusions were significantly more frequent in LAMPC patients. ERBB2 mutations were only detected in non-MPC patients. Gene mutations in the Wnt pathway were significantly more common in LAMPC patients as compared to non-MPC patients. ALK fusions were more prevalent in younger patients. Patients with KRAS or LBP1B mutations had significantly larger tumor diameters than patients with wild-type KRAS or LBP1B. Patients with KRAS mutations were more likely to develop vascular tumor thrombus. Using the cBioPortal public database, we determined that mutations in EGFR were significantly higher in Chinese patients than in a Memorial Sloan Kettering Cancer Center (MSKCC) Western cohort. ALK fusions were exclusively detected in the Chinese cohort, while mutations in KEAP1 and NOTCH4 were only detected in the MSKCC cohort. Our analysis of signaling pathways revealed that Wnt pathway gene mutations were significantly higher in the Chinese cohort.

CONCLUSION

LA patients with higher proportions of MPCs were determined to have a higher tumor stage, pleural invasion, and vascular tumor thrombosis formation. We comprehensively analyzed the genomic mutation characteristics of LAMPC patients and identified multiple, novel MPC-related gene alterations and pathway changes. Our data provide further understanding of the nature of the LAMPC and potential drug-targeted gene alterations, which may lead to new therapeutic strategies.

The prognostic influence of histological subtypes of micropapillary tumors on patients with lung adenocarcinoma ≤ 2 cm

Objective

This study aimed to explore the value of micropapillary histological subtypes in predicting the specific surgical specificity and lymph node metastasis prognosis of early lung adenocarcinoma.

Methods

A total of 390 patients with lung adenocarcinoma were included who underwent surgery in the Department of Thoracic Surgery of the Affiliated Provincial Hospital of Anhui Medical University from January 2016 to December 2017. The data were analysed with SPSS 26.0 statistical software, and the clinicopathological data of the two groups were compared with the chi-square test. The survival rate was calculated by the Kaplan-Meier method, and the difference in survival rate between groups was analysed by the log-rank test. Multivariate survival analysis was performed using the Cox model.

Results

Univariate analysis of the clinicopathological data of the patients showed that the micropapillary histological subtype was significantly associated with the survival rate of patients (p=0.007). The clinicopathological data of the patients were substituted into the Cox model for multivariate analysis, and the results showed that the micropapillary histological subtype was an independent prognostic factor affecting the survival rate of the patients (p=0.009).The average survival time of Group A (micronipple composition > 5%) was 66.7 months; the 1-year, 3-year, and 5-year survival rates were 98.8%, 93.0%, and 80.9%, respectively.The survival of the lobectomy group was better than that of the sublobectomy group and the survival of patients with systematic dissection was better than that of patients with limited lymph node dissection. The average survival time of Group B (micronipple composition ≤ 5%) was 70.5 months; the 1-year, 3-year, and 5-year survival rates were 99.3%, 95.4%, and 90.6%, respectively. There was no difference in the survival rate between the lobectomy group and sublobectomy group, and there was also no difference in survival between systematic lymph node dissection and limited lymph node dissection, The survival rate of Group B was significantly better than that of Group A.

Conclusion

The micropapillary histological component is an independent risk factor after surgery in patients with ≤2 cm lung adenocarcinoma. When the proportion of micropapillary components is different, the prognosis of patients is different when different surgical methods and lymph node dissections are performed. Lobectomy and systematic lymph node dissection are recommended for patients with a micropapillary histological composition >5%; sublobar resection and limited lymph node dissection are recommended for patients with a micropapillary histological composition ≤5%.

Comparison of outcomes following lobectomy, segmentectomy, and wedge resection based on pathological subtyping in patients with pN0 invasive lung adenocarcinoma ≤1 cm

PURPOSE

We sought to analyze the prognostic significance of lung adenocarcinoma classification for patients with pathological N0 (pN0) lung invasive adenocarcinomas ≤1 cm who underwent surgical resection and investigate the optimal surgical procedure according to lung adenocarcinoma classification.

METHODS

A total of 1409 consecutive patients with resected pN0 invasive lung adenocarcinoma ≤1 cm were retrospectively reviewed. Comprehensive histologic subtyping was determined according to IASLC/ATS/ERS lung adenocarcinoma classification. Recurrence-free survival (RFS) and overall survival (OS) were compared between patients receiving lobectomy, segmentectomy, and wedge resection.

RESULTS

RFS and OS favored lobectomy and segmentectomy compared with wedge resection in the entire cohort. Five-year RFS rates were 100%, 98.2%, 97.3%, 77.8%, and 82.8% (p < 0.001) for lepidic, acinar, papillary, micropapillary, and solid predominant subtypes, while 5-year OS rates were 100%, 98.4%, 98.1%, 88.9%, and 96.5% (p < 0.001), respectively. Multivariate analysis showed that adenocarcinoma predominant pathological subtype and CT appearance were independent prognostic factors for RFS, and surgical procedure was independent factor for both RFS and OS. Specifically, wedge resection showed worse survival compared with anatomical resection in patients with papillary, micropapillary, or solid predominant subtypes, whereas in patients with lepidic predominant and acinar predominant subtypes, wedge resection showed comparable RFS with anatomical resection.

CONCLUSIONS

Anatomical resection showed better survival for patients with pN0 invasive lung adenocarcinoma ≤1 cm. For patients with invasive adenocarcinoma ≤1 cm in whom anatomical resection is not feasible, wedge resection could provide similar oncological effect when tumor is lepidic predominant or acinar predominant.