Non-Small Cell Lung Carcinoma Biomarker Testing: The Pathologist's Perspective

Real-world biomarker testing rate and positivity rate in NSCLC in Spain: Prospective Central Lung Cancer Biomarker Testing Registry (LungPath) from the Spanish Society of Pathology (SEAP)

AIM

The aim of this study was to describe the testing rate and frequency of molecular alterations observed in the Lung Cancer Biomarker Testing Registry (LungPath).

METHODS

A descriptive study of NSCLC biomarker determinations collected from March 2018 to January 2019, from 38 Spanish hospitals, was carried out. Only adenocarcinoma and not otherwise specified histologies were included for epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS1) and programmed death ligand-1 (PD-L1) expression. The testing rate and the positivity rate were calculated. Multivariate logistic regression was used to explore the joint relationship between independent explanatory factors and both testing and positivity rates. Two models were adjusted: one with sample type and histology as independent factors, and the other adding the testing rate or the positivity rate of the other biomarkers.

RESULTS

3226 patient samples were analysed, where EGFR, ALK, ROS1 and PD-L1 information was collected (a total of 12 904 determinations). Overall, 9118 (71.4%) determinations were finally assessed. EGFR (91.4%) and ALK (80.1%) were the mainly tested biomarkers. Positivity rates for EGFR, ALK, ROS1 and PD-L1 were 13.6%, 3.4%, 2.0% and 49.2%, respectively. Multivariate models showed a lower testing rate for ALK in surgical pieces, fine-needle aspiration or other types of samples versus biopsies.

CONCLUSIONS

Despite the high testing rate in EGFR and ALK in NSCLC, the real-world evidence obtained from the LungPath demonstrates that ROS1 and PD-L1 were not determined in a significant portion of patients. LungPath provides crucial information to improve the coverage in molecular testing in lung cancer, to monitor the positivity rate and the introduction of new biomarker testing in clinical practice.

Impact of Pre-Analytical Conditions on the Antigenicity of Lung Markers: ALK and MET

Diagnostic assays for molecular alterations highly correlated with prognosis, predictive efficacy or safety of therapeutics are valuable clinical tools and in some cases approved as companion diagnostics (CDx) by the Federal Food and Drug Administration. For example, assays that determine echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) translocation status have been approved as CDx assay for therapies that target this molecular alteration. Characterizing the parameters that may compromise diagnostic accuracy for molecular biomarkers is critical for optimal patient care. To investigate the impact of pre-analytical handling and processing of tumor tissue on commonly used diagnostic immunohistochemistry-based assays for ALK and mesenchymal epithelial transition protein [c-mesenchymal epithelial transition (c-MET)], we investigated the effects of cold ischemia, fixative type, fixation time, and cut-slide age on staining consistency and intensity using human lung xenograft tumor tissue. Cold ischemia times for up to 5 to 6 hours for c-MET or ALK, respectively had minimal impact on staining. The optimal fixation conditions for both assays were found to be at least 6 hours and up to 48 hours for c-MET or 72 hours for ALK, in 10% neutral buffered formalin and Zinc formalin. The ALK antigen demonstrated marked staining intensity differences across non-neutral buffered formalin fixative types and times. Finally, cut-slide age influenced assay performance for both ALK and c-MET, with maximum stability observed when cut slides were stored at ambient temperatures (30°C) for no longer than 3, and 5 months, respectively. This study highlights the potential for pre-analytical factors to confound diagnostic test result interpretation.

Concomitant Pathogenic Mutations and Fusions of Driver Oncogenes in Tumors

Driver oncogene alterations have always been one of leading causes in the process of occurrence and development of tumors. And the effects of driver oncogene alterations on tumorigenesis and progression in different kinds of tumors have been studied heatedly. And the roles that the driver oncogenes alterations play have been elucidated clearly in previous studies. The phenomenon of concomitant driver oncogenes mutations and driver genes fusions has gained much concentration in the past two decades. And a growing number of studies reported this phenomenon, either coexistence or mutually exclusivity. Here we reviewed on the phenomenon of concomitant mutations in three common types of carcinomas—lung cancer, thyroid cancer, and leukemia, which have been studied relatively more detailed and more general compared with others.

Concurrent Driver Gene Mutations as Negative Predictive Factors in Epidermal Growth Factor Receptor-Positive Non-Small Cell Lung Cancer

BACKGROUND

Tyrosine kinase inhibitors (TKIs) are clinically effective in non-small cell lung cancer (NSCLC) patients harbouring epidermal growth factor receptor (EGFR) oncogene mutations. Genetic factors, other than EGFR sensitive mutations, that allow prognosis of TKI treatment remain undefined.

METHODS

We retrospectively screened 423 consecutive patients with advanced NSCLC and EGFR 19del or 21L858R mutations. A total of 71 patients whose progression-free survivals (PFS) were shorter than 6 months or longer than 24 months were included and stratified into separate groups. Genetic background discrepancy was analysed in the two groups using next generation sequencing (NGS).

FINDINGS

Sensitive EGFR mutations of 19del or 21L858R were detected by NGS in all patients; the 21L858R mutation was the major type. The most frequent accompanying somatic mutations were TP53, RB1, MAP2K. ALK fusion, MET amplification, and BRAF V600E were found only in the short PFS group. Concurrent pretreament T790 M mutation was found in both groups, but was proportionally higher in the short PFS group. In the short PFS group, patients had significantly more driver gene mutations than in long PFS group (P = 0·018). The numbers of concomitant somatic mutations, EGFR pathway-related mutations, and tumor mutation burden (TMB) were not significantly different between the two groups.

INTERPRETATION

Co-occuring driver gene mutations were negative predictive factors of TKI therapy in EGFR-mutated patients. This study highlights the importance of exploring co-occuring genomic alterations before initiation of EGFR-TKIs.

[Advances in Double Mutations of EGFR and ALK Gene in Non-small Cell Lung Cancer]

Molecular target therapy is one of the most popular field of non-small cell lung cancer (NSCLC) treatmnet. Epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) rearragement are the most important two oncogenic drivers in NSCLC, early studies suggested that EGFR mutations and ALK rearrangements are mutually exclusive, but isolated cases or small sample research with concomitant EGFR and ALK alterations have been constantly reported. The co-occurrence of EGFR mutations and anaplastic lymphoma kinase (ALK) rearrangements constitutes a rare molecular, the frequency of EGFR/ALK co-alterations was about 1%, however, little has been known about clinicopathologic feature and treatment. This review summarized published case report, EGFR and ALK alterations are common in female, Asian origin, never smoker, IV stage, and denocarcinomas. First-line treatment can choose EGFR or ALK tyrosine kinase inhibitors (TKIs). However, studies about the origin and resistance mechanism in EGFR/ALK co-alterations are little, require more experimental and clinical research.
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Gene set selection via LASSO penalized regression (SLPR)

Gene set testing is an important bioinformatics technique that addresses the challenges of power, interpretation and replication. To better support the analysis of large and highly overlapping gene set collections, researchers have recently developed a number of multiset methods that jointly evaluate all gene sets in a collection to identify a parsimonious group of functionally independent sets. Unfortunately, current multiset methods all use binary indicators for gene and gene set activity and assume that a gene is active if any containing gene set is active. This simplistic model limits performance on many types of genomic data. To address this limitation, we developed gene set Selection via LASSO Penalized Regression (SLPR), a novel mapping of multiset gene set testing to penalized multiple linear regression. The SLPR method assumes a linear relationship between continuous measures of gene activity and the activity of all gene sets in the collection. As we demonstrate via simulation studies and the analysis of TCGA data using MSigDB gene sets, the SLPR method outperforms existing multiset methods when the true biological process is well approximated by continuous activity measures and a linear association between genes and gene sets.

Targeted Therapies for Non-Small Cell Lung Cancer: An Update on Epidermal Growth Factor Receptor and Anaplastic Lymphoma Kinase Inhibitors

BACKGROUND

The development of targeted therapies has revolutionized the treatment of advanced non-small cell lung cancer (NSCLC), with new clinical trials and therapies consistently providing new information. This rapidly changing field mandates ongoing education for nursing professionals whose foremost priority is patient care.

OBJECTIVES

This review aims to summarize the history and current status of targeted therapies for NSCLC, focusing on two types of drugs that have had the most impact to date.

METHODS

The safety profiles of first- and second-generation EGFR and ALK inhibitors are described, and strategies for the management of the most commonly experienced adverse events are summarized. Information is also provided to help identify which patients might be eligible for treatment with EGFR or ALK inhibitors in addition to the implications of targeted therapies.

FINDINGS

Therapies designed to target specific molecular features of individual tumor cells are one of the most important developments in treating NSCLC. The safety profiles of targeted therapies differ greatly from chemotherapy and present unique challenges to nurses. Education of nurses and patients on implementation of effective adverse event management and improvement in patient adherence will maximize the benefits of these drugs.

Approach to biomarker testing: perspectives from various specialties

BACKGROUND

Despite its importance for patient outcomes, biomarker testing for lung cancer is not uniformly integrated into the Canadian health care system. To better understand current practice patterns for lung cancer biomarker testing, we assessed physician perspectives by specialty and region.

METHODS

A national survey of Canadian lung cancer specialists was conducted to understand their perspectives on biomarker testing in lung cancer. The 11-item survey assessed the current practice and challenges of testing. The survey was sent to 375 specialists.

RESULTS

The overall response rate for the survey was 36%. Nearly all specialists reported that knowing tumour genotyping results affects patient outcome and influences the treatment decision. Medical oncologists most commonly initiated molecular testing; however, most respondents suggested a shared model involving medical oncologists and pathologists. More than half of all responding specialists had the perception that fewer than 25% of test results are available for first-line treatment decisions. Identified barriers to routine testing for all lung cancer patients included cost, lack of funding, tissue availability, and sample quality.

CONCLUSIONS

There was clear agreement that biomarker testing is important in determining appropriate treatment for patients. There is a need for general consensus on who should initiate molecular testing. Clear clinical guidance for pathologists has to be established for molecular testing, including defining the population to be tested, the timing of testing, and the tests to be performed. Testing could be facilitated by including more information on diagnostic sample requisitions, such as clinical suspicion of primary lung cancer, cancer history, and other samples already collected.

Epidermal growth factor receptor mutations in nonsmall cell lung carcinoma patients in Kuwait

CONTEXT

Nonsmall cell lung carcinoma (NSCLC) is the most frequently diagnosed form of lung cancer in Kuwait. NSCLC samples from Kuwait have never been screened for epidermal growth factor receptor (EGFR) gene aberration, which is known to affect treatment options.

AIMS

This study investigated the feasibility of using fine-needle aspiration (FNA) material for mutational screening, and whether common EGFR mutations are present in NSCLC samples from Kuwait.

SETTINGS AND DESIGN

Eighteen NSCLC samples from five Kuwaitis and 13 non-Kuwaitis were included in this study.

MATERIALS AND METHODS

DNA was extracted from FNA cell blocks and screened for EGFR gene mutations using peptide nucleic acid (PNA)-clamp assay, and EGFR gene amplification using fluorescent in situ hybridization (EGFR-FISH). EGFR protein expression was assessed using immunohistochemistry.

RESULTS

Five EGFR mutations were detected in five non-Kuwaiti NSCLC patients (27.8%). EGFR gene amplification was evident in 10 samples (55.5%) by direct amplification or under the influence of chromosomal polysomy. Four samples had EGFR mutations and EGFR gene amplification, out of which only one sample had coexisting EGFR overexpression.

CONCLUSIONS

Given the evidence of EGFR gene alterations occurring in NSCLC patients in Kuwait, there is a need to incorporate EGFR gene mutational screen for NSCLC patients to implement its consequent use in patient treatment.

Diagnostic and prognostic value of serum thioredoxin and DJ-1 in non-small cell lung carcinoma patients

In response to reactive oxygen species (ROS), thioredoxin and DJ-1 are upregulated to counteract the detrimental effect of ROS under normal condition. However, cancer cells can take advantage of thioredoxin and DJ-1 against ROS-induced cell damage. In several human cancer types, thioredoxin and DJ-1 were found to be overexpressed. The present study aimed to explore the serum levels of thioredoxin and DJ-1 in non-small cell lung cancer (NSCLC) patients and its relationship to the diagnosis and prognosis of this particular malignancy. Sera from 134 NSCLC patients and 168 healthy controls were obtained. Using the enzyme-linked immunosorbent assay (ELISA) method, the levels of serum thioredoxin and DJ-1 were measured and correlated to the clinicopathological characteristics of NSCLC patients. The diagnostic and prognostic significance of the biomarkers were evaluated by using receiver operating curve (ROC), Kaplan-Meier curve, and log-rank analyses and the Cox proportional hazard model, respectively. Serum thioredoxin and DJ-1 levels were significantly higher in the NSCLC patients than that in the controls (23.5 ± 6.57 vs. 13.8 ± 2.49 and 7.11 ± 2.02 vs. 5.18 ± 1.26, respectively). NSCLC patients at later stage cancer showed significantly higher levels of serum thioredoxin and DJ-1 than those at the early stages (P < 0.01 and P < 0.05, respectively). Multivariate logistic regression analysis showed that high serum thioredoxin level was an independent risk factor for lymph nodal metastases and distant metastases (OR = 2.18, 95 % CI 1.26-3.41 and OR = 3.68, 95 % CI 2.16-5.33, respectively). In addition, an increase in the serum DJ-1 level was also identified as an independent risk factor for nodal metastases (OR = 1.37, 95 % CI 1.11-3.04). For predicting the development of NSCLC, ROC/area under the curve (AUC) analysis for thioredoxin indicated an AUC of 0.80 (sensitivity 0.62, specificity 0.92), and ROC/AUC analysis for DJ-1 showed an AUC of 0.78 (sensitivity 0.66, specificity 0.89). NSCLC patients with high serum thioredoxin and DJ-1 levels had lower survival rates than those with low levels, and multivariate analyses for overall survival revealed that high serum thioredoxin levels served as an independent prognostic factor for NSCLC (HR = 2.07, 95 % CI 1.19-3.48). Serum levels of thioredoxin and DJ-1 were significantly higher in NSCLC patients; therefore, these may be utilized as novel diagnostic and prognostic biomarkers for NSCLC.

Epidermal Growth Factor Receptor Mutation Status in the Treatment of Non-small Cell Lung Cancer: Lessons Learned

Advances in oncology research have led to identification of tumor-specific biomarkers, some of which are important predictive indicators and ideal targets for novel therapeutics. One such biomarker in non-small cell lung cancer (NSCLC) is the epidermal growth factor receptor (EGFR). Patients with NSCLC who harbor an activating EGFR mutation show a more favorable response to treatment with an EGFR inhibitor, such as gefitinib, erlotinib, or afatinib, than to chemotherapy. The prevalence of EGFR mutations in East Asian patients is higher than that in other populations, and in some clinical settings, patients have been treated with EGFR inhibitors based on clinicopathologic characteristics with no information on EGFR status. However, based on results from a series of studies in which East Asian patients with advanced non-squamous NSCLC were treated with EGFR inhibitors alone or in combination with standard chemotherapy, this may not be the best practice because EGFR mutation status was found to be a key predictor of outcome. Data from these studies highlight the necessity of EGFR testing in determining the most suitable treatment for patients with advanced or metastatic NSCLC.

C-arm cone-beam CT-guided transthoracic lung core needle biopsy as a standard diagnostic tool: an observational study

C-arm cone-beam computed tomography (CT)-guided transthoracic lung core needle biopsy (CNB) is a safe and accurate procedure for the evaluation of patients with pulmonary nodules. This article will focus on the clinical features related to CNB in terms of diagnostic performance and complication rate. Moreover, the concept of categorizing pathological diagnosis into 4 categories, which could be used for clinical management, follow-up, and quality assurance is also introduced. We retrospectively collected data regarding 375 C-arm cone-beam CT-guided CNBs from January 2010 and June 2014. Clinical and radiological variables were evaluated in terms of success or failure rate. Pathological reports were inserted in 4 homogenous groups (nondiagnostic--L1, benign--L2, malignant not otherwise specified--L3, and malignant with specific histotype--L4), defining for each category a hierarchy of suggested actions. The sensitivity, specificity, and positive and negative predictive value and accuracy for patients subjected to CNBs were of 96.8%, 100%, 100%, 100%, and 97.2%, respectively. Roughly 75% of our samples were diagnosed as malignant, with 60% lung adenocarcinoma diagnoses. Molecular analyses were performed on 85 malignant samples to verify applicability of targeted therapy. The rate of "nondiagnostic" samples was 12%. C-arm cone-beam CT-guided transthoracic lung CNB can represent the gold standard for the diagnostic evaluation of pulmonary nodules. A clinical and pathological multidisciplinary evaluation of CNBs was needed in terms of integration of radiological, histological, and oncological data. This approach provided exceptional performances in terms of specificity, positive and negative predictive values; sensitivity in our series was lower compared with other large studies, probably due to the application of strong criteria of adequacy for CNBs (L1 class rate). The satisfactory rate of collected material was evaluated not only in terms of merely diagnostic performances but also for predictive results by molecular analysis.