Positive (18)Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography Predicts Preinvasive Endobronchial Lesion Progression to Invasive Cancer

Evaluation of hypermetabolic mediastinal-hilar lymph nodes determined by PET/CT with EBUS-TBNA and calculation of SUVmax cutoff values in differentiation of malignancy

Computed tomography (CT) and positron emission tomography (PET) are the most commonly used methods for diagnosis and staging in both malignant and benign diseases of the lung parenchyma and mediastinum. Endobronchial ultrasonography (EBUS) guided transbronchial needle aspiration biopsy (TBNA) has become widespread in recent years because it allows minimally invasive tissue sampling. PET-CT has high sensitivity in the diagnosis of malignancy but has low specificity. The false positive rate is high with the SUVmax 2.5 cutoff value, which is widely used in studies about malignancy. In our study, we evaluated lymph nodes with high F18-fluorodeoxyglucose (FDG) uptake on PET/CT and sampled by EBUS-TBNA. We aimed to calculate the new SUVmax cutoff values in the differentiation of malignancy. Our study included 103 patients who were examined for any reason and who underwent biopsy with EBUS-TBNA due to mediastinal or hilar lymph node enlargement on PET-CT. The relationship between PET-CT findings and EBUS findings, EBUS-TBNA results was evaluated. Biopsies were taken from 140 lymph nodes in 103 patients included in our study, and 39 (27.8%) were diagnosed as malignant. In our study, when the SUVmax cutoff value in PET-CT is taken as 2.54, the sensitivity is 98%, but the specificity remains at the level of 12%. When the SUVmax cutoff value in PET-CT was taken as 4.58, the sensitivity was 92% and the specificity was 49%. When this value was accepted as 5.25, and 6.09 the sensitivity was respectively 90% and 85%, the specificity was respectively 52% and 60%. In evaluations, we conducted in order to determine different SUVmax cutoff values that can be used for higher sensitivity and specificity in malignancy studies, the cutoff values were 4.58, 5.25, and 6.09. It is thought that these cutoff values will be useful both for diagnosing malignancy and for distinguishing benign pathologies.

Focal 18 F-FDG uptake predicts progression of pre-invasive squamous bronchial lesions to invasive cancers

INTRODUCTION

Pre-invasive squamous lesions of the central airways can progress into invasive lung cancers. Identifying these high-risk patients could enable detection of invasive lung cancers at an early stage. In this study, we investigated the value of ¹⁸ F-fluorodeoxyglucose (¹⁸ F-FDG) positron emission tomography (PET) scans in predicting progression in patients with pre-invasive squamous endobronchial lesions.

METHODS

In this retrospective study, patients with pre-invasive endobronchial lesions, who underwent an ¹⁸ F-FDG PET scan at the VU University Medical Center Amsterdam, between January 2000 and December 2016, were included. Autofluorescence bronchoscopy (AFB) was used for tissue sampling and was repeated every 3 months. The minimum and median follow-up was 3 and 46.5 months. Study endpoints were the occurrence of biopsy proven invasive carcinoma, time-to-progression and overall survival (OS).

RESULTS

A total number of 40 of 225 patients met the inclusion criteria of which 17 (42.5%) patients had a positive baseline ¹⁸ F-FDG PET scan. A total of 13 of 17 (76.5%) developed invasive lung carcinoma during follow-up, with a median time to progression of 5.0 months (range, 3.0-25.0). In 23 (57.5%) patients with a negative ¹⁸ F-FDG PET scan at baseline, 6 (26%) developed lung cancer, with a median time to progression of 34.0 months (range, 14.0-42.0 months, p < 0.002). With a median OS of 56.0 months (range, 9.0-60.0 months) versus 49.0 months (range, 6.0-60.0 months) (p = 0.876) for the ¹⁸ F-FDG PET positive and negative groups, respectively.

CONCLUSIONS

Patients with pre-invasive endobronchial squamous lesions and a positive baseline ¹⁸ F-FDG PET scan were at high-risk for developing lung carcinoma, highlighting that this patient group requires early radical treatment.

Endoscopic follow-up of low-grade precancerous bronchial lesions in high-risk patients: long-term results of the SELEPREBB randomised multicentre trial

BACKGROUND

3-9% of low-grade preinvasive bronchial lesions progress to cancer. This study assessed the usefulness of an intensive bronchoscopy surveillance strategy in patients with bronchial lesions up to moderate squamous dysplasia.

METHODS

SELEPREBB (ClinicalTrials.gov NCT00213603) was a randomised study conducted in 17 French centres. After baseline lung computed tomography (CT) and autofluorescence bronchoscopy (AFB) to exclude lung cancer and bronchial severe squamous dysplasia or carcinoma in situ (CIS), patients were assigned to standard surveillance (arm A) with CT and AFB at 36 months or to intensive surveillance (arm B) with AFB every 6 months. Further long-term data were obtained with a median follow-up of 4.7 years.

RESULTS

364 patients were randomised (A: 180, B: 184). 27 patients developed invasive lung cancer and two developed persistent CIS during the study, with no difference between arms (OR 0.63, 95% CI 0.20-1.96, p=0.42). Mild or moderate dysplasia at baseline bronchoscopy was a significant lung cancer risk factor both at 3 years (8 of 74 patients, OR 6.9, 95% CI 2.5-18.9, p<0.001) and at maximum follow-up (16 of 74 patients, OR 5.9, 95% CI 2.9-12.0, p<0.001). Smoking cessation was significantly associated with clearance of bronchial dysplasia on follow-up (OR 0.12, 95% CI 0.01-0.66, p=0.005) and with a reduced risk of lung cancer at 5 years (OR 0.15, 95% CI 0.003-0.99, p=0.04).

CONCLUSION

Patients with mild or moderate dysplasia are at very high risk for lung cancer at 5 years, with smoking cessation significantly reducing the risk. Whereas intensive bronchoscopy surveillance does not improve patient outcomes, the identification of bronchial dysplasia using initial bronchoscopy maybe useful for risk stratification strategies in lung cancer screening programmes.

Lung Basal Stem Cells Rapidly Repair DNA Damage Using the Error-Prone Nonhomologous End-Joining Pathway

Lung squamous cell carcinoma (SqCC), the second most common subtype of lung cancer, is strongly associated with tobacco smoking and exhibits genomic instability. The cellular origins and molecular processes that contribute to SqCC formation are largely unexplored. Here we show that human basal stem cells (BSCs) isolated from heavy smokers proliferate extensively, whereas their alveolar progenitor cell counterparts have limited colony-forming capacity. We demonstrate that this difference arises in part because of the ability of BSCs to repair their DNA more efficiently than alveolar cells following ionizing radiation or chemical-induced DNA damage. Analysis of mice harbouring a mutation in the DNA-dependent protein kinase catalytic subunit (DNA-PKcs), a key enzyme in DNA damage repair by nonhomologous end joining (NHEJ), indicated that BSCs preferentially repair their DNA by this error-prone process. Interestingly, polyploidy, a phenomenon associated with genetically unstable cells, was only observed in the human BSC subset. Expression signature analysis indicated that BSCs are the likely cells of origin of human SqCC and that high levels of NHEJ genes in SqCC are correlated with increasing genomic instability. Hence, our results favour a model in which heavy smoking promotes proliferation of BSCs, and their predilection for error-prone NHEJ could lead to the high mutagenic burden that culminates in SqCC. Targeting DNA repair processes may therefore have a role in the prevention and therapy of SqCC.