Costs of Biopsy and Complications in Patients with Lung Cancer

Design, infectability, and transcriptomic analysis of transregionally differentiated and scalable lung organoids derived from adult bronchial cells

The lung is a primary target for many lethal respiratory viruses, leading to significant global mortality. Current organoid models fail to completely mimic the cellular diversity and intricate tubular and branching structures of the human lung. Lung organoids derived from adult primary cells have so far only included cells from the input cell region, proximal or distal. Existing models are expensive. They often require cells from invasive deep lung tissue biopsies. The present study aimed to address these limitations. The lung organoids obtained using an original protocol exhibited transregional differentiation and were derived from relatively more accessible primary cells from the trachea/bronchi. Immortal bronchial cell lines were also used to simplify organoid fabrication and improve its scalability. The lung organoids are formed starting from bronchial cells with fibroblasts feeder cells in an alginate hydrogel coated with base membrane zone proteins. Characterizations were performed using bulk RNA sequencing and tandem mass tags. The resulting organoids express markers of different lung regions and mimic to some extent the tubular and branching morphology of the lung. The proteomic profile of organoid from primary cells and from cell lines was found to evolve towards that of mature lung tissue. Upregulated genes were mostly related to the respiratory system, tube development, and various aspects of respiratory viral infections. Infection with SARS-CoV-2 and influenza H1N1 was successful and did not require organoid disassembly. The organoids matured within 21 days and did not require complex or expensive culture methods. Transregionally differentiated lung organoid may find applications for the study of emerging or re-emerging viral infections and fostering the development of novel in-vitro therapeutic strategies.

Quantifying the Value of Reduced Health Disparities: Low-Dose Computed Tomography Lung Cancer Screening of High-Risk Individuals Within the United States

OBJECTIVE

This study aimed to measure the value of increasing lung cancer screening rates for high-risk individuals and its impact on health disparities.

METHODS

The model estimated changes in health economic outcomes if low-dose computed tomography screening increased from current to 100% compliance, following clinical guidelines. Current low-dose computed tomography screening rates were estimated by income, education, and race, using 2017-2019 Behavioral Risk Factor Surveillance System data. The model contained a decision tree module to segment the population by screening outcomes and a Markov chain module to estimate cancer progression over time. Model parameters included information on survival, quality of life, and costs related to cancer diagnosis, treatment, and adverse events. Distributional cost-effectiveness analysis estimated the net monetary value from reduced health disparities-measured using quality-adjusted life expectancy-across income, education, and race groups. Outcomes were assessed over 30 years.

RESULTS

Lung cancer screening eligibility using US Preventive Services Task Force guidelines was higher for individuals with income <$15 000 (47.2%) and without a high-school education (46.1%) than individuals with income >$50 000 (16.6%) and with a college degree (13.5%), respectively. Increasing lung cancer screening to 100% compliance was cost-effective ($64 654 per quality-adjusted life-year) and produced economic value by up to $560 per person ($182.1 billion for United States overall). Up to 32.2% of the value was due to reductions in health disparities.

CONCLUSIONS

Significant value in increasing lung cancer screening rates derived from reducing health disparities. Policy makers and clinicians may not be appropriately prioritizing cancer screening if value from reducing health disparities is unconsidered.

The association between patient preoperative disposition and outcomes after diagnostic lung biopsy

Background

Surgical diagnostic lung biopsy (DLB) is performed to guide the management of pulmonary disease with unclear etiology. However, the utilization of surgical DLB in critically ill patients remains unclear. The purpose of this study was to determine if patient preoperative disposition impacts complication rates after DLB.

Methods

This was retrospective cohort study using electronic health record (EHR) data at one academic institution [2013-2021]. Patients who underwent DLB were identified using current procedural terminology (CPT) codes and cohorted based on preoperative disposition. The primary outcome was 30-day mortality; secondary outcomes were overall morbidity, individual complications, and changes to medical therapy. Complication rates were compared using chi-squared tests, Fisher's exact tests, or analysis of variance (ANOVA). Multivariable logistic regression was performed to generate risk-adjusted odds ratios (ORs) for each complication.

Results

Of 285 patients, 238 (83.5%) presented from home, 26 (9.1%) from inpatient floor units, and 21 (7.4%) from intensive care units (ICUs). Patients requiring ICU had the highest 30-day rates of mortality, overall morbidity, and all individual complications (all P<0.05). After risk adjustment, non-ICU inpatients had higher odds of postoperative ventilator use, prolonged ventilation, and ICU need than outpatients (all P<0.05). Preoperative ICU disposition was associated with increased OR of 30-day mortality [OR, 70.92; 95% confidence interval (CI): 5.55-906.32] and overall morbidity (OR, 7.27; 95% CI: 1.93-27.42) compared to patients with other preoperative dispositions. There were no differences in changes to medical therapy between the cohorts.

Conclusions

Patients requiring ICU before DLB had significantly higher risk-adjusted rates of mortality and postoperative complications than outpatients and other inpatients. A clear benefit from tissue diagnosis should be defined prior to performing DLB on critically ill patients.

Meta-Analysis of Circulating Tumor Cell PD-L1 Expression and the Association with Clinical Outcomes in Non-Small Cell Lung Cancer

BACKGROUND

Programmed death ligand-1 (PD-L1) expression on circulating tumor cells (CTCs) has been suggested to provide prognostic information in non-small cell lung cancer (NSCLC), but consensus relative to treatment outcomes is lacking. We conducted the first comprehensive meta-analysis exploring its potential as a prognostic and predictive marker, and assessed the concordance between PD-L1 + CTCs and paired tumor tissue in NSCLC patients.

METHOD

A comprehensive search was applied to PubMed and EMBASE to identify 26 studies that evaluated PD-L1 + CTCs and their association with survival outcomes in 1236 NSCLC patients.

RESULTS

The meta-analysis estimated a mean PD-L1 + CTCs detection rate of 61% (95% CI, 49-72). Subgroup analysis based on treatment showed that PD-L1 + CTCs was not significantly associated with better overall survival (OS) in NSCLC patients treated with immune checkpoint inhibitors (ICIs) (Hazard Ratio (HR) = 0.96, 95% CI, 0.35-2.65, P = 0.944), but was predictive of worse OS in those treated with other therapies (HR = 2.11, 95% CI, 1.32-3.36, P = 0.002). Similarly, PD-L1 + CTCs was not significantly associated with superior progressing free survival (PFS) in NSCLCs treated with ICIs (HR = 0.67, 95% CI, 0.41-1.09, P = 0.121), but was significantly associated with shorter PFS in patients treated with other therapies (HR = 1.91, 95% CI, 1.24-2.94, P = 0.001). The overall estimate for the concordance between PD-L1 expression on CTCs and tumor cells was 63% (95% CI, 44-80).

CONCLUSION

The average detection rate of PD-L1 + CTCs was comparable to the rate of PD-L1 expression in NSCLC tumors. There was a trend towards better PFS in ICI-treated NSCLC patients with PD-L1 + CTCs. Larger longitudinal studies on the association of PD-L1 + CTCs with clinical outcomes in NSCLC patients treated with ICIs are warranted.

A brain metastasis liquid biopsy: Where are we now?

Brain metastases remain a challenging and feared complication for patients with cancer and research in this area has lagged behind research into metastases to other organs. Due to their location and the risks associated with neurosurgical biopsies, the biology underpinning brain metastases response to treatment and evolution over time remains poorly understood. Liquid biopsies are proposed to overcome many of the limitations present with tissue biopsies, providing a better representation of tumor heterogeneity, facilitating repeated sampling, and providing a noninvasive assessment of tumor biology. Several different liquid biopsy approaches have been investigated including circulating tumor cells, circulating tumor DNA, extracellular vesicles, and tumor-educated platelets; however, these have generally been less effective in assessing brain metastases compared to metastases to other organs requiring improved techniques to investigate these approaches, studies combining different liquid biopsy approaches and/or novel liquid biopsy approaches. Through this review, we highlight the current state of the art and define key unanswered questions related to brain metastases liquid biopsies.

Ultrasound-Guided Needle Biopsy as an Alternative to Chamberlain's Mediastinotomy and Video-Assisted Thoracoscopic Surgery (VATS) in the Diagnosis of Anterior Mediastinal Neoformations: A Retrospective Analysis

(1) Background: The prompt diagnosis of anterior mediastinal lesions is a challenge due to their often being categorized as malignant tumours. Ultrasound-guided Transthoracic Core Needle Biopsy (US-TCNB) is an innovative technique that is arousing increasing interest in clinical practice. However, studies in this area are still scarce. This study aims to compare the diagnostic accuracy and complication rate of US-TCNB with those of traditional surgical methods-Anterior Mediastinotomy and Video Assisted Thoracoscopic Surgery (VATS)-in patients with anterior mediastinal lesions. (2) Methods: This retrospective study involved patients evaluated between January 2011 and December 2021 who had undergone US-TCNB at the Interdepartmental Unit of Internal and Interventional Ultrasound, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy. Personal data, diagnostic questions, and technical information concerning the bioptic procedure, periprocedural complications and histological reports were collected. (3) Results: Eighty-three patients were included in the analysis. Histological examination was performed in 78 cases, with an overall diagnostic accuracy of 94.0% (sensitivity 94%; specificity 100%). Only in 5 patients was a diagnosis not achieved. Complications occurred in 2 patients who were quickly identified and properly treated without need of hospitalization. The accuracy of US-TCNB was comparable to the performance of the main traditional diagnostic alternatives (95.3% for anterior mediastinotomy, and 98.4% for VATS), with a much lower complication rate (2.4% vs. 3-16%). The outpatient setting offered the additional advantage of saving resources. (4) Conclusions: a US-guided needle biopsy can be considered effective and safe, and in the near future it may become the procedure of choice for diagnosing anterior mediastinal lesions in selected patients.

Induction therapy in lung transplantation: A contemporary analysis of trends and outcomes

OBJECTIVES

We provide a contemporary consideration of long-term outcomes and trends of induction therapy use following lung transplantation in the United States.

METHODS

We reviewed the United Network for Organ Sharing registry from 2006 to 2018 for first-time, adult, lung-only transplant recipients. Long-term survival was compared between induction classes (Interleukin-2 inhibitors, monoclonal or polyclonal cell-depleting agents, and no induction therapy). A 1:1 propensity score match was performed, pairing patients who received basiliximab with similar risk recipients who did not receive induction therapy. Outcomes in matched populations were compared using Cox, Kaplan-Meier and Logistic regression modeling.

MEASUREMENTS AND MAIN RESULTS

22 025 recipients were identified; 8003 (36.34%) were treated with no induction therapy, 11 045 (50.15%) with basiliximab, 1556 (7.06%) with alemtuzumab and 1421 (6.45%) with anti-thymocyte globulin. Compared with those who received no induction, patients receiving basiliximab, alemtuzumab or anti-thymocyte globulin were found on multivariable Cox-regression analyses to have lower long-term mortality (all p < .05). Following propensity score matching of basiliximab and no induction populations, analyses demonstrated a statistically significant association between basiliximab use and long- term survival (p < .001). Basiliximab was also associated with a lower risk of acute rejection (p < .001) and renal failure (p = .002).

CONCLUSION

Induction therapy for lung transplant recipients-specifically basiliximab-is associated with improved long-term survival and a lower risk of renal failure or acute rejection.

The Evaluation of Lymphadenopathy in a Resource-Limited Setting

Lymphadenopathy (LAP) refers to abnormalities in the size or consistency of lymph nodes. A wide range of etiologies contributes to the difficulty in diagnosing LAP, from mild self-limited viral infections to grave autoimmune diseases and malignancies. Detailed history-taking and a thorough physical examination are essential. Some physicians in developing countries may consider therapeutic testing. Certain groups may require additional evaluations and special treatment. When treating LAP, the etiology is targeted, but corticosteroids should not be administered before a complete diagnosis has been established due to their ability to mask the histological diagnosis of lymphoma and malignancy. This review aims to provide more straightforward and affordable methods available in almost all healthcare settings, especially those with limited resources.

Discriminating rectal cancer grades using restriction spectrum imaging

PURPOSE

Restriction spectrum imaging (RSI) is a novel diffusion MRI model that separates water diffusion into several microscopic compartments. The restricted compartment correlating to the tumor cellularity is expected to be a potential indicator of rectal cancer aggressiveness. Our aim was to assess the ability of RSI model for rectal tumor grading.

METHODS

Fifty-eight patients with different rectal cancer grading confirmed by biopsy were involved in this study. DWI acquisitions were performed using single-shot echo-planar imaging (SS-EPI) with multi-b-values at 3 T. We applied a three-compartment RSI model, along with ADC model and diffusion kurtosis imaging (DKI) model, to DWI images of 58 patients. ROC and AUC were used to compare the performance of the three models in differentiating the low grade (G1 + G2) and high grade (G3). Mean ± standard deviation, ANOVA, ROC analysis, and correlation analysis were used in this study.

RESULTS

The volume fraction of restricted compartment C₁ from RSI was significantly correlated with grades (r = 0.403, P = 0.002). It showed significant difference between G1 and G3 (P = 0.008) and between G2 and G3 (P = 0.01). As for the low-grade and high-grade discrimination, significant difference was found in C₁ (P < 0.001). The AUC of C₁ for differentiation between low-grade and high-grade groups was 0.753 with a sensitivity of 72.0% and a specificity of 70.0%.

CONCLUSION

The three-compartment RSI model was able to discriminate the rectal cancer of low and high grades. The results outperform the traditional ADC model and DKI model in rectal cancer grading.

Patient out-of-pocket costs for suspicious pulmonary nodule biopsy in lung cancer patients

AIMS

Dynamic changes in the payer landscape have resulted in increasing out-of-pocket costs (OOPCs). Little is known about OOPC for patients undergoing biopsy for suspicious pulmonary nodules in the United States. This study seeks to describe the spectrum of OOPC for diagnostic tissue sampling for suspicious pulmonary nodule with an ultimate diagnosis of lung cancer.

METHODS

Retrospective cohort study of adult patients with a primary lung cancer diagnosis and treatment who underwent diagnostic biopsy for suspicious pulmonary nodule utilizing IBM Marketscan Databases (2013-2017). Claims data included both total hospital and physician billed costs, insurer reimbursement and OOPC. OOPCs were further stratified by type of biopsy, whether the patient underwent a single or multiple biopsies, and year of biopsy.

RESULTS

A total of 22,870 patients aged 18-95 who underwent diagnostic lung biopsy were identified. The gender ratio was 49:51 for female:male and 50% of patients were aged 65 or above. 78% of patients had a co-morbidity. The median OOPC for a patient receiving a single biopsy (any type) was $600, two biopsies: $706, three biopsies: $811, and four biopsies: $1,177. By biopsy type, the median OOPC for a patient requiring a single biopsy was $604 for percutaneous biopsy, $316 for surgical biopsy, $674 for bronchoscopic biopsy, and $545 for mediastinoscopic biopsy.

LIMITATIONS

Under-estimation of OOP expenses from costs of transportation, job loss, and loss of productivity. Over-estimation of OOPC from lack of individual claims adjudication.

CONCLUSIONS

The median OOPC for lung cancer patient requiring a single diagnostic lung biopsy is $600. Prior research indicates that almost 50% of the lung cancer patient population undergoes multiple biopsies increasing costs anywhere between 20% and 100% resulting in further patient financial burden for each episodic biopsy attempt. Further cost-effectiveness research is needed to differentiate various diagnostic technologies for lung biopsy.