Late recurrence of non-small cell lung cancer more than 5 years after complete resection: incidence and clinical implications in patient follow-up

Late recurrence of completely resected stage I to IIIA lung adenocarcinoma

OBJECTIVE

Research into the risk factors associated with late recurrence (>2 years after surgery) of lung adenocarcinoma is limited. We investigated the incidence of and clinicopathologic and genomic features associated with late recurrence of resected stage I-IIIA lung adenocarcinoma.

METHODS

We performed a retrospective analysis of patients with completely resected pathologic stage I-IIIA lung adenocarcinoma (2010-2019). Patients with a history of lung cancer, neoadjuvant therapy, or mucinous or noninvasive lung adenocarcinoma, or with follow-up of less than 2 years were excluded. Cox and logistic regression modeling were used to compare clinicopathologic variables among patients with no, early (≤2 years), and late recurrence. Comparisons of genomic mutations were corrected for multiple testing.

RESULTS

Of the 2349 patients included, 537 developed a recurrence during follow-up. Most recurrences (55% [297/537]) occurred early; 45% (240/537) occurred late. A larger proportion of late recurrences than early recurrences were locoregional (37% vs 29%; P = .047). Patients with late recurrence had more aggressive pathologic features (International Association for the Study of Lung Cancer grade 2 and 3, lymphovascular invasion, visceral pleural invasion) and higher stage than patients without recurrence. Pathologic features were similar between patients with early and late recurrence, except stage IIIA disease was more common in the early cohort. No genomic mutations were associated with late recurrence.

CONCLUSIONS

Late recurrence of lung adenocarcinoma after resection is more common than previously reported. Patients without disease more than 2 years after surgery who had aggressive pathologic features at the time of resection have an elevated risk of recurrence and may benefit from more aggressive follow-up.

Impact of Adjuvant Atezolizumab on Recurrences Avoided and Treatment Cost Savings for Patients with Stage II-IIIA Non-Small Cell Lung Cancer in Canada

This epidemiological model forecasted reductions in recurrences and recurrence treatment cost savings with adjuvant atezolizumab vs best supportive care among Canadians with stage II-IIIA non-small cell lung cancer (NSCLC) at national and provincial levels. The population had resected, programmed cell death 1 ligand 1 (PD-L1)-high (≥50%), EGFR-, ALK-, stage II-IIIA NSCLC eligible for adjuvant treatment. Patients with recurrence or death and the costs of treating recurrences were estimated for those receiving adjuvant atezolizumab or best supportive care each year (2024-2034). Proportions of patients expected to be event free up to 10 years after treatment initiation were extrapolated with parametric survival analyses. In the base case analysis, 240 fewer recurrences were estimated to occur over 10 years (2024-2034) with adjuvant atezolizumab vs best supportive care across Canada, with 136 (57%) and 104 (43%) fewer locoregional and metastatic recurrences, respectively. Projected costs of treated recurrences were CAD 33.2 million less over 10 years with adjuvant atezolizumab at a national level (adjuvant atezolizumab, CAD 135.8 million; best supportive care, CAD 169.0 million). This model predicts a considerable long-term reduction in recurrences and substantial treatment cost savings with adjuvant atezolizumab vs best supportive care for patients with PD-L1-high early-stage NSCLC in Canada.

Long term outcomes beyond 5 years after pulmonary resection for non-small-cell lung cancer

OBJECTIVES

We investigated the incidence of late recurrence beyond 5 years after pulmonary resection and aimed to identify candidates for long-term surveillance.

METHODS

We retrospectively reviewed the medical records of 978 non-small-cell lung cancer patients who underwent pulmonary resection between 2002 and 2015 and survived without recurrence for 5 years. Clinicopathological factors associated with recurrence-free survival beyond 5 years after surgery were investigated using univariate and multivariate analyses. The development of late metachronous malignancies was also investigated.

RESULTS

The median follow-up period from 5 years post-surgery was 27 months in the whole cohort. Late recurrence occurred in 37 (3.8%) patients. Late metachronous malignancies were diagnosed in 116 patients (11.9%), including 57 (5.8%) with lung cancer. One-, three-, and five-year recurrence-free survival rates beyond 5 years after surgery were 97.6%, 94.7%, and 94.7%, respectively. The recurrence-free survival of patients with pN1-2 was significantly poorer than that of patients with pN0 disease. Multivariate analysis revealed that adenocarcinoma and pN1-2 status were significantly associated with poor recurrence-free survival beyond 5 years post-surgery (P = 0.009 and 0.007, respectively).

CONCLUSIONS

Non-adenocarcinoma histology and pN0 status were significant favorable factors for recurrence-free survival beyond 5 years post-surgery. The efficacies of long-term surveillance for the detection of late recurrence were considered limited for these populations. Twelve percent of the patients experienced late metachronous malignancies after pulmonary resection.

Brain Metastasis of Non-small Cell Lung Cancer After Disease-Free Survival of 5 years: Case Series and Comprehensive Literature Review

BACKGROUND

In the treatment of nonsmall cell lung cancer (NSCLC), a disease-free survival of 5 years is a criterion for cure. This study aimed to evaluate the characteristics and outcomes of patients with brain metastases of NSCLC after a disease-free survival of 5 years (late recurrent brain metastasis [LRBM]).

METHODS

We reviewed 1281 consecutive patients with brain metastasis of lung cancer at a single institute between November 2014 and December 2022. Relevant articles were retrieved from PubMed. Only peer-reviewed journals published in English were included.

RESULTS

Six patients (0.47%) showed LRBM. Three were male. The median age at lung cancer diagnosis was 45 years. The histological diagnosis of all patients was adenocarcinoma. Driver gene mutations were observed in five patients. The median latency period from lung cancer treatment to the development of brain metastasis was 13 years. All patients had no metastasis to any other organs and underwent craniotomies. The median follow-up duration after craniotomy was 3.5 years. No local intracranial recurrences were observed. Three patients had distant intracranial recurrences at 7, 2, and 0.6 years after craniotomy. Five patients survived for 8, 4, 3, 2, and 0.3 years after craniotomy. One patient experienced re-recurrence in the lung 4 years after craniotomy and died 3.7 years later. In our systematic review, only six studies described LRBM of NSCLC.

CONCLUSIONS

LRBM is rare in patients with NSCLC. In our institution, many of these patients harbored driver gene mutations, and achieved long-term survival with aggressive local therapy. Multicenter analysis is mandatory.

Genomic landscape and tumor mutational features of resected preinvasive to invasive lung adenocarcinoma

Introduction

Adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) are considered pre-invasive forms of lung adenocarcinoma (LUAD) with a 5-year recurrence-free survival of 100%. We investigated genomic profiles in early tumorigenesis and distinguished mutational features of preinvasive to invasive adenocarcinoma (IAC) for early diagnosis.

Methods

Molecular information was obtained from a 689-gene panel in the 90 early-stage LUAD Chinese patients using next-generation sequencing. Gene signatures were identified between pathology subtypes, including AIS/MIA (n=31) and IAC (n=59) in this cohort. Mutational and clinicopathological information was also obtained from the Cancer Genome Atlas (TCGA) as a comparison cohort.

Results

A higher mutation frequency of TP53, RBM10, MUC1, CSMD, MED1, LRP1B, GLI1, MAP3K, and RYR2 was observed in the IAC than in the AIS/MIA group. The AIS/MIA group showed higher mutation frequencies of ERBB2, BRAF, GRIN2A, and RB1. Comparable mutation rates for mutually exclusive genes (EGFR and KRAS) across cohorts highlight the critical transition to invasive LUAD. Compared with the TCGA cohort, EGFR, KRAS, TP53, and RBM10 were frequently mutated in both cohorts. Despite limited gene mutation overlap between cohorts, we observed variant mutation types in invasive LUAD. Additionally, the tumor mutation burden (TMB) values were significantly lower in the AIS/MIA group than in the IAC group in both the Chinese cohort (P=0.0053) and TCGA cohort (P<0.01).

Conclusion

These findings highlight the importance of distinguishing preinvasive from invasive LUAD in the early stages of LUAD and both pathology and molecular features in clinical practice, revealing genomic tumor heterogeneity and population differences.

What Is an Adequate Margin During Sublobar Resection of ≤3 cm N0 Subsolid Lung Adenocarcinomas?

BACKGROUND

Sublobar resection offers noninferior survival vs lobectomy for ≤2 cm non-small cell lung cancer and is commonly used for subsolid tumors. Although data exist for solid tumors, the minimum adequate margin of resection for subsolid adenocarcinomas remains unclear.

METHODS

This was a retrospective review of 1101 adenocarcinoma resections at our institution from 2006 to 2022. Inclusion criteria were tumors ≤3 cm with ≥10% radiographic ground glass, excised by sublobar resection. Exclusions were positive nodes or positive or unreported margin. The primary outcome was the rate of local recurrence (LR) at multiple thresholds of margin distance. The relationship between margin distance and solid component size was also explored.

RESULTS

Inclusion criteria were met by 194 patients. Median (interquartile range) tumor diameter and margin distance were 12 mm (9-17 mm) and 10 mm (5-17 mm), respectively. Median follow-up was 42.5 months. There was a progressive increase in LR with diminishing margin (0.1-cm decrements) from 1.5 cm to 0.5 cm. The difference in the rate of LR between "over" (n = 143) and "under" (n = 51) was most significant at 0.5 cm (8 of 51 [15.7%] vs 6 of 143 [4.2%]; P = .01) but did not reach α adjusted for multiple comparisons. On Cox regression for LR-free survival, margin ≤0.5 cm (P = .19) and solid component percentage (P = .14) trended to significance. Combining these using a ratio of margin distance-to-solid component size, a ratio of ≤1 showed a significantly higher rate of LR (7 [14.3%] vs 2 [2.0%], P = .009). Treatment of LRs provided at least intermediate-term survival in 87% of recurrences (median postrecurrence follow-up was 44 months).

CONCLUSIONS

During sublobar resection of subsolid lung adenocarcinomas, a margin distance-to-solid component size ratio of >1.0 appears to be a more reliable factor than margin distance alone to minimize local recurrence. Local recurrence, however, may not impact survival in patients with subsolid adenocarcinomas if timely treatment is administered.

Ten-year follow-up outcomes of limited resection trial for radiologically less-invasive lung cancer

BACKGROUND

The JCOG0804/WJOG4507L single-arm confirmatory trial indicated a satisfactory 10-year prognosis for patients who underwent limited resection for radiologically less-invasive lung cancer. However, only one prospective trial has reported a 10-year prognosis.

METHODS

We conducted a multicenter prospective study coordinated by the National Cancer Center Hospital East and Kanagawa Cancer Center. We analyzed the long-term prognosis of 100 patients who underwent limited resection of a radiologically less-invasive lung cancer in the peripheral lung field. We defined radiologically less-invasive lung cancer as lung adenocarcinoma with a maximum tumor diameter of ≤2 cm, tumor disappearance ratio of ≥0.5 and cN0. The primary endpoint was the 10-year local recurrence-free survival.

RESULTS

Our patients, with a median age of 62 years, included 39 males. A total of 58 patients were non-smokers; 87 had undergone wide wedge resection and 9 underwent segmentectomy. A total of four cases were converted to lobectomy because of the presence of poorly differentiated components in the frozen specimen or insufficient margin with segmentectomy. The median follow-up duration was 120.9 months. The 10-year recurrence-free survival and overall survival rates of patients with lung cancer were both 96.0%. Following the 10-year long-term follow-up, two patients experienced recurrences at resection ends after wedge resection.

CONCLUSIONS

Limited resection imparted a satisfactory prognosis for patients with radiologically less-invasive lung cancer, except two cases of local recurrence >5 years after surgery. These findings suggest that patients with this condition who underwent limited resection may require continued follow-up >5 years after surgery.

Long-term outcomes of 5-year survivors without recurrence after the complete resection of non-small cell lung cancer after lobectomy: a landmark analysis in consideration of competing risks

PURPOSE

Among non-small cell lung cancers (NSCLC), 5 years is a benchmark in cancer control and treatment, but a certain percentage of cases recur after 5 years. The long-term post-recurrence outcomes remain controversial. To examine the accurate prognostic factors associated with survival and cancer recurrence among 5-year survivors, a landmark analysis that considered competing risks was performed.

METHODS

Complete resection of NSCLC was performed in 2482 patients between January 2003 and December 2015. A total of 1431 patients were 5-year survivors without recurrence. A landmark time analysis was applied to the overall survival (OS) and recurrence-free survival (RFS) from 5 years after surgery, and the findings were calculated using the Kaplan-Meier method. The cumulative incidence of cause-specific death and recurrence was estimated using the cumulative incidence function, while carefully considering the competing risks.

RESULTS

Postoperative recurrence was detected in 732 patients, of whom 68 (9.3%) had recurrence after 5 years. The median follow-up period was 8.2 years. In the competing risk analysis, the independent poor prognostic factors associated with cause-specific death were age ≥ 75 years, lymph node metastasis and pleural invasion.

CONCLUSIONS

Patients requiring a follow-up for > 5 years were aged ≥ 75 years and had either lymph node metastasis or pleural invasion.

Dynamic Analysis of the Impact of Micropapillary Component on Different Recurrence Patterns of Pathological Stage IA3 Lung Adenocarcinoma: A Multicenter, Retrospective Study

BACKGROUND

This study aimed to evaluate the dynamic impact of the micropapillary (MIP) component on local recurrence (LR), distant metastasis (DM), and multiple recurrence (MR) of pathological stage IA3 lung adenocarcinoma.

METHODS

Between July 2012 and July 2020, a total of 351 patients at two medical institutions were enrolled in this study. Cumulative incidence of curves, dynamic risk curves, and time-dependent multivariate analysis was performed to evaluate the effect of the MIP component on patients.

RESULTS

The 5-year cumulative incidence of total recurrence with or without an MIP component was 34.2% and 12.3%, respectively (p = 0.001). In three recurrence patterns, our findings revealed that the 5-year cumulative incidence of LR (p = 0.048) and DM (p = 0.005) was higher in the 'MIP-present' group than in the 'MIP-absent' group. In the dynamic recurrence curve, the risk of the three recurrence patterns was different and varied over time between the two groups, especially in DM. Moreover, the dynamic cumulative event curve showed that after 1, 2, and 3 years of survival, the cumulative incidence of DM in the group with MIP continued to be higher than that in the group without MIP (all p < 0.05). Time-dependent Cox regression analysis indicated that the MIP component continued to be an independent risk factor for the cumulative incidence of DM in patients with 3-year survival.

CONCLUSIONS

Of the three recurrence patterns, the MIP component mainly aggravated the risk of DM in patients with pathological stage IA3 lung adenocarcinoma, which persisted for 3 years.

Prognosis of early-stage lung adenocarcinoma in young patients

Lung adenocarcinoma (LUAD) is a familiar lung cancer with a poor prognosis. This study was meant to determine whether there are differences in survival between younger and older patients with early-stage LUAD because of the rise in the incidence of LUAD in young individuals over the previous few decades. We analysed the clinical, therapeutic and prognostic features of a cohort (2012-2013) of 831 consecutive patients with stage I/II LUAD who underwent curative surgical resection at Shanghai Pulmonary Hospital. Propensity score matching (PSM) was performed for age, sex, tumour size, tumour stage and therapy in a 2:1 ratio between the two groups without taking gender, illness stage at operation or decisive treatment into account. Following PSM analysis to create a 2:1 match for comparison, the final survival study included 163 patients with early-stage LUAD <50 years and 326 patients ≥50 years. Surprisingly, younger patients were overwhelmingly female (65.6%) and never smokers (85.9%). There were no statistical differences between the two groups in terms of the overall survival rate (P = 0.067) or time to advancement (P = 0.76). In conclusion, no significant differences stood out between older and younger patients with stage I/II LUAD regarding overall and disease-free survival rates. Younger patients with early-stage LUAD were more likely to be female and never smokers, which suggests that risk factors other than active smoking may be responsible for lung carcinogenesis in these patients.

Survival and quality-of-life outcomes in early-stage NSCLC patients: a literature review of real-world evidence

Aim

Assess the long-term survival and quality-of-life outcomes in early-stage NSCLC (eNSCLC) patients.

Methods

Review of long-term survival and quality-of-life after curative treatment in eNSCLC patients in observational studies.

Results

Disease-free proportion decreased in stage III vs stage I patients. Recurrence-free proportion decreased with age and disease stage. Advanced stage and vascular invasion increased risk of late recurrence. Conditional 5-year relative survival rates did not exceed 87%, indicating higher mortality in eNSCLC survivors. Lower conditional survival rates and relative survival rates were associated with older age and advanced disease. Survivors of eNSCLC had poorer physical quality-of-life.

Conclusion

Despite curative-intent therapy, survivors of eNSCLC still face significant risks of recurrence, excess mortality, and diminished quality-of-life.

Cost-effectiveness analysis of adjuvant atezolizumab in stage II-IIIA non-small cell lung cancer expressing ≥50% PD-L1: A United Kingdom health care perspective

OBJECTIVES

Atezolizumab monotherapy has marketing authorisation by the Medicines and Healthcare products Regulatory Agency as adjuvant treatment following complete resection for adults with stage II-IIIA non-small cell lung cancer (NSCLC) whose tumours have PD-L1 expression on ≥ 50% of tumour cells and whose disease has not progressed following adjuvant platinum-based chemotherapy. This study evaluated the cost-effectiveness of atezolizumab vs best supportive care (BSC) in the licensed patient population from a UK perspective.

MATERIALS AND METHODS

Patient characteristics and clinical inputs were derived from the global, randomised, open-label, phaseIII IMpower010 trial. A Markov model with the following health states was developed: disease-free survival (DFS), locoregional recurrence, first-line metastatic recurrence, second-line metastatic recurrence, and death (all partitioned based on receipt of treatment, excluding death). The base case model used a lifetime time horizon (40 years) and 3.5% discounting annually after the first year. DFS from IMpower010 was analysed with parametric survival models to extrapolate outcomes for time points beyond trial follow-up. The models were adjusted to avoid overestimating results for patients with recurrences in the longer term. Grade ≥ 3 treatment-related adverse events with incidences ≥ 2% were included. Health state utility values were derived from the literature and past NICE appraisals. Sensitivity and scenario analyses assessed uncertainty around assumptions and parameter estimates.

RESULTS

In the base case analysis, atezolizumab therapy resulted in an expected gain of 1.87 quality-adjusted life-years (QALYs) corresponding to an incremental cost-effectiveness ratio of £20,392/QALY for atezolizumab vs BSC, demonstrating cost-effectiveness. Results were most influenced by discount effects and utility in the on-treatment DFS state. Scenario analyses were consistent with the base case results.

CONCLUSION

Atezolizumab after adjuvant chemotherapy is cost-effective for adults with NSCLC in the UK.

Prognostic evaluation of preoperative serum tumor marker-negative cases in non-small cell lung cancer: A retrospective study

BACKGROUND

The role of various serum tumor markers (TMs) has been reported in non-small cell lung cancer (NSCLC). However, the prognosis of patients with multiple TM-negative NSCLC remain unclear.

AIMS

This study aimed to describe the characteristics and outcomes of patients with NSCLC undergoing surgery and to investigate their prognostic association with preoperative serum TM-negative cases.

METHODS AND RESULTS

We retrospectively evaluated 442 patients who underwent complete resection of stage I NSCLC between January 2004 and December 2019. These 442 patients were classified into a group whose preoperative serum levels of carcinoembryonic antigen (CEA), cytokeratin-19 fragment (CYFRA21-1), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC Ag) were all negative (TM-negative group; n = 249, 56%) and a group with at least one positive marker (TM-positive group; n = 193, 44%). Among all patients, the TM-negative group showed higher 5-year recurrence-free survival (RFS) (92.6% vs. 79.1%; p < .01), and overall survival (OS) rates (86.3% vs. 68.6%; p < .01). After propensity score matching, patients in the TM-negative group still exhibited good 5-year RFS (92.1% vs. 81.4%; p = .01) and OS rates (87.6% vs. 72.6%; p < .01).

CONCLUSION

Our study suggests that NSCLC patients who are preoperatively negative for all serum TMs, such as CEA, CYFRA21-1, CA19-9, and SCC Ag, represent a subgroup with a particularly good prognosis.

Impact of microvascular invasion on 5-year overall survival of resected non-small cell lung cancer

OBJECTIVES

Non-small cell lung cancer (NSCLC) is an incidental and aggressive type of cancer. Although curative treatment can be offered, the recurrence rate is relatively high. Identifying factors that have a prognostic impact may guide changes in the staging system and recommendations for adjuvant therapy. The aim of this study was to evaluate the impact of microvascular invasion on the 5-year overall survival (OS) of patients with resected NSCLC treated at a reference cancer center.

METHODS

This retrospective, observational cohort study included patients diagnosed with early-stage NSCLC (clinical stages I-IIIA), treated with curative-intent surgery at the Brazilian National Cancer Institute between 2010 and 2016.

RESULTS

The dataset comprised 91 surgical patients, mostly females and white, with a mean age of 62 years (range between 29-83). Cases were distributed as stages I, II, and III in 55%, 29%, and 16%. Adenocarcinoma was the predominant histological subtype (67%), and microvascular invasion was present in 25% of the patients. The 5-year OS probability was 60% (95% CI, 48.3-68.9). Among all characteristics, advanced stages (p = 0.001) and the presence of microvascular invasion (p< 0.001) were related to a worse 5-year OS. After adjusting for age group and pathological stage, the presence of microvascular invasion was associated with a 4-fold increased risk of death (HR 3.9, 95% CI, 1.9-8.2).

CONCLUSION

The presence of microvascular invasion was an independent factor related to worse survival and, therefore, should be routinely assessed in resected specimens.

What is the Definition of Cure in Non-small Cell Lung Cancer?

The concept of cure from cancer is important to patients, but can be difficult to communicate in terms that are meaningful. This is because there are a number of definitions of cure that are applied by clinicians, patients and the public, and by policymakers that have a different meaning and significance. In this article, we provide a narrative review of the evidence concerning cure in lung cancer and show how the different definitions may apply in different settings. A better understanding of the various concepts of cure will improve communication with patients on this important topic. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Prognostic influence of epidermal growth factor receptor mutation and radiological ground glass appearance in patients with early-stage lung adenocarcinoma

OBJECTIVES

The ADAURA demonstrated the efficacy of osimertinib as adjuvant therapy in patients with resected stage IB-IIIA adenocarcinoma harboring epidermal growth factor receptor (EGFR) mutations. However, it is controversial whether adjuvant therapy should be applied to all these patients because of their heterogeneities. This study aimed to examine the influence of GGO and EGFR mutations on the prognosis and to identify optimal targets for the development of perioperative therapy.

MATERIAL AND METHODS

Among the patients who underwent complete resection between 2003 and 2014 and had pathological stage IA3-IIA adenocarcinoma, 505 consecutive patients were examined for EGFR mutation status. The prognosis was analyzed among the clinicopathological factors including EGFR status and presence or absence of GGO.

RESULTS

Of the 489 patients, 193 (39.5%) showed EGFR mutations. The recurrence-free survival (RFS) and overall survival (OS) of the EGFR mutant were slightly better than those of the EGFR wild type. There was no difference in RFS and OS between EGFR mutant and wild type in patients with GGO; however, EGFR mutant showed better OS than EGFR wild type in patients without GGO. The presence of GGO was a strong independent prognostic predictor in OS and RFS, but EGFR mutations was not predictors. In patients without GGO, EGFR mutants showed slightly higher recurrence, especially with a hazard ratio of 1.427 in stage IB.

CONCLUSIONS

Adenocarcinoma with GGO show a very good prognosis, so may not require adjuvant therapy. It will be necessary to further develop perioperative therapy in patients with poor prognosis.

The Clinical Value of Computed Tomography (CT)-Guided 125I Brachytherapy for Locally Advanced Non-Small Cell Lung Cancer After Progression of Concurrent Radiochemotherapy

Purpose

To further evaluate the efficacy and safety of computed tomography (CT)-guided iodine 125 (¹²⁵I) brachytherapy to treat locally advanced non-small cell lung cancer (NSCLC) after progression of concurrent radiochemotherapy (CCRT).

Methods

This study obtained written consent from all patients and was approved by our institution. From January 2006 to June 2018, 210 NSCLC patients (progression of first-line CCRT) were retrospectively recruited and then divided into two groups. A total of 116 patients were given CT-guided ¹²⁵I brachytherapy and second-line chemotherapy (group A), and 94 were treated with second-line chemotherapy alone (group B).

Results

In group A, local response rate (LRR) within 3 years was significantly better (P<0.05). Mean survival time [progression-free survival time (PFST) and overall survival (OS)] was 15.1±1.4 months and 21.2±1.6 months in group A compared with 10.0±1.4 months and 16.2±1.7 months in group B (PFST: P<0.01, HR=1.472, 95% CI 1.097–1.975; OS: P = 0.036, HR=1.342, 95% CI 1.005–1.791). Tumor size and No. of first cycle chemotherapy were independent factors that affected survival, ≤3cm largest tumor diameter and more than 4 first cycles of chemotherapy showed longer PFST and OS (P<0.05). Tumor-related clinical symptoms were relieved in group A (P<0.01). No serious complications occurred in the two groups.

Conclusion

¹²⁵I brachytherapy is effective and safe in locally advanced NSCLC after progression of CCRT.

Pathological features and prognostic implications of ground-glass opacity components on computed tomography for clinical stage I lung adenocarcinoma

PURPOSE

To investigate the prognostic implications and pathological features of clinical stage I lung adenocarcinoma with ground-glass opacity (GGO) on computed tomography (CT).

METHODS

The subjects of this retrospective study were 1228 patients with lung adenocarcinoma classified as clinical stage I, who underwent complete resection by lobectomy. The patients were divided into four groups based on the presence and proportion of GGO according to the consolidation-to-tumor ratio (CTR); A, CTR ≤ 0.5; B, 0.5 < CTR ≤ 0.75; C, 0.75 < CTR ≤ 1.0 with GGO; D, without GGO (pure-solid). We compared overall survival, pathological findings (N/ly/v/STAS), and histological subtypes within each clinical stage among the four groups.

RESULTS

We found no significant differences among tumors with GGO (groups A, B and C) for prognosis or pathological findings in all the clinical stages. The prognoses of groups A, B and C were significantly better than that of group D for patients with clinical stages IA2-IB disease. Tumors without GGO on CT had a significantly larger number of positive N, ly, v and STAS in almost all stages than tumors with GGO on CT. Tumors without GGO on CT had significantly more solid predominant and less lepidic predominant adenocarcinoma.

CONCLUSION

Not the proportion of GGO, but its presence on CT, as well as the size of the solid component, were correlated significantly with pathological characteristics and survival.

Surgery for limited stage small cell lung cancer

Small cell lung cancer (SCLC) is an aggressive tumor type characterized by rapid growth and overall poor prognosis. For the past several decades, chemotherapy and radiotherapy have served as the cornerstone of treatment. Recently, however, the role of surgery for early stage disease has gained considerable interest. Multiple retrospective and observational studies have shown excellent survival for early stage SCLC treated with surgical resection. We herein review the past and present evidence regarding surgical options for limited stage SCLC.

Prognostic Significance of Ground-Glass Opacity Components in 5-Year Survivors With Resected Lung Adenocarcinoma

BACKGROUND

Reports on the prognosis for 5-year survivors with lung adenocarcinoma after resection are sparse. This study aimed to identify factors associated with overall survival (OS) and cancer-specific survival (CSS) for 5-year survivors with completely resected lung adenocarcinoma, and to determine whether preoperative imaging factors, including the presence of ground-glass opacity (GGO) components, affect late recurrence in long-term survivors.

METHODS

Complete resection of lung adenocarcinoma was performed for 1681 patients between January 2000 and December 2013. Of these patients, 936 who survived 5 years or longer after surgery were identified, and factors associated with OS and CSS were determined using the Cox proportional hazard model.

RESULTS

Multivariable analysis demonstrated that lymph node metastasis (p < 0.01) and absence of GGO components (p < 0.01) were independently associated with OS and CSS for the 5-year survivors. The absence of GGO components was significantly associated with OS (p < 0.01) and CSS (p < 0.01) also for the 5-year survivors with stage 1 disease (n = 782) and for the 5-year survivors without recurrence (n = 809). The incidence of recurrence anytime during the 10-year postoperative follow-up period differed significantly between the 5-year survivors with and without GGO components.

CONCLUSIONS

The absence of GGO components was significantly associated with an unfavorable prognosis for the 5-year survivors with completely resected lung adenocarcinoma regardless whether they had recurrences not.

The Role of the ECM in Lung Cancer Dormancy and Outgrowth

The dissemination of tumor cells to local and distant sites presents a significant challenge in the clinical management of many solid tumors. These cells may remain dormant for months or years before overt metastases are re-awakened. The components of the extracellular matrix, their posttranslational modifications and their associated factors provide mechanical, physical and chemical cues to these disseminated tumor cells. These cues regulate the proliferative and survival capacity of these cells and lay the foundation for their engraftment and colonization. Crosstalk between tumor cells, stromal and immune cells within primary and secondary sites is fundamental to extracellular matrix remodeling that feeds back to regulate tumor cell dormancy and outgrowth. This review will examine the role of the extracellular matrix and its associated factors in establishing a fertile soil from which individual tumor cells and micrometastases establish primary and secondary tumors. We will focus on the role of the lung extracellular matrix in providing the architectural support for local metastases in lung cancer, and distant metastases in many solid tumors. This review will define how the matrix and matrix associated components are collectively regulated by lung epithelial cells, fibroblasts and resident immune cells to orchestrate tumor dormancy and outgrowth in the lung. Recent advances in targeting these lung-resident tumor cell subpopulations to prevent metastatic disease will be discussed. The development of novel matrix-targeted strategies have the potential to significantly reduce the burden of metastatic disease in lung and other solid tumors and significantly improve patient outcome in these diseases.

Delayed cut-end recurrence after wedge resection for pulmonary ground-glass opacity adenocarcinoma despite negative surgical margin

Most pulmonary ground-glass opacity (GGO) nodules are pathologically well differentiated adenocarcinomas. We performed a limited resection trial of GGO lesions 2 cm or smaller from 2003 to 2009, in which 95 patients were accumulated. We confirmed negative surgical cut-end during surgery by margin lavage cytology. In the trial, a 51-year-old man underwent right lower lobe wedge resection for a 1.7 cm mixed GGO lesion. The tumor was papillary predominant adenocarcinoma, pT1NxM0. The resection scar became thicker and was diagnosed as adenocarcinoma by needle biopsy 10 years after the initial surgery. We performed a right lower lobectomy and lymph node dissection. Pathologically, the second tumor was adenocarcinoma similar to the initial one, papillary predominant, and was diagnosed as cut-end recurrence. Small papillary predominant adenocarcinoma might develop delayed cut-end recurrence more than 5 years after limited resection. Careful follow-up with special attention to the cut-end is necessary ideally for 10 years.

Ultra-late recurrence of non-small cell lung cancer over 10 years after curative resection

Purpose

Most postoperative recurrences of non-small cell lung cancer (NSCLC) develop within 5 years after curative resection, with ultra-late recurrences developing over 10 years after the resection being rare. This study aimed to analyze the features of ultra-late recurrence in cases with NSCLC who had undergone curative resection.

Patients and methods

Among 1458 consecutive cases with NSCLC who underwent curative resection with systematic lymph node dissection during 1990–2006, 12 cases developed recurrence over 10 years after the resection. We defined the recurrence developing over 10 years after the resection as ultra-late recurrence and analyzed the factors related to it.

Results

Among the 1458 cases, recurrence developed in 476 (32.6%) cases. Of them, ultra-late recurrence developed in 12 (2.5%) cases. The ultra-late recurrence was histopathologically classified as adenocarcinoma in 11 cases and atypical carcinoid in 1 case. All cases were of invasive carcinoma. We compared ultra-late recurrence cases with non-recurrence cases and showed that none of the examined factors significantly influenced ultra-late recurrence; however, lymphatic invasion was close to significantly influencing it. There were two cases in which recurrence developed over 15 years after the resection; both cases were of adenocarcinoma with anaplastic lymphoma kinase (ALK) rearrangement.

Conclusion

There is a possibility of ultra-late recurrence developing over 10 years after the resection of any invasive NSCLC. Lymphatic invasion is close to significantly influencing ultra-late recurrence. Furthermore, a long follow-up period may be required in cases with adenocarcinoma with ALK rearrangement because it has the possibility of recurrence over 15 years after the resection.

LINC00472 Acts as a Tumor Suppressor in NSCLC through KLLN-Mediated p53-Signaling Pathway via MicroRNA-149-3p and MicroRNA-4270

Long non-coding RNAs and microRNAs (miRNAs) have been reported to participate in the progression of non-small-cell lung cancer (NSCLC). Long intergenic non-protein-coding RNA 472 (LINC00472), miR-149-3p, and miR-4270 were found to be involved in tumor activities, suggesting potential roles in NSCLC. Thus, this study aimed to examine the ability of LINC00472 to influence the progression of NSCLC with the involvement of miR-149-3p and miR-4270. Initially, differentially expressed long non-coding RNAs (lncRNAs), downstream regulatory miRNAs, and genes related to NSCLC were identified. Next, the interaction among LINC00472, miR-149-3p and miR-4270, and KLLN and the p53-signaling pathway was determined. The effect of LINC00472 on the expression of E-cadherin, N-cadherin, and Vimentin was examined through gain-of-function and loss-of-function experiments. Lastly, the effects of LINC00472 on NSCLC tumor growth were assessed in vivo. LINC00472 and KLLN were found to exhibit low levels, while miR-149-3p and miR-4270 were highly expressed in NSCLC. In addition, the overexpression of LINC00472 was observed to upregulate KLLN and activate the p53-signaling pathway, which ultimately inhibited the invasion, migration, and EMT of NSCLC cells via miR-149-3p and miR-4270, corresponding to decreased N-cadherin and Vimentin and increased E-cadherin. The overexpression of LINC00472 exerted an inhibitory effect on tumor growth in vivo. Taken together, the key evidence suggests that the overexpression of LINC00472 can downregulate miR-149-3p and miR-4270 to upregulate KLLN and activate the p53-signaling pathway, thus inhibiting the development of NSCLC. This study highlights the potential of LINC00472 as a promising therapeutic target for NSCLC treatment.

Factors associated with distant recurrence following R0 lobectomy for pN0 lung adenocarcinoma

OBJECTIVE

We investigated factors associated with distant recurrence, disease-free survival (DFS), and overall survival (OS) following R0 lobectomy for pathologic node-negative (pN0) lung adenocarcinoma.

METHODS

We performed a retrospective analysis of a prospectively maintained database of patients with pT1-3N0M0 non-small cell lung cancer. Exclusion criteria included metachronous lung cancer, sublobar/incomplete resection, nonadenocarcinoma histology, and induction/adjuvant therapy. The primary outcome was distant recurrence; secondary outcomes were DFS and OS. Associations between variables and outcomes were assessed by Fine-Gray competing-risk regression for distant recurrence and Cox proportional hazard models for DFS and OS.

RESULTS

Of 2392 patients identified with pT1-3N0M0 lung adenocarcinoma, 893 met the inclusion criteria. Median follow-up was 35.0 months (range, 0.1-202 months). Thirteen percent of patients developed recurrence (n = 115), of which 86% (n = 99) were distant. The 5-year cumulative incidence of distant recurrence was 14% (95% confidence interval [CI], 11%-17%). On multivariable analysis, pT2a (hazard ratio [HR], 2.84; 95% CI, 1.56-5.16; P = .001) and pT2b/3 (HR, 6.53; 95% CI, 3.17-13.5; P < .001) tumors were associated with distant recurrence. Recent surgery was associated with decreased distant recurrence (HR, 0.43; 95% CI, 0.20-0.91; P = .028), and lymphovascular invasion was strongly associated with distant recurrence (HR, 1.62; 95% CI, 1.00-2.63; P = .05). DFS was independently associated with pT stage (P < .001) and lymphovascular invasion (P = .004).

CONCLUSIONS

In patients undergoing R0 lobectomy with pN0 lung adenocarcinoma, pT stage and lymphovascular invasion were associated with distant recurrence and decreased DFS. These observations support the inclusion of these patients in future clinical trials investigating adjuvant targeted and immunotherapies.

Temporal and regional distribution of initial recurrence site in completely resected N1-stage II lung adenocarcinoma: The effect of postoperative adjuvant chemotherapy

OBJECTIVES

Understanding the timing and pattern of cancer recurrence is essential to explain the causes of treatment failure. We investigated the recurrence pattern and rate over time in patients with completely resected N1-stage II lung adenocarcinoma.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 333 patients who underwent complete surgical resection for N1-stage II lung adenocarcinoma.

RESULTS

The median recurrence-free survival (RFS) was 38.8 months and the 5-year RFS rate was 39.6%. Left-sided tumors, large tumor size, and lymph node (LN) ratio higher than 0.15 were significantly correlated with a worse RFS, whereas female sex, direct LN involvement, and adjuvant chemotherapy were significantly correlated with a better RFS. Among the 182 patients who experienced recurrences, 46 (25.3%) had only loco-regional recurrences and 136 (74.7%) had distant metastases. The organs most commonly involved in initial recurrence were the lungs (n = 89, 48.9%), followed by bone (n = 41, 22.5%) and the brain (n = 38, 20.9%). The recurrence hazard curve for the entire study population demonstrated a similarly shaped and sized initial and second peak at 15 and 23 months, and a third smaller peak during the fourth year. The recurrence hazard curve of patients who received adjuvant chemotherapy exhibited a more delayed and smaller first peak than those who did not receive adjuvant chemotherapy. The patients treated with adjuvant chemotherapy had a lower rate of distant metastasis (p = 0.037); adjuvant chemotherapy had no effect on brain metastasis (p = 0.640).

CONCLUSION

In the present cohort, the hazard curves suggested that bone and brain recurrences exhibited an earlier first peak, while lung recurrences presented later. Adjuvant chemotherapy not only reduced the recurrence hazard but also delayed the recurrence and altered the pattern of recurrence. However, these results need to be confirmed in a prospective study.

Crizotinib Response in a Late Relapse of ALK-positive Lung Adenocarcinoma

Anaplastic lymphoma kinase (ALK) rearrangement is a therapeutic target in non-small cell lung cancer. To date, few reports have been provided related to ALK-rearranged late recurrence and sensitivity to the treatment with specific ALK inhibitors. We report a case of a 35-year-old man who underwent a right lower lobe lobectomy for lung adenocarcinoma, and treated with the platinum-based chemotherapy regimen. After 10 healthy years, he developed a lung nodule in the same site as the previous. Cytopathologic diagnosis was lung adenocarcinoma. Furthermore, the pulmonary nodule was considered a late recurrence in relation to the lymph node involvement, the same histotype and the site, ALK fluorescence in situ hybridization test and epidermal growth factor receptor analysis were performed on the formalin-fixed paraffin-embedded specimens of the previous resected tumor, because of inadequacity cytologic sample. Being positive for ALK rearrangement, the patient was treated with crizotinib with a good response. To the best of our knowledge, it is the first case of a late relapse of ALK-positive lung adenocarcinoma sensitive to crizotinib in the literature.

Clinicopathological Features of Early and Late Recurrence of Endometrial Carcinoma After Surgical Resection

OBJECTIVES

The incidence of endometrial carcinoma has been increasing annually in developed nations; it is currently the second most common gynecological malignancy. Although the majority of patients are diagnosed at an early stage, 15% to 20% reportedly recur; consequently, patients are usually followed clinically for 3 years after the initial curative surgery. We therefore aimed to determine the incidence and clinicopathological features of early and late recurrences of endometrial carcinoma after surgical resection.

MATERIALS AND METHODS

This retrospective study was performed using the clinical records of 2233 patients who underwent surgical resection for endometrial carcinoma between January 1970 and December 2009 at a single cancer center. Tumor recurrences were classified as early (<5 years) and late (>5 years) after initial surgery. Clinicopathological variables and tumor recurrence patterns were compared between the early and late recurrence groups. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

Among 2233 study patients, 255 (11.4%) experienced endometrial carcinoma recurrence; of these, early and late recurrences occurred in 232 (91.0%) and 23 (9.0%) patients, respectively. Late recurrence was associated with invasion of less than half of the myometrium at diagnosis and the presence of histopathological features of endometrioid adenocarcinoma with low- or intermediate-grade histological subtype and absence of lymphovascular invasion. After recurrence, there was no significant difference in overall survival between the early and late recurrence groups (P = 0.437). Furthermore, surgical treatment was associated with a significantly improved prognosis in the late recurrence group (P = 0.044).

CONCLUSIONS

The findings of this study indicated that patients who initially underwent successful treatment for low-grade and early-stage endometrial carcinoma should be followed clinically for more than 5 years. In cases of late recurrence, surgical management may improve prognosis.

Prognostic value of quantitative PET/CT in patients with a nonsmall cell lung cancer and another primary cancer

OBJECTIVE

The staging and management of patients with newly diagnosed nonsmall cell lung cancer (NSCLC) in the setting of recently diagnosed other (metachronous or synchronous) primary cancer are challenging. This retrospective cohort study was carried out to test our hypothesis that baseline 2-deoxy-2-[F]fluoro-D-glucose (F-FDG) PET/CT parameters, including whole-body metabolic tumor volume (MTVWB), total lesion glycolysis (TLGWB), and maximum standardized uptake value (SUVmaxWB), are associated with the overall survival (OS) of such patients.

PATIENTS AND METHODS

A total of 110 NSCLC patients (52 men and 58 women, aged 68.6±7.8 years) with other primary malignant cancers who had baseline F-FDG PET/CT scans were retrospectively reviewed. MTVWB, TLGWB, and SUVmaxWB were measured. Kaplan-Meier analysis with the log-rank test and Cox regression models were used to assess the association of OS with F-FDG PET/CT parameters and clinical risk factors.

RESULTS

Kaplan-Meier analysis and univariate Cox regression models showed significant associations of OS with ln(MTVWB), ln(TLGWB), ln(SUVmaxWB), TNM stage, and treatment type (surgery vs. no treatment). Multivariable Cox regression models showed a significant relationship of OS with ln(MTVWB) [hazard ratio (HR)=1.368, P=0.001], ln(TLGWB) (HR=1.313, P<0.001), and ln(SUVmaxWB) (HR=1.739, P=0.006), adjusted for age, treatment type, tumor histology, and TNM stage. The TNM stage was not associated significantly with OS when MTVWB, TLGWB, or SUVmaxWB were included in the multivariable models.

CONCLUSION

MTVWB, TLGWB, and SUVmaxWB from baseline F-FDG PET/CT are associated individually with OS of patients with both NSCLC and other primary malignant tumors independent of age, treatment type, tumor histology, and TNM stage.

Pedunculated-type T1 colorectal carcinoma with lung carcinoma metastasis at the deepest invasive portion

We present a rare case of colorectal T1 carcinoma with metastasis of previous lung carcinoma found at the deepest invasive portion. A 61-year-old man presented with cervical lymphadenopathy 18 years after undergoing surgery for right lung carcinoma [poorly differentiated adenocarcinoma stage IIb (T3N0M0)]. Contrast-enhanced computed tomography showed enlarged lymph nodes (LNs) in the neck and mediastinal regions. Combined hybrid-F-fluorodeoxyglucose positron emission-computerized tomography showed increased radionuclide uptake in multiple cervical LNs and mediastinal LNs. LN biopsy revealed a poorly differentiated adenocarcinoma, suspected to be a metastatic tumor of the lung. Subsequent colonoscopy revealed a pedunculated-type lesion with a depressed area in the ascending colon. We performed polypectomy as total excisional biopsy; this tumor was composed mainly of moderately differentiated adenocarcinoma, partially mixed with mucinous adenocarcinoma. The pathological findings of the invasive front of the colorectal carcinoma showed poorly differentiated adenocarcinoma with a morphological pattern similar to that of the previous lung carcinoma. Furthermore, immunohistochemical results for the histological type of the deepest invasive portion of the tissue specimen were positive for thyroid transcription factor-1 but negative for Caudal-type homeobox 2. From these morphological and immunohistochemical findings, the final diagnosis was moderately differentiated lung carcinoma, pTX N3 M1b (LN, colon) Stage IV.

Executive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer

The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals. To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.

Metastatic Latency and Immune Evasion through Autocrine Inhibition of WNT

Metastasis frequently develops years after the removal of a primary tumor, from a minority of disseminated cancer cells that survived as latent entities through unknown mechanisms. We isolated latency competent cancer (LCC) cells from early stage human lung and breast carcinoma cell lines and defined the mechanisms that suppress outgrowth, support long-term survival, and maintain tumor-initiating potential in these cells during the latent metastasis stage. LCC cells show stem-cell-like characteristics and express SOX2 and SOX9 transcription factors, which are essential for their survival in host organs under immune surveillance and for metastatic outgrowth under permissive conditions. Through expression of the WNT inhibitor DKK1, LCC cells self-impose a slow-cycling state with broad downregulation of ULBP ligands for NK cells and evasion of NK-cell-mediated clearance. By expressing a Sox-dependent stem-like state and actively silencing WNT signaling, LCC cells can enter quiescence and evade innate immunity to remain latent for extended periods.

EMT, CTCs and CSCs in tumor relapse and drug-resistance

Tumor relapse and metastasis are the primary causes of poor survival rates in patients with advanced cancer despite successful resection or chemotherapeutic treatment. A primary cause of relapse and metastasis is the persistence of cancer stem cells (CSCs), which are highly resistant to chemotherapy. Although highly efficacious drugs suppressing several subpopulations of CSCs in various tissue-specific cancers are available, recurrence is still common in patients. To find more suitable therapy for relapse, the mechanisms underlying metastasis and drug-resistance associated with relapse-initiating CSCs need to be identified. Recent studies in circulating tumor cells (CTCs) of some cancer patients manifest phenotypes of both CSCs and epithelial-mesenchymal transition (EMT). These patients are unresponsive to standard chemotherapies and have low progression free survival, suggesting that EMT-positive CTCs are related to co-occur with or transform into relapse-initiating CSCs. Furthermore, EMT programming in cancer cells enables in the remodeling of extracellular matrix to break the dormancy of relapse-initiating CSCs. In this review, we extensively discuss the association of the EMT program with CTCs and CSCs to characterize a subpopulation of patients prone to relapses. Identifying the mechanisms by which EMT-transformed CTCs and CSCs initiate relapse could facilitate the development of new or enhanced personalized therapeutic regimens.

Risk Factors for Local and Distant Recurrence After Surgical Treatment in Patients With Non-Small-Cell Lung Cancer

INTRODUCTION

The purpose of this study was to identify independent perioperative and pathologic variables associated with non-small-cell lung cancer (NSCLC) recurrence after complete surgical resection.

PATIENTS AND METHODS

A retrospective examination was performed of a prospectively maintained database of patients who underwent resection for NSCLC from January 2009 to January 2014 at a multi-institution. Clinicopathologic variables were evaluated for their influence on frequency of recurrence. Cox proportional regression hazard model analysis examined the association of recurrence in NSCLC.

RESULTS

Of these patients, 2816 (19.3%) experienced recurrence of primary cancer. Local or distant recurrence was found in 20.5% and 79.5% of patients, respectively. Median follow-up was 27.9 months (range, 11.4-66.0 months). The analysis indicated independent effects of the following risk factors on the risk of recurrence: age 64-90 years (hazard ratio [HR], 1.136; 95% confidence interval [CI] 1.024-1.261), histologic type adenocarcinoma (HR, 1.117; 95% CI 1.005-1.24), blood vessel invasion (HR, 1.236; 95% CI, 1.124-1.359), lymphatic vessel invasion (HR, 1.287; 95% CI, 1.176-1.409), visceral pleural invasion (HR, 1.641; 95% CI, 1.215-2.218), N1 disease (HR, 1.142; 95% CI, 0.99-1.316), N2 disease (HR, 1.596; 95% CI, 1.271-1.649), tumor size of 20-30 mm (HR, 1.235; 95% CI, 1.081-1.41), 30-50 mm (HR, 1.544; 95% CI, 1.33-1.792), 50-70 mm (HR, 1.521; 95% CI, 1.275-1.815), and 70-100 mm (HR, 1.71; 95% CI, 1.385-2.11), pneumonectomy (HR, 1.08; 95% CI, 0.97-1.203), and sublobar resection (HR, 1.762; 95% CI, 1.537-2.019).

CONCLUSION

In the largest series reported to date on postresection recurrence of NSCLC, increasing pathologic stage, advanced age, pneumonectomy, sublobar resection, lymphatic and blood vessel invasion, and visceral pleural invasion were independently associated with local and distant recurrence.

Preliminary results of tomotherapy for treatment of inoperable recurrent non-small cell lung cancer at bronchial stump site after right pneumonectomy

Aim of the study

This study aimed to prospectively investigate the clinical outcomes of curative radical helical tomotherapy (HT) applied to recurrent non-small cell lung cancer (NSCLC) at the bronchial stump site after right pneumonectomy. After right pneumonectomy, the heart shifted right laterally. The chambers of the heart closed with a recurrent mass at the bronchial stump were the right atrium and left atrium due to right shifting of the heart. The unfavorable bronchial stump recurrent cancer-heart geometry due to a right shift of the heart might serve as a reliable predictor of cardiac morbidity for aggressive radiotherapy.

Material and methods

The 23 patients received HT for the recurrent NSCLC at the bronchial stump site after right pneumonectomy between 2008 and 2011. The median age of the patients was 65 years (range 56–74).

Results

We prescribed 95% volume of the primary planning target volume (PTV) to a total dose of 69 Gy in 30 fractions, and 95% of the secondary PTV to a total dose of 54 Gy in 30 fractions with reduction of the 50% volume of the heart < 20 Gy. The median conformal index in the 23 plans was 1.21. The mean fraction of primary PTV receiving more than 95% of the prescribed dose was 97.8%. The mean V₄₅, V₅₀, V₆₀ of the heart were 10.5%, 6.5%, 0.2%, respectively. The median follow-up after tomotherapy was 19.86 months. Median survival was 20 months. The 2-year OS was 39.1%.

Conclusions

The relatively high dose tomotherapy alone for patients with a recurrent bronchial stump mass which was proximal to the heart demonstrated favorable clinical results without severe heart or pulmonary complications.

Prognostic value of the new International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification in stage IB lung adenocarcinoma

BACKGROUND

Patients with pathological stage IB lung adenocarcinoma have a variable prognosis, even if received the same treatment. This study investigated the prognostic value of the new International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) lung adenocarcinoma classification in resected stage IB lung adenocarcinoma.

METHODS

We identified 276 patients with pathological stage IB adenocarcinoma who had undergone surgical resection at the Nanjing Chest Hospital between 2005 and 2010. The histological subtypes of all patients were classified according to the 2011 IASLC/ATS/ERS international multidisciplinary lung adenocarcinoma classification. Kaplan-Meier and Cox regression analyses were used to analyze the correlation between the IASLC/ATS/ERS classification and patients' prognosis.

RESULTS

Two hundred and seventy-six patients with pathological stage IB adenocarcinoma had an 86.2% 5-year overall survival (OS) and 80.4% 5-year disease-free survival (DFS). Patients with micropapillary and solid predominant tumors had a significantly worse OS and DFS as compared to those with other subtypes predominant tumors (p = 0.003 and 0.001). Multivariate analysis revealed that the new classification was an independent prognostic factor for both OS and DFS of pathological stage IB adenocarcinoma (p = 0.009 and 0.003).

CONCLUSION

Our study revealed that the new IASLC/ATS/ERS classification was an independent prognostic factor of pathological stage IB adenocarcinoma. This new classification is valuable of screening out high risk patients to receive postoperative adjuvant therapy.

Little things make big things happen: angiolymphatic invasion and tumor necrosis prognosticate the outcome of locally advanced non-small cell lung cancer treated with a prior induction therapy

OBJECTIVES

Size, invasion of thoracic structures, and ipsilateral mediastinal lymph node involvement (pN2) are well-known prognostic factors that configure the staging of resectable, locally advanced non-small cell lung cancer (LA-NSCLC). The prognostic impact of angiolymphatic invasion (ALI) and tumor necrosis (TN) has been barely explored in LA-NSCLC treated with prior induction therapies.

METHODS

We retrospectively reviewed 47 resected LA-NSCLCs treated with a prior platin-based chemotherapy or chemoradiation. The impact of ALI, TN, and other pathologic features on survival was analyzed.

RESULTS

ALI was presented in 23.4% of cases and TN in 29.8%. Disease-free and overall survival decreased when ALI, TN, or pN2 was present. The incidence of ALI was lower in LA-NSCLC with a good response to induction.

CONCLUSION

Our series is the first to report the prognostic impact of ALI and TN in induction-treated LA-NSCLC. The presence of ALI and TN should be included in the pathologic reports.

[Mortality in early-stage, surgically resected non-small cell lung cancer less than 3 cm of size: Competing risk analysis]

BACKGROUND AND OBJECTIVE

Survival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients.

PATIENTS AND METHOD

This study included 263 patients with resected NSCLC whose diameter was ≤ 3 cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis.

RESULTS

Mortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P=.001) and vascular invasion (P=.020), with age>50 years (P=.034), smoking (P=.009) and the Charlson index ≥ 2 (P=.000) being by no cancer.

CONCLUSIONS

By the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC >3 cm, while non-tumor causes of long-term death were determined.

Local recurrence of lung adenocarcinoma 10 years after left upper lobectomy resembling pseudomesotheliomatous adenocarcinoma: a case report

The form and timing of the local recurrence of lung cancer can be unpredictable and unexpected. Pseudomesotheliomatous adenocarcinoma is a rare tumor that mimics malignant pleural mesothelioma both clinically and pathologically. Distinguishing pseudomesotheliomatous adenocarcinoma from malignant pleural mesothelioma on the basis of clinical findings can be difficult; therefore, a biopsy is usually required for diagnosis. Here we report on a 73-year-old Japanese man who presented with extensive dissemination along the pleural surfaces and clinical findings similar to those of pseudomesotheliomatous lung cancer 10 years after undergoing left upper lobectomy for lung adenocarcinoma. This report provides information that will help physicians establish an accurate diagnosis in similar cases.

Cost-effectiveness of a 14-gene risk score assay to target adjuvant chemotherapy in early stage non-squamous non-small cell lung cancer

Life Technologies has developed a 14-gene molecular assay that provides information about the risk of death in early stage non-squamous non-small cell lung cancer patients after surgery. The assay can be used to identify patients at highest risk of mortality, informing subsequent treatments. The objective of this study was to evaluate the cost-effectiveness of this novel assay. Patients and Methods. We developed a Markov model to estimate life expectancy, quality-adjusted life years (QALYs), and costs for testing versus standard care. Risk-group classification was based on assay-validation studies, and chemotherapy uptake was based on pre- and post-testing recommendations from a study of 58 physicians. We evaluated three chemotherapy-benefit scenarios: moderately predictive (base case), nonpredictive (i.e., the same benefit for each risk group), and strongly predictive. We calculated the incremental cost-effectiveness ratio (ICER) and performed one-way and probabilistic sensitivity analyses. Results. In the base case, testing and standard-care strategies resulted in 6.81 and 6.66 life years, 3.76 and 3.68 QALYs, and $122,400 and $118,800 in costs, respectively. The ICER was $23,200 per QALY (stage I: $29,200 per QALY; stage II: $12,200 per QALY). The ICER ranged from "dominant" to $92,100 per QALY in the strongly predictive and nonpredictive scenarios. The model was most sensitive to the proportion of high-risk patients receiving chemotherapy and the high-risk hazard ratio. The 14-gene risk score assay strategy was cost-effective in 68% of simulations. Conclusion. Our results suggest that the 14-gene risk score assay may be a cost-effective alternative to standard guideline-based adjuvant chemotherapy decision making in early stage non-small cell lung cancer.

How and when to use genetic markers for nonsmall cell lung cancer

PURPOSE OF REVIEW

Many driver mutations that determine the malignant behavior of lung cancer have been identified in recent years. The promise of therapies targeted to the specific molecular pathways altered by such mutations has made genetic testing in nonsmall cell lung cancer (NSCLC) attractive to clinicians. We reviewed recent research on clinically relevant genetic and molecular tests for patients with NSCLC, with an emphasis on the tests linked to actionable mutations that influence therapy and improve outcomes.

RECENT FINDINGS

Mutations in the epidermal growth factor receptor gene (EGFR) and translocations involving the anaplastic lymphoma kinase (ALK) gene have been shown to be common driver mutations in lung adenocarcinoma. The presence or absence of these mutations has been demonstrated to predict response to targeted therapy in many recent studies. Targeted therapies for patients with mutations in the EGFR domain or the echinoderm microtubule-associated protein-like 4 anaplastic lymphoma kinase translocation have been shown to be effective and are approved for use. Ongoing studies continue to define the extent of their utility and may continue to expand their indications. Sufficient tissue for genetic analysis can be obtained from cytologic samples, including those obtained from endobronchial ultrasound-guided transbronchial needle aspiration.

SUMMARY

Genetic testing for driver mutations is useful in identifying patients with NSCLC who are likely to respond to targeted therapy. These tests are best used in patients with adenocarcinoma who have advanced-stage cancer.