Non-Smoking-Associated Lung Cancer: A distinct Entity in Terms of Tumor Biology, Patient Characteristics and Impact of Hereditary Cancer Predisposition

Facing an un-met need in lung cancer screening: The never smokers

Lung cancer (LC) is the leading cause of cancer-related deaths worldwide and the second most common cancer in both men and women. In addition to smoking, other risk factors, such as environmental tobacco smoke, air pollution, biomass combustion, radon gas, occupational exposure, lung disease, family history of cancer, geographic variability, and genetic factors, play an essential role in developing LC. Current screening guidelines and eligibility criteria have limited efficacy in identifying LC cases (50 %), as most screening programs primarily target subjects with a smoking history as the leading risk factor. Implementing LC screening programs in people who have never smoked (PNS) can significantly impact cancer-specific survival and early disease detection. However, the available evidence regarding the feasibility and effectiveness of such programs is limited. Therefore, further research on LC screening in PNS is warranted to determine the necessary techniques for accurately identifying individuals who should be included in screening programs.

Advancing non-small cell lung cancer treatment: the power of combination immunotherapies

Non-small cell lung cancer (NSCLC) remains an unsolved challenge in oncology, signifying a substantial global health burden. While considerable progress has been made in recent years through the emergence of immunotherapy modalities, such as immune checkpoint inhibitors (ICIs), monotherapies often yield limited clinical outcomes. The rationale behind combining various immunotherapeutic or other anticancer agents, the mechanistic underpinnings, and the clinical evidence supporting their utilization is crucial in NSCLC therapy. Regarding the synergistic potential of combination immunotherapies, this study aims to provide insights to help the landscape of NSCLC treatment and improve clinical outcomes. In addition, this review article discusses the challenges and considerations of combination regimens, including toxicity management and patient selection.

Tobacco smoking influences the side effects of radiation therapy-managed patients with various malignancies: A systematic review

BACKGROUND

Tobacco smoking may decrease the effectiveness of radiation therapy. This is because tobacco smoking can cause inflammation and damage to surrounding tissues, which may interfere with radiation delivery to the tumor. Our aim of this study is to investigate the effect of tobacco smoking use on complications in radiotherapy as a systematic review.

METHOD

The articles searched from the MEDLINE, PubMed, EMBASE, and Web of Science databases. The search terms used were "radiotherapy", "outcome", "radiation therapy", "tobacco", "smoking", "complications", "side effects", "cancer", and "malignancy". PRISMA check list was used to assess the overall quality of evidence for each outcome.

RESULT

The outcomes of radiotherapy-inducing tobacco smoking in smokers are more than non-smokers including; high SPC (second primary cancer), decreased median overall survival, higher infections during treatment, increased fatigue (p = 0.027), increased pain (p = 0.009), poorer cognitive function (0.041), affected mouth opening (0.049), more speech disturbances (p = 0.017), higher metastasis risk (p = 0.031 and 0.019), higher locoregional recurrence risk (p = 0.027), oral mucositis (p = 0.03), mucositis severity related to higher tobacco exposure (p = 0.008), severe acute radiation skin reactions, and myocardial infarction.

DISCUSSION

Tobacco smoking appears to be the most significant modifiable factor influencing cancer treatment outcomes. As such, healthcare providers should take detailed notes on patients' smoking histories during both routine and future clinical studies. Beyond immediate cessation, cancer patients should undertake comprehensive smoking cessation programs. These programs can significantly boost the efficacy of radiotherapy and enhance overall patient outcomes.

Cigarette smoke sustains immunosuppressive microenvironment inducing M2 macrophage polarization and viability in lung cancer settings

BACKGROUND

It is amply demonstrated that cigarette smoke (CS) has a high impact on lung tumor progression worsening lung cancer patient prognosis and response to therapies. Alteration of immune cell types and functions in smokers' lungs have been strictly related with smoke detrimental effects. However, the role of CS in dictating an inflammatory or immunosuppressive lung microenvironment still needs to be elucidated. Here, we investigated the effect of in vitro exposure to cigarette smoke extract (CSE) focusing on macrophages.

METHODS

Immortalized murine macrophages RAW 264.7 cells were cultured in the presence of CS extract and their polarization has been assessed by Real-time PCR and cytofluorimetric analysis, viability has been assessed by SRB assay and 3D-cultures and activation by exposure to Poly(I:C). Moreover, interaction with Lewis lung carcinoma (LLC1) murine cell models in the presence of CS extract were analyzed by confocal microscopy.

RESULTS

Obtained results indicate that CS induces macrophages polarization towards the M2 phenotype and M2-phenotype macrophages are resistant to the CS toxic activity. Moreover, CS impairs TLR3-mediated M2-M1 phenotype shift thus contributing to the M2 enrichment in lung smokers.

CONCLUSIONS

These findings indicate that, in lung cancer microenvironment of smokers, CS can contribute to the M2-phenotype macrophages prevalence by different mechanisms, ultimately, driving an anti-inflammatory, likely immunosuppressive, microenvironment in lung cancer smokers.

Navigating the Pitfalls of Lung Cancer Screening: A Case Study on the Risks and Costs of Negative Screenings

Lung cancer is the leading cause of cancer-related deaths in the United States. Low-dose computed tomography is the preferred screening method for high-risk individuals. However, with a false-negative rate reaching 15%, this method can underestimate disease prevalence and delay necessary treatment. This case examines a 61-year-old female smoker with chronic obstructive pulmonary disease who initially received a negative result from screening. Her imaging findings were categorized as Lung Imaging Reporting and Data System (Lung-RADS) 2 but advanced to small cell lung carcinoma. This progression emphasizes the imperative of thoroughly evaluating screening results and patient history. False-negative results from screenings have profound implications, leading to delayed diagnoses, adversely affecting patient outcomes, and increasing healthcare costs. The necessity for vigilant follow-up enhanced diagnostic precision and transparent communication about limitations is paramount. An economic analysis emphasizes the significant financial impact of diagnosing lung cancer at advanced stages, highlighting the need for timely and accurate diagnostics. Comprehensive strategies, such as physician education, patient awareness, and stringent quality control, are crucial to improving the efficacy of lung cancer screening. Addressing the issue of false negatives is vital for enhancing early detection rates, decreasing healthcare expenses, and advancing patient care in lung cancer management. Continuous evaluation and adjustment of screening protocols are essential to reduce risks and optimize outcomes.

Rare Synchronous Lung Cancers in a Nonsmoker with Epidermal Growth Factor Receptor and Mesenchymal-Epithelial Transition Alterations: A Case Report

Introduction

Lung cancer is the second most common cancer; however, synchronous lung cancer is rare and challenging to treat.

Case Presentation

We report the case of an 80-year-old female patient who presented with two lung lesions with primary tumor characteristics, which revealed squamous cell carcinoma and synchronous adenocarcinoma after histological sampling. Next-generation sequencing (NGS) analysis revealed a MET Exon 14 skipping mutation in squamous cell carcinoma and an epidermal growth factor receptor mutation in adenocarcinoma. Capmatinib and stereotactic radiotherapy were initiated for the adenocarcinoma with a good clinical response. Capmatinib treatment had to be discontinued because of stage 3 edema of the lower limbs, after which a left lobectomy was performed. Currently, the patient is considered to be in remission.

Conclusion

This case highlights the need for histological analysis of every lung lesion with primary tumor characteristics, as well as for NGS analysis in search of specific mutations enabling the introduction of targeted therapies. mesenchymal-epithelial transition.

Lung cancer in nonsmokers- A risk factor analysis

INSTITUTIONS

STONY BROOK MEDICAL CENTERRATIONALE: Lung Cancer screening for the high-risk smoking population has been proven to save lives. However, in 2022, 20% of newly diagnosed lung cancers (47,300) were in nonsmokers. These patients were found to be diagnosed at later stages. This may be at least partly due to not meeting criteria for and participating in current lung cancer screening. This study aims to describe characteristics of a never smoker patient population to help identify common risk factors which might merit inclusion in lung cancer screening and thus improve patient outcomes.

METHODS

This retrospective single center study included never-smoker patients diagnosed with lung nodules and never-smoker patients diagnosed with lung cancer from 2016 to 2022. Data was obtained from the Stony Brook Medical Center electronic medical record. 16,056 patients were identified as never-smokers who were asked by the medical assistant if they ever smoked in their lifetime. Patients were eliminated if they had any smoking history up to first diagnosis date. Demographics, radiology, histology, diagnosis dates, comorbidities, smoking status, and exposures collected through ICD10 codes and not self-reported, were investigated.

RESULTS

Of 16,056 never-smoking patients, 9315 (58.02%) were females diagnosed with lung nodules and 6741 (41.98%) were males diagnosed with lung nodules. The univariate analysis showed significant differences between gender, age at nodule diagnosis, and patients with and without comorbidities including chronic obstructive pulmonary disease (COPD), hypertension (HTN), and family history (FHX) of lung cancer. The percentage of lung cancer patients among females was significantly higher than among males. Patients having lung cancer were older. The percentages of lung cancer patients with these comorbidities were significantly higher than those without. However, there was no significant difference found between patients with and without diabetes mellitus (DM). The multivariable logistic regression suggested that age at nodule diagnosis and comorbidities including COPD (which included asthma, emphysema and chronic bronchitis) and family history of lung cancer were significantly associated with lung cancer. Older patients and patients with those comorbidities had a higher risk of developing cancer than those who were younger or without those comorbidities. The study excluded HTN and included age at nodule diagnosis in the logistic regression model as HTN was found to be protective against lung cancer due to age at lung nodule diagnosis. Please refer to the appendix for further details.

CONCLUSION

Never-smoker patients who were older and with COPD and Family History of lung cancer had higher risk of developing lung cancer than younger patients without these comorbidities. In this study, gender had no impact on outcome.

The role of extracellular vesicles in non-small-cell lung cancer, the unknowns, and how new approach methodologies can support new knowledge generation in the field

Extracellular vesicles (EVs) are nanosized particles released from most human cell types that contain a variety of cargos responsible for mediating cell-to-cell and organ-to-organ communications. Current knowledge demonstrates that EVs also play critical roles in many aspects of the progression of Non-Small-Cell Lung Cancer (NSCLC). Their roles range from increasing proliferative signalling to inhibiting apoptosis, promoting cancer metastasis, and modulating the tumour microenvironment to support cancer development. However, due to the limited availability of patient samples, intrinsic inter-species differences between human and animal EV biology, and the complex nature of EV interactions in vivo, where multiple cell types are present and several events occur simultaneously, the use of conventional preclinical and clinical models has significantly hindered reaching conclusive results. This review discusses the biological roles that EVs are currently known to play in NSCLC and identifies specific challenges in advancing today's knowledge. It also describes the NSCLC models that have been used to define currently-known EV functions, the limitations associated with their use in this field, and how New Approach Methodologies (NAMs), such as microfluidic platforms, organoids, and spheroids, can be used to overcome these limitations, effectively supporting future exciting discoveries in the NSCLC field and the potential clinical exploitation of EVs.

A Functional Genomics Review of Non-Small-Cell Lung Cancer in Never Smokers

There is currently a dearth of information regarding lung cancer in never smokers (LCINS). Additionally, there is a difference in somatic mutations, tumour mutational burden, and chromosomal aberrations between smokers and never smokers (NS), insinuating a different disease entity in LCINS. A better understanding of actionable driver alterations prevalent in LCINS and the genomic landscape will contribute to identifying new molecular targets of relevance for NS that will drastically improve outcomes. Differences in treatment outcomes between NS and smokers, as well as sexes, with NSCLC suggest unique tumour characteristics. Epidermal growth factor receptor (EGFR) tyrosine kinase mutations and echinoderm microtubule-associated protein-like 4 anaplastic lymphoma kinase (EML4-ALK) gene rearrangements are more common in NS and have been associated with chemotherapy resistance. Moreover, NS are less likely to benefit from immune mediators including PD-L1. Unravelling the genomic and epigenomic underpinnings of LCINS will aid in the development of not only novel targeted therapies but also more refined approaches. This review encompasses driver genes and pathways involved in the pathogenesis of LCINS and a deeper exploration of the genomic landscape and tumour microenvironment. We highlight the dire need to define the genetic and environmental aspects entailing the development of lung cancer in NS.

Trends in Cancer Incidence in Different Antiretroviral Treatment-Eras amongst People with HIV

Despite cancer being a leading comorbidity amongst individuals with HIV, there are limited data assessing cancer trends across different antiretroviral therapy (ART)-eras. We calculated age-standardised cancer incidence rates (IRs) from 2006-2021 in two international cohort collaborations (D:A:D and RESPOND). Poisson regression was used to assess temporal trends, adjusted for potential confounders. Amongst 64,937 individuals (31% ART-naïve at baseline) and 490,376 total person-years of follow-up (PYFU), there were 3763 incident cancers (IR 7.7/1000 PYFU [95% CI 7.4, 7.9]): 950 AIDS-defining cancers (ADCs), 2813 non-ADCs, 1677 infection-related cancers, 1372 smoking-related cancers, and 719 BMI-related cancers (groups were not mutually exclusive). Age-standardised IRs for overall cancer remained fairly constant over time (8.22/1000 PYFU [7.52, 8.97] in 2006-2007, 7.54 [6.59, 8.59] in 2020-2021). The incidence of ADCs (3.23 [2.79, 3.72], 0.99 [0.67, 1.42]) and infection-related cancers (4.83 [4.2, 5.41], 2.43 [1.90, 3.05]) decreased over time, whilst the incidence of non-ADCs (4.99 [4.44, 5.58], 6.55 [5.67, 7.53]), smoking-related cancers (2.38 [2.01, 2.79], 3.25 [2.63-3.96]), and BMI-related cancers (1.07 [0.83, 1.37], 1.88 [1.42, 2.44]) increased. Trends were similar after adjusting for demographics, comorbidities, HIV-related factors, and ART use. These results highlight the need for better prevention strategies to reduce the incidence of NADCs, smoking-, and BMI-related cancers.

Management of Oncogene Driven Locally Advanced Unresectable Non-small Cell Lung Cancer

INTRODUCTION

The current standard of care of locally advanced non-small cell lung cancer (LA-NSCLC) is concurrent chemoradiation, followed by consolidation durvalumab. However, there is evidence that the efficacy of chemoradiation and also immunotherapy in many oncogene-positive LA-NSCLC are attenuated, and dependent on the subgroup.

AREAS COVERED

We will firstly review the outcomes of standard-of-care therapy in oncogene-driven LA-NSCLC. We looked at various oncogene driven subgroups and the tumor microenvironment that may explain differential response. Finally, we review the role of targeted therapy in the treatment of LA-NSCLC.

EXPERT OPINION

Each oncogene-positive subgroup should be treated as its own entity, and continued efforts should be undertaken to incorporate targeted therapy, which is likely to yield superior survival outcomes if trial design can be optimized and toxicities can be managed.

Impact of Molecular Testing Using Next-Generation Sequencing in the Clinical Management of Patients with Non-Small Cell Lung Cancer in a Public Healthcare Hospital

Next-generation sequencing (NGS) is a molecular approach able to provide a comprehensive molecular profile of non-small cell lung cancer (NSCLC). The broad spectrum of biomarker-guided therapies has positioned molecular diagnostic laboratories as a central component of patient clinical management. Here, we show the results of an UNE-EN ISO 15189:2022 NGS-accredited assay in a cohort of 350 patients. TP53 (51.0%), KRAS (26.6%) and EGFR (12.9%) were the most frequently mutated genes. Furthermore, we detected co-occurring and mutually exclusive alterations, as well as distinct molecular profiles according to sex and smoking habits. Actionable genetic alterations were significantly more frequent in female patients (80.5%, p < 0.001) and in never-smoker patients (87.7%, p < 0.001). When NGS was established as the main molecular testing strategy, 36.4% of patients received at least one line of targeted treatment. Among 200 patients with stage IV NSCLC, first-line treatment with targeted therapies was associated with a longer progression-free survival (PFS) (13.4 months (95% CI, 10.2–16.6) (p = 0.001)). Similarly, the overall survival (OS) of patients receiving at least one targeted drug was significantly longer (26.2 months (95% CI, 11.8–40.5) (p < 0.001)). Our results show that the implementation of NGS in the public healthcare system has provided a broader application of precision medicine.

Smoking Habit and Respiratory Function Predict Patients' Outcome after Surgery for Lung Cancer, Irrespective of Histotype and Disease Stage

BACKGROUND

Growing evidence suggests that sublobar resections offer more favorable outcomes than lobectomy in early-stage lung cancer surgery. However, a percentage of cases that cannot be ignored develops disease recurrence irrespective of the surgery performed with curative intent. The goal of this work is thus to compare different surgical approaches, namely, lobectomy and segmentectomy (typical and atypical) to derive prognostic and predictive markers.

PATIENTS AND METHODS

Here we analyzed a cohort of 153 NSCLC patients in clinical stage TNM I who underwent pulmonary resection surgery with a mediastinal hilar lymphadenectomy from January 2017 to December 2021, with an average follow-up of 25.5 months. Partition analysis was also applied to the dataset to detect outcome predictors.

RESULTS

The results of this work showed similar OS between lobectomy and typical and atypical segmentectomy for patients with stage I NSCLC. In contrast, lobectomy was associated with a significant improvement in DFS compared with typical segmentectomy in stage IA, while in stage IB and overall, the two treatments were similar. Atypical segmentectomy showed the worst performance, especially in 3-year DFS. Quite unexpectedly, outcome predictor ranking analysis suggests a prominent role of smoking habits and respiratory function, irrespective of the tumor histotype and the patient's gender.

CONCLUSIONS

Although the limited follow-up interval cannot allow conclusive remarks about prognosis, the results of this study suggest that both lung volumes and the degree of emphysema-related parenchymal damage are the strongest predictors of poor survival in lung cancer patients. Overall, these data point out that greater attention should be addressed to the therapeutic intervention for co-existing respiratory diseases to obtain optimal control of early lung cancer.

Effects of Light-absorbing Carbons in Intraoperative Molecular Imaging-Guided Lung Cancer Resections

BACKGROUND

One of the novel advancements to enhance the visual aspects of lung cancer identification is intraoperative molecular imaging (IMI), which can reliably detect tumors that would otherwise be missed by standard techniques such as tactile and visual feedback, particularly for sub-centimeter or ground-glass nodules. However, there remains a subset of patients who do not benefit from IMI due to excessive background fluorescence secondary to parenchymal light-absorbing carbon deposition. Our goal was to identify the effects of these carbonaceous materials on the quality of IMI-guided lung cancer resections.

STUDY DESIGN AND METHODS

Between July 2014 and May 2021, a total of 311 patients were included in the study. Patients underwent infusion of the study drug OTL38 or ICG up to 24 h prior to VATS for lung cancer. Several factors such as age, tumor subtype, PET SUV, smoking, demographics, chronic lung conditions, patient domicile, and anthracosis were analyzed with respect to lung fluorescence during IMI. P values < 0.05 were considered statistically significant.

RESULTS

Variables such as age, sex, and race had no statistical correlation to IMI success. However, smoking status and pack year had a statistically significant correlation with background parenchymal fluorescence and lung inflammation (p < 0.05). MFI of background (lung parenchyma) correlated with smoking history (p < 0.05) which led to decreased tumor-to-background ratio (TBR) measurements for all patients with proven malignancy (p < 0.05). Patients with chronic lung disease appear to have increased background parenchymal fluorescence regardless of smoking history (287 vs. 154, p < 0.01). City dwellers compared to other groups appear to be exposed to higher pollutant load and have higher rates of anthracosis, but living location's impact on fluorescence quantification appears to be not statistically significant.

CONCLUSION

Smokers with greater than 10 PPY and those with chronic lung disease appear to have decreased lesion-to-background discrimination, significant anthracosis, and reduced IMI efficacy secondary to light-absorbing carbon deposition.

Genetic differences between smokers and never-smokers with lung cancer

Smoking is a major risk factor for lung cancer, therefore lung cancer epidemiological trends reflect the past trends of cigarette smoking to a great extent. The geographic patterns in mortality closely follow those in incidence. Although lung cancer is strongly associated with cigarette smoking, only about 15% of smokers get lung cancer, and also some never-smokers develop this malignancy. Although less frequent, lung cancer in never smokers is the seventh leading cause of cancer deaths in both sexes worldwide. Lung cancer in smokers and never-smokers differs in many aspects: in histological types, environmental factors representing a risk, and in genes associated with this disease. In this review, we will focus on the genetic differences between lung cancer in smokers versus never-smokers: gene expression, germ-line polymorphisms, gene mutations, as well as ethnic and gender differences. Finally, treatment options for smokers and never-smokers will be briefly reviewed.

Recent Advances in Lung Cancer Therapy Based on Nanomaterials: A Review

Lung cancer is one of the commonest cancers with a significant mortality rate for both genders, particularly in men. Lung cancer is recognized as one of the leading causes of death worldwide, which threatens the lives of over 1.6 million people every day. Although cancer is the leading cause of death in industrialized countries, conventional anticancer medications are unlikely to increase patients' life expectancy and quality of life significantly. In recent years, there are significant advances in the development and applications of nanotechnology in cancer treatment. The superiority of nanostructured approaches is that they act more selectively than traditional agents. This progress led to the development of a novel field of cancer treatment known as nanomedicine. Various formulations based on nanocarriers, including lipids, polymers, liposomes, nanoparticles and dendrimers have opened new horizons in lung cancer therapy. The application and expansion of nano-agents lead to an exciting and challenging research era in pharmaceutical science, especially for the delivery of emerging anti-cancer agents. The objective of this review is to discuss the recent advances in three types of nanoparticle formulations for lung cancer treatments modalities, including liposomes, polymeric micelles, and dendrimers for efficient drug delivery. Afterward, we have summarized the promising clinical data on nanomaterials based therapeutic approaches in ongoing clinical studies.

PM2.5 promotes NSCLC carcinogenesis through translationally and transcriptionally activating DLAT-mediated glycolysis reprograming

Background

Airborne fine particulate matter (PM2.5) has been associated with lung cancer development and progression in never smokers. However, the molecular mechanisms underlying PM2.5-induced lung cancer remain largely unknown. The aim of this study was to explore the mechanisms by which PM2.5 regulated the carcinogenesis of non-small cell lung cancer (NSCLC).

Methods

Paralleled ribosome sequencing (Ribo-seq) and RNA sequencing (RNA-seq) were performed to identify PM2.5-associated genes for further study. Quantitative real time-PCR (qRT-PCR), Western blot, and immunohistochemistry (IHC) were used to determine mRNA and protein expression levels in tissues and cells. The biological roles of PM2.5 and PM2.5-dysregulated gene were assessed by gain- and loss-of-function experiments, biochemical analyses, and Seahorse XF glycolysis stress assays. Human tissue microarray analysis and ¹⁸F-FDG PET/CT scans in patients with NSCLC were used to verify the experimental findings. Polysome fractionation experiments, chromatin immunoprecipitation (ChIP), and dual-luciferase reporter assay were implemented to explore the molecular mechanisms.

Results

We found that PM2.5 induced a translation shift towards glycolysis pathway genes and increased glycolysis metabolism, as evidenced by increased L-lactate and pyruvate concentrations or higher extracellular acidification rate (ECAR) in vitro and in vivo. Particularly, PM2.5 enhanced the expression of glycolytic gene DLAT, which promoted glycolysis but suppressed acetyl-CoA production and enhanced the malignancy of NSCLC cells. Clinically, high expression of DLAT was positively associated with tumor size, poorer prognosis, and SUVmax values of ¹⁸F-FDG-PET/CT scans in patients with NSCLC. Mechanistically, PM2.5 activated eIF4E, consequently up-regulating the expression level of DLAT in polysomes. PM2.5 also stimulated transcription factor Sp1, which further augmented transcription activity of DLAT promoter.

Conclusions

This study demonstrated that PM2.5-activated overexpression of DLAT and enhancement in glycolysis metabolism contributed to the tumorigenesis of NSCLC, suggesting that DLAT-associated pathway may be a therapeutic target for NSCLC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13046-022-02437-8.

DNA and histone modifications as potent diagnostic and therapeutic targets to advance non-small cell lung cancer management from the perspective of 3P medicine

Lung cancer has a very high mortality in females and males. Most (~ 85%) of lung cancers are non-small cell lung cancers (NSCLC). When lung cancer is diagnosed, most of them have either local or distant metastasis, with a poor prognosis. In order to achieve better outcomes, it is imperative to identify the molecular signature based on genetic and epigenetic variations for different NSCLC subgroups. We hypothesize that DNA and histone modifications play significant roles in the framework of predictive, preventive, and personalized medicine (PPPM; 3P medicine). Epigenetics has a significant impact on tumorigenicity, tumor heterogeneity, and tumor resistance to chemotherapy, targeted therapy, and immunotherapy. An increasing interest is that epigenomic regulation is recognized as a potential treatment option for NSCLC. Most attention has been paid to the epigenetic alteration patterns of DNA and histones. This article aims to review the roles DNA and histone modifications play in tumorigenesis, early detection and diagnosis, and advancements and therapies of NSCLC, and also explore the connection between DNA and histone modifications and PPPM, which may provide an important contribution to improve the prognosis of NSCLC. We found that the success of targeting DNA and histone modifications is limited in the clinic, and how to combine the therapies to improve patient outcomes is necessary in further studies, especially for predictive diagnostics, targeted prevention, and personalization of medical services in the 3P medicine approach. It is concluded that DNA and histone modifications are potent diagnostic and therapeutic targets to advance non-small cell lung cancer management from the perspective of 3P medicine.

Molecular Profiling in Non-Squamous Non-Small Cell Lung Carcinoma: Towards a Switch to Next-Generation Sequencing Reflex Testing

Molecular diagnosis of lung cancer is a constantly evolving field thanks to major advances in precision oncology. The wide range of actionable molecular alterations in non-squamous non-small cell lung carcinoma (NS-NSCLC) and the multiplicity of mechanisms of resistance to treatment resulted in the need for repeated testing to establish an accurate molecular diagnosis, as well as to track disease evolution over time. While assessing the increasing complexity of the molecular composition of tumors at baseline, as well as over time, has become increasingly challenging, the emergence and implementation of next-generation sequencing (NGS) testing has extensively facilitated molecular profiling in NS-NSCLC. In this review, we discuss recent developments in the molecular profiling of NS-NSCLC and how NGS addresses current needs, as well as how it can be implemented to address future challenges in the management of NS-NSCLC.

Lung cancer in never smokers: Tumor immunology and challenges for immunotherapy

Lung cancer is the second most common and the most lethal malignancy worldwide. It is estimated that lung cancer in never smokers (LCINS) accounts for 10-25% of cases, and its incidence is increasing according to recent data, although the reasons remain unclear. If considered alone, LCINS is the 7th most common cause of cancer death. These tumors occur more commonly in younger patients and females. LCINS tend to have a better prognosis, possibly due to a higher chance of bearing an actionable driver mutation, making them amenable to targeted therapy. Notwithstanding, these tumors respond poorly to immune checkpoint inhibitors (ICI). There are several putative explanations for the poor response to immunotherapy: low immunogenicity due to low tumor mutation burden and hence low MANA (mutation-associated neo-antigen) load, constitutive PD-L1 expression in response to driver mutated protein signaling, high expression of immunosuppressive factors by tumors cells (like CD39 and TGF-beta), non-permissive immune TME (tumor microenvironment), abnormal metabolism of amino acids and glucose, and impaired TLS (Tertiary Lymphoid Structures) organization. Finally, there is an increasing concern of offering ICI as first line therapy to these patients owing to several reports of severe toxicity when TKIs (tyrosine kinase inhibitors) are administered sequentially after ICI. Understanding the biology behind the immune response against these tumors is crucial to the development of better therapeutic strategies.

CircRNA hsa_circ_0070659 predicts poor prognosis and promotes non-small cell lung cancer (NSCLC) progression via microRNA-377 (miR-377) / Ras-Associated Binding Protein 3C (RAB3C) pathway

A large number of circular RNAs (circRNAs) are dysregulated in lung cancer and affect the progression and prognosis of lung disease. Herein, this study selected specific circular RNA (circ_0070659) by bioinformatics analysis and aimed to investigate the role of circ_0070659 in non-small cell lung cancer (NSCLC). The differentially expressed circRNA (hsa_circ_0070659) in NSCLC was screened from public databases (GEO), and real-time quantitative polymerase chain reaction (RT-qPCR) was carried out to identify the circ_0070659 levels in cancer tissues and cells. NSCLC cell proliferation, migration, and invasion abilities after circ_0070659 silencing was detected by colony formation assay, Cell Counting Kit-8 (CCK-8) assay and Transwell assay. Targeted binding between microRNA-377 (miR-377) and circ_0070659 or Ras-Associated Binding Protein 3C (RAB3C) was verified by western blot, dual-luciferase reporter assay, and RNA pull-down assay. Our experimental results showed that circ_0070659 levels were largely increased in tumor tissues and cells. Biologically, knockdown of circ_0070659 obviously inhibited proliferation, migration, and invasion of NSCLC cells. Mechanistically, circ_0070659 promoted RAB3C-mediated proliferation and invasion through sponging miR-377. Furthermore, miR-377 inhibitor reversed the inhibitory ability of circ_0070659 silencing on malignant biological behavior of NSCLC cells. Our study revealed a novel signaling pathway that circ_0070659/miR-377/RAB3C axis regulates tumor progression, and it may become a new therapeutic target for NSCLC.

Occupational Exposures and Lung Cancer Risk-An Analysis of the CARTaGENE Study

OBJECTIVE

To determine the associations between prevalent occupational agents and lung cancer risk.

METHODS

A case-cohort design (ncases= 147; nsub-cohort= 1,032) was nested within the CARTaGENE prospective cohort study. The Canadian Job Exposure Matrix was used to determine the probability of exposure to 27 agents in participants' longest-held jobs. Multivariable logistic regression with robust variance estimators was used to determine the associations between each agent and lung cancer risk while adjusting for established lung cancer risk factors.

RESULTS

Increased lung cancer risk was observed among those exposed to ashes, calcium sulfate, formaldehyde, cooking fumes, alkanes, aliphatic aldehydes, and cleaning agents. Lower lung cancer risk was found among participants exposed to carbon monoxide and polycyclic aromatic hydrocarbons from petroleum.

CONCLUSION

Our findings support the role of several occupational agents, for which we have limited knowledge, in contributing to lung cancer risk.

Discriminating Spontaneous From Cigarette Smoke and THS 2.2 Aerosol Exposure-Related Proliferative Lung Lesions in A/J Mice by Using Gene Expression and Mutation Spectrum Data

Mice, especially A/J mice, have been widely employed to elucidate the underlying mechanisms of lung tumor formation and progression and to derive human-relevant modes of action. Cigarette smoke (CS) exposure induces tumors in the lungs; but, non-exposed A/J mice will also develop lung tumors spontaneously with age, which raises the question of discriminating CS-related lung tumors from spontaneous ones. However, the challenge is that spontaneous tumors are histologically indistinguishable from the tumors occurring in CS-exposed mice. We conducted an 18-month inhalation study in A/J mice to assess the impact of lifetime exposure to Tobacco Heating System (THS) 2.2 aerosol relative to exposure to 3R4F cigarette smoke (CS) on toxicity and carcinogenicity endpoints. To tackle the above challenge, a 13-gene gene signature was developed based on an independent A/J mouse CS exposure study, following by a one-class classifier development based on the current study. Identifying gene signature in one data set and building classifier in another data set addresses the feature/gene selection bias which is a well-known problem in literature. Applied to data from this study, this gene signature classifier distinguished tumors in CS-exposed animals from spontaneous tumors. Lung tumors from THS 2.2 aerosol-exposed mice were significantly different from those of CS-exposed mice but not from spontaneous tumors. The signature was also applied to human lung adenocarcinoma gene expression data (from The Cancer Genome Atlas) and discriminated cancers in never-smokers from those in ever-smokers, suggesting translatability of our signature genes from mice to humans. A possible application of this gene signature is to discriminate lung cancer patients who may benefit from specific treatments (i.e., EGFR tyrosine kinase inhibitors). Mutational spectra from a subset of samples were also utilized for tumor classification, yielding similar results. “Landscaping” the molecular features of A/J mouse lung tumors highlighted, for the first time, a number of events that are also known to play a role in human lung tumorigenesis, such as Lrp1b mutation and Ros1 overexpression. This study shows that omics and computational tools provide useful means of tumor classification where histopathological evaluation alone may be unsatisfactory to distinguish between age- and exposure-related lung tumors.

DNA Methylation in Lung Cancer: Mechanisms and Associations with Histological Subtypes, Molecular Alterations, and Major Epidemiological Factors

Lung cancer is the major leading cause of cancer-related mortality worldwide. Multiple epigenetic factors-in particular, DNA methylation-have been associated with the development of lung cancer. In this review, we summarize the current knowledge on DNA methylation alterations in lung tumorigenesis, as well as their associations with different histological subtypes, common cancer driver gene mutations (e.g., KRAS, EGFR, and TP53), and major epidemiological risk factors (e.g., sex, smoking status, race/ethnicity). Understanding the mechanisms of DNA methylation regulation and their associations with various risk factors can provide further insights into carcinogenesis, and create future avenues for prevention and personalized treatments. In addition, we also highlight outstanding questions regarding DNA methylation in lung cancer to be elucidated in future studies.

Impact of Smoking Status on Lung Cancer Characteristics and Mortality Rates between Screened and Non-Screened Lung Cancer Cohorts: Real-World Knowledge Translation and Education

This was a retrospective hospital-based cohort study of participants diagnosed with lung cancer in the lung cancer register database, and our goal was to evaluate the impact of smoking and screening status on lung cancer characteristics and clinical outcomes. According to the hospital-based lung cancer register database, a total of 2883 lung cancers were diagnosed in 2883 patients between January 2007 and September 2017, which were divided into four groups according to smoking and screening status. A comparison was performed in terms of clinical characteristics and outcomes of lung cancer between the four groups. For non-smokers, age, gender, screened status, tumor size, targeted therapy, and curative surgery were independent prognostic factors of overall survival for lung cancer subjects. However, screened status and gender were not significant prognostic factors for lung cancer survival in smokers with lung cancer. For the non-smoker group, about 4.9% of lung cancer subjects (N = 81) were detected by screening. However, only 0.97% of lung cancer subjects (N = 12) were detected by screening in smokers. This could be attributed to smokers' negative attitudes and low socioeconomic status preventing LDCT lung cancer screening. In summary, our real-world data suggest that effectively encouraging smokers to be more willing to participate in lung cancer screening programs with screening allowance and educational training in the future is an important issue.

The molecular characteristics of high-grade gastroenteropancreatic neuroendocrine neoplasms

High-grade (HG) gastroenteropancreatic (GEP) neuroendocrine neoplasms (NEN) are rare but have a very poor prognosis and represent a severely understudied class of tumours. Molecular data for HG GEP-NEN are limited, and treatment strategies for the carcinoma subgroup (HG GEP-NEC) are extrapolated from small-cell lung cancer (SCLC). After pathological re-evaluation, we analysed DNA from tumours and matched blood samples from 181 HG GEP-NEN patients; 152 neuroendocrine carcinomas (NEC) and 29 neuroendocrine tumours (NET G3). Based on the sequencing of 360 cancer-related genes, we assessed mutations and copy number alterations (CNA). For NEC, frequently mutated genes were TP53 (64%), APC (28%), KRAS (22%) and BRAF (20%). RB1 was only mutated in 14%, but CNAs affecting RB1 were seen in 34%. Other frequent copy number losses were ARID1A (35%), ESR1 (25%) and ATM (31%). Frequent amplifications/gains were found in MYC (51%) and KDM5A (45%). While these molecular features had limited similarities with SCLC, we found potentially targetable alterations in 66% of the NEC samples. Mutations and CNA varied according to primary tumour site with BRAF mutations mainly seen in colon (49%), and FBXW7 mutations mainly seen in rectal cancers (25%). Eight out of 152 (5.3%) NEC were microsatellite instable (MSI). NET G3 had frequent mutations in MEN1 (21%), ATRX (17%), DAXX, SETD2 and TP53 (each 14%). We show molecular differences in HG GEP-NEN, related to morphological differentiation and site of origin. Limited similarities to SCLC and a high fraction of targetable alterations indicate a high potential for better-personalized treatments.

Impact of Smoking History on Response to Immunotherapy in Non-Small-Cell Lung Cancer: A Systematic Review and Meta-Analysis

Objectives

To evaluate the impact of smoking history on the clinical benefit of immunotherapy in patients with non-small cell lung cancer (NSCLC).

Methods

Twenty-three randomized clinical trials and seven real-world studies were included in this meta-analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS) and progression-free survival (PFS) and odds ratios for the overall response rate (ORR) were extracted. A fixed-effects or random-effects model was applied to obtain pooled estimates.

Results

Data from 16 high-quality trials involving 10,643 NSCLC patients receiving either immunotherapy or chemotherapy/placebo enabled direct comparison of the survival impact of smoking. Anti-PD-1/PD-L1/CTLA-4 immunotherapy was found to significantly prolong OS and PFS as compared to chemotherapy/placebo in smokers (HR for OS, 0.76 [0.69-0.83], P<0.00001; HR for PFS, 0.65 [0.56-0.75], P<0.00001), and these trends were less or not significant in non-smokers (HR for OS, 0.91 [0.78-1.06], P=0.25; HR for PFS, 0.68 [0.45-1.03], P=0.07). Consistent results were obtained for the first-line or second/third-line use of immunotherapy and for non-squamous NSCLC patients only. Furthermore, the data from 7 trials and 7 real-world studies involving 4,777 patients receiving immunotherapy allowed direct comparison of therapeutic outcomes between smokers and non-smokers. Prolonged OS (HR 0.86 [0.75-0.99], P=0.04) and PFS (HR 0.69 [0.60-0.81], P<0.0001) and a higher response rate (ORR 1.20 [0.94-1.53], P=0.15) were observed in smokers compared to non-smokers receiving immunotherapy.

Conclusions

Immunotherapy was found to have a greater benefit in NSCLC patients with a smoking history than in those who had never smoked.

Screening for Lung Cancer in Individuals Who Never Smoked: An International Association for the Study of Lung Cancer Early Detection and Screening Committee Report

Screening with low-dose computed tomography of high-risk individuals with a smoking history reduces lung cancer mortality. Current screening guidelines and eligibility criteria can miss more than 50% of lung cancers, and in some geographic areas, such as East Asia, a large proportion of the missed lung cancers are in never-smokers. Although randomized trials revealed the benefits of screening for people who smoke, these trials generally excluded never-smokers. Thus, the feasibility and effectiveness of lung cancer screening of individuals who never smoked are uncertain. Several known and suspected risk factors for lung cancers in never-smokers such as exposure to secondhand smoke, occupational carcinogens, radon, air pollution, and pulmonary diseases, such as chronic obstructive pulmonary disease and interstitial lung diseases, and intrinsic factors, such as age, are well noted. In this regard, knowledge of risk factors may make possible quantification and prediction of lung cancer risk in never smokers. It is worth considering if and how never smokers could be included in population-based screening programs. As the implementation of these programs is challenging in many countries owing to multiple factors and the epidemiologic differences by global regions, these issues will need to be evaluated in each country taking into account various factors, including accuracy of risk assessment and cost-effectiveness of screening in never smokers. This report aims to outline current knowledge on risk factors for lung cancer in never smokers to propose research strategies for this topic and initiate a broader discussion on lung cancer screening of never smokers. Similar considerations can be made in current and ex-smokers, which do not fulfill the current screening inclusion criteria, but otherwise are at increased risk. Although screening of never smokers may in the future be effectively conducted, current evidence to support widespread implementation of this practice is lacking.

ZNF768 Expression Associates with High Proliferative Clinicopathological Features in Lung Adenocarcinoma

Simple Summary

Zinc-finger protein 768 (ZNF768) is a transcription factor that was recently shown to promote proliferation and repress senescence downstream of growth factor signaling in vitro. This protein was found to be overexpressed in a small cohort of lung adenocarcinoma (LUAD) compared to normal tissue, but its clinical value in this cancer remains unknown. The aim of this study was to determine whether ZNF768 associates with clinicopathological features in LUAD. We found that ZNF768 levels are often elevated in LUAD and that ZNF768 protein levels positively correlate with Ki-67 and other proliferative clinicopathological features in this cancer. Supporting a role for ZNF768 in promoting proliferation, ZNF768 depletion severely impairs proliferation in several lung cancer cell lines. Our study, that extends previous in vitro data, provides the first clinical observations supporting a possible role for ZNF768 in promoting cancer cell proliferation and tumor development in humans.

Abstract

Lung adenocarcinoma (LUAD) is the most common type of lung cancer and a leading cause of cancer-related deaths worldwide. Despite important recent advances, the prognosis for LUAD patients is still unfavourable, with a 5 year-survival rate close to 15%. Improving the characterization of lung tumors is important to develop alternative options for the diagnosis and the treatment of this disease. Zinc-finger protein 768 (ZNF768) is a transcription factor that was recently shown to promote proliferation and repress senescence downstream of growth factor signaling. Although ZNF768 protein levels were found to be elevated in LUAD compared to normal lung tissue, it is currently unknown whether ZNF768 expression associates with clinicopathological features in LUAD. Here, using tissue microarrays of clinical LUAD surgical specimens collected from 364 patients, we observed that high levels of ZNF768 is a common characteristic of LUAD. We show that ZNF768 protein levels correlate with high proliferative features in LUAD, including the mitotic score and Ki-67 expression. Supporting a role for ZNF768 in promoting proliferation, we report that ZNF768 depletion severely impairs proliferation in several lung cancer cell lines in vitro. A marked decrease in the expression of key proliferative genes was observed in cancer cell lines depleted from ZNF768. Altogether, our findings support a role for ZNF768 in promoting proliferation of LUAD.

A comprehensive meta-analysis and a case-control study give insights into genetic susceptibility of lung cancer and subgroups

Reports of genetic association of polymorphisms with lung cancer in the Indian subcontinent are often conflicting. To summarise and replicate published evidence for association with lung cancer and its subgroups. We performed a meta-analysis of candidate associations on lung cancer, its histological subtypes and smoking status in the Indian subcontinent following PRISMA guidelines. Multiple testing corrections were done by the Benjamini-Hochberg method through assessment of significance at a false discovery rate of 10%. We genotyped and investigated rs1048943/CYP1A1 in a case-control sample from eastern India, followed by its global meta-analysis using a similar protocol. Meta-analysis of 18 variants of 11 genes reported in 39 studies (7630 cases and 8169 controls) showed significant association of rs1048943/CYP1A1 [2.07(1.49-2.87)] and rs4646903/CYP1A1 [1.48(1.93-1.95)] with overall lung cancer risk at 10% FDR, while nominal association (p < 0.05) was observed for del1/GSTT1, del2/GSTM1, rs1695/GSTP1 and rs17037102/ DKK2. Subtype analysis showed a significant association of del1/GSTT1 with adenocarcinoma, rs4646903/CYP1A1 with squamous carcinoma, and rs1048943/CYP1A1 with both. Association of rs4646903/CYP1A1 in smokers and effect modification by meta-regression analysis was observed. Genotyping of rs1048943/CYP1A1 that presented significant heterogeneity (p < 0.1) revealed an association with adenocarcinoma among eastern Indian smokers, while a global meta-analysis in 10458 cases and 10871 controls showed association with lung cancer and its subgroups. This study identified the susceptibility loci for lung cancer and its covariate-subgroups.

The Role of Nutritional Support in Malnourished Patients With Lung Cancer

This review aimed to aggregate and describe the available data about clinical nutrition in lung cancer and the role of the dietitian in multidisciplinary patient care. Scientific literature was searched in order to summarize key aspects related to clinical nutrition in lung cancer. This information can be used to arrange a proper nutritional therapy that can enhance patient treatment responses, prevent side-effects, shorten recovery time, improve prognosis and increase quality of life. An anti-inflammatory diet rich in antioxidants, immunomodulatory compounds, dietary fibre and an appropriate intake of protein can reduce the risk of initiation and progression of lung cancer, support the regeneration of tissues (also after surgery) and improve the nutritional status during the disease and after remission. A correct intake of nutrients is significant prior to disease occurrence and at every stage of treatment and recovery.

The interplay between DNA damage and autophagy in lung cancer: A mathematical study

The rising mortality in lung cancer, as well as the constraints of the existing drugs, have made it a major research topic. DNA damage marks the early onset of cancer as it often results from vulnerabilities due to UV rays, oxidative stress, ionizing radiation, and various types of genotoxic attacks. p53 plays an unequivocal role in the DNA repair process and has an abiding presence at the crossroads of the pathways linking DNA damage and cancer. p53 also regulates autophagy in a dual manner based on its cellular localization. The plexus of autophagy regulated by p53 includes AMPK and BCL2, which are positive and negative regulators of prime autophagy inducer beclin1, respectively. Although autophagy is a quintessential process, its levels need to be monitored as uncontrolled autophagy may lead to cell death. The association of p53 and autophagic cell death is very vital as the former acts whenever any threat comes to DNA while the latter may play a role in getting rid of the culprit cell. Therefore, in this paper, we have formulated a seven-dimensional mathematical model connecting p53, DNA damage, and autophagy in lung cancer. We performed both local and global sensitivity analysis along with parameter recalibration analysis to understand the system dynamics. We hypothesized that, by the modulation of beclin1 level, the regulation of AMPK and BCL2 could be a possible strategy to mitigate the progression of lung cancer.

BAI1 nuclear expression reflects the survival of nonsmoking non-small cell lung cancer patients

Background

Smoking‐ and nonsmoking‐associated lung cancers have different mechanisms of carcinogenesis. We divided non‐small cell lung cancer (NSCLC) patients into nonsmoking and smoking groups with the aim of trying to understand the utility of brain‐specific angiogenesis inhibitor 1 (BAI1) expression in the separate groups.

Methods

Clinicopathological data were obtained from 148 patients who had undergone surgery for NSCLC of the lung. Tissue microarray blocks were made of samples from NSCLC patients. Two pathologists graded the intensity of BAI1 expression as high or low expression in the cancer cells of patients in the smoking and nonsmoking groups.

Results

NSCLC nonsmokers with higher BAI1 nuclear expression had poor disease‐specific survival (DSS) (hazard ratio: 2.679; 95% confidence interval [CI]:1.022–7.022, p = 0.045). The Kaplan–Meier survival curve confirmed that higher BAI1 expression was significantly associated with poor DSS (p = 0.034) in the nonsmoking group.

Conclusions

We divided NSCLC patients into nonsmoking and smoking groups and found that nuclear BAI1 expression was related to patient survival in nonsmoking NSCLC patients. We suggest BAI1 expression as a predictive marker of nonsmoking‐associated NSCLC and recommend that it be evaluated as an AJCC staging criterion in the future.

Overcoming of Radioresistance in Non-small Cell Lung Cancer by microRNA-320a Through HIF1α-Suppression Mediated Methylation of PTEN

Background

Radioresistance is a major challenge in the use of radiotherapy for the treatment of lung cancer while microRNAs (miRs) have been reported to participate in multiple essential cellular processes including radiosensitization. This study was conducted with the main objective of investigating the potential role of miR-320a in radioresistance of non-small cell lung cancer (NSCLC) via the possible mechanism related to HIF1α, KDM5B, and PTEN.

Methods

Firstly, NSCLC radiosensitivity-related microarray dataset GSE112374 was obtained. Then, the expression of miR-320a, HIF1α, KDM5B, and PTEN was detected in the collected clinical NSCLC samples, followed by Pearson's correlation analysis. Subsequently, ChIP assay was conducted to determine the content of the PTEN promoter fragment enriched by the IgG antibody and H3K4me3 antibody. Finally, a series of in vitro and in vivo assays were performed in order to evaluate the effects of miR-320a on radioresistance of NSCLC with the involvement of HIF1α, KDM5B, and PTEN.

Results

The microarray dataset GSE112374 presented with a high expression of miR-320a in NSCLC radiosensitivity samples, which was further confirmed in our clinical samples with the use of reverse transcription-quantitative polymerase chain reaction. Moreover, miR-320a negatively targeted HIF1α, inhibiting radioresistance of NSCLC. Interestingly, miR-320a suppressed the expression of KDM5B, and KDM5B was found to enhance the radioresistance of NSCLC through the downregulation of PTEN expression. The inhibition of miR-320a in radioresistance of NSCLC was also reproduced by in vivo assay.

Conclusion

Taken together, our findings were suggestive of the inhibitory effect of miR-320a on radioresistance of NSCLC through HIF1α-suppression mediated methylation of PTEN.

Nano targeted Therapies Made of Lipids and Polymers have Promising Strategy for the Treatment of Lung Cancer

The introduction of nanoparticles made of polymers, protein, and lipids as drug delivery systems has led to significant progress in modern medicine. Since the application of nanoparticles in medicine involves the use of biodegradable, nanosized materials to deliver a certain amount of chemotherapeutic agents into a tumor site, this leads to the accumulation of these nanoencapsulated agents in the right region. This strategy minimizes the stress and toxicity generated by chemotherapeutic agents on healthy cells. Therefore, encapsulating chemotherapeutic agents have less cytotoxicity than non-encapsulation ones. The purpose of this review is to address how nanoparticles made of polymers and lipids can successfully be delivered into lung cancer tumors. Lung cancer types and their anatomies are first introduced to provide an overview of the general lung cancer structure. Then, the rationale and strategy applied for the use of nanoparticle biotechnology in cancer therapies are discussed, focusing on pulmonary drug delivery systems made from liposomes, lipid nanoparticles, and polymeric nanoparticles. Many nanoparticles fabricated in the shape of liposomes, lipid nanoparticles, and polymeric nanoparticles are summarized in our review, with a focus on the encapsulated chemotherapeutic molecules, ligand-receptor attachments, and their targets. Afterwards, we highlight the nanoparticles that have demonstrated promising results and have been delivered into clinical trials. Recent clinical trials that were done for successful nanoparticles are summarized in our review.

Artificial Intelligence Tools for Refining Lung Cancer Screening

Nearly one-quarter of all cancer deaths worldwide are due to lung cancer, making this disease the leading cause of cancer death among both men and women. The most important determinant of survival in lung cancer is the disease stage at diagnosis, thus developing an effective screening method for early diagnosis has been a long-term goal in lung cancer care. In the last decade, and based on the results of large clinical trials, lung cancer screening programs using low-dose computer tomography (LDCT) in high-risk individuals have been implemented in some clinical settings, however, this method has various limitations, especially a high false-positive rate which eventually results in a number of unnecessary diagnostic and therapeutic interventions among the screened subjects. By using complex algorithms and software, artificial intelligence (AI) is capable to emulate human cognition in the analysis, interpretation, and comprehension of complicated data and currently, it is being successfully applied in various healthcare settings. Taking advantage of the ability of AI to quantify information from images, and its superior capability in recognizing complex patterns in images compared to humans, AI has the potential to aid clinicians in the interpretation of LDCT images obtained in the setting of lung cancer screening. In the last decade, several AI models aimed to improve lung cancer detection have been reported. Some algorithms performed equal or even outperformed experienced radiologists in distinguishing benign from malign lung nodules and some of those models improved diagnostic accuracy and decreased the false-positive rate. Here, we discuss recent publications in which AI algorithms are utilized to assess chest computer tomography (CT) scans imaging obtaining in the setting of lung cancer screening.

Interplay between estrogen and Stat3/NF-κB-driven immunomodulation in lung cancer

K-ras mutant lung adenocarcinoma (LUAD) is the most common type of lung cancer, displays abysmal prognosis and is tightly linked to tumor-promoting inflammation, which is increasingly recognized as a target for therapeutic intervention. We have recently shown a gender-specific role for epithelial Stat3 signaling in the pathogenesis of K-ras mutant LUAD. The absence of epithelial Stat3 in male K-ras mutant mice (LR/Stat3Δ/Δ mice) promoted tumorigenesis and induced a nuclear factor-kappaB (NF-κB)-driven pro-tumor immune response while reducing tumorigenesis and enhancing anti-tumor immunity in female counterparts. In the present study, we manipulated estrogen and NF-κB signaling to study the mechanisms underlying this intriguing gender-disparity. In LR/Stat3Δ/Δ females, estrogen deprivation by bilateral oophorectomy resulted in higher tumor burden, an induction of NF-κB-driven immunosuppressive response, and reduced anti-tumor cytotoxicity, whereas estrogen replacement reversed these changes. On the other hand, exogenous estrogen in males successfully inhibited tumorigenesis, attenuated NF-κB-driven immunosuppression and boosted anti-tumor immunity. Mechanistically, genetic targeting of epithelial NF-κB activity resulted in reduced tumorigenesis and enhanced the anti-tumor immune response in LR/Stat3Δ/Δ males, but not females. Our data suggest that estrogen exerts a context-specific anti-tumor effect through inhibiting NF-κB-driven tumor-promoting inflammation and provide insights into developing novel personalized therapeutic strategies for K-ras mutant LUAD.

Integrative analysis of genomic alteration, immune cells infiltration and prognosis of lung squamous cell carcinoma (LUSC) to identify smoking-related biomarkers

Lung squamous cell carcinoma (LUSC) is the most common histologic type of smoking-related non-small cell lung cancer (NSCLC). However, there are no identified potential biomarkers for smoking-related LUSC diagnosis and prognosis. Especially, the characteristics of genetic alteration and tumor microenvironment induced by cigarette smoking remain unknown. Here, we performed integrative analysis of 463 LUSC with smoking history information from The Cancer Genome Atlas (TCGA). Non-smokers had the best prognosis, and current reformed smokers had better overall survival (OS) than current smokers in all and stage I-II cohort. Then, pathway enrichment analysis might suggest that smoking may play a role in regulating tumor metabolism and invasion and metastasis via those pathways. We constructed an eight-gene signature and identified WNT7A, Solute carrier-7A5 (SLC7A5) and Brain‑type glycogen phosphorylase (PYGB), which may be served as biomarkers related to the smoking. Notably, the single copy deletion of WNT7A and SLC17A5 and the low-level amplification of PYGB may be related to the epigenetic mechanism of smoking on tumorigenesis. We also estimated the relative proportion of 24 immune cell subtypes within tumor microenvironment in different smoking status. Interestingly, we found NK cells activated, NK cells resting and endothelial cells might play an important role in immunologic dysfunction and harmful tumor microenvironment induced by cigarette smoking. Our research has identified potential biomarkers for smoking-related LUSC diagnosis and prognosis, which would help to further understand the pathogenesis of LUSC.

Smoking Behaviors in Survivors of Smoking-Related and Non-Smoking-Related Cancers

IMPORTANCE

The population of cancer survivors is rapidly growing in the US. Tobacco smoking is associated with many cancers; however, whether cigarette smoking behaviors among cancer survivors vary according to cancer type-that is, smoking-related cancers (SRCs) vs non-smoking-related cancers (NSRCs)-remains unclear.

OBJECTIVES

To examine cigarette smoking prevalence and behaviors (ie, continuing or quitting smoking) among cancer survivors and to compare them between survivors of SRCs and NSRCs.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional analysis of the 2017 National Health Interview Survey, a household survey of civilian US residents who were aged 18 years or older. The National Health Interview Survey is population based and is representative of the US population. Data analysis was performed from June to October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcomes were prevalence of current cigarette smoking among cancer survivors and prevalence of continuing smoking and quitting smoking after a cancer diagnosis. Secondary outcomes included factors associated with continued smoking vs quitting smoking after a cancer diagnosis.

RESULTS

A total of 26 742 respondents (mean [SD] age, 50.97 [18.61] years; 14 646 women [51.76%]) to the 2017 National Health Interview Survey were included in this study. Of the 3068 individuals (9.42%) in the study population who had cancer, 589 (19.96%) were SRC survivors, 2297 (74.50%) were NSRC survivors, 168 (4.96%) were survivors of both SRC and NSRC, and the remaining 14 (0.58%) had missing information about the type of cancer. Four hundred forty-nine SRC survivors (54.08%) were women, compared with 1412 NSRC survivors (54.30%). Ninety-six SRC survivors (15.69%) and 151 NSRC survivors (7.99%) were younger than 45 years. Overall, 372 cancer survivors (13.16%) were current smokers. Current smoking prevalence was higher among survivors of SRCs (145 survivors [19.78%]) compared with NSRC survivors (251 survivors [10.63%]). Among cancer survivors, 309 current smokers at cancer diagnosis (43.96%) reported having successfully quit smoking and 372 (56.04%) reported continuing smoking. Among the continuing smokers, 176 (56.49%) reported an unsuccessful quit attempt in the last 12 months. After cancer diagnosis, SRC survivors had higher odds of continued smoking compared with NSRC survivors (odds ratio [OR], 2.10; 95% CI, 1.12-3.93; P = .02). Men (OR, 1.93; 95% CI, 1.05-3.57; P = .04), those with angina pectoris (OR, 5.40; 95% CI, 1.33-21.91; P = .02), and those with chronic bronchitis (OR, 2.55; 95% CI, 1.05-6.19; P = .04) had higher odds of continued smoking, whereas Hispanic participants (compared with non-Hispanic white participants: OR, 0.18; 95% CI, 0.05-0.68; P = .01) and married participants (compared with never married participants: OR, 0.33; 95% CI, 0.12-0.96; P = .04) had lower odds of continued smoking.

CONCLUSIONS AND RELEVANCE

These findings suggest that compared with NSRC survivors, SRC survivors may be at higher risk of being cigarette smokers at cancer diagnosis and of continuing smoking afterward. Although smoking cessation interventions are critically important for all cancer survivors, special efforts should target survivors of SRCs.

Assessing the Current State of Lung Cancer Chemoprevention: A Comprehensive Overview

Chemoprevention of lung cancer is thought to significantly reduce the risk of acquiring these conditions in the subpopulation of patients with underlying health issues, such as chronic obstructive pulmonary disorder and smoking-associated lung problems. Many strategies have been tested in the previous decades, with very few translating to successful clinical trials in specific subpopulations of patients. In this review, we analyze these strategies, as well as new approaches that have emerged throughout the last few years, including synthetic lethality concept and microbiome-induced regulation of lung carcinogenesis. Overall, the continuous effort in the area of lung chemoprevention is required to develop practical therapeutical approaches. Given the inconsistency of results obtained in clinical trials targeting lung cancer chemoprevention in various subgroups of patients that differ in the underlying health condition, race, and gender, we believe that individualized approaches will have more promise than generalized treatments.

Downregulation of hsa-microRNA-204-5p and identification of its potential regulatory network in non-small cell lung cancer: RT-qPCR, bioinformatic- and meta-analyses

Background

Pulmonary malignant neoplasms have a high worldwide morbidity and mortality, so the study of these malignancies using microRNAs (miRNAs) has attracted great interest and enthusiasm. The aim of this study was to determine the clinical effect of hsa-microRNA-204-5p (miR-204-5p) and its underlying molecular mechanisms in non-small cell lung cancer (NSCLC).

Methods

Expression of miR-204-5p was investigated by real-time quantitative PCR (RT-qPCR). After data mining from public online repositories, several integrative assessment methods, including receiver operating characteristic (ROC) curves, hazard ratios (HR) with 95% confidence intervals (95% CI), and comprehensive meta-analyses, were conducted to explore the expression and clinical utility of miR-204-5p. The potential objects regulated and controlled by miR-204-5p in the course of NSCLC were identified by estimated target prediction and analysis. The regulatory network of miR-204-5p, with its target genes and transcription factors (TFs), was structured from database evidence and literature references.

Results

The expression of miR-204-5p was downregulated in NSCLC, and the downtrend was related to gender, histological type, vascular invasion, tumor size, clinicopathologic grade and lymph node metastasis (P<0.05). MiR-204-5p was useful in prognosis, but was deemed unsuitable at present as an auxiliary diagnostic or prognostic risk factor for NSCLC due to the lack of statistical significance in meta-analyses and absence of large-scale investigations. Gene enrichment and annotation analyses identified miR-204-5p candidate targets that took part in various genetic activities and biological functions. The predicted TFs, like MAX, MYC, and RUNX1, interfered in regulatory networks involving miR-204-5p and its predicted hub genes, though a modulatory loop or axis of the miRNA-TF-gene that was out of range with shortage in database prediction, experimental proof and literature confirmation.

Conclusions

The frequently observed decrease in miR-204-5p was helpful for NSCLC diagnosis. The estimated target genes and TFs contributed to the anti-oncogene effects of miR-204-5p.

Therapeutic landscape of metastatic non-small-cell lung cancer in Canada in 2020

Lung cancer is the most commonly diagnosed cancer in Canada and remains associated with high mortality. Nevertheless, recent advances in the fields of immuno-oncology and precision medicine have led to significant improvements in clinical outcome in metastatic non-small-cell lung cancer (nsclc). Those improvements were facilitated by a greater understanding of the biologic classification of nsclc, which catalyzed discoveries of novel therapies. Here, we present a comprehensive review of the recent avalanche of practice-changing trials in metastatic nsclc, and we offer an approach to the management of this disease from a Canadian perspective. We begin with an overview of the pathologic and molecular characterization of metastatic nsclc. Next, we review the indications for currently approved immune checkpoint inhibitors, and we provide an approach to the management of disease with a driver mutation. Finally, we address future avenues in both diagnostics and therapeutics for patients with advanced and metastatic nsclc.

Optimizing Mutation and Fusion Detection in NSCLC by Sequential DNA and RNA Sequencing

INTRODUCTION

Frequently, patients with locally advanced or metastatic NSCLC are screened for mutations and fusions. In most laboratories, molecular workup includes a multitude of tests: immunohistochemistry (ALK, ROS1, and programmed death-ligand 1 testing), DNA sequencing, in situ hybridization for fusion, and amplification detection. With the fast-emerging new drugs targeting specific fusions and exon-skipping events, this procedure harbors a growing risk of tissue exhaustion.

METHODS

In this study, we evaluated the benefit of anchored, multiplexed, polymerase chain reaction-based targeted RNA sequencing (RNA next-generation sequencing [NGS]) in the identification of gene fusions and exon-skipping events in patients, in which no pathogenic driver mutation was found by DNA-based targeted cancer hotspot NGS (DNA NGS). We analyzed a cohort of stage IV NSCLC cases from both in-house and referral hospitals, consisting 38.5% cytology samples and 61.5% microdissected histology samples, mostly core needle biopsies. We compared molecular findings in a parallel workup (DNA NGS and RNA NGS, cohort 1, n = 198) with a sequential workup (DNA NGS followed by RNA NGS in selected cases, cohort 2, n = 192). We hypothesized the sequential workup to be the more efficient procedure.

RESULTS

In both cohorts, a maximum of one oncogenic driver mutation was found per case. This is in concordance with large, whole-genome databases and suggests that it is safe to omit RNA NGS when a clear oncogenic driver is identified in DNA NGS. In addition, this reduced the number of necessary RNA NGS to only 53% of all cases. The tumors of never smokers, however, were enriched for fusions and exon-skipping events (32% versus 4% in former and current smokers, p = 0.00), and therefore benefited more often from the shorter median turnaround time of the parallel approach (15 d versus only 9 d in the parallel workup).

CONCLUSIONS

We conclude that sequentially combining DNA NGS and RNA NGS is the most efficient strategy for mutation and fusion detection in smoking-associated NSCLC, whereas for never smokers we recommend a parallel approach. This approach was shown to be feasible on small tissue samples including for cytology tests, can drastically reduce the complexity and cost of molecular workup, and also provides flexibility in the constantly evolving landscape of actionable targets in NSCLC.

Inherited lung cancer: a review

Lung cancer is the most common cancer worldwide and has high rates of mortality. The major risk factor associated with this disease is tobacco smoke, but approximately 10%-25% of all lung cancer cases occur in patients who have never smoked. Data suggest that lung cancer in never-smokers has a different molecular profile, tumour microenvironment and epidemiology than that in smokers. Several risk factors have been associated with its occurrence, and the possibility of inherited predisposition is becoming clearer. A better understanding of this disease is essential for the future development of personalised screening, diagnosis and treatment approaches, with consequent reduction of mortality. In this review, we discuss historical studies of lung cancer in never-smokers and the currently available evidence of inherited predisposition to this disease.