EGFRgene mutations in patients with adenosquamous lung carcinoma

Adenosquamous Carcinoma of the Lung: Survival, Radiologic Findings, PD-L1, and Driver Mutations

Background: Adenosquamous carcinoma of the lung (ASC) is a rare non-small-cell lung cancer (NSCLC) subtype combining components of squamous cell carcinoma (SCC) and adenocarcinoma (AC). Data on ASC, particularly in Caucasian populations, are limited. Methods: We reviewed clinicopathological and radiological characteristics of ASC patients diagnosed between 1996 and 2023. Patients were classified into AC-predominant ASC (AC-ASC) and SCC-predominant ASC (SCC-ASC) groups for analysis. Results: Among the 66 patients included, the median overall survival was 41.7 (95% CI, 25.0-54.4), while it was 48.1 (95% CI, 27.3-88.0) in patients treated with curative surgery (n = 44) and 15.3 (95% CI, 6.5-42.6) months for palliative patients (n = 22). The five-year survival rates were 39% and 26%, respectively. Recurrence occurred in 43% of stage I patients and was associated with worse survival (HR 3.303 (95% CI, 1.10-9.89) p = 0.033). AC-ASCs (n = 17) more frequently showed air-bronchogram (p = 0.002) and pleural effusions (p = 0.054) compared to SCC-ASCs (n = 26). SCC-ASCs exhibited more vascular invasion (p = 0.006) and PD-L1 values between 1 and 49% (TPS) (p = 0.032). The subtype did not influence survival. EGFR and ALK alterations were found in 17% and 2% of patients, respectively. Conclusions: Despite early-stage disease, ASC patients had a high recurrence rate, associated with worse survival. Clinicopathologic differences between AC-ASCs and SCC-ASCs did not influence survival.

Efficacy of epidermal growth factor receptor-tyrosine kinase inhibitor for lung adenosquamous cell carcinoma harboring EGFR mutation: a retrospective study and pooled analysis

Objectives

To explore the efficacy of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) on lung adenosquamous cell carcinoma (ASC) with EGFR mutation.

Methods

Efficacy of EGFR-TKIs in the treatment of advanced or recurrent lung ASC with EGFR mutations was assessed retrospectively in 44 patients. Pooled analysis of 74 patients using EGFR-TKIs, including 30 patients selected from 11 publications, was conducted.

Results

In our retrospective research, patients treated with EGFR-TKI in ASC with EGFR mutations had objective response rate (ORR) of 54.5%, disease control rate (DCR) of 79.5%, median progression free survival (mPFS) of 8.8 months, and median overall survival (mOS) of 19.43 months, respectively. A pooled analysis reveals ORR, DCR, mPFS, and mOS are, respectively, 63.4%, 85.9%, 10.00 months, and 21.37 months for ASC patients. In patients with deletions in exon 19 and exon 21 L858R mutations, mPFS (11.0 versus 10.0 months, P=0.771) and mOS (23.67 versus 20.33 months, P=0.973) were similar. Erlotinib or gefitinib-treated patients had an overall survival trend that was superior to that of icotinib-treated patients.

Conclusions

ASC harboring EGFR mutations can be treated with EGFR-TKI in a similar manner to Adenocarcinoma (ADC) harboring EGFR mutations. There is still a need for further investigation to identify the separate roles of ASC's two components in treating EGFR.

Current management of uncommon EGFR mutations in non-small cell lung cancer

Epidermal growth factor receptor (EGFR) mutations are frequently implicated in non-small cell lung cancer (NSCLC). Though these typically involve exon 19 in-frame deletions or L858R mutations in exon 21, uncommon EGFR mutations comprise 10-15 % of all EGFR mutations. These most frequently include G719X mutations in exon 18, L861Q mutations in exon 21, S768I mutations in exon 20, and in-frame insertions and/or duplications in exon 20. It is crucial to understand these distinct variants and their specific responses to active treatment options to optimize care. In this review, we discuss these uncommon mutations in depth and dissect the current literature regarding their treatment outcomes and subsequent evidence-based management guidelines.

A nomogram to predict prognosis of patients with lung adenosquamous carcinoma: a population-based study

Background

Adenosquamous carcinoma (ASC) of the lung is an infrequent variant of lung cancer. This study aimed to identify independent risk factors and to develop a predictive model for the prognosis of ASC patients.

Methods

Patient data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database (2004 to 2016) and database in our department (2010 to 2014). Overall survival (OS) was evaluated by the Kaplan-Meier method. Significant prognostic factors were identified by univariate analysis (UVA) and multivariate analysis (MVA) using the Cox proportional hazards regression. Competing risk model analyses were performed using cancer-specific survival outcomes. A nomogram was developed to predict patient 3-year and 5-year OS and was validated using data from the two databases.

Results

A total of 4,600 patients with ASC were included and divided into a training cohort (n=3,202) and two validation cohorts (n=1,372, n=26). Patients with ASC had significantly older age, lower grades of tumor differentiation or incidences of nodal, and distant invasions than adenocarcinoma and squamous cell carcinoma (SCC) of the lung (P<0.001), while the median survival time of ASC patients was intermediate [21.0 (19.3-22.7) months]. Age, sex, primary site of tumor, histological grade, T stage, N stage, M stage of the tumor, as well as surgery to the primary tumor site and chemotherapy were identified as independent factors for ASC (P<0.001). A reliable nomogram was established with a group of validation plots and concordance indices (C-indices) (internal: 0.755±0.010; external: 0.748±0.049 and 0.721±0.045).

Conclusions

Age, sex, primary site of tumor, histological grade, T stage, N stage, M stage of the tumor, as well as surgery to the primary site of tumors and chemotherapy were independent risk factors for ASC patients. A validated nomogram was constructed to predict the prognosis based on the patient clinical characteristics.

[Clinical Characteristics and Prognostic Factors of Lung Adenosquamous Carcinoma in SEER Database between 2010 and 2015]

背景与目的

肺癌发病率和死亡率均位居所有恶性肿瘤的第一，严重影响人类健康。非小细胞肺癌（non-small cell lung cancer, NSCLC）中常见病理类型为腺癌和鳞癌，临床研究和关注较多，而肺腺鳞癌是一种较为罕见的肺癌病理类型，其临床特征及预后相关因素尚未完全明确。本研究即对肺腺鳞癌的临床特征及预后进行分析，并构建了列线图来预测患者的预后。

方法

我们纳入了2010年-2015年美国SEER（Surveillance, Epidemiology, and End Results）数据库中的肺腺鳞癌数据，与同期的肺腺癌和肺鳞癌的临床特征和预后进行了比较。随后我们采用单因素和多因素分析研究了肺腺鳞癌患者预后的独立相关因素，以此构建了列线图并进行了验证。

结果

我们一共入组了肺腺鳞癌患者1, 453例。与同期的肺腺癌和肺鳞癌患者相比较，肺腺鳞癌患者在大多数变量中的分布情况均介于肺腺癌和鳞癌之间，其预后也优于肺鳞癌但差于肺腺癌患者。多因素分析发现，年龄、分化程度、肿瘤-淋巴结-转移（tumor-node-metastasis, TNM）、手术和化疗是患者预后的独立影响因素（P均 < 0.001）。我们以此构建了列线图，其C-index为0.783（0.767-0.799），区分度检验和一致性检验均表明这一列线图可以有效地预测患者预后。

结论

肺腺鳞癌具有独特的临床病理和预后特征。年龄、分化、T、N、M、手术和化疗状况是肺腺鳞癌患者预后的独立预测因素。我们以此构建的列线图可以较好地预测患者预后。

Surgical significance and efficacy of epidermal growth factor receptor tyrosine kinase inhibitors in patients with primary lung adenosquamous carcinoma

Background

Primary adenosquamous carcinoma (ASC) of the lung is a rare and aggressive disease. The accurate diagnosis of ASC based on small biopsies is challenging because of the mixed components within the tumor, and this may lead to suboptimal treatment. Furthermore, information about the efficacy of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in lung ASC is limited.

Patients and methods

Data on a cohort of patients with lung ASC who underwent surgery between October 2008 and December 2016 at a single institution were retrospectively reviewed.

Results

This study analyzed 148 patients. Differences between the pre- and post-resection diagnosis were observed. Based on the results of preoperative biopsy, patients were diagnosed as having squamous cell carcinoma (n=26), adenocarcinoma (n=20), poorly differentiated carcinoma (n=20), and large cell carcinoma (n=1), and finally diagnosed as having ASC based on histopathological examination of the surgical specimens. Thirty patients (20.3%) with EGFR-sensitizing mutations (TKI group) were treated with EGFR-TKIs after surgery, whereas the remaining patients (79.7%) with unknown EGFR-mutation status received chemotherapy or chemoradiotherapy alone (non-TKI group). TKI treatment was associated with better median overall survival (OS) (HR=0.619; p=0.034). Multivariate analysis identified the presence of EGFR-TKI treatment as an independent prognostic factor for OS (HR=0.471; p=0.003).

Conclusion

Discrepancies between the pre- and post-operative diagnosis reflect the inadequacy of non-resection approaches to the diagnosis of ASC. ASC patients harboring EGFR-sensitizing mutations who were treated with EGFR-TKIs showed a significantly better prognosis than those receiving chemotherapy or chemoradiotherapy alone.

Predictors of EGFR mutation and factors associated with clinical tumor stage at diagnosis: Experience of the INSIGHT study in Poland

Targeted therapy of non-small cell lung cancer (NSCLC) patients with mutations in the epidermal growth factor receptor (EGFR) gene has been associated with improved prognosis. However, there is a shortage on data from real-world clinical practice in management of EGFR-positive NSCLC patients in Poland. The present study retrospectively analyzed data from the INSIGHT study to evaluate the incidence and clinical management of EGFR-positive NSCLC in Poland. The authors additionally aimed to identify predictors of the EGFR mutation and factors associated with clinical stage of the tumor at diagnosis. Incidence of EGFR mutations was 11.8% and the most common mutations were a deletion on exon 19 and an L858R substitution on exon 21. Mutations were strongly associated with female gender [male vs. female odds ratio (OR): 0.51; P=0.004] and never having smoked (current/past smoker vs. never smoked OR: 0.16; P<0.001), and advanced clinical stage (stage IV vs. stage I/II OR: 2.89; P=0.029). Patients with EGFR mutation were also observed to have a greater propensity to develop bone metastasis (OR: 11.62; P=0.008). Multivariate regression analysis demonstrated that patients with past or current smoking history or a poor performance on the Eastern Cooperative Oncology Group (ECOG) scale were less likely to have the EGFR mutation. Furthermore, EGFR-positive patients with greater ECOG scores and a tumor other than adenocarcinoma or squamous cell carcinoma were more likely to present advanced tumors. Early screening for EGFR mutation and the use of EGFR-targeting therapies as first-line agents may lead to better prognosis and successful clinical management of EGFR-positive NSCLC patients.

Correlation between EGFR Gene Mutations and Lung Cancer: a Hospital-Based Study

Epidermal growth factor receptor (EGFR) is one of the targeted molecular markers in many cancers including lung malignancies. Gefitinib and erlotinib are two available therapeutics that act as specific inhibitors of tyrosine kinase (TK) domains. We performed a case-control study with formalin-fixed paraffin-embedded tissue blocks (FFPE) from tissue biopsies of 167 non-small cell lung carcinoma (NSCLC) patients and 167 healthy controls. The tissue biopsies were studied for mutations in exons 18-21 of the EGFR gene. This study was performed using PCR followed by DNA sequencing. We identified 63 mutations in 33 men and 30 women. Mutations were detected in exon 19 (delE746-A750, delE746-T751, delL747-E749, delL747-P753, delL747-T751) in 32 patients, exon 20 (S786I, T790M) in 16, and exon 21 (L858R) in 15. No mutations were observed in exon 18. The 63 patients with EFGR mutations were considered for upfront therapy with oral tyrosine kinase inhibitor (TKI) drugs and have responded well to therapy over the last 15 months. The control patients had no mutations in any of the exons studied. The advent of EGFR TKI therapy has provided a powerful new treatment modality for patients diagnosed with NSCLC. The study emphasizes the frequency of EGFR mutations in NSCLC patients and its role as an important predictive marker for response to oral TKI in the south Indian population.

Improved survival associated with a balanced structure between adenomatous and squamous components in patients with adenosquamous carcinoma of the lung

BACKGROUND

Primary adenosquamous carcinoma (ASC) of the lung is rare and its biological behavior has not yet been thoroughly described. The aim of this study was to analyze the clinicopathological characteristics and prognostic factors associated with ASC.

MATERIALS

Clinical records of patients with ASC of the lung who underwent surgery between October 2008 and December 2014 in a single institution were retrospectively reviewed.

RESULTS

A total of 205 patients were identified. Patients with balanced structural components had significantly better prognosis than those with squamous (p = 0.014) or adenomatous (p < 0.001) predominance, and those with N0, N1, and N2 ASC (N0 vs. N1 [ p = 0.031] and N1 vs. N2 [p = 0.037], respectively), or stage I, II and IIIA ASC (stage I vs. II [p = 0.021] and stage II vs. IIIA [p = 0.007], respectively) had significant differences with respect to overall survival (OS). Multivariate analysis identified structural components (p = 0.011), tumor, node and metastasis (TNM) status (p < 0.001), and adjuvant chemotherapy (p = 0.008) as significantly prognostic factors for OS, and structural components (p = 0.030), TNM stage (p < 0.001) and adjuvant chemotherapy (p = 0.005) as the corresponding variables for disease-free survival.

CONCLUSIONS

A balanced structure between adenomatous and squamous components in patients with primary ASC of the lung was associated with better prognosis.

Epidermal Growth Factor Receptor Activating Mutations in Squamous Histology of Lung Cancer Patients of Southern Bulgaria

There is only limited data on the prevalence of epidermal growth factor receptor (EGFR) activating mutations in squamous cell carcinomas and adenosquamous carcinomas of the lung in patients of the Southern Bulgarian region and the efficacy of EGFR tyrosine kinase inhibitors. AIM: Previous reports for Bulgarian population showed high incidence of EGFR mutations in the squamous cell carcinomas, so we set the goal to investigate their frequency in Southern Bulgaria, after precise immunohistochemical verification of lung cancers. MATERIALS AND METHODS: Two hundred and thirty-six lung carcinomas were included in this prospective study. All biopsies were initially analysed with p63, TTF1, Napsin A, CK7, CK34βE12, synaptophysin, CK20 and CDX2. Two hundred and twenty-five non-small cell lung carcinomas were studied with real-time PCR technology to assess the status of the EGFR gene. RESULTS: We detected 132 adenocarcinomas (58.7%), 89 squamous cell carcinomas (39.2%), 4 adenosquamous carcinomas (1.8%), 9 large cell neuroendocrine carcinomas (3.8%) and 2 metastatic colorectal adenocarcinomas (0.8%). Activating mutations in the EGF receptor had 3 out of 89 squamous cell carcinomas (3.37%). We have established mutations in L858R, deletion in exon 19 and rare mutation in S7681. One out of four adenosquamous carcinomas had a point mutation in the L858R (25%). CONCLUSIONS: The frequency of EGFR mutations we found in lung squamous cell carcinomas in a Southern Bulgarian region is lower than that in European countries. Ethnic diversity in the region does not play role of an independent predictive factor in terms of mutation frequency.

Gefitinib upregulates death receptor 5 expression to mediate rmhTRAIL-induced apoptosis in Gefitinib-sensitive NSCLC cell line

Background

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) triggers apoptosis in tumor cells, but when used alone, it is not effective in the treatment of TRAIL-resistant tumors. Some studies have shown that gefitinib interacts with recombinant mutant human TRAIL (rmhTRAIL) to induce high levels of apoptosis in gefitinib-responsive bladder cancer cell lines; however, the molecular mechanisms underlying the anticancer effects are not fully understood. Several reports have shown that the death receptor 5 (DR5) plays an important role in sensitizing cancer cells to apoptosis induced by TRAIL. Therefore, we investigated the effects of the combination of drugs and the expression of the DR5 to analyze the growth of a gefitinib-responsive non-small cell lung cancer cell line PC9, which was treated with rmhTRAIL and gefitinib individually or in combination.

Methods

Human PC9 non-small cell lung cancer cells harboring an epidermal growth factor receptor mutation were used as a model for the identification of the therapeutic effects of gefitinib alone or in combination with rmhTRAIL, and cytotoxicity was assessed by MTT assays. Cell cycle and apoptosis were investigated using flow cytometry. Moreover, the effects of drugs on DR5, BAX, FLIP, and cleaved-caspase3 proteins expressions were analyzed using Western blot analyses. Finally, quantitative polymerase chain reaction analysis was carried out to assess whether rmhTRAIL and gefitinib modulate the expression of genes related to drug activity.

Results

Gefitinib and rmhTRAIL synergistically interact to inhibit cell proliferation, and apoptosis assessment demonstrated that associations of drug increased the apoptotic index. rmhTRAIL when used alone downregulated DR5 and upregulated BAX, FLIP, and cleaved-caspase3 proteins expressions. However, results obtained in Western blot analyses demonstrated that the combined treatment-induced cell apoptosis was achieved involving upregulated DR5, cleaved-caspase3, and BAX proteins expression and downregulated FLIP protein expression. Moreover, quantitative polymerase chain reaction showed that gefitinib modulated the expression of targets related to rmhTRAIL activity.

Conclusion

These results indicate that epidermal growth factor receptor inhibitors enhance rmhTRAIL antitumor activity in the gefitinib-responsive PC9 cell line, and upregulated DR5 expression plays a critical role in activating caspase-signaling apoptotic pathway.

Surgical specimen histology revealed inadequacy of conventional transbronchial needle aspiration sample in the diagnosis of adenosquamous lung carcinoma

OBJECTIVE

We retrospectively reviewed the accuracy of conventional transbronchial needle aspiration (cTBNA) in the subtyping of lesions located in or around central airways by comparing the histological diagnosis based on TBNA and surgical specimens.

MATERIALS AND METHODS

cTBNA was conducted in consecutive patients with lesions located in or around the central airways (trachea, left and right primary bronchi, hilar and mediastinal masses or lymph nodes) between October 2012 and May 2014 in Wuhan No. 1 Hospital. The aspirated specimens in all patients were performed cytological and/or histopathological examination. Of these patients, some were subjected to surgical resection and histopathological examination was performed by the Department of Pathology. In the patients with gross specimens, the final diagnosis was established based on histopathological results from these specimens.

RESULTS

In 63 patients diagnosed with cTBNA for the lesions located in or around the central airways, 23 patients with a diagnosis of lung cancer or atypical hyperplasia underwent surgery. The final diagnosis based on histopathology of surgery specimen was lung cancer in 22 patients [3 small cell lung cancer (SCLC), 9 squamous cell carcinoma (SCC), 5 adenocarcinoma (ADC), 4 adenosquamous carcinoma (ADS) and 1 neuroendocrine carcinoma], and inflammatory pseudotumor in 1 patient. The overall diagnostic yield of cTBNA for lung cancer was 95.7% (22/23), but the accuracy for histological typing of lung cancer is only 63.6% (14/22), for adenosquamous lung carcinoma was only 25% (1/4).

CONCLUSIONS

cTBNA is a safe and effective procedure that can be used for the diagnosis of central lung cancer. However, the accuracy of TBNA for the histological classification of lung cancer is relatively low, especially for adenosquamous lung carcinoma.

Biomarker expression and druggable gene alterations for development of an appropriate therapeutic protocol for pulmonary adenosquamous carcinoma

AIMS

Pulmonary adenosquamous carcinoma (ASC) is more aggressive than adenocarcinoma (AC) and squamous cell carcinoma (SCC). The genetic features and biomarkers of ASC are not well known. Here, we attempted to identify potential therapeutic markers for ASC.

METHODS AND RESULTS

Surgically resected ASC samples from 65 patients were analysed. We examined the expression of β III-tubulin, thymidylate synthase, breast cancer susceptibility gene 1 and ribonucleotide reductase M1 (RRM1); identified mutations in epidermal growth factor receptor (EGFR), KRAS, BRAF and HER2; and detected ALK, ROS1 and RET rearrangements. Gene amplification and expression of EGFR, human epidermal growth factor receptor 2 (HER2), fibroblast growth factor receptor-1 and MET were also examined. β III-Tubulin showed the highest expression (P = 0.002), and its expression was more frequent in the AC than in the SCC component (P = 0.013). RRM1 expression was more frequent in the SCC component (P = 0.046). EGFR and KRAS mutations were detected in both components (21.5 and 10.9%, respectively). ALK and ROS1 rearrangements and MET amplification were detected in both components in one (1.5%) case.

CONCLUSIONS

In ASC, drug response-specific gene alterations could occur in both AC and SCC components, suggesting that patients with confirmed or suspected ASC should undergo further testing for driver gene analyses.

Detection of common and less frequent EGFR mutations in cytological samples of lung cancer

OBJECTIVE

Lung cancer represents the leading cause of cancer death. EGFR mutations, detected in 10-40% of lung adenocarcinomas, are an essential key to therapeutic management. EGFR-activated mutations comprise mainly deletions in exon 19 and point mutations in exon 21. Although histology is the traditional method of detection, we investigated the role of cytology in EGFR mutations.

STUDY DESIGN

A total of 774 lung cancers were studied for EGFR mutations (676 histological and 98 cytological samples), including 424 adenocarcinomas, 326 non-small cell lung carcinomas not otherwise specified, and 24 squamous cell carcinomas.

RESULTS

We had a total of 164 (21.2%) cases of mutations. Common mutations were short in-frame deletions in exon 19 (53.7%) and single-nucleotide substitutions in exon 21 (34.1%); less frequent mutations included single-nucleotide substitutions in exon 18 (3.7%) and in-frame insertions/deletions in exon 20 (8.5%). Histologically, EGFR mutations in exons 19 and 21 occurred in 19.4% and in exons 18 and 20 in 2.2%, while the rates cytologically were 13.3% for exons 19 and 21 and 5.1% for exons 18 and 20.

CONCLUSIONS

The sensitivity for the detection of EGFR mutations in cytological samples overlaps histology, so the use of cytological material constitutes an adequate approach for treatment selection in patients with locally advanced or metastatic lung cancer.