Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition)

Risk Factors and Preventive Measures for Lung Cancer in the European Union

BACKGROUND

Lung cancer is worldwide one of the most common types of cancer with still very high mortality rates. The aim of this study was to identify and demonstrate correlations between lung cancer mortality rates and potential influencing factors in EU countries.

METHODS

This retrospective study investigated the connections between the mortality rates in the EU countries (n = 28) and potential influencing factors. The significant factors from the correlation analysis were identified using a stepwise multiple regression analysis.

RESULTS

The most important factors for both genders are the incidence of lung cancer, the price of tobacco, and the number of doctors per 100,000 inhabitants.

CONCLUSION

Lung cancer is a significant global health challenge. The study identified potential strategies for reducing the mortality rate from lung cancer. These strategies include an increase in the number of physicians, enhanced accessibility to cutting-edge antineoplastic medications, and state-funded coverage of the associated costs. It would be beneficial for politicians to consider implementing LDCT screening for the early detection of the disease. The implementation of uniform healthcare system optimization across the EU, combined with improvements in socio-economic conditions, has the potential to mitigate the risk of developing lung cancer.

Development and Implementation of a Digital Quality Measure of Emergency Cancer Diagnosis

PURPOSE

Missed and delayed cancer diagnoses are common, harmful, and often preventable. Automated measures of quality of cancer diagnosis are lacking but could identify gaps and guide interventions. We developed and implemented a digital quality measure (dQM) of cancer emergency presentation (EP) using electronic health record databases of two health systems and characterized the measure's association with missed opportunities for diagnosis (MODs) and mortality.

METHODS

On the basis of literature and expert input, we defined EP as a new cancer diagnosis within 30 days after emergency department or inpatient visit. We identified EPs for lung cancer and colorectal cancer (CRC) in the Department of Veterans Affairs (VA) and Geisinger from 2016 to 2020. We validated measure accuracy and identified preceding MODs through standardized chart review of 100 records per cancer per health system. Using VA's longitudinal encounter and mortality data, we applied logistic regression to assess EP's association with 1-year mortality, adjusting for cancer stage and demographics.

RESULTS

Among 38,565 and 2,914 patients with lung cancer and 14,674 and 1,649 patients with CRCs at VA and Geisinger, respectively, our dQM identified EPs in 20.9% and 9.4% of lung cancers, and 22.4% and 7.5% of CRCs. Chart reviews revealed high positive predictive values for EPs across sites and cancer types (72%-90%), and a substantial percent represented MODs (48.8%-84.9%). EP was associated with significantly higher odds of 1-year mortality for lung cancer and CRC (adjusted odds ratio, 1.78 and 1.83, respectively, 95% CI, 1.63 to 1.86 and 1.61 to 2.07).

CONCLUSION

A dQM for cancer EP was strongly associated with both mortality and MODs. The findings suggest a promising automated approach to measuring quality of cancer diagnosis in US health systems.

The HDAC2-MTA3 interaction induces nonsmall cell lung cancer cell migration and invasion by targeting c-Myc and cyclin D1

Genome-wide association studies have identified numerous single-nucleotide polymorphisms (SNPs) associated with lung cancer; however, the functions of histone deacetylase 2 (HDAC2) rs13213007 and HDAC2 in nonsmall cell lung cancer (NSCLC) remain unclear. Here we identified HDAC2 rs13213007 as a risk SNP and showed that HDAC2 was upregulated in both peripheral blood mononuclear cells (PBMCs) and NSCLC tissues with the rs13213007 A/A genotype compared with those with the rs13213007 G/G or G/A genotype. Patient clinical data indicated strong associations between rs13213007 genotype and N classification. Immunohistochemical staining confirmed that higher expression of HDAC2 was associated with NSCLC progression. Furthermore, we generated 293T cells with the rs13213007 A/A genotype using CRISPR (clustered regularly interspaced short palindromic repeats)/Cas9 gene editing. Chromatin immunoprecipitation sequencing followed by motif analysis showed that HDAC2 can bind to c-Myc in rs13213007 A/A 293T cells. Cell Counting Kit-8, colony formation, wound-healing, and Transwell assays revealed that HDAC2 upregulates c-Myc and cyclin D1 expression and promotes NSCLC cell proliferation, migration, and invasion. Co-immunoprecipitation, quantitative reverse transcription-polymerase chain reaction, and western blot analysis assays showed that MTA3 interacts with HDAC2, decreases HDAC2 expression, and rescues the migration and invasion abilities of NSCLC cells. Taken together, these findings identify HDAC2 as a potential therapeutic biomarker in NSCLC.

A rare case of concomitant Lambert-Eaton myasthenic syndrome and syndrome of inappropriate antidiuretic hormone secretion in a patient with small cell lung carcinoma

Small cell lung carcinoma (SCLC) is a neuroendocrine carcinoma with a poor prognosis and is a common cause of paraneoplastic syndromes. Paraneoplastic syndromes are characterized by neurological and endocrinological problems in patients with malignancy and are often associated with difficulty in induction of chemotherapy. Here we report the case of a patient with SCLC concomitant with two paraneoplastic syndromes, syndrome of inappropriate antidiuretic hormone secretion (SIADH) and Lambert-Eaton myasthenic syndrome (LEMS), who was treated with a platinum-doublet chemotherapy regimen. A 66-year-old male patient presented with a 1-month history of progressive proximal muscle weakness, ataxia gait and 5 kg of body weight loss. The laboratory tests revealed hyponatremia due to SIADH and the existence of antibodies against P/Q-type voltage-gated calcium channels. The nerve conduction study showed a low amplitude of compound muscle action potential (0.38 mv), a 34% decrement on 3-Hz stimulation, and a 1939% increment after maximum voluntary contraction in 10 seconds (7.75 mv). The endobronchial ultrasound transbronchial needle aspiration biopsy revealed the pathological findings of SCLC. A 2-cycle chemotherapy regimen of irinotecan plus cisplatin resulted in temporary tumor shrinkage that lasted 2 months, but the improvement of proximal muscle weakness and hyponatremia were maintained over the tumor re-progression period after chemotherapy. Although paraneoplastic syndromes accelerate the decrease in performance status, chemotherapy for SCLC may improve symptoms related to paraneoplastic syndromes and could be considered in similar cases.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

Identification of SKOR2 IgG as a novel biomarker of paraneoplastic neurologic syndrome

Introduction

The development of new autoantigen discovery techniques, like programmable phage immunoprecipitation sequencing (PhIP-Seq), has accelerated the discovery of neural-specific autoantibodies. Herein, we report the identification of a novel biomarker for paraneoplastic neurologic syndrome (PNS), Sloan-Kettering-Virus-Family-Transcriptional-Corepressor-2 (SKOR2)-IgG, utilizing PhIP-Seq. We have also performed a thorough clinical validation using normal, healthy, and disease/cancer control samples.

Methods

Stored samples with unclassified staining at the junction of the Purkinje cell and the granule cell layers were analyzed by PhIP-Seq for putative autoantigen identification. The autoantigen was confirmed by recombinant antigen-expressing cell-based assay (CBA), Western blotting, and tissue immunofluorescence assay colocalization.

Results

PhIP-Seq data revealed SKOR2 as the candidate autoantigen. The target antigen was confirmed by a recombinant SKOR-2-expressing, and cell lysate Western blot. Furthermore, IgG from both patient samples colocalized with a commercial SKOR2-specific IgG on cryosections of the mouse brain. Both SKOR2 IgG-positive patients had central nervous system involvement, one presenting with encephalitis and seizures (Patient 1) and the other with cognitive dysfunction, spastic ataxia, dysarthria, dysphagia, and pseudobulbar affect (Patient 2). They had a refractory progressive course and were diagnosed with adenocarcinoma (Patient 1: lung, Patient 2: gallbladder). Sera from adenocarcinoma patients without PNS (n=30) tested for SKOR2-IgG were negative.

Discussion

SKOR2 IgG represents a novel biomarker for PNS associated with adenocarcinoma. Identification of additional SKOR2 IgG-positive cases will help categorize the associated neurological phenotype and the risk of underlying malignancy.

Can combined non-invasive methods improve diagnosis of lung cancer?

Background

Lung cancer is the most common malignancy in both gender. Early diagnosis is needed to reduce morbidity and mortality. There is a debate about the most accurate investigating modality for the diagnosis of lung cancer.

Methods

It is a retrospective cohort analysis to determine whether an approach of combined contrast-enhanced computed tomography (CECT) thorax with bronchoscopy method has higher sensitivity and specificity than combined CECT thorax with sputum cytology method. Records of patients with lung cancer who had visited the hospital within the last 6 months were retrospectively analyzed for their diagnostic modality. SPSS version 19 software was used for statistical analysis of the data. CECT scan thorax, bronchoscopy, and sputum cytology for lung cancer patients were analyzed. The CECT thorax plus bronchoscopy method was compared with the CECT thorax plus sputum cytology method. Their sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in diagnosing lung cancer were analyzed.

Results

Sixty-two patients were considered, including 62.9% males with a mean age of 55.5 years. In patients diagnosed with lung cancer, CECT thorax combined with bronchoscopy method was found to have a sensitivity of 96.67% than CECT thorax combined with sputum cytology method with a sensitivity of 90% and the difference in sensitivity between all individual approaches as well as the combined method was statistically significant with a P = 0.00001 and Chi-square value of 86.5909 owing to the low sensitivity of sputum cytology. CECT thorax combined with sputum cytology approach had a better specificity than CECT thorax combined with bronchoscopy.

Conclusion

Combined CECT thorax with sputum cytology method has a better specificity in diagnosing lung cancer than combined CECT thorax with bronchoscopy method.

Emerging Biosensing Methods to Monitor Lung Cancer Biomarkers in Biological Samples: A Comprehensive Review

Lung cancer is the most commonly diagnosed of all cancers and one of the leading causes of cancer deaths among men and women worldwide, causing 1.5 million deaths every year. Despite developments in cancer treatment technologies and new pharmaceutical products, high mortality and morbidity remain major challenges for researchers. More than 75% of lung cancer patients are diagnosed in advanced stages, leading to poor prognosis. Lung cancer is a multistep process associated with genetic and epigenetic abnormalities. Rapid, accurate, precise, and reliable detection of lung cancer biomarkers in biological fluids is essential for risk assessment for a given individual and mortality reduction. Traditional diagnostic tools are not sensitive enough to detect and diagnose lung cancer in the early stages. Therefore, the development of novel bioanalytical methods for early-stage screening and diagnosis is extremely important. Recently, biosensors have gained tremendous attention as an alternative to conventional methods because of their robustness, high sensitivity, inexpensiveness, and easy handling and deployment in point-of-care testing. This review provides an overview of the conventional methods currently used for lung cancer screening, classification, diagnosis, and prognosis, providing updates on research and developments in biosensor technology for the detection of lung cancer biomarkers in biological samples. Finally, it comments on recent advances and potential future challenges in the field of biosensors in the context of lung cancer diagnosis and point-of-care applications.

Imaging of brain metastasis in non-small-cell lung cancer: indications, protocols, diagnosis, post-therapy imaging, and implications regarding management

Increased survival (due to the use of targeted therapies based on genomic profiling) has resulted in the increased incidence of brain metastasis during the course of disease, and thus, made it essential to have proper imaging guidelines in place for brain metastasis from non-small-cell lung cancer (NSCLC). Brain parenchymal metastases can have varied imaging appearances, and it is pertinent to be aware of the various molecular risk factors for brain metastasis from NSCLC along with their suggestive imaging appearances, so as to identify them early. Leptomeningeal metastasis requires additional imaging of the spine and an early cerebrospinal fluid (CSF) analysis. Differentiation of post-therapy change from recurrence on imaging has a bearing on the management, hence the need for its awareness. This article will provide in-depth literature review of the epidemiology, aetiopathogenesis, screening, detection, diagnosis, post-therapy imaging, and implications regarding the management of brain metastasis from NSCLC. In addition, we will also briefly highlight the role of artificial intelligence (AI) in brain metastasis screening.

Endoscopic Technologies for Peripheral Pulmonary Lesions: From Diagnosis to Therapy

Peripheral pulmonary lesions (PPLs) are frequent incidental findings in subjects when performing chest radiographs or chest computed tomography (CT) scans. When a PPL is identified, it is necessary to proceed with a risk stratification based on the patient profile and the characteristics found on chest CT. In order to proceed with a diagnostic procedure, the first-line examination is often a bronchoscopy with tissue sampling. Many guidance technologies have recently been developed to facilitate PPLs sampling. Through bronchoscopy, it is currently possible to ascertain the PPL's benign or malignant nature, delaying the therapy's second phase with radical, supportive, or palliative intent. In this review, we describe all the new tools available: from the innovation of bronchoscopic instrumentation (e.g., ultrathin bronchoscopy and robotic bronchoscopy) to the advances in navigation technology (e.g., radial-probe endobronchial ultrasound, virtual navigation, electromagnetic navigation, shape-sensing navigation, cone-beam computed tomography). In addition, we summarize all the PPLs ablation techniques currently under experimentation. Interventional pulmonology may be a discipline aiming at adopting increasingly innovative and disruptive technologies.

Combining Shape-Sensing Robotic Bronchoscopy With Mobile Three-Dimensional Imaging to Verify Tool-in-Lesion and Overcome Divergence: A Pilot Study

Objective

To determine whether CT-to-body divergence can be overcome to improve the diagnostic yield of peripheral pulmonary nodules with the combination of shape-sensing robotic-assisted bronchoscopy (SSRAB) and portable 3-dimensional (3D) imaging.

Patients and Methods

A single-center, prospective, pilot study was conducted from February 9, 2021, to August 4, 2021, to evaluate the combined use of SSRAB and portable 3D imaging to visualize tool-in-lesion as a correlate to diagnostic yield.

Results

Thirty lesions were subjected to biopsy in 17 men (56.7%) and 13 women (43.3%). The median lesion size was 17.5 mm (range, 10-30 mm), with the median airway generation of 7 and the median distance from pleura of 14.9 mm. Most lesions were in the upper lobes (18, 60.0%). Tool-in-lesion was visualized at the time of the procedure in 29 lesions (96.7%). On the basis of histopathologic review, 22 (73.3%) nodules were malignant and 6 (20.0%) were benign. Two (6.7%) specimens were suggestive of inflammation, and the patients elected observation. The mean number of spins was 2.5 (±1.6) with a mean fluoroscopy time of 8.7 min and a mean dose area product of 50.3 Gy cm² (±32.0 Gy cm²). There were no episodes of bleeding or pneumothorax. The diagnostic yield was 93.3%.

Conclusion

This pilot study shows that the combination of mobile 3D imaging and SSRAB of pulmonary nodules appears to be safe and feasible. In conjunction with appropriate anesthetic pathways, nodule motion and divergence can be overcome in most patients.

Trial Registration

https://clinicaltrials.gov Identifier NCT04740047

Role of hemoglobin alpha and hemoglobin beta in non-small-cell lung cancer based on bioinformatics analysis

The differentially expressed genes (DEGs) were identified and screened differentially in non-small-cell lung cancer (NSCLC) using information from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus databases, and the correlation of DEGs in protein interaction, function, and pathway enrichment were analyzed to search for new biomarkers and potential therapeutic targets for NSCLC. Protein-protein interaction network (PPI) analysis showed that CDK1 and GNGT1 were the most significantly upregulated hub nodes, while FPR2 was the most significantly downregulated. Gene Ontology enrichment analysis showed that upregulated DEGs were significantly enriched in protein heterodimerization activity and other functions, while downregulated DEGs were enriched in functions such as heparin-binding. Kyoto Encyclopedia of Genes and Genomes pathway analysis showed that upregulation of DEGs were significantly associated with neuroactive ligand-receptor interaction pathways, while downregulation of DEGs were significantly associated with malaria pathways. According to the analysis results, we identified hemoglobin alpha (HBA) and hemoglobin beta (HBB) as the genes of interest for further study. Through tissue level and cell level experiments, we found that the expressions of HBA and HBB in NSCLC tissues were significantly lower than those in paracancerous tissues, and downregulation of HBA and HBB could significantly affect the proliferation ability of NSCLC cells. In addition, we also found that changes in HBA and HBB may affect NSCLC cells through the p38/MAPK pathway and JNK pathway, and ultimately affect the occurrence and development of NSCLC.

Organ Manifestation and Systematic Organ Screening at the Onset of Inflammatory Rheumatic Diseases

BACKGROUND

Inflammatory rheumatic diseases (IRD) are often associated with the involvement of various organs. However, data regarding organ manifestation and organ spread are rare. To close this knowledge gap, this cross-sectional study was initiated to evaluate the extent of solid organ manifestations in newly diagnosed IRD patients, and to present a structured systematic organ screening algorithm.

MATERIALS AND METHODS

The study included 84 patients (63 women, 21 men) with newly diagnosed IRD. None of the patients received any rheumatic therapy. All patients underwent a standardised organ screening programme encompassing a basic screening (including lungs, heart, kidneys, and gastrointestinal tract) and an additional systematic screening (nose and throat, central and peripheral nervous system) on the basis of clinical, laboratory, and immunological findings.

RESULTS

Represented were patients with connective tissue diseases (CTD) (72.6%), small-vessel vasculitis (16.7%), and myositis (10.7%). In total, 39 participants (46.5%) had one or more organ manifestation(s) (one organ, 29.7%; two organs, 10.7%; ≥three organs, 6.0%). The most frequently involved organs were the lungs (34.5%), heart (11.9%), and kidneys (8.3%). Lastly, a diagnostic algorithm for organ manifestation was applied.

CONCLUSION

One-half of the patients presented with a solid organ involvement at initial diagnosis of IRD. Thus, in contrast to what has been described in the literature, organ manifestations were already present in a high proportion of patients at the time of diagnosis of IRD rather than after several years of disease. Therefore, in IRD patients, systematic organ screening is essential for treatment decisions.

Inhalable polymeric micro and nano-immunoadjuvants for developing therapeutic vaccines in the treatment of non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is a leading cause of death in millions of cancer patients. Lack of diagnosis at an early stage in addition to no specific guidelines for its treatment, and a higher rate of treatment-related toxicity further deteriorate the conditions. Current therapies encompass surgery, chemotherapy, radiation therapy, and immunotherapy according to the pattern and the stage of lung cancer. Among all, with a longlasting therapeutic action, reduced side-effects, and a higher rate of survival, therapeutic cancer vaccine is a new, improved strategy for treating NSCLC. Immunoadjuvants are usually incorporated into the therapeutic vaccines to shield the antigen against environmental and physiological harsh conditions in addition to boosting the immune potential. Conventional immunoadjuvants are often associated with an inadequate cellular response, poor target specificity, and low antigen load. Recently, inhalable polymeric nano/micro immunoadjuvants have exhibited immense potential in the development of therapeutic vaccines for the treatment of NSCLC with improved mucosal immunization. The development of polymeric micro/nano immunoadjuvants brought a new era for vaccines with increased strength and efficiency. Therefore, in the present review, we explained the potential application of micro/nano immunoadjuvants for augmenting the stability and efficacy of inhalable vaccines in the treatment of NSCLC. In addition, the role of biodegradable, biocompatible, and non-toxic polymers has also been discussed with case studies.

Advances in Diagnostic Bronchoscopy

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

Pinocembrin suppresses proliferation and enhances apoptosis in lung cancer cells in vitro by restraining autophagy

Lung cancer is one of the leading causes of human death, and the 5-year survival rate for lung cancer patients remains a relative low level. Pinocembrin (Pino) was reported to play an important role in the inhibition of cancer development, so this study was designed to explore the role of pino in lung cancer. A549 cells were treated with different concentration of Pino (25, 50, 100, 150 and 200 µM) for 24, 48 and 72, respectively to detect cell viability by Cell counting kit-8 (CCK-8) assay. Then, the proliferation, apoptosis and autophagy of A549 cells under pino exposure were detected using colony formation, TUNEL and immunofluorescence staining, respectively. Western blot was used to analyze proliferation-, apoptosis-, and autophagy-related proteins. To measure the effects of pino on cell autophagy, the above-mentioned functional assays were conducted again in A549 cells treated with pino and 20 µM autophagy activator rapamycin (RAPA). Declined trends in cell viability, proliferation, and autophagy were found in A549 cells treated with increasing doses of pino, by contrast with those without any treatment. Additionally, the apoptosis of A549 cells was enhanced upon pino exposure, accompanied by elevated caspase3 activity. However, RAPA reversed the anti-proliferative, anti-autophagic and pro-apoptotic properties of pino in A549 cells. In conclusion, this paper is the first to verify that pino suppresses the proliferation and enhances the apoptosis of lung cancer cells by restraining autophagy, indicating that pino has potential therapeutic effects on the treatment of lung cancer.

Patient with respiratory distress, facial oedema and refractory hypokalaemia

Small cell lung carcinoma, when associated with co-occurrence of complications such as paraneoplastic syndrome and superior vena cava syndrome, poses a greater management challenge to the clinical team. We report a 56-year-old man who was eventually diagnosed with stage III small cell lung carcinoma, presenting with respiratory distress, facial and upper body oedema, proximal muscle weakness, hypokalaemia, new-onset hypertension and hyperglycaemia. His medical management was complicated by associated superior vena cava syndrome and Cushing’s syndrome leading to refractory hypokalemia, immunosuppression and depression. Although the patient improved clinically and biochemically with the chemotherapy and other treatments, the development of neutropenic pneumonia led to his demise. This case highlights the importance of a multidisciplinary approach to achieve better patient care and the need for good clinical vigilance to identify possible humoral manifestations of aggressive malignancies such as small cell carcinoma of the lung to assist their early detection.

Neuroendocrine-Related Circulating Transcripts in Small-Cell Lung Cancers: Detection Methods and Future Perspectives

Simple Summary

The recent implementation of techniques to study circulating tumor cells allowed a rapid increase in knowledge about the molecular basis of Small-Cell Lung Cancer (SCLC), which appears to be more heterogeneous and dynamic than expected. Here, we present a summary of current knowledge and new findings about some of the neuroendocrine-related transcripts expressed in SCLC patients that could offer a great opportunity in distinguishing and managing different SCLC phenotypes.

Abstract

No well-established prognostic or predictive molecular markers of small-cell lung cancer (SCLC) are currently available; therefore, all patients receive standard treatment. Adequate quantities and quality of tissue samples are frequently unavailable to perform a molecular analysis of SCLC, which appears more heterogeneous and dynamic than expected. The implementation of techniques to study circulating tumor cells could offer a suitable alternative to expand the knowledge of the molecular basis of a tumor. In this context, the advantage of SCLC circulating cells to express some specific markers to be explored in blood as circulating transcripts could offer a great opportunity in distinguishing and managing different SCLC phenotypes. Here, we present a summary of published data and new findings about the detection methods and potential application of a group of neuroendocrine related transcripts in the peripheral blood of SCLC patients. In the era of new treatments, easy and rapid detection of informative biomarkers in blood warrants further investigation, since it represents an important option to obtain essential information for disease monitoring and/or better treatment choices.

Diagnostic Value of Virtual Bronchoscopic Navigation Combined With Endobronchial Ultrasound Guided Transbronchial Lung Biopsy for Peripheral Pulmonary Lesions

Objective:

X-ray guided transbronchial ultrasound-guided transbronchial lung biopsy (EBUS-TBLB) can improve the diagnostic yield of peripheral pulmonary lesions (PPLs), but it needs special requirements. The purpose of this study was to investigate the clinical value of virtual bronchoscopy navigation (VBN) combined with EBUS-TBLB in the diagnosis of PPLs without X-ray guidance.

Methods:

The 105 patients with PPLs underwent EBUS-TBLB with or without VBN randomly. The diagnostic yield, the operation time and complications were evaluated in the 2 groups.

Results:

No significant difference was found between the VBN+EBUS group and the EBUS group (76.0% vs. 65.5%, P = 0.287). The operation time of VBN+EBUS group was significantly shorter than that of EBUS group (20.6 ± 12.8 min vs. 28.6 ± 14.3 min, P = 0.023). No severe procedure related complications occurred.

Conclusions:

VBN can shorten the operation time. The combination of VBN and EBUS-TBLB is a safe and effective diagnosis technique for PPLs.

Comparison of Chief Complaints and Patient-Reported Symptoms of Treatment-Naive Lung Cancer Patients Before Surgery

BACKGROUND

Lung cancer patients without chief complaints have been increasingly identified by physical examination. This study aimed to profile and compare chief complaints with patient-reported symptoms of lung cancer patients before surgery.

METHODS

Data were extracted from a multicenter, prospective longitudinal study (CN-PRO-Lung 1) in China from November 2017 to January 2020. A comparison between chief complaints and patient-reported symptoms was analyzed using the Chi-squared test.

RESULTS

A total of 201 (50.8%) lung cancer patients without chief complaints were found by physical examination at admission, and 195 (49.2%) patients had chief complaints. The top 5 chief complaints were coughing (38.1%), expectoration (25.5%), chest pain (13.6%), hemoptysis (10.6%), and shortness of breath (5.3%). There were significantly more patients with chief complaints of coughing (38.1% vs 15.0%, P <0.001) and pain (20.5% vs 6.9%, P<0.001) than those with the same symptoms rated ≥4 via MD Anderson Symptom Inventory‒Lung Cancer (MDASI-LC). There were less patients with chief complaints of fatigue (1.8% vs 10.9%, P<0.001), nausea (0.3% vs 2.5%, P=0.006), and vomiting (0.3% vs 1.8%, p=0.032) than those with the same symptoms rated ≥4 via MDASI-LC. In patients without chief complaints, the five most common moderate to severe patient-reported symptoms were disturbed sleep (19.5%), distress (13.5%), dry mouth (13%), sadness (12%), and difficulty remembering (11.1%).

CONCLUSION

Symptoms of lung cancer patients not included in the chief complaint could be identified via a patient-reported outcome instrument, suggesting the necessity of implementing the patient-reported outcome assessment before lung cancer surgery for better patient care.

Epidemiology of stage III lung cancer: frequency, diagnostic characteristics, and survival

Stage III non-small cell lung cancer (NSCLC) includes a highly heterogeneous group of patients with differences in the extent and localization of disease. Many aspects of stage III disease are controversial. The data supporting treatment approaches are often subject to a number of limitations, due to the heterogeneous patient populations involved in the trials. Furthermore, the definition of stage III disease has changed over time, and early studies were frequently inadequately powered to detect small differences in therapeutic outcome, were not randomized, or had a limited follow-up times. Major improvements in therapy, including the use of more active chemotherapy agents and refinements in radiation and surgical techniques, also limit the interpretation of earlier clinical trials. Lastly, improvements in pretreatment staging have led to reclassification of patients with relatively minimal metastatic disease as stage IV rather than stage III, leading to an apparent increase in the overall survival of both stage III and IV patients. Median overall stage III NSCLC survival ranges from 9 to 34 months. Higher survival rates are observed in younger Caucasian women with good performance status, adenocarcinoma, mutations, stage IIIA, and in patients with multidisciplinary-team-based diagnoses.

Gender and lung cancer-SEER-based analysis

BACKGROUND

Lung cancer remains a major cause of death worldwide. While in the past it was considered to primarily afflict males, in recent decades the number of female patients has risen, such that rates among females are similar to those among males. Nevertheless, it has been found previously (e.g., in cardiovascular disease) that when there is a sex-specific stereotype to a disease, it may remain entrenched in medical diagnostic processes, so as to cause belated diagnosis among the other sex. Gender-based differences in incidence and diagnosis are likely to exist with respect to lung cancer because of smoking habits and stereotypes, geographic and socioeconomic differences, and past epidemiologic differences between the sexes. Here we aim to characterize the effects of gender on lung cancer diagnosis and whether such effects have changed over time.

METHODS

The SEER (Statistics, Epidemiology, and End Results) database was used to check for sex-based differences by tumor type and stage at diagnosis and to investigate whether these patterns have changed with time by comparing staging data in different age cohorts over time. Results were stratified by location and analyzed with data regarding possible confounders such as smoking and socioeconomic factors.

RESULTS

We examined 458,132 cases of lung cancer from the years 2004-2012; 243,021 (53%) in males and 215,111 (47%) in females. Lung cancer rates were 73.8 (73.5-74.1) per 100k in males and 51.6 (51.4-51.8) per 100k in females. Of these, 400,800 had the stage listed, 214,479 (54%) in males, and 186,321 (46%) in females. Total lung cancer rates were higher in males than females at all disease stages. Male patients were more likely than female patients to be diagnosed at stage 3-4, consistent across lung cancer types, cancer registries, smoking, and socioeconomic backgrounds. The difference between the percentage of males versus females diagnosed in stages 3-4 correlated negatively with increased female ever-smokers and with squamous and small cell carcinoma and were not correlated with the rate of cancer in females, or the difference between male and female cancer rates.

CONCLUSIONS

Our study showed that there is no belated diagnosis of lung cancer in females. Results appear to point to the fact that smoking females are more likely to be diagnosed at later stages, which is consistent with the current literature.

PP4R1 interacts with HMGA2 to promote non-small-cell lung cancer migration and metastasis via activating MAPK/ERK-induced epithelial-mesenchymal transition

Protein phosphatase 4 regulatory subunit 1 (PP4R1) has been shown to play a role in the regulation of centrosome maturation, apoptosis, DNA repair, and tumor necrosis factor signaling. However, the function of PP4R1 in non-small-cell lung cancer remains unclear. In this study, we identify PP4R1 as an oncogene through Oncomine database mining and immunohistochemical staining, and we showed that PP4R1 is upregulated in lung cancer tissues as compared with that in normal lung tissues and correlated with a poor prognosis in lung cancer patients. Furthermore, in vitro study by wound-healing and Transwell assay showed that PP4R1 could promote migration and invasion of lung cancer cells. Mechanistic investigations revealed that PP4R1 could cooperate with high mobility group AT-hook 2 and thereby promotes epithelial-mesenchymal transition via MAPK/extracellular receptor kinase activation. Taken together, our study provides a rich resource for understanding PP4R1 in lung cancer and indicates that PP4R1 may serve as a potential biomarker in lung cancer therapies.

Small cell carcinoma of the bladder presenting with paraneoplastic syndrome of inappropriate antidiuretic hormone

Small cell carcinoma (SCC) of the bladder is a rare malignancy, representing less than 1% of bladder cancers diagnosed annually in the USA. In contrast to SCC of the lung, paraneoplastic syndromes are rarely documented in cases of extrapulmonary SCCs, particularly those of genitourinary origin. We present a case of SCC of the bladder presenting with paraneoplastic syndrome of inappropriate antidiuretic hormone, which resolved after treatment with sequential chemoradiation.

Systemic Therapy for Locally Advanced and Metastatic Non-Small Cell Lung Cancer: A Review

IMPORTANCE

Non-small cell lung cancer remains the leading cause of cancer death in the United States. Until the last decade, the 5-year overall survival rate for patients with metastatic non-small cell lung cancer was less than 5%. Improved understanding of the biology of lung cancer has resulted in the development of new biomarker-targeted therapies and led to improvements in overall survival for patients with advanced or metastatic disease.

OBSERVATIONS

Systemic therapy for metastatic non-small cell lung cancer is selected according to the presence of specific biomarkers. Therefore, all patients with metastatic non-small cell lung cancer should undergo molecular testing for relevant mutations and expression of the protein PD-L1 (programmed death ligand 1). Molecular alterations that predict response to treatment (eg, EGFR mutations, ALK rearrangements, ROS1 rearrangements, and BRAF V600E mutations) are present in approximately 30% of patients with non-small cell lung cancer. Targeted therapy for these alterations improves progression-free survival compared with cytotoxic chemotherapy. For example, somatic activating mutations in the EGFR gene are present in approximately 20% of patients with advanced non-small cell lung cancer. Tyrosine kinase inhibitors such as gefitinib, erlotinib, and afatinib improve progression-free survival in patients with susceptible EGFR mutations. In patients with overexpression of ALK protein, the response rate was significantly better with crizotinib (a tyrosine kinase inhibitor) than with the combination of pemetrexed and either cisplatin or carboplatin (platinum-based chemotherapy) (74% vs 45%, respectively; P < .001) and progression-free survival (median, 10.9 months vs 7.0 months; P < .001). Subsequent generations of tyrosine kinase inhibitors have improved these agents. For patients without biomarkers indicating susceptibility to specific targeted treatments, immune checkpoint inhibitor-containing regimens either as monotherapy or in combination with chemotherapy are superior vs chemotherapy alone. These advances in biomarker-directed therapy have led to improvements in overall survival. For example, the 5-year overall survival rate currently exceeds 25% among patients whose tumors have high PD-L1 expression (tumor proportion score of ≥50%) and 40% among patients with ALK-positive tumors.

CONCLUSIONS AND RELEVANCE

Improved understanding of the biology and molecular subtypes of non-small cell lung cancer have led to more biomarker-directed therapies for patients with metastatic disease. These biomarker-directed therapies and newer empirical treatment regimens have improved overall survival for patients with metastatic non-small cell lung cancer.

Paraneoplastic syndromes in lung cancer and their management

Paraneoplastic syndromes are most frequently associated with lung cancer. This review considers a variety of paraneoplastic syndromes associated with lung cancer and discusses their pathophysiology, clinical features and management options.

A systematic review of pharmacoeconomic evaluations of erlotinib in the first-line treatment of advanced non-small cell lung cancer

OBJECTIVE

To review and assess the quality of the available evidence on the cost-effectiveness of erlotinib in the first-line treatment of advanced non-small cell lung cancer (NSCLC).

METHODS

A systematic review was conducted to identify full-text original economic evaluations of erlotinib in the first-line treatment of advanced NSCLC written in English and published from the year 2000 onwards. Study characteristics and results were recorded and compared. The quality of the studies was assessed by the Quality of Health Economic Studies (QHES) questionnaire.

RESULTS

Eleven out of 130 papers were chosen for this review. Comparative regimens consisted of a best supportive care, reverse strategy, bevacizumab, cisplatin plus pemetrexed, carboplatin plus gemcitabine or gefitinib. The methods most used in these studies were modeling and sensitivity analysis and cost-effectiveness analysis. All of the studies evaluated direct costs and used quality-adjusted life-year (QALY) and life-years gained (LYG) as outcome, with 3% and 3.5% discount rate. The studies assigned ICER that ranged from dominant to I$305,510.31/QALY and from I$31,209.55/LYG to I$66,540.20/LYG. Based on the willingness to pay threshold, seven studies concluded that erlotinib was cost-effective, two studies showed that erlotinib was cost-effective on specific patients with certain conditions, and two studies comparing erlotinib with reverse strategy did not find a difference in cost-effectiveness. The high quality of these studies was confirmed using the QHES tool: the mean score was 75.77 out of 100 (SD 9.38).

CONCLUSION

Most of these high-quality studies suggested that erlotinib was cost-effective in the first-line treatment of advanced NSCLC.

Lung adenocarcinoma metastasis to pancreas after the absence of primary tumour for almost two years

This case report can argue in favour of optimal surgical management for isolated metastases to the pancreas, especially in patients with low surgical risk.

Preoperative Pulmonary Evaluation

The preanesthesia evaluation is an opportunity to elucidate a patient's underlying medical disease, determine if the patient is optimized, treat modifiable conditions, screen for potentially unrecognized disorders, and present the clear picture of the patient's overall risk for perioperative complications. This article presents the preoperative assessment of pulmonary patients in 2 sections. First, the components of a thorough assessment of patients presenting for preanesthesia evaluation, which should occur for all patients, regardless of the presence of pulmonary pathology, are discussed. Then, the considerations unique to patients with pulmonary diseases commonly encountered are described.

Cancer Pain Assessment and Classification

More than half of patients affected by cancer experience pain of moderate-to-severe intensity, often in multiple sites, and of different etiologies and underlying mechanisms. The heterogeneity of pain mechanisms is expressed with the fluctuating nature of cancer pain intensity and clinical characteristics. Traditional ways of classifying pain in the cancer population include distinguishing pain etiology, clinical characteristics related to pain and the patient, pathophysiology, and the use of already validated classification systems. Concepts like breakthrough, nociceptive, neuropathic, and mixed pain are very important in the assessment of pain in this population of patients. When dealing with patients affected by cancer pain it is also very important to be familiar to the characteristics of specific pain syndromes that are usually encountered. In this article we review methods presently applied for classifying cancer pain highlighting the importance of an accurate clinical evaluation in providing adequate analgesia to patients.

Inhibition of thymidine phosphorylase expression by Hsp90 inhibitor potentiates the cytotoxic effect of salinomycin in human non-small-cell lung cancer cells

Salinomycin is a polyether ionophore antibiotic having anti-tumorigenic property in various types of cancer. Elevated thymidine phosphorylase (TP) levels, a key enzyme in the pyrimidine nucleoside salvage pathway, are associated with an aggressive disease phenotype and poor prognoses. Heat shock protein 90 (Hsp90) is a ubiquitous molecular chaperone that is responsible for the stabilization and maturation of many oncogenic proteins. In this study, we report whether Hsp90 inhibitor 17-AAG could enhance salinomycin-induced cytotoxicity in NSCLC cells through modulating TP expression in two non-small-cell lung cancer (NSCLC) cell lines, A549 and H1975. We found that salinomycin increased TP expression in a MKK3/6-p38 MAPK activation manner. Knockdown of TP using siRNA or inactivation of p38 MAPK by pharmacological inhibitor SB203580 enhanced the cytotoxic and growth inhibition effects of salinomycin. In contrast, enforced expression of MKK6E (a constitutively active form of MKK6) reduced the cytotoxicity and cell growth inhibition of salinomycin. Moreover, Hsp90 inhibitor 17-AAG enhanced cytotoxicity and cell growth inhibition of salinomycin in NSCLC cells, which were associated with down-regulation of TP expression and inactivation of p38 MAPK. Together, the Hsp90 inhibition induced TP down-regulation involved in enhancing the salinomycin-induced cytotoxicity in A549 and H1975 cells.

Usefulness of virtual bronchoscopic navigation combined with endobronchial ultrasound guided transbronchial lung biopsy for solitary pulmonary nodules

BACKGROUND

The aim of this study was to evaluate the diagnostic utility of virtual bronchoscopic navigation (VBN) combined with endobronchial ultrasound (EBUS) guided transbronchial lung biopsy for solitary pulmonary nodules (SPN).

METHODS

A total of 115 patients with suspected SPN who underwent transbronchial lung biopsy were evaluated. The patients were randomly divided into an EBUS (EBUS) group and a virtual bronchoscopic navigation combined with endobronchial ultrasound (VBN+EBUS) group. The diagnostic yield and examination time were compared.

RESULTS

There was no significant difference in the diagnostic yield between the VBN+EBUS group and the EBUS group (83.6% vs 66.7%, P = .419). When the lesions less than 20 mm in diameter of the lesions were analyzed, the diagnostic yield was higher in the VBN+EBUS group than in the EBUS group (80.0% vs 53.6%, P = .041). The time for positioning lesions in VBN+EBUS group was less than that in EBUS group (5.67 ± 2.48 min vs 8.65 ± 2.23 min, P = .015). But the total examination time was not significantly different between the 2 groups (20.59 ± 2.12 min vs 21.53 ± 1.62 min, P = .236). The incidence of complications did not differ between the 2 groups.

CONCLUSIONS

In conclusion, VBN can shorten the positioning time and it is a safe and effective technique for pulmonary nodules.

Assessing the referral of clients with respiratory symptoms to general physicians: a survey of community pharmacists in Beirut

OBJECTIVES

The main objective of this study was to assess the ability of community pharmacists practicing in Beirut to identify red flag respiratory symptoms, and therefore to adequately refer clients to a general physician when warranted. Secondary objectives included determining whether demographic factors affect the odds of referral, and to qualify degree of agreement of community pharmacists with a panel of expert physicians.

METHODS

In this cross-sectional study, pharmacies were randomly selected and invited to complete a self-administered survey, each containing 10 clinical vignettes that combined different characteristics (age group, gender, presenting symptom, duration of symptoms). Bivariate and multivariate logistic regressions were used to inspect predictors of referral, correct referral and under-referral.

KEY FINDINGS

A total of 214 pharmacies were visited and 141 (65.9%) responded. Pharmacists were more likely to refer female patients (P = 0.035) and patients who presented with a longer duration of symptoms (P < 0.001). Correct referral was higher in pharmacies that were more than 20 min away from the nearest hospital (P = 0.013) and with clients who presented with haemoptysis (P < 0.001), dyspnoea (P < 0.001) or wheezing (P < 0.027), while it was lower with female patients (P < 0.001). Under-referral was higher in pharmacies that served more than 500 clients weekly (P = 0.048) and in patients presenting for dry cough (P < 0.001) or productive cough (P < 0.001).

CONCLUSION

This study has shown that there is a need for further investigation into the practices of community pharmacists of Beirut. An action plan may be advised to alleviate the burden of patients who might currently be under-referred and experience morbidity as a result.

Location of stage I-III non-small cell lung cancer and survival rate: Systematic review and meta-analysis

BACKGROUND

The association between the location of non-small cell lung cancer (NSCLC) and prognosis is a debated issue. Some studies have provided evidence of better prognosis of upper lobe tumors than lower to middle lobe tumors, while other studies have reported contrasting conclusions. The aim of this study was to further assess this association through a systematic review and meta-analysis.

METHODS

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched up to 27 January 2017. Patients pathologically diagnosed with stage I-III NSCLC with three or five-year survival data were included. The main meta-analysis compared differences in survival rates according to the primary tumor location using the Mantel-Haenszel method with a random effect model. Sensitivity analysis was conducted according to lymph node metastasis, tumor node metastasis stage, staging method, and treatment modality.

RESULTS

Ten clinical studies and 35 570 patients were recruited. Patients with tumors in the upper lobes had a higher rate of five-year survival compared to those with tumors in non-upper lobes (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.15-1.49). Similarly, the three-year survival rate was high in patients with tumors in the upper lobes (OR 1.99, 95% CI 1.02-3.86) and low in those with lower lobe tumors (OR 0.31, 95% CI 0.12-0.77).

CONCLUSIONS

Stage I-III NSCLC located in the upper lobes showed higher five-year survival rates compared to other tumor locations.

A Rare Case of Isolated Chronic Cough Caused by Pulmonary Lymphangitic Carcinomatosis as a Primary Manifestation of Rectum Carcinoma

A 36-year old man was referred to our hospital due to isolated chronic cough that was refractory to anti-asthma medications, including inhaled corticosteroids/long-acting β₂ agonists. Chest X-ray showed diffuse nodular and enhanced vascular shadows with Kerley lines in both lungs. A blood analysis showed elevated serum carcinoembryonic antigen (CEA) and CA19-9 levels. A transbronchial biopsy revealed well to moderately differentiated adenocarcinoma, the origin of which was immunohistochemically suspected to be the gastrointestinal tract. Colonoscopy confirmed the diagnosis of primary rectum carcinoma. Pulmonary lymphangitic carcinomatosis was therefore regarded as the origin of the cough. Lymphangitic carcinomatosis is an uncommon diagnosis but important to consider in patients with persistent cough.

Endocrine paraneoplastic syndromes in lung cancer

Paraneoplastic syndromes are defined as a combination of clinical disorders associated with malignant diseases that are caused by the secretion of various substances by the tumor without, however, being caused by the direct growth and infiltration of the primary tumor, or due to the development of distant metastases. Despite the fact that lung cancer represents the number one cause of death from cancer worldwide, the new methods of treatment increase patient survival and the incidence of paraneoplastic syndromes. The most important ones of these are humoral hypercalcemia of malignancy, syndrome of inappropriate antidiuretic hormone, hyponatremia of malignancy, ectopic Cushing's syndrome, carcinoid syndrome, and hypoglycemia and are usually a poor prognostic marker. Early diagnosis of those syndromes is achieved using specific criteria and may lead to early diagnosis of the underlying malignancy. It is essential to treat them with the overriding objective of improving the patients' quality of life.

Aberrant methylation of mutL homolog 1 is associated with increased risk of non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is a common malignant tumor. DNA hypermethylation in the promoter region has been served as a potential molecular marker for several tumors. The goal of the current study was to assess the diagnostic ability of mutL homolog 1 (MLH1) promoter methylation in NSCLC.

METHODS

A total of 111 NSCLC patients' paired tissue samples were obtained to explore the association between MLH1 promoter methylation and NSCLC by methylation-specific polymerase chain reaction (MSP) method. Public databases including The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) were used to verify our findings.

RESULTS

Our results showed a significantly higher MLH1 methylation frequency in tumor tissue samples than their paired adjacent tissues (P = .008). ROC curve indicated that MLH1MSP assay was a sensitive but not a specific method in the diagnosis for NSCLC (sensitivity = 0.964, specificity = 0.135, AUC = 0.550). And the association between the methylation level and clinical characteristics has no statistical significance. TCGA cohort evinced a higher methylation probability in tumor group compared with nontumor group (the mean β value: -0.449 [-0.467, -0.437] vs -0.466 [-0.472, -0.437], P = .011), which was consistent with our results. Meanwhile, an inverse correlation between MLH1 methylation and MLH1 expression was detected in TCGA and GEO databases.

CONCLUSIONS

The MSP method for MLH1 methylation was a sensitive but not a specific diagnostic method for NSCLC.

The diagnostic role of plasma circulating precursors of miRNA-944 and miRNA-3662 for non-small cell lung cancer detection

INTRODUCTION

microRNA (miRNA) seem to be most attractive cancer markers due their crucial role in tumor development and possibility of their analysis using liquid biopsy. To date there is little known about role of miRNA precursors (pri-miRNA) in carcinogenesis and their utility as tumor markers.

MATERIAL AND METHODS

miRNA-944 and miRNA-3662 precursors as potential non-small cell lung cancer (NSCLC) markers were analyzed in plasma samples of 56 patients in an early stage of NSCLC and 100 healthy individuals.

RESULTS

Diagnostic test based on two studied markers for stage I-IIIA of the disease allowed to distinguish NSCLC from healthy individuals with 75.7% sensitivity and 82.3% specificity (AUC=0.898). pri-miRNA-944 distinguished SCC from AC with sensitivity of 78.6% and specificity of 91.7% (AUC=0.771), and pri-miRNA-3662 distinguished AC from SCC with 57.1% sensitivity and 90% specificity (AUC=0.845).

CONCLUSION

Circulating pri-miRNA-944 and 3662 can improve non-invasive NSCLC detection of operable stages of SCC and AC. miRNA precursors could be considered as novel potential lung cancer biomarkers.

Prognostic Significance of Host-related Biomarkers for Survival in Patients with Advanced Non-Small Cell Lung Cancer

OBJECTIVE

This study identified host-related prognostic biomarkers for survival in patients with advanced non-small cell lung cancer (NSCLC).

METHODS

This study was based on the retrospective review of the medical records of 135 patients with pathologically confirmed advanced NSCLC. The host-related biomarkers assessed in this study that reflected patient condition included hemoglobin (Hb) levels; platelet (PLT), neutrophil, lymphocyte, and monocyte counts; and ferritin concentrations. The overall survival (OS) was calculated by Kaplan-Meier analysis and compared using log-rank tests. Univariate and multivariate analyses of Cox proportional hazards regression were used to evaluate the prognostic impact for survival.

RESULTS

Of the enrolled patients, 91.1% had stage IV NSCLC, 42.2% had ECOG-PS scores of 2, and 57% had undergone multiple rounds of prior systemic therapy. The prognostic factors included low Hb concentration (men: Hb < 13 g/dL, women: Hb < 12 g/dL; p = 0.046), increased neutrophil count (> 7,700 cells/μL; p < 0.001), decreased lymphocyte count (≤ 1500 cells/μL; p = 0.011), increased monocyte count (> 800 cells/μL; p < 0.001), and high ferritin level (men: > 200 ng/mL, women: > 150 ng/mL; p < 0.001), which were associated with poor OS and increased hazard of mortality. The multivariate proportional hazards model revealed that lymphocyte count, monocyte count, and ferritin level were independent host-related prognostic biomarkers for survival. Increased monocyte count (HR, 3.15; 95% CI, 1.64-6.04; p < 0.001) and high ferritin level (HR, 1.81; 95% CI, 1.24-2.64; p = 0.002) were significantly associated with poor survival, whereas increased lymphocyte count (HR, 0.57; 95% CI, 0.40-0.83; p = 0.004) showed prolonged survival.

CONCLUSION

Immune factors, such as lymphocyte and monocyte counts, as well as serum ferritin levels, are significant host-related prognostic biomarkers for survival with direct relevance to survival time in patients with advanced NSCLC.

Potential paraneoplastic syndromes and selected autoimmune conditions in patients with non-small cell lung cancer and small cell lung cancer: A population-based cohort study

BACKGROUND

Little is known about the occurrence and distribution of types of paraneoplastic syndromes (PNS) in patients with lung cancer. Identification of autoimmune PNS is particularly important for discerning them from immune-related adverse events of novel immunotherapies. We estimated the occurrence of PNS among patients with lung cancer and compared it with that in the general population.

METHODS

In this registry-based cohort study in Denmark, we identified all patients with incident primary lung cancer between 1997 and 2010, and in a general-population comparison cohort matched on calendar time, sex, age, and residence. Among patients with non-small cell lung cancer (NSCLC) and small-cell lung cancer (SCLC), we estimated prevalence of potential PNS and selected autoimmune conditions and compared their incidence rates with those of equivalent conditions in the general population cohort, using hazard ratios (HRs) adjusted for baseline comorbidity.

RESULTS

There were 35,319 patients with NSCLC and 6,711 patients with SCLC. The incidence rates per 1000 person-years (95% confidence interval) of any potential PNS or selected autoimmune disorders were 135.4 (131.9-139.1) among NSCLC patients and 237.3 (224.4-250.5) among SCLC patients. Adjusted HRs for any potential PNS or selected autoimmune disorders were 4.8 (4.7-5.0) for NSCLC and 8.2 (7.6-8.8) for SCLC.

CONCLUSION

Incidence rate of any potential PNS or selected autoimmune disorders among patients with lung cancer was greater than that in the general population and was greater after SCLC than after NSCLC.

IMPACT

These results provide context to discerning PNS from adverse effects of novel immunotherapies during the clinical course of NSCLC and SCLC.

Detection of brain-directed autoantibodies in the serum of non-small cell lung cancer patients

Antibodies against brain proteins were identified in the plasma of cancer patients and are defined to cause paraneoplastic neurological syndromes. The profiles of brain-directed antibodies in non-small cell lung cancer (NSCLC) are largely unknown. Here, for the first time, we compared autoantibodies against brain proteins in NSCLC (n = 18) against those present in age-matched non-cancer control subjects (n = 18) with a similar life-style, habit, and medical history. Self-recognizing immunoglobulin (IgG) are primarily directed against cells in the cortex (P = 0.008), hippocampus (P = 0.003–0.05), and cerebellum (P = 0.02). More specifically, IgG targets were prominent in the pyramidal, Purkinje, and granule cell layers. Furthermore, autoimmune IgG signals were localized to neurons (81%), astrocytes (48%), and endothelial (29%) cells. While cancer sera yielded overall higher intensity signals, autoantigens of 100, 65, 45, 37, and 30 kDa molecular weights were the most represented. Additionally, a group of 100 kDa proteins seem more prevalent in female adenocarcinoma patients (4/5, 80%). In conclusion, our results revealed autoantigen specificity in NSCLC, which implicitly depends on patient’s demographics and disease history. Patients at risk for lung cancer but with no active disease revealed that the immune profile in NSCLC is disease-dependent.

Proteomic analysis of bronchoalveolar lavage fluid (BALF) from lung cancer patients using label-free mass spectrometry

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality in both men and women throughout the world. The need to detect lung cancer at an early, potentially curable stage, is essential and may reduce mortality by 20%. The aim of this study was to identify distinct proteomic profiles in bronchoalveolar fluid (BALF) and plasma that are able to discriminate individuals with benign disease from those with non-small cell lung cancer (NSCLC).

METHODS

Using label-free mass spectrometry analysis of BALF during discovery-phase analysis, a significant number of proteins were found to have different abundance levels when comparing control to adenocarcinoma (AD) or squamous cell lung carcinoma (SqCC). Validation of candidate biomarkers identified in BALF was performed in a larger cohort of plasma samples by detection with enzyme-linked immunoassay.

RESULTS

Four proteins (Cystatin-C, TIMP-1, Lipocalin-2 and HSP70/HSPA1A) were selected as a representative group from discovery phase mass spectrometry BALF analysis. Plasma levels of TIMP-1, Lipocalin-2 and Cystatin-C were found to be significantly elevated in AD and SqCC compared to control.

CONCLUSION

The results presented in this study indicate that BALF is an important proximal biofluid for the discovery and identification of candidate lung cancer biomarkers.

GENERAL SIGNIFICANCE

There is good correlation between the trend of protein abundance levels in BALF and that of plasma which validates this approach to develop a blood biomarker to aid lung cancer diagnosis, particularly in the era of lung cancer screening. The protein signatures identified also provide insight into the molecular mechanisms associated with lung malignancy.

Induction of cell death by pyropheophorbide-α methyl ester-mediated photodynamic therapy in lung cancer A549 cells

Pyropheophorbide‐α methyl ester (MPPa) was a promising photosensitizer with stable chemical structure, strong absorption, higher tissue selectivity and longer activation wavelengths. The present study investigated the effect of MPPa‐mediated photodynamic treatment on lung cancer A549 cells as well as the underlying mechanisms. Cell Counting Kit‐8 was employed for cell viability assessment. Reactive oxygen species levels were determined by fluorescence microscopy and flow cytometry. Cell morphology was evaluated by Hoechst staining and transmission electron microscopy. Mitochondrial membrane potential, cellular apoptosis and cell cycle distribution were evaluated flow‐cytometrically. The protein levels of apoptotic effectors were examined by Western blot. We found that the photocytotoxicity of MPPa showed both drug‐ and light‐ dose dependent characteristics in A549 cells. Additionally, MPPa‐PDT caused cell apoptosis by reducing mitochondrial membrane potential, increasing reactive oxygen species (ROS) production, inducing caspase‐9/caspase‐3 signaling activation as well as cell cycle arrest at G₀/G₁ phase. These results suggested that MPPa‐PDT mainly kills cells by apoptotic mechanisms, with overt curative effects, indicating that MPPa should be considered a potent photosensitizer for lung carcinoma treatment.

Paraneoplastic Hypocalcemia Developed in Gastric Cancer Accompanied by Osteoblastic Metastasis

Paraneoplastic syndromes are generally defined as clinical disorders associated with malignant diseases, and hypocalcemia associated with cancer is a rare condition. A woman in her 60s was referred to our hospital for the further examination of massive ascites due to carcinoma of unknown primary origin. She complained of numbness around her lips, and marked hypocalcemia of 5.0 mg/dL was noted. After two courses of chemotherapy, computed tomography showed a decrease in the ascites, and her serum calcium level increased. Although hypocalcemia is a very rare condition in patients with gastric cancer, serum calcium values should be evaluated when neurological symptoms are observed.