Synchronous multiple lung cancers presenting as multifocal pure ground glass nodules: are whole-body positron emission tomography/computed tomography and brain enhanced magnetic resonance imaging necessary?

PET/CT-aided biopsy of lung lesions enhances diagnostic efficacy, especially for lesions >3cm

Objectives

The purpose of this study was to compare the diagnostic efficacy of PET/CT-aided CT-guided and routine CT-guided transthoracic needle biopsy for lung lesions.

Methods

A total of 458 patients with suspicious lung lesions were referred for CT-guided biopsy, with 227 patients assigned to the PET/CT group and 231 patients assigned to the CT group. The clinical characteristics and diagnostic yield were compared between the two groups. Furthermore, conducting subgroup analysis to evaluate the differences of diagnostic success or failure between the two groups.

Results

The sensitivity and diagnostic accuracy rate differed significantly (P = 0.035, P = 0.048). In the PET/CT group, the values were 95.7% and 96.3%, respectively, while in the CT group, they were 90.1% and 91.9%. When considering non-diagnostic cases, the overall diagnostic success rate increased markedly in PET/CT group (93.0% vs. 83.1%, P = 0.001). In our subgroup analysis, the PET/CT group demonstrated superiority in detecting lesions larger than 3 cm (OR, 4.81; 95CI%, 2.03 - 11.36), while showing a moderate effect in lesions smaller than 3 cm (OR, 1.09; 95CI%, 0.42 - 2.81). Significant effect modification was observed in large lesions in the PET/CT group (P for interaction = 0.023).

Conclusions

18F-FDG-PET/CT enhances the diagnostic efficacy of CT-guided transthoracic needle biopsy for lung lesions, and the incremental value can be modified by lesion size, particularly when the diameter is larger than 3 cm.

Distinct gene mutation profiles among multiple and single primary lung adenocarcinoma

With the development of technologies, multiple primary lung cancer (MPLC) has been detected more frequently. Although large-scale genomics studies have made significant progress, the aberrant gene mutation in MPLC is largely unclear. In this study, 141 and 44 lesions from single and multiple primary lung adenocarcinoma (SP- and MP-LUAD) were analyzed. DNA and RNA were extracted from formalin-fixed, paraffin-embedded tumor tissue and sequenced by using the next-generation sequencing-based YuanSu450TM gene panel. We systematically analyzed the clinical features and gene mutations of these lesions, and found that there were six genes differently mutated in MP-LUAD and SP-LUAD lesions, including RBM10, CDK4, ATRX, NTRK1, PREX2, SS18. Data from the cBioPortal database indicated that mutation of these genes was related to some clinical characteristics, such as TMB, tumor type, et al. Besides, heterogeneity analysis suggested that different lesions could be tracked back to monophyletic relationships. We compared the mutation landscape of MP-LUAD and SP-LUAD and identified six differentially mutated genes (RBM10, CDK4, ATRX, NTRK1, PREX2, SS18), and certain SNV loci in TP53 and EGFR which might play key roles in lineage decomposition in multifocal samples. These findings may provide insight into personalized prognosis prediction and new therapies for MP-LUAD patients.

Airway Microbiota in Patients With Synchronous Multiple Primary Lung Cancer: The Bacterial Topography of the Respiratory Tract

Microbes and microbiota dysbiosis are correlated with the development of lung cancer; however, the airway taxa characteristics and bacterial topography in synchronous multiple primary lung cancer (sMPLC) are not fully understood. The present study aimed to investigate the microbiota taxa distribution and characteristics in the airways of patients with sMPLC and clarify specimen acquisition modalities in these patients. Using the precise positioning of electromagnetic navigation bronchoscopy (ENB), we analyzed the characteristics of the respiratory microbiome, which were collected from different sites and using different sampling methods. Microbiome predictor variables were bacterial DNA burden and bacterial community composition based on 16sRNA. Eight non-smoking patients with sMPLC in the same pulmonary lobe were included in this study. Compared with other sampling methods, bacterial burden and diversity were higher in surface areas sampled by bronchoalveolar lavage (BAL). Bacterial topography data revealed that the segment with sMPLC lesions provided evidence of specific colonizing bacteria in segments with lesions. After taxonomic annotation, we identified 4863 phylotypes belonging to 185 genera and 10 different phyla. The four most abundant specific bacterial community members detected in the airway containing sMPLC lesions were Clostridium, Actinobacteria, Fusobacterium, and Rothia, which all peaked at the segments with sMPLC lesions. This study begins to define the bacterial topography of the respiratory tract in patients with sMPLC and provides an approach to specimen acquisition for sMPLC, namely BAL fluid obtained from segments where lesions are located.

Correlation between apparent diffusion coefficient and Ki-67 in different pathological types of lung cancer

BACKGROUND

Computed tomography (CT) is common and valuable non-invasive method to evaluate proliferative activity in lung cancer; however, magnetic resonance (MR) is rarely used in lung cancer. To evaluate whether there were different expression levels of Ki-67 in different pathological types of lung cancer and the correlation between Ki-67 index and apparent diffusion coefficient (ADC) value.

METHODS

The clinical and pathological data of 165 patients with lung cancer confirmed by needle biopsy or surgery were retrospectively evaluated, among whom 54 underwent MR examination. The level of Ki-67 was tested using the international standard IHC 2-step method. Kruskal-Wallis H test was used to compare the different expression level of Ki-67 index of adenocarcinoma, squamous cell carcinoma, and small cell carcinoma, and the least significant difference (LSD) method was used for pair-group comparison. Spearman correlation coefficient was used to analyze the correlation between Ki-67 index and ADC value. All statistical tests were bilateral, and P<0.05 was considered statistically significant.

RESULTS

The median of Ki-67 index in adenocarcinoma, squamous cell carcinoma, and small cell carcinoma were 20 (10, 30), 40 (40, 60), and 70 (60, 80), respectively. There was a statistical difference in the expression level of Ki-67 index in the 3 different pathological types of lung cancer (H=103.762, P=0.000). In 54 cases of lung cancer with MR examination, there was a significant negative correlation between average ADC value and expression level of Ki-67 index (r=-0.506, P=0.000), while there was no correlation between ADC value and Ki-67 index in distinguishing different pathological types of lung cancer.

CONCLUSIONS

The expression level of Ki-67 index was different among different pathological types of lung cancer. The ADC value is correlated with Ki-67 index in lung cancer, which can be used to evaluate the proliferative activity of lung cancer.

Managing screening-detected subsolid nodules-the Asian perspective

The broad application of low-dose computed tomography (CT) screening has resulted in the detection of many small pulmonary nodules. In Asia, a large number of these detected nodules with a radiological ground glass pattern are reported as lung adenocarcinomas or premalignant lesions, especially among female non-smokers. In this review article, we discuss controversial issues and conditions involving these subsolid pulmonary nodules that we often face in Asia, including a lack or insufficiency of current guidelines; the roles of preoperative biopsy and imaging; the location of lesions; appropriate selection of localization techniques; the roles of dissection and sampling of frozen sections and lymph nodes; multifocal lesions; and the roles of non-surgical treatment modalities. For these complex issues, we have tried to present up-to-date evidence and our own opinions regarding the management of subsolid nodules. It is our hope that this article helps surgeons and physicians to manage the complex issues involving ground glass nodules (GGNs) in a balanced manner in their daily practice and provokes further discussion towards better guidelines and/or algorithms.

A multidisciplinary approach for the differential diagnosis between multiple primary lung adenocarcinomas and intrapulmonary metastases

PURPOSE

The distinction between multiple primary lung cancers (MPLCs) and intrapulmonary metastases has a significant impact on tumor staging and therapeutic choices. Several criteria have been proposed to solve this diagnostic issue, but a definitive consensus is still missing. We tested the efficacy of a combined clinical, histopathological and molecular ("real world") approach for the correct classification of multiple lung tumors in a selected cohort of patients.

METHODS

24 multiple lung tumors with a diagnosis of adenocarcinoma from 10 patients were retrospectively reviewed. Radiological, pathological and clinical information, including follow-up, were integrated with molecular profiling via a routine multigene panel sequencing.

RESULTS

Comprehensive histologic assessment revealed readily distinguishable histologic patterns between multiple tumors suggesting unrelated lesions in 7 cases, in agreement with clinical, radiological and molecular data, thus leading to final diagnosis of MPLCs. In the remaining 3 cases, the differential diagnosis between MPLCs and intrapulmonary metastases was challenging, since the histologic features of the lesions were similar or identical. The final interpretation (2 MPLCs and 1 most likely intrapulmonary metastases) was reached thanks to the integration of all available data, and was confirmed by follow-up.

CONCLUSIONS

A multidisciplinary approach including a routinely affordable multigene panel sequencing is a useful tool to discriminate MPLCs from intrapulmonary metastases in multiple lung nodules sharing the adenocarcinoma histotype.

Characteristics and prognosis of synchronous multiple primary lung cancer after surgical treatment: A systematic review and meta-analysis of current evidence

Background

This study aims to quantitatively summary the characteristics of synchronous multiple primary lung cancer (sMPLC), postoperative mortality, long‐term prognosis, and prognostic effects of potential clinical parameters in patients with sMPLC after surgery.

Methods

PubMed and Embase databases were systematically searched to identify studies that explored the prognosis of patients with sMPLC after surgery.

Results

Fifty‐two studies with 3486 participants were included, and clinical characteristics were quantitatively summarized. The pooled proportion of sMPLC in lung cancer was 2.0% (95%CI, 1.6%–2.5%) with an increasing trend over time, and postoperative mortality was 1.4% (95%CI, 0.5%–2.7%) with a decreasing trend over time. The 5‐year survival rate was 44.9% (95%CI, 37.4%–52.6%) and all long‐term survival rates showed increasing trends over time. Poor long‐term prognosis was observed in both limited resection (HR = 1.357, 95%CI, 1.047–1.759, p = 0.0210) and pneumonectomy (HR = 2.643, 95%CI, 1.539–4.541, p = 0.0004) by comparison of anatomical resection. Other clinical parameters of age, gender, smoking status, FEV1, and lymph node metastasis significantly impacted the long‐term prognosis (all p < 0.05).

Conclusions

The proportion of sMPLC in lung cancer and 5‐year survival rate are increasing, while postoperative mortality is decreasing trend over time. Lobectomy should be preferred, while pneumonectomy should be avoided for sMPLC. Age, gender, FEV1, smoking, tumor size, surgical methods, and lymph node status are prognostic factors for sMPLC. Considering the heterogeneity and publication bias, these findings should be treated with caution.