New developments in locally advanced nonsmall cell lung cancer

CD8+ T cells infiltrating into tumors were controlled by immune status of pulmonary lymph nodes and correlated with non-small cell lung cancer (NSCLC) patients' prognosis treated with chemoimmunotherapy

PURPOSE

Neoadjuvant chemoimmunotherapy has the potential to reduce tumor burden, improve the pathological complete response (pCR) rate, and significantly prolong patients' disease-free survival (DFS). However, the treatment's effectiveness varies among NSCLC patients. The immunological mechanisms contributing to tumor regression still require further exploration and elucidation.

METHODS

The immune status of patients' local tumor microenvironment (TME) before and after neoadjuvant chemoimmunotherapy, their paired pulmonary lymph nodes (11th LNs) after therapy, including infiltrating immune cell densities and their correlations, were analyzed using multiplex immunofluorescence.

RESULTS

Fifty-six NSCLC patients undergoing neoadjuvant chemoimmunotherapy were enrolled and subsequently underwent surgical resection and pathological evaluation. Among these, 19 patients achieved a pCR, 6 patients exhibited a major pathological response (MPR), and 31 patients did not achieve MPR. There were no significant difference in the densities of CD8+ T cell, Treg and Dendritic cell (DC) in patients' TME before neoadjuvant therapy (n = 26, P = 0.091, P = 0.753, P = 0.905, respectively), but after treament, these immune cells' dynamics were significantly different between different response group. CD8+ T cell densities were increased in pCR gourp (P = 0.006), but not in non-pCR group (P = 0.389); the densities of Treg were increased in non-pCR gourp (P = 0.0004), but DC were significantly decreased in non-pCR gourp (P = 0.005). After surgery, the TME were also significantly different: patients achieving pCR typically demonstrated high densities of CD8+ T cell, DC and low densities of Tregs (P = 0.0001, P < 0.0001 and P = 0.0004). The immune status of 11th LNs also exhibited significant differences. DC densities were much higher in pCR patients, whereas Treg in the pCR group were significantly lower than those in the non-pCR group (P = 0.0008 and P = 0.003). Furthermore, the densities of DC in the TME showed a moderate positive correlation with DC in 11th LNs (P = 0.0002), while the densities of Tregs in the TME exhibited a moderate negative correlation with DC densities in 11th LNs (P = 0.03). Patients who had high densities of CD8+ T cell in the resection tissues and DC in the LNs, experienced longer DFS (P = 0.048 and P = 0.024).

CONCLUSION

Immune cells in both pulmonary LNs and the TME collectively influence the remodeling of the NSCLC patient's TME, thus impacting treatment response and prognosis.

Transbronchial lung cryobiopsy for peripheral pulmonary lesions. A narrative review

An increasing number of peripheral pulmonary lesions (PPLs) requiring tissue verification to establish a definite diagnosis for further individualized management are detected due to the growing adoption of lung cancer screening by chest computed tomography (CT), especially low-dose CT. However, the morphological diagnosis of PPLs remains challenging. Transbronchial lung cryobiopsy (TBLC) that can retrieve larger specimens with more preserved cellular architecture and fewer crush artifacts in comparison with conventional transbronchial forceps biopsy (TBFB), as an emerging technology for diagnosing PPLs, has been demonstrated to have the potential to resolve the clinical dilemma pertaining to currently available sampling devices (e.g., forceps, needle and brush) and become a diagnostic cornerstone for PPLs. Of note, with the introduction of the 1.1 mm cryoprobe that will be more compatible with advanced bronchoscopic navigation techniques, such as radial endobronchial ultrasound (r-EBUS), virtual bronchoscopic navigation (VBN) and electromagnetic navigation bronchoscopy (ENB), the use of TBLC is expected to gain more popularity in the diagnosis of PPLs. While much remains for exploration using the TBLC technique for diagnosing PPLs, it can be envisaged that the emergence of additional studies with larger data accrual will hopefully add to the body of evidence in this field.

Effective neoadjuvant immunotherapy and chemotherapy in stage IIIA adenosquamous carcinoma of the lung with a complete response and surgical success: A case report

There has been rapid advancement in the development of neoadjuvant therapy for non-small cell lung cancer (NSCLC), which holds great promise as an effective treatment strategy. Some clinical trials have confirmed that immunotherapy in combination with chemotherapy can be a recommended first-line regimen for neoadjuvant treatment of NSCLC. The present study describes the case of a male patient aged 65 years who was diagnosed with stage IIIA (cT2N2M0) adenosquamous carcinoma of the lung. After the administration of two cycles of neoadjuvant immunotherapy (sintilimab) in combination with chemotherapy, stable disease was observed in the primary tumor, whereas partial remission was detected in the mediastinal lymph nodes based on imaging assessment. The patient underwent an immediate upper lobectomy of the left lung. Pathological analysis revealed a complete response in the primary lesion, with only minimal presence of tumor cells observed in the lymph nodes surrounding the mediastinum and bronchi. This indicated that the present neoadjuvant therapy could be used in the treatment of stage III adenosquamous lung carcinoma; however, to conclusively determine its efficacy, further studies targeting this specific cancer type are essential.

Robotic versus Open Surgery in Locally Advanced Non-Small Cell Lung Cancer: Evaluation of Surgical and Oncological Outcomes

Locally advanced non-small cell lung cancer (NSCLC) consists of a heterogeneous group, with different pulmonary extension and lymph nodal involvement. Robotic surgery can play a key role in these tumours thanks to its technological features, although open surgery is still considered the gold-standard approach. Our study aims to evaluate the surgical and oncological outcomes of locally advanced NSCLC patients who underwent robotic surgery in a high-volume centre. Data from consecutive patients with locally advanced NSCLC who underwent robotic lobectomy were retrospectively analysed and compared with patients treated with open surgery. Clinical characteristics and surgical and oncological information were evaluated. From 2010 to 2020, 131 patients underwent anatomical lung resection for locally advanced NSCLC. A total of 61 patients were treated with robotic surgery (46.6%); the median hospitalization time was 5.9 days (range 2-27) and the postoperative complication rate was 18%. Open surgery was performed in 70 patients (53.4%); the median length of stay was 9 days (range 4-48) and the postoperative complication rate was 22.9%. The median follow-up time was 70 months. The 5-year overall survival was 34% in the robotic group and 31% in the thoracotomy group. Robotic surgery can be considered safe and feasible not only for early stages but also for the treatment of locally advanced NSCLC.

A rare case report: co-occurrence of two types of lung cancer with hamartoma and pulmonary tuberculosis

With the widespread use of low-dose chest Computed Tomography (CT), lung nodules are being increasingly detected. Common pulmonary conditions such as lung adenocarcinoma, lung squamous cell carcinoma, and tuberculosis are typically diagnosable through imaging examinations. Nevertheless, when multiple types of lung cancer are combined with other benign tumors, how can an accurate diagnosis be made? In this report, we present a rare case of a patient with the simultaneous occurrence of lung adenocarcinoma, lung squamous cell carcinoma, pulmonary tuberculosis, and pulmonary hamartoma, which has not been previously reported. This patient underwent surgical intervention in the Department of Thoracic Surgery at the Second Hospital of Jilin University and has now fully recovered and been discharged. The patient's preoperative positron emission tomography-CT(PET-CT)results did not align with the postoperative pathological diagnosis. The imaging findings were atypical, and the pathological diagnosis was exceptionally rare. We share this case report to contribute to the accumulation of clinical experience.

Robot-assisted thoracic surgery for stages IIB-IVA non-small cell lung cancer: retrospective study of feasibility and outcome

Robot-assisted thoracic surgery (RATS) for higher stages non-small cell lung carcinoma (NSCLC) remains controversial. This study reports the feasibility of RATS in patients with stages IIB-IVA NSCLC. A single-institute, retrospective study was conducted with patients undergoing RATS for stages IIB-IVA NSCLC, from January 2015 until January 2020. Unforeseen N2 disease was excluded. Data were collected from the Dutch Lung Cancer Audit database. Conversion rate, radical (R0) resection rate, local recurrence rate and complications were analyzed, as were risk factors for conversion. RATS was performed in 95 patients with NSCLC clinical or pathological stages IIB (N = 51), IIIA (N = 39), IIIB (N = 2) and IVA (N = 3). 10.5% had received neoadjuvant chemoradiotherapy. Pathological staging was T3 in 33.7% and T4 in 34.7%. RATS was completed in 77.9% with a radical resection rate of 94.8%. Lobectomy was performed in 67.4% of the total resections. Conversion was for strategic (18.9%) and emergency (3.2%) reasons. Pneumonectomy (p = 0.001), squamous cell carcinoma (p < 0.001), additional resection of adjacent structures (p = 0.025) and neoadjuvant chemoradiation (p = 0.017) were independent risk factors for conversion. Major post-operative complications occurred in ten patients (10.5%) including an in-hospital mortality of 2.1% (n = 2). Median recurrence-free survival was estimated at 39.4 months (CI 16.4-62.5). Two- and 5-year recurrence-free survival rates were 53.8% and 36.7%, respectively. This study concludes that RATS is safe and feasible in higher staged NSCLC tumors after exclusion of unforeseen N2 disease. It brings new perspective on the potential of RATS in higher stages, dealing with larger and more invasive tumors.

Confirmatory Factor Analysis and Measurement Invariance of the Functional Assessment of Cancer Therapy Lung Cancer Utility Index (FACT-LUI)

Background. A portion of the Functional Assessment of Cancer Therapy-Lung (FACT-L) instrument contributed to a previously published utility index, the FACT Lung Utility Index or FACT-LUI. Six FACT items representing lung cancer quality of life covered fatigue, pain, dyspnea, cough, anxiety, and depression. Two FACT items had been previously combined by the index authors into one for nausea and/or appetite loss, resulting in 7 final domains. Methods. The objective was to perform measurement invariance testing within a confirmatory factor analysis (CFA) framework to support the feasibility of using the FACT-LUI for non-preference-based psychometric applications. The original index patients comprised group 1, and similar FACT patient data (n = 249) from another published study comprised group 2. One 2-factor model and two 1-factor CFA models were evaluated to assess measurement invariance across groups, using varying degrees of item parceling and a small number of residual covariances, all justified by the literature. Results. The 1-factor models were most optimal. A 1-factor model with 1 pair of items parceled showed invariance to the partial scalar level using usual fit criteria across groups, requiring 2 unconstrained intercepts. A 1-factor model with 3 pairs of justified parcels showed full configural, metric, and scalar invariance across groups. Conclusions. The FACT-LUI items fit a partially to fully invariant 1-factor model, suggesting feasibility for non-preference-based applications. Implications. Results suggest useful incorporation of the FACT-LUI into clinical trials with no substantial increased respondent burden, allowing preference-based and other psychometric applications from the same index items.

Highlights

This work suggests that in addition to being originally designed for use as a utility index, the 7 FACT-LUI items together also fit simple CFA and measurement invariance models. This less expected result indicates that these items as a group are also potentially useful in non-preference-based applications.Clinical trials can make for challenging decisions concerning which patient-reported outcome measures to include without being burdensome. However, the literature suggests a need for improved reporting of quality of life in lung cancer in particular as well as cancer in general. Inclusion of more disease-specific items such as the FACT-LUI may allow for information gathering of both preference-based and non-preference-based data with less demand on patients, similar to what has been done with some generic instruments.

Creation of an Integrated Clinical Trial Database and Data Sharing for Conducting New Research by the Japan Lung Cancer Society

Introduction

Although data accumulated in clinical trials have higher accuracy compared with real-world data and are irreplaceably valuable, most previous clinical trial data have been left unused.

Methods

The Japan Lung Cancer Society (JLCS) asked six clinical trial groups that conducted randomized clinical trials on curative chemoradiation for locally advanced NSCLC to provide data. After obtaining consent from all six groups, data were collected from August 2019 to June 2021.

Results

A total of eight trials, JCOG9812, JCOG0301, NJLCG0601, OLCSG0007, WJTOG0105, WJOG5008L, SPECTRA, and TORG1018, were included. More than 3000 data items were integrated into 408 items by adjusting their definitions and units. The total number of collected cases was 1288: median age (range), 66 (30-93) years; sex (male/female) 1064/224; pathological type (squamous cell carcinoma, adenocarcinoma, other NSCLC, and unknown) 517, 629, 138, and 4; and stage IIIA and B, 536 and 752. The median overall survival was 26.0 months, with 2-, 5-, and 10-year survival rates of 53.7%, 24.8%, and 15.2%, respectively, in all enrollments. The median progression-free survival was 9.6 months, with 2-, 5-, and 10-year progression-free survival rates of 23.6%, 14.0%, and 9.4%, respectively. Part of the information in the database has been made available on the JLCS web page, and the JLCS members were provided the right to propose research using the database.

Conclusions

The integration and sharing of clinical trial data for research purposes was made real by the nonprofit, academic organization, the JLCS. This database will lead to innovative researches and contribute to the improvement of lung cancer treatment and future research.