Management of stage I and II nonsmall cell lung cancer

Perioperative immunotherapy for patients with EGFR mutant non-small cell lung cancer: Unexpected potential benefits

Given that immunotherapy has resulted in a significant overall survival (OS) benefit in advanced-stage disease, it is of notable interest to determine the effectiveness of these agents in early-stage non-small cell lung cancer (NSCLC). The potential exists for the immunotherapeutic approach in early-stage NSCLC to mirror the paradigm seen in advanced NSCLC, wherein survival enhancements have notably benefited the majority of patients. However, their performance in early-stage epidermal growth factor receptor (EGFR) mutant NSCLC is controversial. In the limited studies that included patients with EGFR mutation status, we found unexpected, good survival benefits of perioperative immune checkpoint inhibitors (ICIs) in resectable EGFR-positive NSCLC, which is controversial with those in advanced EGFR-mutant NSCLC. It is possible because of the shift toward immunosuppression that the immune environment undergoes during tumor progression. In the early disease stages, the anti-tumor immune response can be activated with fewer hindrances. In the context of EGFR mutant tumors, intratumor genetic heterogeneity can generate treatment-sensitive and -resistant subclones. The subclonality of the resistant subclone is pivotal in therapy response, with tyrosine kinase inhibitors (TKIs) selectively controlling EGFR-mutant cell proliferation and "competitive release" potentially explaining lower pathological responses in adjuvant TKIs trials. This review delves into emerging data on perioperative treatment modalities for early-stage EGFR mutant NSCLC, exploring unique mechanisms and predictive biomarkers to guide perioperative management strategies.

Soluble PD-L1 shows no association to relapse and overall survival in early stage non-small cell lung cancer (NSCLC)

BACKGROUND

Cancer immune evasion is critical in non-small cell lung cancer (NSCLC) and has been targeted by immunotherapy. High soluble (s)PD-L1 is associated with reduced survival and treatment failure in advanced stages. Here we evaluated the effects of sPD-L1 on T cells, relapse free survival, and overall survival in early stage NSCLC.

METHODS

In vitro T cell stimulation was performed in the presence of sPD-L1 to evaluate its immunomodulatory activity. Data from The Cancer Genome Atlas (TCGA) were investigated for PD-L1 splice variants and enzymes involved in proteolytic cleavage (i.e. ADAM10). Plasma from 74 NSCLC (stage IA-IIIB), as well as an additional 73 (control cohort) patients was collected prior to curative surgery. Thereafter sPD-L1 levels from an immunosorbent assay were correlated with patient outcome.

RESULTS

In vitro sPD-L1 inhibited IFN-γ production and proliferation of T cells and induced a terminal effector CD4 T cell subtype expressing CD27. Data from the TCGA demonstrated that elevated mRNA levels of ADAM10 is a negative predictor of outcome in NSCLC patients. To investigate the clinical relevance of these in vitro and TCGA findings, we quantified sPD-L1 in the plasma of early-stage NSCLC patients. In the first cohort we found significantly higher sPD-L1 levels in relapsing NSCLC patients, with a multivariate analysis revealing high sPD-L1 (>1000 pg/mL) as an independent predictor of survival. However, these findings could not be validated in two independent control cohorts.

DISCUSSION

Although in vitro and TCGA data support the suppressive effect of sPD-L1 we were unable to translate this in our clinical setting. These results may be due to the small patient number and their heterogeneity as well as the lack of a standardized sPD-L1 ELISA. Our inconclusive results regarding the value of sPD-L1 in early stage NSCLC warrant assay validation and further investigation in larger (neo-)adjuvant trials.

Surgically resectable nonsmall cell lung cancer: a contemporary approach

New treatment paradigms for resectable nonsmall cell lung cancer (NSCLC), with an emphasis on personalised care and a multidisciplinary approach, have significantly improved patient outcomes. The incorporation of immune checkpoint inhibitors into neoadjuvant, perioperative and adjuvant treatment algorithms is reshaping the standard of care for resectable NSCLC. Adjuvant targeted therapy trials have also paved the way for a much-needed personalised approach for patients with actionable genomic alterations. Innovative surgical techniques and judicious use of postoperative radiotherapy may mitigate the toxicity associated with a multimodality approach. Amid the many new treatment options, questions remain about the best approach to consider for each patient. Measurement of minimal residual disease and achievement of pathological complete response are emerging biomarkers of interest to help further refine treatment selection. This review summarises the current management of resectable NSCLC, focusing on ongoing and recent advances in surgical approaches, the role of postoperative radiotherapy and the rapidly changing field of systemic therapies.

From detection to disappearance: A tale of a nodule

Spindle cell lesions span from benign to aggressively malignant, the most concerning being the carcinoma, sarcoma, and melanoma species. While spindle cell carcinoma is the most common spindle cell lesion found along the upper aerodigestive tract (UADT), it only accounts for <0.5 % of pulmonary malignancies [1,2]. We present an adult male admitted for chest pain, who was found to have a malignant left upper lobe (LUL) spindle cell neoplasm. Three pathology departments preformed immunohistochemical analysis on various tissue specimens, searching for a speciated diagnosis, highlighting the importance of advanced immunostains for the diagnosis and subsequent treatment of these difficult lesions.

N1-positive non-small cell lung cancer: surgeons' perspective before undertaking a major resection

Among various reasons for a rise in surgical referrals for locally advanced non-small cell lung cancer, few are improved clinical-pathological staging, better understanding of oncological driver mutation, and aggressive neoadjuvant treatment options. These cases with positive ipsilateral bronchopulmonary lymph nodes are intriguing subset where multiple treatment options have been explored to improve disease-free survival. Targeted neoadjuvant therapy followed by surgical resection is becoming a new norm and surgeons are referred these complex cases. This narrative review is highlighting the importance of proper preoperative staging, contemporary practices in surgical decision-making, and procedural aspect of hilar node dissection.

Circulating microRNA Panel for Prediction of Recurrence and Survival in Early-Stage Lung Adenocarcinoma

Early-stage lung adenocarcinoma (LUAD) patients remain at substantial risk for recurrence and disease-related death, highlighting the unmet need of biomarkers for the assessment and identification of those in an early stage who would likely benefit from adjuvant chemotherapy. To identify circulating miRNAs useful for predicting recurrence in early-stage LUAD, we performed miRNA microarray analysis with pools of pretreatment plasma samples from patients with stage I LUAD who developed recurrence or remained recurrence-free during the follow-up period. Subsequent validation in 85 patients with stage I LUAD resulted in the development of a circulating miRNA panel comprising miR-23a-3p, miR-320c, and miR-125b-5p and yielding an area under the curve (AUC) of 0.776 in predicting recurrence. Furthermore, the three-miRNA panel yielded an AUC of 0.804, with a sensitivity of 45.8% at 95% specificity in the independent test set of 57 stage I and II LUAD patients. The miRNA panel score was a significant and independent factor for predicting disease-free survival (p < 0.001, hazard ratio [HR] = 1.64, 95% confidence interval [CI] = 1.51-4.22) and overall survival (p = 0.001, HR = 1.51, 95% CI = 1.17-1.94). This circulating miRNA panel is a useful noninvasive tool to stratify early-stage LUAD patients and determine an appropriate treatment plan with maximal efficacy.

Radiotherapy in the management of lung oligometastases

In recent years, the development of both medical imaging and new systemic agents (targeted therapy and immunotherapy) have revolutionized the field of oncology, leading to a new entity: oligometastatic disease. Adding local treatment of oligometastases to systemic treatment could lead to prolonged survival with no significant impact on quality of life. Given the high prevalence of lung oligometastases and the new systemic agents coming with increased pulmonary toxicity, this article provides a comprehensive review of the current state-of-art for radiotherapy of lung oligometastases. After reviewing pretreatment workup, the authors define several radiotherapy regimen based on the localization and size of the oligometastases. A comment on the synergistic combination of medical treatment and radiotherapy is also made, projecting on future steps in this specific clinical setting.

Detection of early (T1) lung cancers and lepidic adenocarcinomas in sputum and bronchial cytology

BACKGROUND

The lung is an extensively epithelialized organ, producing ample exfoliated material for sputum and bronchial cytology. In view of the updates in the World Health Organization classification of early (T1/≤ 3 cm) lung cancer with respect to adenocarcinomas with lepidic pattern, this study retrospectively reviews sputum and bronchial cytology paired with resection-confirmed lung cancers.

METHODS

A computerized search for all lung resection specimens of carcinomas over a 20-year period was performed. Cytologic diagnoses of corresponding sputum and bronchial cytology were classified into five-tiered categories (C1-insufficient/inadequate, C2-benign, C3-atypia, C4-suspicious and C5-malignant). Reports and slides of the resection specimen were reviewed for reclassification of T1 cancers.

RESULTS

Totally 472 and 383 sputum and bronchial cytology specimens respectively were included. Sensitivity for T1 lesions on sputum cytology were 10.6 %, 2.1 % and 0.5 % at cutoffs of atypia/C3, suspicious/C4 and malignant/C5 categories, lower than bronchial cytology (35.1 %, 15.5 %, 8.1 %; p < 0.001). T1 lesions correlated with lower detection rates, whereas squamous cell carcinoma histology, larger size and bronchial invasion were associated with increased detection rates in sputum and bronchial cytology (p < 0.050). Detection rates for abrasive bronchial cytology (brushing) were overall higher (p = 0.018- < 0.001), but on subgroup comparison, non-abrasive (aspiration, lavage and washing) cytology demonstrated favorable trends (p = 0.063-0.088) in detecting T1 lesions. Adenocarcinomas with lepidic pattern had lower suspicious/C4 (p = 0.040) or above and malignant/C5 (p = 0.019), but not atypia/C3 or above (p = 0.517) rates.

CONCLUSIONS

Most adenocarcinomas with lepidic pattern are only diagnosed as atypia/C3 on cytology. With its modest sensitivity, interpretation of negative and indeterminate cytology results mandates caution.

Stereotactic radiotherapy for ultracentral lung tumours

Ultracentral (UC) lung lesions are generally defined by the presence of the tumour or the Planning Target Volume (PTV) abutting proximal bronchial tree (PBT) or the esophagus. Initial reports rose awareness regarding the potential toxicity of stereotactic body radiotherapy (SBRT) when delivered to UC lesions. Major concerns include necrosis, stenosis, and bleeding of the PBT. Technological improvements now enable the delivery of more accurate treatments, possibly redefining the historical "no-fly zone". In this review, studies focusing on the treatment of UC lesions with SBRT are presented. The narrow therapeutic window requires a multidisciplinary approach.

Real-World Biomarker Test Utilization and Subsequent Treatment in Patients with Early-Stage Non-small Cell Lung Cancer in the United States, 2011-2021

INTRODUCTION

Biomarker testing is increasingly crucial for patients with early-stage non-small cell lung cancer (eNSCLC). We explored biomarker test utilization and subsequent treatment in eNSCLC patients in the real-world setting.

METHODS

Using COTA's oncology database, this retrospective observational study included adult patients ≥ 18 years old diagnosed with eNSCLC (disease stage 0-IIIA) between January 1, 2011 and December 31, 2021. Date of first eNSCLC diagnosis was the study index date. We reported testing rates by index year for patients who received any biomarker test within 6 months of eNSCLC diagnosis and by each molecular marker. We also evaluated treatments received among patients receiving the five most common biomarker tests.

RESULTS

Among the 1031 eNSCLC patients included in the analysis, 764 (74.1%) received ≥ 1 biomarker test within 6 months of eNSCLC diagnosis. Overall, epidermal growth factor receptor (EGFR; 64%), anaplastic lymphoma kinase (ALK; 60%), programmed death receptor ligand 1 (PD-L1; 48%), ROS proto-oncogene 1 (ROS1; 46%), B-Raf proto-oncogene (40%), mesenchymal epithelial transition factor receptor (35%), Kirsten rat sarcoma viral oncogene (29%), RET proto-oncogene (22%), human epidermal growth factor receptor 2 (21%), and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (20%) were the 10 most frequently tested biomarkers. The proportion of patients undergoing biomarker testing rose from 55.3% in 2011 to 88.1% in 2021. The most common testing methods were Sanger sequencing for EGFR (244, 37%), FISH (fluorescence in situ hybridization) for ALK (464, 75%) and ROS1 (357, 76%), immunohistochemical assay for PD-L1 (450, 90%), and next-generation sequencing testing for other biomarkers. Almost all the 763 patients who received the five most common biomarker tests had a test before the initiation of a systemic treatment.

CONCLUSION

This study suggests a high biomarker testing rate among patients with eNSCLC in the US, with testing rates for various biomarkers increasing over the past decade, indicating a continuous trend towards the personalization of treatment decisions.

Survival impact of fibrotic interstitial lung abnormalities in resected stage IA non-small cell lung cancer

OBJECTIVES

To assess the association between fibrotic interstitial lung abnormalities (ILAs) and long-term survival in patients with resected Stage IA non-small cell lung cancer (NSCLC).

METHODS

Data of patients who underwent curative resection of pathological Stage IA NSCLC between 2010 and 2015 were retrospectively analysed. ILAs were evaluated using pre-operative high-resolution CT scans. The association between ILAs and cause-specific mortality was assessed via Kaplan-Meier analysis and the log-rank test. Cox proportional hazards regression was performed to determine the risk factors for cause-specific death.

RESULTS

Overall, 228 patients were identified (63.27 ± 8.54 years, 133 men [58.3%]). ILAs were detected in 24 patients (10.53%). Fibrotic ILAs were observed in 16 patients (7.02%), and there was a significantly higher cause-specific mortality rate among patients with fibrotic ILAs compared with patients with no ILAs (p < 0.001). Patients with fibrotic ILAs had a significantly higher cause-specific mortality rate than patients without ILAs at 5 post-operative years (survival rate: 61.88% vs 93.03%, p < 0.001). The presence of afibrotic ILA was an independent risk factor for cause-specific death (adjusted hazard ratio = 3.22; 95% confidence interval: 1.10, 9.44; p = 0.033).

CONCLUSION

The presence of afibrotic ILA was a risk factor for cause-specific death in patients with resected Stage IA NSCLC. Radiologists and clinicians should be familiar with the relatively new concept of ILAs and understand the close association between ILA status and long-term survival in resected Stage IA NSCLC. Patients presenting fibrotic ILAs should receive appropriate surveillance and management to optimise prognosis.

ADVANCES IN KNOWLEDGE

Fibrotic ILAs are important findings implicated inthe long-term survival of patients with resected Stage IA NSCLC. Specific management is required for this group.

Real-world study of disease-free survival & patient characteristics associated with disease-free survival in early-stage non-small cell lung cancer: A retrospective observational study

INTRODUCTION/ BACKGROUND

Surgical resection remains standard of care for patients with early-stage non-small cell lung cancer (NSCLC), but research shows that adjuvant therapy can reduce the risk of disease recurrence. Our objective was to characterize disease-free survival (DFS) using real-world data.

MATERIALS AND METHODS

This was a retrospective study using the COTA real-world database derived from electronic health records in the United States (US). Adults diagnosed with stage IB-IIIA NSCLC from 2013 to 2018 who underwent complete surgical resection (index date) for NSCLC were included. DFS was analyzed using the Kaplan-Meier method. A multivariable Cox-Proportional Hazard (PH) model stratified by year of diagnosis was developed to evaluate covariates associated with DFS.

RESULTS

703 patients met the study criteria (mean age 66.2 years, female (56%), White (82%), and median follow-up time was 37.4 months from index date. Approximately 48% of patients experienced recurrence or death with a median DFS of 42.9 months (95% CI: 37.4-52.2). Patients who received adjuvant therapy, neoadjuvant and adjuvant therapy, neoadjuvant therapy, and surgery only experienced a median DFS of 43.7, 32.3, 33.7, and 49.4 months, respectively. After adjustment, stage at diagnosis and adjuvant therapy status were significantly associated with DFS events.

CONCLUSIONS

Higher stage at diagnosis and lack of adjuvant therapy were associated with greater risk of recurrence. Future research should focus on the adoption and effect of adjuvant/ neoadjuvant therapies on disease recurrence, including in patients with oncogenic driver mutations.

Lung cancer survivors' views on telerehabilitation following curative intent therapy: a formative qualitative study

OBJECTIVES

To inform personalised home-based rehabilitation interventions, we sought to gain in-depth understanding of lung cancer survivors' (1) attitudes and perceived self-efficacy towards telemedicine; (2) knowledge of the benefits of rehabilitation and exercise training; (3) perceived facilitators and preferences for telerehabilitation; and (4) health goals following curative intent therapy.

DESIGN

We conducted semi-structured interviews guided by Bandura's Social Cognitive Theory and used directed content analysis to identify salient themes.

SETTING

One USA Veterans Affairs Medical Center.

PARTICIPANTS

We enrolled 20 stage I-IIIA lung cancer survivors who completed curative intent therapy in the prior 1-6 months. Eighty-five percent of participants had prior experience with telemedicine, but none with telerehabilitation or rehabilitation for lung cancer.

RESULTS

Participants viewed telemedicine as convenient, however impersonal and technologically challenging, with most reporting low self-efficacy in their ability to use technology. Most reported little to no knowledge of the potential benefits of specific exercise training regimens, including those directed towards reducing dyspnoea, fatigue or falls. If they were to design their own telerehabilitation programme, participants had a predominant preference for live and one-on-one interaction with a therapist, to enhance therapeutic relationship and ensure correct learning of the training techniques. Most participants had trouble stating their explicit health goals, with many having questions or concerns about their lung cancer status. Some wanted better control of symptoms and functional challenges or engage in healthful behaviours.

CONCLUSIONS

Features of telerehabilitation interventions for lung cancer survivors following curative intent therapy may need to include strategies to improve self-efficacy and skills with telemedicine. Education to improve knowledge of the benefits of rehabilitation and exercise training, with alignment to patient-formulated goals, may increase uptake. Exercise training with live and one-on-one therapist interaction may enhance learning, adherence, and completion. Future work should determine how to incorporate these features into telerehabilitation.

Relationship between Systemic Inflammatory Markers, GLUT1 Expression, and Maximum 18F-Fluorodeoxyglucose Uptake in Non-Small Cell Lung Carcinoma and Their Prognostic Significance

BACKGROUND

Factors involved in inflammation and cancer interact in various ways with each other, and biomarkers of systemic inflammation may have a prognostic value in cancer. Glucose transporter 1 (GLUT1) plays a pivotal role in glucose transport and metabolism and it is aberrantly expressed in various cancer types. We evaluated the differential expression of GLUT1, along with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in non-small-cell lung cancer (NSCLC), and then analyzed their prognostic significance.

METHODS

A total of 163 patients with resectable NSCLC were included in this study. Tumor sections were immunohistochemically stained for GLUT1 and GLUT3. Maximum standardized uptake value (SUV_max) was measured by preoperative FDG-PET, and neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR) were derived from pretreatment blood count.

RESULTS

GLUT1 and GLUT3 was positively expressed in 74.8% and 6.1% of the NSCLC tissues, respectively. GLUT1 expression was significantly correlated with squamous cell carcinoma histology, poor differentiation, high pathologic stage, old age, male, smoking, and high SUV_max (>7) (all p < 0.05). The squamous cell carcinoma and smoker group also showed significantly higher SUV_max (both p < 0.001). Systemic inflammation markers, including NLR, PLR, and LMR, were positively correlated with high SUV_max (all p < 0.05). High GLUT1 expression, high SUV_max, high NLR, and low LMR, were significantly associated with poor overall survival in patients with NSCLC. However, in the multivariate survival analysis, LMR was an independent prognostic factor overall (HR 1.86, 95% CI 1.05-3.3) and for the stage I/II cohort (HR 2.3, 95% CI 1.24-4.3) (all p < 0.05).

CONCLUSIONS

Systemic inflammatory markers-NLR, PLR, and LMR are strongly correlated with the SUV_max and are indicators of aggressive tumor behavior. Specifically, LMR is a promising prognostic biomarker in NSCLC patients.

Emerging precision neoadjuvant systemic therapy for patients with resectable non-small cell lung cancer: current status and perspectives

Over the past decade, targeted therapy for oncogene-driven NSCLC and immune checkpoint inhibitors for non-oncogene-driven NSCLC, respectively, have greatly improved the survival and quality of life for patients with unresectable NSCLC. Increasingly, these biomarker-guided systemic therapies given before or after surgery have been used in patients with early-stage NSCLC. In March 2022, the US FDA granted the approval of neoadjuvant nivolumab and chemotherapy for patients with stage IB-IIIA NSCLC. Several phase II/III trials are evaluating the clinical efficacy of various neoadjuvant immune checkpoint inhibitor combinations for non-oncogene-driven NSCLC and neoadjuvant molecular targeted therapies for oncogene-driven NSCLC, respectively. However, clinical application of precision neoadjuvant treatment requires a paradigm shift in the biomarker testing and multidisciplinary collaboration at the diagnosis of early-stage NSCLC. In this comprehensive review, we summarize the current diagnosis and treatment landscape, recent advances, new challenges in biomarker testing and endpoint selections, practical considerations for a timely multidisciplinary collaboration at diagnosis, and perspectives in emerging neoadjuvant precision systemic therapy for patients with resectable, early-stage NSCLC. These biomarker-guided neoadjuvant therapies hold the promise to improve surgical and pathological outcomes, reduce systemic recurrences, guide postoperative therapy, and improve cure rates in patients with resectable NSCLC.

Adjuvant chemotherapy may improve long-term outcomes in stage IB non-small cell lung cancer patients with previous malignancies: A propensity score-matched analysis

Background

Routine administration of adjuvant chemotherapy for stage IB non-small cell lung cancer (NSCLC) remains controversial. To our knowledge, no available studies have assessed the outcomes of chemotherapy in patients with stage IB NSCLC who had prior malignancies.

Methods

Patients with pathological stage IB NSCLC with previous malignancies who underwent surgery between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were categorized into chemotherapy and observation group based on whether they received adjuvant chemotherapy. Propensity score matching was performed to reduce confounding bias, and Kaplan–Meier curves and log-rank tests were used to compare overall survival (OS) and cancer-specific survival (CSS) between the two groups. Subgroup analyses of the matched cohorts were then conducted to evaluate the relationship between clinical features and chemotherapy.

Results

A total of 894 eligible patients were identified; 90 (10.1%) patients received postoperative chemotherapy. Patients who received adjuvant chemotherapy obtained obvious OS benefits compared with those who received observation alone (HR = 0.68, 95% CI: 0.48–0.97, P = 0.031). In addition, the 5-year OS rate and median OS time in the chemotherapy group were higher and longer, respectively. Although chemotherapy offered no obvious benefits for CSS (HR = 0.80, 95% CI: 0.57–1.14, P = 0.35), patients who received chemotherapy showed a better 5-year CSS rate. On subgroup analyses, a chemotherapy advantage was observed in advanced age (≥65 years, HR = 0.62, 95% CI: 0.38–0.99, P = 0.045). The same chemotherapy advantages were observed in patients diagnosed with higher histological grades (poorly differentiated to undifferentiated) (HR = 0.56, 95% CI: 0.33–0.96, P = 0.033) and tumor sizes >3.1–4 cm (HR = 0.57, 95% CI: 0.37–0.87, P = 0.010). Interestingly, NSCLC patients with previous malignancies originating from the kidney and bladder (HR = 0.34, 95% CI: 0.12–0.99, P = 0.049) showed a chemotherapy advantage. The same chemotherapy advantages were observed in patients diagnosed with NSCLC within 3 to 5 years after prior cancers (HR = 0.39, 95% CI: 0.16–0.98, P = 0.044) and with localized SEER stage of prior cancers (HR = 0.49, 95% CI: 0.29–0.86, P = 0.012).

Conclusion

These findings indicate that adjuvant chemotherapy may improve long-term outcomes for stage IB NSCLC patients with previous malignancies. It is recommended that physicians consider the clinical features of previous cancers when making adjuvant chemotherapy decisions for these patients.

Oncologic Outcomes of Patients With Resected T3N0M0 Non-small Cell Lung Cancer

In the eighth edition TNM staging, the T3N0M0 category represents a heterogeneous group of non-small cell lung cancers (NSCLC). This study aims to compare the oncologic outcomes associated with individual T3 features. We performed a single-institution, retrospective analysis of 280 consecutive patients with pT3N0M0 NSCLC. Multivariate regression models were used to estimate associations of clinical factors with oncologic outcomes. The patients were grouped according to their T3 features into 4 prognostic groups: chest wall infiltration (CWI-PG), largest diameter >5 cm and ≤7 cm (Size-PG), presence of a satellite nodule (SN-PG), and all other T3 features. Overall survival (OS) and progression-free survival (PFS) were estimated using Kaplan-Meier and Cox proportional hazard analyses. Tumors were most often classified as T3N0M0 by size (156 patients, 55.7%), and the highest rate of incomplete resection occurred in patients with CWI (n = 7, 25.9%). In multivariate analysis, CWI (hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.36, 4.44), incomplete resection (HR 3.01, 95% CI 1.29, 7.05), and age >65 (HR 1.6; 95% CI 1.08, 2.38) were independently associated with worse OS, and female sex was associated with better OS (HR 0.6, 95% CI 0.42, 0.87). The CWI-PG had poorer OS when compared with each of the other prognostic groups (P < 0.05), and the Size-PG had inferior OS when compared with the SN-PG (P = 0.039). This single-center study demonstrated significant differences in OS and PFS between patients with different T3 classifying features and suggest that further subdivision of the T3 category should be considered.

Microwave ablation with local pleural anesthesia for subpleural pulmonary nodules: our experience

Objectives

To explore the efficacy and safety of local pleural anesthesia (LPA) for relieving pain during microwave ablation (MWA) of pulmonary nodules in the subpleural regions.

Materials and Methods

From June 2019 to December 2021, 88 patients with 97 subpleural nodules underwent percutaneous CT-guided MWA. Patients were divided into two groups according to whether LPA was applied; 53 patients with local pleural anesthesia during MWA; and 35 patients with MWA without LPA. The differences in technical success, pre-and post- and intra-operative visual analog scale (VAS) pain scores, complications of the procedure, and local progression-free survival (LPFS) between the two groups were assessed. Thus, to evaluate the efficacy and safety of MWA combined with LPA for treating subpleural nodules.

Results

In this study, the procedures in all patients of both groups achieved technical success according to pre-operative planning. There was no statistically significant difference in the pre-operative VAS pain scores between the two groups. Intra-operative VAS scores were significantly higher in the non-LPA (NLPA) group than in the LPA group. They remained significantly higher in the NLPA group than in the LPA group during the short postoperative period. Analgesics were used more in the NLPA group than in the LPA group intra- and postoperatively, with a statistically significant difference, especially during the MWA procedures. The overall LPFS rates were 100%, 98.333%, 98.333%, and 98.333% at 1, 3, 6, and 12 months postoperatively in the LPA group and 100%, 97.297%, 94.595%, and 94.595% postoperatively in the NLPA group, respectively. Tumor recurrence occurred in one and two patients with lung adenocarcinoma in the LPA and NLPA groups. The incidence of pneumothorax was significantly higher in the NLPA group (25,714%, 9/35) than in the LPA group (15.094%, 8/53), and there were three cases of pleural effusion (blood collection) and one case of pulmonary hemorrhage in the NLPA group.

Conclusion

Percutaneous CT-guided MWA is a safe and effective treatment for subpleural pulmonary nodules. Applying a combined LPA technique can reduce the patient's pain and complications during and after the MWA. The long-term efficacy must be verified in more patients and a longer follow-up.

Chemo-radiotherapy plus durvalumab for loco-regional relapse of resected NSCLC

BACKGROUND

tumor recurrence after NSCLC surgical resection is the most common cause of treatment failure that sharply reduces the patient's life expectancy. The optimal treatment strategy for loco-regional recurrences developing after surgical resection in patients with non-small-cell lung cancer (NSCLC) is not established yet. This report aims to describe the pattern of relapse, PFS, and OS in patients treated with radio-chemotherapy and durvalumab for loco-regional relapse after surgery.

METHODS

 We conducted a multicenter, retrospective study including subjects who underwent surgical resection for NSCLC and were treated with Pacific protocol after loco-regional relapse.

RESULTS

Twenty-four patients met the inclusion criteria. At the time of diagnosis mean age was 65 years (range 47-78), the majority being male (58.3%). The 12-month progression-free survival rate was 68.7%, the 18-month progression-free survival rate was 45.8%, and the 24-month progression-free survival rate was 34.3%. There were three deaths: the 12-month survival rate was 91%, and the 18-month survival rate was 82.8%.

CONCLUSIONS

In this article, we propose a treatment strategy that might prolong post recurrence survival in patients with good performance status experiencing loco-regional relapse after surgery.

Percutaneous local tumor ablation vs. stereotactic body radiotherapy for early-stage non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

Percutaneous local tumor ablation (LTA) and stereotactic body radiotherapy (SBRT) have been regarded as viable treatments for early-stage lung cancer patients. The purpose of this study was to compare the efficacy and safety of LTA with SBRT for early-stage non-small cell lung cancer (NSCLC).

METHODS

PubMed, Embase, Cochrane library, Ovid, Google scholar, CNKI, and CBMdisc were searched to identify potential eligible studies comparing the efficacy and safety of LTA with SBRT for early-stage NSCLC published between January 1, 1991, and May 31, 2021. Hazard ratios (HRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were applied to estimate the effect size for overall survival (OS), progression-free survival (PFS), locoregional progression (LP), and adverse events.

RESULTS

Five studies with 22,231 patients were enrolled, including 1443 patients in the LTA group and 20,788 patients in the SBRT group. The results showed that SBRT was not superior to LTA for OS (HR = 1.03, 95% CI: 0.87-1.22, P = 0.71). Similar results were observed for PFS (HR = 1.09, 95% CI: 0.71-1.67, P = 0.71) and LP (HR = 0.66, 95% CI: 0.25-1.77, P = 0.70). Subgroup analysis showed that the pooled HR for OS favored SBRT in patients with tumors sized >2 cm (HR = 1.32, 95% CI: 1.14-1.53, P = 0.0003), whereas there was no significant difference in patients with tumors sized ≤2 cm (HR = 0.93, 95% CI: 0.64-1.35, P = 0.70). Moreover, no significant differences were observed for the incidence of severe adverse events (≥grade 3) (OR = 1.95, 95% CI: 0.63-6.07, P = 0.25) between the LTA group and SBRT group.

CONCLUSIONS

Compared with SBRT, LTA appears to have similar OS, PFS, and LP. However, for tumors >2 cm, SBRT is superior to LTA in OS. Prospective randomized controlled trials are required to determine such findings.

INPLASY REGISTRATION NUMBER

INPLASY202160099.

PTEN mutant non-small cell lung cancer require ATM to suppress pro-apoptotic signalling and evade radiotherapy

Background

Despite advances in treatment of patients with non-small cell lung cancer, carriers of certain genetic alterations are prone to failure. One such factor frequently mutated, is the tumor suppressor PTEN. These tumors are supposed to be more resistant to radiation, chemo- and immunotherapy.

Results

We demonstrate that loss of PTEN led to altered expression of transcriptional programs which directly regulate therapy resistance, resulting in establishment of radiation resistance. While PTEN-deficient tumor cells were not dependent on DNA-PK for IR resistance nor activated ATR during IR, they showed a significant dependence for the DNA damage kinase ATM. Pharmacologic inhibition of ATM, via KU-60019 and AZD1390 at non-toxic doses, restored and even synergized with IR in PTEN-deficient human and murine NSCLC cells as well in a multicellular organotypic ex vivo tumor model.

Conclusion

PTEN tumors are addicted to ATM to detect and repair radiation induced DNA damage. This creates an exploitable bottleneck. At least in cellulo and ex vivo we show that low concentration of ATM inhibitor is able to synergise with IR to treat PTEN-deficient tumors in genetically well-defined IR resistant lung cancer models.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13578-022-00778-7.

LncRNA HOXC-AS3 promotes non-small-cell lung cancer growth and metastasis through upregulation of YBX1

NSCLC is common and is the primary cause of cancer-related deaths due to a lack of early diagnosis and its propensity for metastasis. The pathogenesis of NSCLC is still unclear. Here, we explored the molecular mechanisms underlying NSCLC development, focusing on the HOXC-AS3/YBX1/HOXC8 axis. Human NSCLC specimens and cell lines were used. qRT-PCR and western blotting were utilised to examine the levels of HOXC-AS3/YBX1/HOXC8. CCK-8, colony formation, scratch wound healing and Transwell assays were performed to evaluate cancer cell proliferation, migration and invasion. A nude mouse xenograft model was used to examine tumour growth and metastasis in vivo. RNA pull-down, chromatin immunoprecipitation, coimmunoprecipitation and dual-luciferase assays were applied to validate the interactions of HOXC-AS3/YBX1, MDM2/YBX1 and the YBX1/HOXC8 promoter. The levels of HOXC-AS3 and HOXC8 were increased in human NSCLC specimens and cells. Knockdown of HOXC-AS3 suppressed NSCLC cell proliferation, migration and invasion, as well as tumour growth and metastasis in vivo. HOXC-AS3 directly bound to YBX1 to suppress its ubiquitination mediated by MDM2. YBX1 bound to the HOXC8 promoter and enhanced its transcription. Knockdown of HOXC8 inhibited the effects of HOXC-AS3 overexpression on NSCLC. HOXC-AS3 promotes NSCLC growth and metastasis by stabilising YBX1 and thus increasing HOXC8 transcription. Our study indicates that the HOXC-AS3/YBX1/HOXC8 axis could serve as a biomarker for NSCLC diagnosis or as a target for therapy development.

USP28 enables oncogenic transformation of respiratory cells and its inhibition potentiates molecular therapy targeting mutant EGFR, BRAF and PI3K

Oncogenic transformation of lung epithelial cells is a multistep process, frequently starting with the inactivation of tumour suppressors and subsequent development of activating mutations in proto‐oncogenes, such as members of the PI3K or MAPK families. Cells undergoing transformation have to adjust to changes, including altered metabolic requirements. This is achieved, in part, by modulating the protein abundance of transcription factors. Here, we report that the ubiquitin carboxyl‐terminal hydrolase 28 (USP28) enables oncogenic reprogramming by regulating the protein abundance of proto‐oncogenes such as c‐JUN, c‐MYC, NOTCH and ∆NP63 at early stages of malignant transformation. USP28 levels are increased in cancer compared with in normal cells due to a feed‐forward loop, driven by increased amounts of oncogenic transcription factors such as c‐MYC and c‐JUN. Irrespective of oncogenic driver, interference with USP28 abundance or activity suppresses growth and survival of transformed lung cells. Furthermore, inhibition of USP28 via a small‐molecule inhibitor resets the proteome of transformed cells towards a ‘premalignant’ state, and its inhibition synergizes with clinically established compounds used to target EGFR^L858R‐, BRAF^V600E‐ or PI3K^H1047R‐driven tumour cells. Targeting USP28 protein abundance at an early stage via inhibition of its activity is therefore a feasible strategy for the treatment of early‐stage lung tumours, and the observed synergism with current standard‐of‐care inhibitors holds the potential for improved targeting of established tumours.

Effect of prior antibiotic or chemotherapy treatment on immunotherapy response in non-small cell lung cancer

BACKGROUND

Treatment outcomes of advanced non-small cell lung cancer (NSCLC) have substantially improved with immune checkpoint inhibitors (ICI), although only approximately 19% of patients respond to immunotherapy alone, increasing to 58% with the addition of chemotherapy. The gut microbiome has been recognized as a modulator of ICI response via its priming effect on the host immune response. Antibiotics as well as chemotherapy reduce gut microbial diversity, hence altering composition and function of the gut microbiome. Since the gut microbiome may modify ICI efficacy, we conducted a retrospective study evaluating the effects of prior antibiotic or chemotherapy use on NSCLC patient response to ICI.

METHODS

We retrospectively evaluated 256 NSCLC patients treated between 2011-2017 at Moffitt Cancer Center with ICI ± chemotherapy, examining the associations between prior antibiotic or chemotherapy use, overall response rate and survival. Relative risk regression using a log-link with combinatorial expectation maximization algorithm was performed to analyze differences in response between patients treated with antibiotics or chemotherapy versus patients who didn't receive antibiotics or chemotherapy. Cox proportional hazards models were constructed to evaluate associations between risk factors and overall survival.

RESULTS

Only 46 (18% of 256) patients used antibiotics prior to and/or during ICI treatment, and 146 (57%) had prior chemotherapy. Antibiotic users were 8% more likely to have worse overall response rate (RR:1.08; CI:0.93-1.26; p = 0.321), as well as a 35% worse overall survival (HR:1.35; CI:0.91-2.02; p = 0.145), although results were not statistically significant. However, prior use of chemotherapy was significantly associated with poor ICI response (RR:1.24; CI:1.05-1.47; p = 0.013) and worse overall survival (HR:1.47; CI:1.07-2.03; p = 0.018).

CONCLUSIONS

Patients receiving antibiotics prior to and/or during ICI therapy might experience worse treatment outcomes and survival than unexposed patients, although these associations were not statistically significant and hence warrant further prospective study. Prior chemotherapy significantly reduced ICI response and overall survival. Antibiotic or chemotherapy exposure may negatively impact ICI response, perhaps through disruption of the eubiotic gut microbiome.

Effectiveness of Postoperative or Preoperative Radiotherapy on Prognosis in Patients with Stage II Resectable Non-Small Cell Lung Cancer: A Retrospective Study Based on the SEER Database

Background and Objectives: The research on the therapeutic effect of preoperative radiotherapy (PRRT) for patients with early non-small cell lung cancer (NSCLC) is still insufficient, and the impact of postoperative radiotherapy (PORT) on the prognosis of patients with early NSCLC remains controversial. We conducted this study to investigate the effect of PORT and PRRT on prognosis for these patients. Materials and Methods: In total, 3640 patients with stage II NSCLC who underwent a lobectomy or pneumonectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate regression was adopted to identify the independent influence of PORT or PRRT on patients’ prognosis. Subgroup analysis of survival was performed in patients with different combinations of key clinical features. We also used Kaplan-Meier analysis and competitive risk analysis to explore to which extent PORT or PRRT impacted the overall survival and cumulative mortality. Results: PORT was an independent risk factor of NSCLC-specific death among patients with N0 stage (HR, 1.648; 95% CI, 1.309–2.075, p < 0.001) and in N1 stage with <3 positive lymph nodes (HR, 2.698; 95% CI, 1.910–3.812, p < 0.001) in multivariate analysis. Findings from subgroup analysis for the risk of NSCLC-specific death, competitive risk analysis of NSCLC-specific cumulative mortality, and overall survival analysis also demonstrated PORT was detrimental to patients in these two subgroups above (p < 0.05). However, in patients with N1 stage with ≥3 positive lymph nodes, PORT may help prolong median survival. PRRT was an independent risk factor for NSCLC-specific death in multivariate analysis of patients with N0 stage (HR, 1.790; 95% CI, 1.201–2.668, p = 0.004), and significantly decreased overall survival in these patients (p < 0.001). Conclusion: PORT is associated with worse survival outcome and better cumulative mortality of stage II patients of NSCLC with N0 disease or N1 disease (<3 nodes), while PRRT is associated with reduced prognosis in patients with N0 stage. On the other hand, PORT may help to improve the prognosis of patients with N1 stage who have three or more lymph node metastases. Hence, PORT and PRRT should not be recommended for patients with N0 stage. However, in patients with “high volume” N1 stage, PORT might improve oncological outcomes.

Research on the application of uniportal video-assisted thoracoscopic segmental resection of the lung in elderly patients with non-small cell lung cancer aged over 65 years

Introduction

The literature regarding the application of uniportal video-assisted thoracoscopic segmental resection of the lung in patients aged over 65 years with non-small cell lung cancer (NSCLC) is sparse. This paper reports 175 cases of uniportal video-assisted thoracoscopic segmental resection of the lung performed at one center, of which 63 patients were over 65 years old.

Aim

To investigate the safety and feasibility of uniportal video-assisted thoracoscopic segmental resection of the lung in elderly patients aged over 65 years with NSCLC.

Material and methods

A retrospective analysis of 175 NSCLC patients who underwent uniport video-assisted thoracoscopic segmental resection of the lung in the center from August 2018 to August 2020 was conducted, and based on the age of 65 years, patients were divided into elderly and non-elderly groups. The general data and perioperative indicators of the two groups were compared.

Results

The procedures were completed in all patients without death or conversion to open surgery. In the general data of the two groups of patients, the prevalence of emphysema in the elderly group was significantly higher than that in the non-elderly group (p = 0.001). However, there was no statistically significant difference between the two groups in surgery time, intraoperative blood loss, thoracic drainage tube retention time, postoperative hospital stay, incision satisfaction, or postoperative complications (p > 0.05).

Conclusions

Uniportal video-assisted thoracoscopic segmental resection of the lung is feasible and safe in elderly patients with NSCLC aged over 65 years.

Overall Survival Analyses following Adjuvant Chemotherapy or Nonadjuvant Chemotherapy in Patients with Stage IB Non-Small-Cell Lung Cancer

Background

Adjuvant chemotherapy (ACT) can improve prognosis for stages II-IIIA patients with non-small-cell lung cancer (NSCLC), but its implication in stage I patients is still an intractable puzzle. This study aims to seek ACT candidates for stage IB NSCLC and establish a nomogram to predict overall survival (OS) of specific patient for clinician's decision.

Method

We performed a retrospective study on 16,765 patients (ACT group: n = 2,187; non-ACT group: n = 14,578) from the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival was assessed in two groups. We performed propensity-score matching for risk adjustment. The risk factors were identified and used to create nomogram. Concordance index (C-index), Hosmer–Lemeshow test, and calibration were applied to evaluate model performance. To further evaluate the influence of tumor size on the selection of potential ACT candidates for patients with stage IB NSCLC, subgroup analyses were executed.

Result

Survival analysis for the entire study cohort showed that ACT had better OS than non-ACT (HR = 0.800, CI: (0.751–0.851), P < 0.0001). In matched cohort, ACT also presented better OS than non-ACT (HR = 0.775, CI: (0.704–0.853), P < 0.0001). Univariate and multivariate Cox regression analysis revealed that eight prognostic factors, including gender, age, grade, pathological subtype, tumor size, visceral pleural invasion, surgical procedure, and the number of removed lymph nodes, were significantly correlated with OS. The nomogram was further constructed based on these prognostic factors. The C-index of nomogram was 0.639 (95%CI: 0.632–0.646). The Hosmer–Lemeshow test, and calibration presented good congruence between the predictions and actual observations. Subgroup analyses of tumor size group showed that ACT shared similar OS to non-ACT in NSCLC patients with tumor size ≤20 mm (P > 0.05). However, for NSCLC patients with 20 mm < size ≤30 mm (HR = 0.845, 95%CI (0.724–0.986), P=0.032) and 30 mm < size ≤40 mm (HR = 0.912, 95%CI (0.833–1.000), P=0.049), ACT associated with better OS.

Conclusion

In this study, we found that ACT had better OS than non-ACT in patients with stage IB NSCLC. The nomogram provided an individual prediction of OS for patients after surgical resection. Patients with tumor size >20 mm and ≤40 mm may be potential candidates for ACT.

12 × 6 Gy stereotactic radiotherapy for lung tumors. Is there a difference in response between lung metastases and primary bronchial carcinoma?

PURPOSE

The aim of this study was to evaluate the safety and long-term tumor control after stereotactic radiotherapy (SRT) with 12 × 6 Gy of patients with primary bronchial carcinoma (BC) or with pulmonary metastases (MET) of various solid tumors. Local progression-free survival (LPFS), progression-free survival (PFS), overall survival (OS), and prognostic factors were compared.

METHODS

Between May 2012 and January 2020, 168 patients with 206 pulmonary lesions (170 MET and 36 primary BC) were treated with 12 × 6 Gy (BED₁₀ 116 Gy). The irradiated pulmonary MET were from the following cancers: 47 (27.6%) head and neck, 37 (21.8%) rectum or colon, 30 (17.6%) bronchial, 13 (7.6%) malignant melanoma, 9 (5.3%) esophageal, 9 (5.3%) sarcoma, and 25 (14.8%) other.

RESULTS

The median follow-up was 16.26 months (range: 0.46-89.34) for BC and 19.18 months (0.89-91.11) for MET. Survival rates at 3 years were: OS 43% for BC and 35% for MET; LPFS BC 96% and MET 85%; PFS BC 35% and MET 29%. The most frequently observed grade 3 adverse events (AEs) were pneumonitis (5.9% BC, 4.8% MET), pulmonary fibrosis (2.9% BC, 4% MET), and pulmonary embolism (2.9% BC, 0.8% MET). The favorable prognostic effects on overall survival of patients with MET were female gender (log-rank: p < 0.001), no systemic progression (log-rank; p = 0.048, multivariate COX regression p = 0.039), and malignant melanoma histology (log-rank; p = 0.015, multivariate COX regression p = 0.020). For patients with BC, it was tumor location within the lower lobe (vs. upper lobe, log-rank p = 0.027). LPFS of patients with metastatic disease was beneficially influenced by female gender (log-rank: p = 0.049).

CONCLUSION

The treatment concept of 12 × 6 Gy is associated with 96% local progression-free survival for BC and 85% for pulmonary metastases after 3 years. There was no difference in response after SRT of primary lung carcinoma or pulmonary metastases.

Multi-disciplinary approach for the management of non-metastatic non-small cell lung cancer in the Middle East and Africa: Expert panel recommendations

The Middle East and Africa (MEA) region, a large geographical area, lies at the confluence of Asian, Caucasian and African races and comprises of a population with several distinct ethnicities. The course of management of non-small cell lung cancer (NSCLC) differs as per patients' performance status as well as stage of disease, requiring personalized therapy decisions. Although management of NSCLC has received a significant impetus in the form of molecularly targeted therapies and immune therapies in last few years, surgery remains gold standard for patients with early-stage disease. In case of unresectable disease, radiotherapy and chemotherapy are the primary management modalities. With newer therapies being approved for treatment of early stage disease, use of multi-disciplinary team (MDT) for comprehensive management of NSCLC is of prime importance. A group of experts with interest in thoracic oncology, deliberated and arrived at a consensus statement for the community oncologists treating patients with NSCLC in the MEA region. The deliberation was based on the review of the published evidence including literature and global and local guidelines, subject expertise of the participating panellists and experience in real-life management of patients with NSCLC. We present the proposed regional adaptations of international guidelines and recommends the MDT approach for management of NSCLC in MEA.

Society of Interventional Radiology Quality Improvement Standards on Percutaneous Ablation of Non-Small Cell Lung Cancer and Metastatic Disease to the Lungs

PURPOSE

To provide guidance on quality improvement thresholds for outcomes and complications of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease.

MATERIALS AND METHODS

A multidisciplinary writing group conducted a comprehensive literature search to identify studies on the topic of interest. Data were extracted from relevant studies and thresholds were derived from a calculation of 2 standard deviations from the weighted mean of each outcome. A modified Delphi technique was used to achieve consensus agreement on the thresholds.

RESULTS

Data from 29 studies, including systematic reviews and meta-analyses, retrospective cohort studies, and single-arm trials were extracted for calculation of the thresholds. The expert writing group agreed on thresholds for local control, overall survival and adverse events associated with image-guided thermal ablation.

CONCLUSION

SIR recommends utilizing the indicator thresholds to review and assess the efficacy of ongoing quality improvement programs. When performance falls above or below specific thresholds, consideration of a review of policies and procedures to assess for potential causes, and to implement changes in practices, may be warranted.

18F-FDG and 68Ga-FAPI PET/CT in the Evaluation of Ground-Glass Opacity Nodule

ABSTRACT

A 50-year-old woman with a newly detected pulmonary ground-glass opacity (GGO) nodule underwent PET/CT to determine the likelihood of malignancy. This patient was enrolled in the prospective study (NCT04588064) to determine the effectiveness of 18F-FDG and 68Ga-FAPI PET/CT for characterization of the GGO nodule. On PET/CT images, minimal 18F-FDG uptake but intense 68Ga-FAPI uptake was observed in this GGO nodule. This patient subsequently underwent video-assisted thoracoscopic surgery, and postoperative pathological examination confirmed the diagnosis of invasive adenocarcinoma. This case presented an example where 68Ga-FAPI PET/CT showed higher tracer uptake than 18F-FDG in the malignant GGO nodule.

Prognostic utility of pretreatment neutrophil-lymphocyte ratio in survival outcomes in localized non-small cell lung cancer patients treated with stereotactic body radiotherapy: Selection of an ideal clinical cutoff point

•

Neutrophil-lymphocyte ratio is a promising prognostic marker for several cancers.

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NLR is not useful as a marker of lung cancer survival in localized lung cancer.

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NLR has potential as a marker of competing mortality risk in localized lung cancer.

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NLR cutoff of 4.0 is proposed as a clinically useful cutoff point.

Background and purpose

Neutrophil-lymphocyte ratio (NLR) has been associated with overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to assess the utility of NLR as a predictor of lung cancer-specific survival (LCS) and identify an optimal, pretreatment cutoff point in patients with localized NSCLC treated with stereotactic body radiotherapy (SBRT) within the Veterans Affairs’ (VA) national database.

Materials and methods

In the VA database, we identified patients with biopsy-proven, clinical stage I NSCLC treated with SBRT between 2006 and 2015. Cutoff points for NLR were calculated using Contal/O’Quigley’s and Cox Wald methods. Primary outcomes of OS, LCS, and non-lung cancer survival (NCS) were evaluated in Cox and Fine-Gray models.

Results

In 389 patients, optimal NLR cutoff was identified as 4.0. In multivariable models, NLR > 4.0 was associated with decreased OS (HR 1.44, p = 0.01) and NCS (HR 1.68, p = 0.01) but not with LCS (HR 1.32, p = 0.09). In a subset analysis of 229 patients with pulmonary function tests, NLR > 4.0 remained associated with worse OS (HR 1.51, p = 0.02) and NCS (HR 2.18, p = 0.01) while the association with LCS decreased further (HR 1.22, p = 0.39).

Conclusion

NLR was associated with worse OS in patients with localized NSCLC treated with SBRT; however, NLR was only associated with NCS and not with LCS. Pretreatment NLR, with a cutoff of 4.0, offers potential as a marker of competing mortality risk which can aid in risk stratification in this typically frail and comorbid population. Further studies are needed to validate pretreatment NLR as a clinical tool in this setting.

Prognostic value of positron emission tomography in resected stage IA non-small cell lung cancer

OBJECTIVES

To investigate the role of PET in predicting the prognosis of resected stage IA non-small cell lung cancer (NSCLC) and planning individualized therapeutic strategies.

METHODS

We retrospectively reviewed the data of patients who underwent surgical resection for lung cancer between January 2004 and December 2014. The clinical data, imaging characteristics of nodules, surgical approaches, and outcomes were analyzed.

RESULTS

We evaluated 998 cases; 637 patients with pathological stage I disease were categorized as follows: stage IA1 (251 cases), stage IA2 (250 cases), and stage IA3 (136 cases). The mean follow-up period was 109 months. Significant differences were observed in sex, tumor differentiation, epidermal growth factor receptor mutation, smoking habits, lymphovascular space invasion, tumor size, maximum standard uptake value (SUVmax), and carcinoembryonic antigen level among the groups. Multivariable Cox regression revealed that ground-glass opacity ratio (hazard ratio (HR) = 0.001) and tumor SUVmax independently predicted the postoperative risk of relapse for stage IA3 NSCLC. The HR for SUVmax > 4 was 8.986 (p < 0.001). The 5-year overall survival (OS) rates were 87.2%, 92.9%, and 82.7%, and the 5-year disease-free survival (DFS) rates were 93.2%, 84.2%, and 70.51% for stage IA1, IA2, and IA3 NSCLC, respectively (both p < 0.001). OS and DFS rates were poor in stage IA3 NSCLC patients with an SUVmax uptake > 4 (OS, 71.0% and 92.2%; DFS, 50.2% and 87.3%, for SUVmax > 4 and ≤ 4, respectively; both p = 0.001).

CONCLUSIONS

SUVmax was a prognostic factor for resected stage IA NSCLC. Postoperative treatment may be considered for IA3 NSCLC with SUVmax > 4.

KEY POINTS

• PET helps surgeons to assess patients with early-stage lung cancer. • This retrospective study revealed that PET plays an influential role in predicting the prognosis of resected lung cancer. • Better prognostication aids better planning of therapeutic strategies with diversification.

Solid Components in the Mediastinal Window of Computed Tomography Define a Distinct Subtype of Subsolid Nodules in Clinical Stage I Lung Cancers

BACKGROUND

We aimed to validate the clinicopathologic characteristics and prognostic value of the presence of solid components in the mediastinal window of computed tomography scan in clinical stage I pulmonary subsolid nodules (SSNs).

METHODS

We retrospectively evaluated patients with pulmonary SSNs resected between 2011 and 2016. We classified SSNs into heterogeneous ground-glass nodules (HGGNs) (solid component detected only in lung window) and part-solid nodules (PSNs) (solid component detected both in lung/mediastinal windows).

RESULTS

A total of 487 patients (216 PSNs) were included. PSNs were associated with higher frequencies of micropapillary or solid pathologic patterns (18.1% vs. 3.3%; P < .001), epidermal growth factor receptor gene mutation (39.4% vs. 32.8%), and other types of gene mutations (2.3% vs. 1.1%; P = .043). Logistic regression analysis revealed that male sex (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.20-5.57; P = .016) and higher consolidation tumor ratio (CTR) (OR, 110.04; 95% CI, 8.56-1414.39; P < .001) remained independent for invasive adenocarcinomas with poor differentiation. Receiver operating characteristic analyses revealed that solid component size in the mediastinal window (area under the curve [AUC], 0.731; 95% CI, 0.653-0.808; P < .0001) showed a better predictive ability to poor differentiation compared with solid component size in the lung window and CTR. The 5-year recurrence-free survival (RFS) rate of PSNs was worse than that of HGGNs (94.6% vs. 99.1%; P = .019). Multivariate Cox regression revealed that positive lymph node status (hazard ratio, 22.99; 95% CI, 4.52-116.86; P < .001) indicated worse RFS for PSNs.

CONCLUSION

SSNs with solid components in mediastinal window demonstrated clinicopathologic and prognostic features different from those without in clinical stage I lung cancer. Solid components in mediastinal window was a strong predictor of poor differentiation.

Navigating Diagnostic and Treatment Decisions in Non-Small Cell Lung Cancer: Expert Commentary on the Multidisciplinary Team Approach

Non-small cell lung cancer (NSCLC) accounts for approximately one in five cancer-related deaths, and management requires increasingly complex decision making by health care professionals. Many centers have therefore adopted a multidisciplinary approach to patient care, using the expertise of various specialists to provide the best evidence-based, personalized treatment. However, increasingly complex disease staging, as well as expanded biomarker testing and multimodality management algorithms with novel therapeutics, have driven the need for multifaceted, collaborative decision making to optimally guide the overall treatment process. To keep up with the rapidly evolving treatment landscape, national-level guidelines have been introduced to standardize patient pathways and ensure prompt diagnosis and treatment. Such strategies depend on efficient and effective communication between relevant multidisciplinary team members and have both improved adherence to treatment guidelines and extended patient survival. This article highlights the value of a multidisciplinary approach to diagnosis and staging, treatment decision making, and adverse event management in NSCLC. IMPLICATIONS FOR PRACTICE: This review highlights the value of a multidisciplinary approach to the diagnosis and staging of non-small cell lung cancer (NSCLC) and makes practical suggestions as to how multidisciplinary teams (MDTs) can be best deployed at individual stages of the disease to improve patient outcomes and effectively manage common adverse events. The authors discuss how a collaborative approach, appropriately leveraging the diverse expertise of NSCLC MDT members (including specialist radiation and medical oncologists, chest physicians, pathologists, pulmonologists, surgeons, and nursing staff) can continue to ensure optimal per-patient decision making as treatment options become ever more specialized in the era of biomarker-driven therapeutic strategies.

Roles of Lipid Profiles in Human Non-Small Cell Lung Cancer

Aims: This review aims to identify lipid biomarkers of non-small cell lung cancer (NSCLC) in human tissue samples and discuss the roles of lipids in tissue molecular identification, the discovery of potential biomarkers, and surgical margin assessment. Methods: A review of the literature focused on lipid-related research using mass spectrometry (MS) techniques in human NSCLC tissues from January 1, 2015, to November 20, 2020, was conducted. The quality of included studies was assessed using the QUADAS-2 tool. Results: Twelve studies met the inclusion criteria and were included in the review. The risk of bias was unclear in the majority of the studies. The contents of lipids including fatty acids, phosphatidyl choline, phosphatidyl ethanolamine, phosphatidyl inositol, cardiolipin, phosphatidyl serine, phosphatidyl glycerol, ceramide, lysophosphatidylethanolamine, lysophosphatidylcholine, and lysophosphatidylglycerol differed significantly between cancer and healthy tissues. The sensitivity or specificity of the discrimination model was reported in 8 studies, and the sensitivity and specificity varied among the reported methods. The lipid profiles differed between adenocarcinoma and squamous cell carcinoma NSCLC subtypes. Conclusion: In preclinical studies, MS analysis and multiple discrimination models can be combined to distinguish NSCLC tissues from healthy tissues based on lipid profiles, which provides a new opportunity to evaluate the surgical margin and cancer subtype intraoperatively. Future studies should provide guidance for selecting patients and discrimination models to develop an improved method for clinical application.

Long-term Overall Survival Outcomes in Patients with Early Stage, Peripherally Located, Non-small Cell Lung Cancer Treated with Stereotactic Ablative Radiotherapy in a Non-academic Cancer Centre

AIMS

To report long-term outcomes of patients treated with stereotactic ablative radiotherapy (SABR) for early stage, peripherally located non-small cell lung cancer.

MATERIALS AND METHODS

Data were collected retrospectively between September 2009 and May 2019. Electronic medical records were reviewed for baseline characteristics, treatment details and outcomes. All patients were treated according to local protocol based on the national UK SABR Consortium guidelines. Risk-adapted treatment schedules were used depending on the size and the location of the tumour (54 Gy in three fractions, 55 Gy in five fractions, 60 Gy in eight fractions or 50 Gy in 10 fractions). Overall survival outcomes were evaluated using the Kaplan-Meier method.

RESULTS

In total, 412 patients were included in the analysis. The median age was 76 years (range 48-93 years). Histological confirmation was obtained in 233 cases (56.6%). The median overall survival for all patients was 42.3 months (95% confidence interval 37.3-47.3 months), with 3- and 5-year overall survival of 52.8% and 37.3%, respectively. For biopsy-proven patients (56.6%), 3- and 5-year overall survival was 57.3% and 40.1%, respectively. With respect to overall survival, univariate and multivariate analysis revealed no significant difference in survival by technique (volume-modulated arc therapy versus conformal; three-dimensional computed tomography versus four-dimensional computed tomography), tumour location, smoking status at first contact, pre-treatment tumour stage or pre-treatment standardised uptake value. Survival was poorer for patients who received the 50 Gy in 10 fractions schedule. Treatment was very well tolerated with very low rates of grade 3-4 toxicity (1%).

CONCLUSIONS

SABR for peripherally located, medically inoperable non-small cell lung cancer can be safely and effectively implemented in a non-academic institution with appropriate equipment and training. Overall survival outcomes and toxicity rates are comparable with internationally published studies. Patients treated with 50 Gy in 10 fractions had a poorer survival outcome.

Platinum versus immunotherapy for early resectable non-small cell lung cancer: A protocol for systematic review and meta analysis

BACKGROUND

Lung cancer is one of the most common malignant tumors. Non-small cell Lung cancer (NSCLC) accounts for about 85% of the total lung cancer. For patients with resectable early NSCLC, conventional postoperative adjuvant therapy can significantly prolong the overall survival of patients and reduce the risk of tumor recurrence. With the emergence and maturity of molecular targeted therapy and immunotherapy, the strategy of postoperative chemotherapy for lung cancer patients has changed greatly. To evaluate the efficacy of postoperative chemotherapy (platinum based chemotherapy and immunotherapy) with or without radiotherapy for NSCLC patients, we will conduct a systematic review and meta-analysis of published or unpublished randomized controlled trials.

METHODS

We will search Pubmed (Medline), Embase, Google Scholar, Cancerlit, and the Cochrane Central Register of Controlled Trials for related studies published without language restrictions before June 20, 2021. Two review authors will search and assess relevant studies independently. Randomized controlled trials and quasi-randomized controlled trials studies will be included. we will perform subgroup analysis in different methods of postoperative adjuvant therapy for patients with resectable early NSCLC. Because this study will be based on published or unpublished records and studies, there is no need for ethics approval. INPLASY registration number: INPLASY202080064.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will compare the efficacy of platinum chemotherapy and immunotherapy in patients with resectable early NSCLC. Since the large sample randomized trials that meet the inclusion criteria of this study may be inadequate, we will consider incorporating some high quality small sample related tests, which may lead to heterogeneity and affect the reliability of the results.

Elevated preoperative CEA is associated with subclinical nodal involvement and worse survival in stage I non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor markers might aid in the detection of subclinical advanced disease. The aim of this study is to review the predictive value of tumor markers in patients with clinical stage I NSCLC.

METHODS

A comprehensive search was performed using the Medline, EMBASE, Scopus data bases. Abstracts included based on the following inclusion criteria: 1) adult ≥18 years old, 2) clinical stage I NSCLC, 3) Tumor markers (CEA, SCC, CYFRA 21-1), 4) further imaging or procedure, 5) > 5 patients, 6) articles in English language. The primary outcome of interest was utility of tumour markers for predicting nodal involvement and oncologic outcomes in patients with clinical stage I NSCLC. Secondary outcomes included sub-type of lung cancer, procedure performed, and follow-up duration.

RESULTS

Two hundred seventy articles were screened, 86 studies received full-text assessment for eligibility. Of those, 12 studies were included. Total of 4666 patients were involved. All studies had used CEA, while less than 50% used CYFRA 21-1 or SCC. The most common tumor sub-type was adenocarcinoma, and the most frequently performed procedure was lobectomy. Meta-analysis revealed that higher CEA level is associated with higher rates of lymph node involvement and higher mortality.

CONCLUSION

There is significant correlation between the CEA level and both nodal involvement and survival. Higher serum CEA is associated with advanced stage, and poor prognosis. Measuring preoperative CEA in patient with early stage NSCLC might help to identify patients with more advanced disease which is not detected by CT scans, and potentially identify candidates for invasive mediastinal lymph node staging, helping to select the most effective therapy for patients with potentially subclinical nodal disease. Further prospective studies are needed to standardize the use of CEA as an adjunct for NSCLC staging.

Development and validation of a robust immune-related prognostic signature in early-stage lung adenocarcinoma

Background

The incidence of stage I and stage II lung adenocarcinoma (LUAD) is likely to increase with the introduction of annual screening programs for high-risk individuals. We aimed to identify a reliable prognostic signature with immune-related genes that can predict prognosis and help making individualized management for patients with early-stage LUAD.

Methods

The public LUAD cohorts were obtained from the large-scale databases including 4 microarray data sets from the Gene Expression Omnibus (GEO) and 1 RNA-seq data set from The Cancer Genome Atlas (TCGA) LUAD cohort. Only early-stage patients with clinical information were included. Cox proportional hazards regression model was performed to identify the candidate prognostic genes in GSE30219, GSE31210 and GSE50081 (training set). The prognostic signature was developed using the overlapped prognostic genes based on a risk score method. Kaplan–Meier curve with log-rank test and time-dependent receiver operating characteristic (ROC) curve were used to evaluate the prognostic value and performance of this signature, respectively. Furthermore, the robustness of this prognostic signature was further validated in TCGA-LUAD and GSE72094 cohorts.

Results

A prognostic immune signature consisting of 21 immune-related genes was constructed using the training set. The prognostic signature significantly stratified patients into high- and low-risk groups in terms of overall survival (OS) in training data set, including GSE30219 (HR = 4.31, 95% CI 2.29–8.11; P = 6.16E−06), GSE31210 (HR = 11.91, 95% CI 4.15–34.19; P = 4.10E−06), GSE50081 (HR = 3.63, 95% CI 1.90–6.95; P = 9.95E−05), the combined data set (HR = 3.15, 95% CI 1.98–5.02; P = 1.26E−06) and the validation data set, including TCGA-LUAD (HR = 2.16, 95% CI 1.49–3.13; P = 4.54E−05) and GSE72094 (HR = 2.95, 95% CI 1.86–4.70; P = 4.79E−06). Multivariate cox regression analysis demonstrated that the 21-gene signature could serve as an independent prognostic factor for OS after adjusting for other clinical factors. ROC curves revealed that the immune signature achieved good performance in predicting OS for early-stage LUAD. Several biological processes, including regulation of immune effector process, were enriched in the immune signature. Moreover, the combination of the signature with tumor stage showed more precise classification for prognosis prediction and treatment design.

Conclusions

Our study proposed a robust immune-related prognostic signature for estimating overall survival in early-stage LUAD, which may be contributed to make more accurate survival risk stratification and individualized clinical management for patients with early-stage LUAD.

Interactive Verification Analysis of Multiple Sequencing Data for Identifying Potential Biomarker of Lung Adenocarcinoma

Background

Lung adenocarcinoma (LUAD) comprises around 40% of all lung cancers, and in about 70% of patients, it has spread locally or systemically when first detected leading to a worse prognosis.

Methods

We filtered out differentially expressed genes (DEGs) based on the RNA sequencing data in the Gene Expression Omnibus database and verified and deeply analyzed screened DEGs using a combined bioinformatics approach.

Results

Expressions of 11,143 genes in 694 nontumor lung tissues and LUAD cases from 8 independent laboratories were analyzed; 188 mRNAs were identified as differentially expressed genes (DEGs). A PPI network constructed with 188 DEGs screened out 8 hub DEGs (CDH5, PECAM1, VWF, CLDN5, COL1A1, MMP9, SPP1, and IL6) which highly interconnected with other nodes. The expression levels of 8 hub genes in LUAD and control were assessed in the Oncomine database, and the results were consistent. The survival curves of 8 hub genes showed that their expressions are significantly related to the prognosis of lung cancer and LUAD patients except for IL6. Since the expression of IL6 is nonspecific and highly sensitive, we choose the other 7 hub genes we had verified to do the next analysis. Mutual exclusivity or cooccurrence analysis of 7 hub genes identified a tendency towards cooccurrence between CDH5, PECAM1, and VWF in LUAD. The coexpression profiles of CDH5 in LUAD were identified, and we found that PECAM1 and VWF coexpressed with CDH5. Immunohistochemistry and RT-PCR analysis showed that higher levels of CDH5, PECAM1, and VWF were expressed in normal lung tissues but a low or undetectable level was found in LUAD tissues.

Conclusions

Taken together, we speculate that CDH5, PECAM1, and VWF played an important role in LUAD.

Nanomedicine in Non-Small Cell Lung Cancer: From Conventional Treatments to Immunotherapy

Non-small cell lung cancer (NSCLC) remains the most common cause of cancer-related mortality. The heterogeneous nature of this disease hinders its diagnosis and treatment, requiring continuous advances in research aiming to understand its intricate nature. Consequently, the retrospective analysis of conventional therapies has allowed the introduction of novel tools provided by nanotechnology, leading to considerable improvements in clinical outcomes. Furthermore, the development of novel immunotherapies based on the recently understood interaction of the immune system with the tumor highlights the real possibility of definitively treating NSCLC from its early stages. Novel engineering approaches in nanomedicine will enable to overcome the intrinsic limits of conventional and emerging therapies regarding off-site cytotoxicity, specificity, resistance mechanisms, and administration issues. The convergence point of these therapies with nanotechnology lays the foundation for achieving currently unmet needs.

Validation of the Eighth Edition Clinical T Categorization System for Clinical Stage IA, Resected Lung Adenocarcinomas: Prognostic Implications of the Ground-Glass Opacity Component

INTRODUCTION

There is controversy regarding the clinical T (cT) category of lung adenocarcinomas that manifest as part-solid nodules (PSNs). We aimed to validate the cT category and to evaluate the independent prognostic role of the nodule type (i.e., part-solid versus solid).

METHODS

We retrospectively evaluated the prognostic value of clinico-radiologic factors regarding the overall survival of patients with clinical stage IA lung adenocarcinomas that were resected between 2008 and 2014. cT Category, nodule type, and their interaction term were included in the multivariable Cox regression analysis with other variables. In addition, a mixture cure model analysis was performed to investigate the association between the covariates and long-term survival.

RESULTS

A total of 744 patients (420 women; 362 PSNs; median age, 63 y) were included. The multivariable-adjusted hazard ratio (HR) of the nodule type was not significant (1.30, 95% confidence interval [CI]: 0.80-2.10, p = 0.291). However, the cT categories were significantly associated with overall survival (HR of cT1b, 2.33 [95% CI: 1.07-5.06, p = 0.033]; HR of cT1c, 5.74 [95% CI: 2.51-13.12, p < 0.001]). There were no interactions between the nodule type and the cT categories (all p > 0.05). The multivariable mixture cure model revealed that solid nodules were associated with a decreased probability of long-term survival (OR = 0.40, 95% CI: 0.18-0.92, p = 0.030). In addition, cT1c was a negative predictor of long-term survival (OR = 0.26, 95% CI: 0.07-0.94, p = 0.040).

CONCLUSIONS

The cT categorization system is valid for PSNs and solid nodules. Nevertheless, PSNs are a prognostic factor associated with long-term survival.

The IκB Kinase Inhibitor ACHP Targets the STAT3 Signaling Pathway in Human Non-Small Cell Lung Carcinoma Cells

STAT3 is an oncogenic transcription factor that regulates the expression of genes which are involved in malignant transformation. Aberrant activation of STAT3 has been observed in a wide range of human malignancies and its role in negative prognosis is well-documented. In this report, we performed high-throughput virtual screening in search of STAT3 signaling inhibitors using a cheminformatics platform and identified 2-Amino-6-[2-(Cyclopropylmethoxy)-6-Hydroxyphenyl]-4-Piperidin-4-yl Nicotinonitrile (ACHP) as the inhibitor of the STAT3 signaling pathway. The predicted hit was evaluated in non-small cell lung cancer (NSCLC) cell lines for its STAT3 inhibitory activity. In vitro experiments suggested that ACHP decreased the cell viability and inhibited the phosphorylation of STAT3 on Tyr705 of NSCLC cells. In addition, ACHP imparted inhibitory activity on the constitutive activation of upstream protein tyrosine kinases, including JAK1, JAK2, and Src. ACHP decreased the nuclear translocation of STAT3 and downregulated its DNA binding ability. Apoptosis was evidenced by cleavage of caspase-3 and PARP with the subsequent decline in antiapoptotic proteins, including Bcl-2, Bcl-xl, and survivin. Overall, we report that ACHP can act as a potent STAT3 signaling inhibitor in NSCLC cell lines.

Postoperative adjuvant therapy for resectable early non-small cell lung cancer: A protocol for a systematic review and meta-analysis

BACKGROUND

Lung cancer is one of the most common malignant tumors, and non-small cell lung cancer (NSCLC) accounts for about 85% of lung cancer diagnosed. For patients with resectable early stage non-small cell lung cancer, routine postoperative adjuvant therapy can significantly prolong overall patient survival and reduce the risk of cancer recurrence. With the emergence and maturity of molecular targeted therapy and immunotherapy, the postoperative chemotherapy strategy of lung cancer patients has changed a lot. To evaluate the efficacy of postoperative adjuvant therapy (platinum-based chemotherapy, platinum-based chemotherapy plus molecular targeted therapy, platinum-based chemotherapy plus anti-angiogenic agents, or platinum-based chemotherapy plus immunotherapy) with or without radiotherapy for patients with NSCLC, we will conduct a systematic review and meta-analysis of the published or unpublished relevant randomized controlled trials.

METHODS

We will search PubMed (Medline), Embase, Google Scholar, Cancerlit, and the Cochrane Central Register of Controlled Trials for related studies published without language restrictions before June 20, 2019. Two review authors will search and assess relevant studies independently. Randomized controlled trials (RCTs) and quasi-RCTs studies will be included. We will perform subgroup analysis in different methods of postoperative adjuvant therapy for patients with resectable early NSCLC. Because this study will be based on published or unpublished records and studies, there is no need for ethics approval.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will comprehensively compare the efficacy of platinum-based chemotherapy with that of molecular targeted therapy and immunotherapy for patients after surgery with resectable early NSCLC. Since large-sample randomized trials meeting the inclusion criteria of this study may be insufficient, we will consider incorporating some high-quality small-sample-related trials, which may lead to high heterogeneity and affect the reliability of the results.

Adjuvant Chemotherapy Candidates in Stage I Lung Adenocarcinomas Following Complete Lobectomy

BACKGROUND

This study aimed to explore adjuvant chemotherapy (ACT) candidates based on a recurrence risk-scoring model in completely lobectomized stage I patients with lung adenocarcinoma (LAD).

METHODS

A retrospective study was performed on 4606 patients (non-ACT group: n = 3514; ACT group: n = 1092) who underwent complete lobectomy for LAD at Shanghai Chest Hospital from 2008 to 2014. The nomogram predicting recurrence-free survival (RFS) was developed in the non-ACT group using Cox proportional hazards regression. The nomogram-based risk score was calculated in the entire cohort. Differences of RFS between the non-ACT and ACT groups were compared as stratified by the risk score. The score cut-off points were determined using the X-tile software.

RESULTS

Six independent predictors, including age, sex, tumor size, pathological subtype, visceral pleural invasion (VPI), and lymphovascular invasion (LVI) were associated with RFS. The nomogram more accurately predicted RFS than the 8th TNM staging {C-index: 0.784 [95% confidence interval (CI) 0.756-0.812] vs. 0.719 (95% CI 0.689-0.749), p = 0.0017}. A significant RFS difference was observed among the low-, intermediate- and high-risk groups (p < 0.0001), as divided by the optimal cut-points of risk score (203 and 244). ACT did not improve RFS for patients at intermediate-risk, or was even detrimental for low-risk patients; however, improved RFS was observed in ACT receivers at high-risk (p = 0.0416). ACT candidates with a risk score ≥ 245 constituted 2.6% of stage I patients.

CONCLUSIONS

The nomogram provided an individual prediction of RFS for stage I LAD following lobectomy. High-risk patients (score ≥ 245) may benefit from postoperative ACT.

Lung segmentectomy: does it offer a real functional benefit over lobectomy?

Anatomical segmentectomy has been developed to offer better pulmonary function preservation than lobectomy, in stage IA lung cancer. Despite the retrospective nature of most of the studies and the lack of randomised studies, a substantial body of literature today allows us to evaluate to what extent lung function decreases after segmentectomy and whether segmentectomy offers a real functional benefit over lobectomy. From the available series, it emerges that the mean decrease in forced expiratory volume in 1 s (FEV1) is low, ranging from −9% to −24% of the initial value within 2 months and −3 to −13% 12 months after segmentectomy. This reduction in lung function is significantly lower than that induced by lobectomy, but saves only a few per cent of pre-operative FEV1. Moreover, the published results do not firmly establish the functional benefit of segmentectomy over lobectomy in patients with poor lung function. Some issues remain to be addressed, including whether video-assisted thoracic surgery (VATS) segmentectomy may preserve lung function better than VATS lobectomy in patients with poor lung function, especially within the early days after surgery, and whether this may translate to lowering the functional limit for surgery. Eventually, trials comparing stereotactic ablative body radiotherapy, radiofrequency ablation and segmentectomy functional consequences are warranted.

Non-intubated uniportal left-lower lobe upper segmentectomy (S6)

Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures.

Salvage surgery after high-dose radiotherapy

Salvage surgery is a relatively new entity in thoracic surgery and oncology. Salvage resection after radiotherapy refers to surgery as only remaining therapeutic option in patients who were treated with high-dose stereotactic radiotherapy (SRT) for early-stage lung cancer or full-dose chemoradiation for locally advanced lung cancer. Indications include locally progressive tumors, recurrent local or locoregional disease, or specific complications after radiotherapy such as lung abscesses or infected, necrotic cavities. Small, retrospective series demonstrate that salvage surgery after high-dose radiotherapy is feasible and may yield good long-term results. A clear distinction should be made between salvage surgery after SRT for early-stage lung cancer and salvage procedures after full-dose chemoradiation for lung cancers with locoregional extension into the mediastinum. Salvage surgery after SRT may be rather straightforward and in specific cases even feasible by a minimally invasive approach. In contrast, surgery after a full dose of chemoradiation delivered several months or years earlier, can be quite challenging and the dissection of the pulmonary artery and mediastinal lymph nodes technically demanding. Due to the more central irradiation an intrapericardial dissection is often required. To prevent a bronchopleural fistula protection of the bronchial stump with well-vascularized flaps is recommended. Each individual patient in whom salvage surgery is considered, should be discussed thoroughly within a multidisciplinary board, detailed cardiopulmonary functional evaluation is required, and the operation should be performed by an experienced team including a thoracic surgeon, anaesthesiologist and intensive care physician. At the present time only retrospective series are available. Carefully designed prospective studies are necessary to more precisely define indications and results of salvage surgery not only after SRT for peripherally localized lesions but also following full-dose chemoradiation for locoregionally advanced disease.