[China Experts Consensus on Icotinib for Non-small Cell Lung Cancer Treatment (2016 version)]

Lung adenocarcinoma relapse with emerging EGFR mutation following complete response of small cell lung cancer warrants routine re-biopsy: A case report

Transformation of small cell lung cancer (SCLC) to lung adenocarcinoma (LUAD) is rarely reported. Here, we report a case initially presented with SCLC and was diagnosed as LUAD when the lesion relapsed at the same site. A 56-year-old patient with SCLC who received etoposide and cisplatin chemotherapy combined with radiotherapy achieved a complete radiological response. After 28 months of stable disease, a computed tomography scan revealed a new lesion at the same site as the primary tumor. Pathological examination suggested a LUAD with an emerging EGFR exon 19 deletion. The patient was then treated with icotinib and achieved a near-complete radiological response. Nineteen months later, the patient developed resistance caused by EGFR T790M mutation and received treatment with osimertinib. At the last follow-up in January 2022, the patient was symptom-free. This case warrants re-biopsy and genetic testing as a routine operation when SCLC relapses at the same site as the primary tumor for an extended period, and prospective investigation is required.

The Public Health Insurance Coverage of Novel Targeted Anticancer Medicines in China-In Favor of Whom? A Retrospective Analysis of the Insurance Claim Data

Objectives: This study took Fuzhou city as a case, described how the public health insurance coverage policy in 2016 of novel anti-lung cancer medicines benefited patients, and who benefited the most from the policy in China.

Methods: This was a retrospective study based on health insurance claim data with a longitudinal analysis of the level and trend changes of the monthly number of patients to initiate treatment with the novel targeted anti-lung cancer medicines gefitinib and icotinib before and after health insurance coverage. The study also conducted a multivariate linear regression analysis to predict the potential determinants of the share of patient out-of-pocket (OOP) expenditure for lung cancer treatment with the study medicines.

Results: The monthly number of the insured patients in Fuzhou who initiated the treatment with the studied novel targeted anti-lung cancer medication abruptly increased by 26 in the month of the health insurance coverage (95% CI: 14–37, p < 0.01) and kept at an increasing level afterward (p < 0.01). By controlling the other factors, the shares of OOP expenditure for lung cancer treatment of the patients who were formal employee program enrollees not entitled to government-funded supplementary health insurance coverage and resident program enrollees were 18.3% (95% CI: 14.1–22.6) and 26.7% (95% CI: 21.0–32.4) higher than that of the patients who were formal employee program enrollees with government-funded supplementary health insurance coverage.

Conclusion: The public health insurance coverage of novel anti-lung cancer medicines benefited patients generally. To enable that patients benefit from this policy more equally and thoroughly, in order to achieve the policy goal of not to leave anyone behind, it is necessary to strengthen the benefits package of the resident program and to optimize the current financing mechanism of the public health insurance system.

Nei Endonuclease VIII-like 2 Gene rs8191670 Polymorphism affects the Sensitivity of Non-small Cell Lung Cancer to Cisplatin by binding with MiR-548a

Background: Nei endonuclease VIII-like 2 (NEIL2) is a gene encoding DNA repair enzyme, which is involved in the base excision repair (BER) pathway in mammalian cells. Cisplatin is a common cytotoxic anti-tumor agent in clinic by destroying normal structure of DNA and inducing cell apoptosis. However, how NEIL2 affects the sensitivity of NSCLC to cisplatin is still unclear. Methods: The clinical data from 206 patients diagnosed pathologically were collected. The DNA sequencing of NEIL2 gene 3'UTR and the PFS curve of NSCLC patients receiving cisplatin-based chemotherapy were performed. Western blot analysis and immunohistochemistry were used to detect NEIL2 protein expression. Human NSCLC cell lines A549 and H1299 were cultured and evaluated for cell viability. RT-PCR was performed for quantitative detection of miR-548a. 3'UTR reporter plasmid was constructed and luciferase reporter assay was used to verify the target gene regulated by miR-548a. Results: In this study, we found that the Neil2 gene had the polymorphism (T/C) in rs8191670 and it is associated with the PFS of advanced NSCLC patients. MiR-548a targets NEIL2 3'UTR to suppress its expression. Upregulation of NEIL2 expression or downregulation of miR-548a could reduce the sensitivity of NSCLC cells to cisplatin. Conclusion: Our results demonstrated that NEIL2 gene rs8191670 polymorphism affects the PFS of advanced NSCLC patients, and the underlying molecular mechanisms may be that miR-548a can regulate NEIL2 expression by binding to its 3'UTR seed region containing rs8191670.

Comparative review of drug-drug interactions with epidermal growth factor receptor tyrosine kinase inhibitors for the treatment of non-small-cell lung cancer

The development of small-molecule tyrosine kinase inhibitors (TKIs) that target the epidermal growth factor receptor (EGFR) has revolutionized the management of non-small-cell lung cancer (NSCLC). Because these drugs are commonly used in combination with other types of medication, the risk of clinically significant drug–drug interactions (DDIs) is an important consideration, especially for patients using multiple drugs for coexisting medical conditions. Clinicians need to be aware of the potential for clinically important DDIs when considering therapeutic options for individual patients. In this article, we describe the main mechanisms underlying DDIs with the EGFR-TKIs that are currently approved for the treatment of NSCLC, and, specifically, the potential for interactions mediated via effects on gastrointestinal pH, cytochrome P450-dependent metabolism, uridine diphosphate-glucuronosyltransferase, and transporter proteins. We review evidence of such DDIs with the currently approved EGFR-TKIs (gefitinib, erlotinib, afatinib, osimertinib, and icotinib) and discuss several information sources that are available online to aid clinical decision-making. We conclude by summarizing the most clinically relevant DDIs with these EFGR-TKIs and provide recommendations for managing, minimizing, or avoiding DDIs with the different agents.

Clinical efficacy and safety evaluation of pemetrexed combined with radiotherapy in treatment of patients with lung adenocarcinoma brain metastasis

Clinical efficacy and adverse reactions of pemetrexed combined with stereotactic gamma-ray radiotherapy in the treatment of patients with lung adenocarcinoma brain metastasis in The First People's Hospital of Yunnan Province were evaluated. A total of 67 patients with lung adenocarcinoma brain metastasis in experimental group were treated with simple pemetrexed chemotherapy, and then with radiotherapy, followed by pemetrexed chemotherapy. Their treatment results were compared with those of 53 patients treated with simple gamma knife in control group. The results were analyzed by comparing the clinical efficacy, side reactions, serum level changes, and survival between the two groups. Among 67 patients in the experimental group, there were 16 cases of complete response (CR), 39 cases of partial response (PR), 7 cases of stable disease (SD) and 5 cases of progressive disease (PD), with an effective rate of 82.09% (55/67) and a tumor local control rate of 92.54% (62/67). Among 53 patients in the control group, there were 13 cases of CR, 20 cases of PR, 9 cases of SD and 11 cases of PD, with an effective rate of 62.26% (33/53) and a tumor local control rate of 79.25% (42/53). There were statistically significant differences in the effective rate and local control rate between the two groups (P<0.05). The 6-, 12- and 24-month survival rates in experimental group were higher than those in control group (P<0.05). The main adverse reactions after pemetrexed combined with radiotherapy were lower than those after simple radiotherapy (P<0.05). The expression levels of the tumor markers carcinoembryonic antigen (CEA) and cytokeratin fragment antigen 21-1 (CYFRA21-1) in the two groups of patients after treatment were lower than those before treatment (P<0.05). After treatment, the expression levels of serum CEA and CYFRA21-1 in the experimental group were significantly lower than those in the control group (P<0.05). Pemetrexed combined with radiotherapy in the treatment of lung adenocarcinoma brain metastasis is more effective than simple radiotherapy, with lighter adverse reactions, worthy of clinical application and promotion.

[Circular RNA CircHIPK3 Promotes NCI-H1299 and NCI-H2170 Cell Proliferation through miR-379 and its Target IGF1]

背景与目的

已有的研究证明：环状RNA是一类在哺乳动物中普遍存在的具有稳定闭合环状结构的内源性RNA分子。环状RNA circHIPK3（circular RNA HIPK3, circHIPK3）在肝细胞癌（hepatocellular carcinoma, HCC）中表达水平较高，促进肝癌细胞生长。但是其在非小细胞肺癌（non-small cell lung cancer, NSCLC）中的作用及其调控机制尚无文献报道。本研究拟探讨环状RNA circHIPK3对NSCLC细胞系NCI-H1299和NCI-H2170细胞增殖的影响，并进一步研究其调控的分子机制。

方法

Real-time PCR法检测circHIPK3在NSCLC各细胞系中的表达水平。CCK-8实验和克隆形成实验检测过量表达和干扰circHIPK3对细胞增殖的影响。双荧光素酶报告基因实验分别检验miR-379与circHIPK3及miR-379与IGF1 mRNA的结合情况。Western blot和ELISA检测细胞内外的IGF1蛋白表达水平。

结果

环状RNA circHIPK3在6株NSCLC细胞株中均有表达，其中H1299表达最低，H2170表达最高，通过转染过表达的circHIPK3可显著促进NCI-H1299细胞增殖，干扰circHIPK3可显著抑制NCI-H2170细胞增殖。miR-379可与circHIPK3及IGF1 mRNA直接结合。过表达circHIPK3导致IGF1表达量上调，干扰circHIPK3能够下调IGF1表达水平，转入miR-379 mimics恢复了circHIPK3稳转细胞株IGF1表达水平的上调及细胞增殖表型。

结论

环状RNA circHIPK3在NSCLC细胞系NCI-H1299及NCI-H2170中可通过miR-379调控IGF1表达促进细胞增殖，环状RNA circHIPK3可能成为非小细胞肺癌治疗的新靶点。

[Clinical Evaluation of A New Pathological Classification for Non-small Cell Lung Cancer Based on Histogenesis of Bronchial Tree]

背景与目的

近年来对肺癌研究的巨大发展，肺癌的病理学分类不断推陈出新。本研究旨在研究和验证非小细胞肺癌（non-small cell lung cancer, NSCLC）组织起源分子病理分类的临床价值和意义。

方法

通过免疫组织化学双染法对105例肺癌标本及正常肺组织进行P63/NapsinA、TTF-1/CK7标记，结合肿瘤免疫特征、组织学特点及正常肺组织的免疫特征，提出了NSCLC组织起源分子病理分类体系，将NSCLC分为支气管上皮癌、细支气管肺泡癌、肺泡细胞癌及分泌腺癌，并分析本分类与表皮生长因子受体（epidermal growth factor receptor, EGFR）突变及临床预后的关系。

结果

本分类体系下不同亚型NSCLC中EGFR突变及其类型具有相对特异性；生存分析表明该分类有助于NSCLC患者预后情况的判断。

结论

本研究提出的基于组织起源的NSCLC分类体系具有较好的临床实用价值。

Cost-effectiveness of gefitinib, icotinib, and pemetrexed-based chemotherapy as first-line treatments for advanced non-small cell lung cancer in China

Tyrosine kinase inhibitors of the epidermal growth factor receptor (EGFR) are becoming the standard treatment option for patients with advanced non-small cell lung cancer (NSCLC) harboring an EGFR mutation, but the economic impact of this practice is unclear, especially in a health resource-limited setting. A decision-analytic model was developed to simulate 21-day patient transitions in a 10-year time horizon. The health and economic outcomes of four first-line strategies (pemetrexed plus cisplatin [PC] alone, PC followed by maintenance with pemetrexed, or initial treatment with gefitinib or icotinib) among patients harboring EGFR mutations were estimated and assessed via indirect comparisons. Costs in the Chinese setting were estimated. The primary outcome was the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed. The icotinib strategy resulted in greater health benefits than the other three strategies in NSCLC patients harboring EGFR mutations. Relative to PC alone, PC followed by pemetrexed maintenance, gefitinib and icotinib resulted in ICERs of $104,657, $28,485 and $19,809 per quality-adjusted life-year gained, respectively. The cost of pemetrexed, the EGFR mutation prevalence and the utility of progression-free survival were factors that had a considerable impact on the model outcomes. When the icotinib Patient Assistance Program was available, the economic outcome of icotinib was more favorable. These results indicate that gene-guided therapy with icotinib might be a more cost-effective treatment option than traditional chemotherapy.

[Correlation between Serum Tumor Markers and Efficacy of First-line EGFR-TKIs in Patients with Advanced Lung Adenocarcinoma]

BACKGROUND

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) significantly improve the survival of advanced lung adenocarcinoma patients harboring EGFR mutation. Limited to the standards of tumor tissue samples and detection methods, still some people can't receive target therapy following genetic guidance. This study was to explore the relevance between serum tumor markers and treatment of EGFR-TKIs.

METHODS

We retrospectively collected the clinical information of advanced lung adenocarcinoma patients harboring EGFR mutation, who received EGFR-TKIs as first-line therapy from June 2009 to June 2014 in Peking University Cancer Hospital, analyzed the relationship between serum tumor markers and efficacy of EGFR-TKIs.

RESULTS

The objective response rate (ORR) was 52.8% and the disease control rate (DCR) was 89.3%. The results showed that, patients with high CEA level before treatment responded better to TKIs (ORR 61.3% vs 35.9%, DCR 95.2% vs 74.4%, P<0.001). Similar phenomena was found in patients with CEA decreased 1 month later (61.5% vs 25%, P=0.002). Progression-free survival (PFS) significantly prolonged in patients with elevated baseline CEA (mPFS 9.8 mo vs 5.9 mo, P=0.027). To the opposite, PFS was significantly shorter in patients with elevated baseline CYFRA21-1 and CA125 (mPFS 9.0 mo vs 11.4 mo, P=0.029; 9.0 mo vs 11.5 mo, P=0.023, respectively). Multivariate analysis showed that Eastern Cooperative Oncology Group (ECOG) score of 0-1, normal baseline CYFRA21-1 and CEA decline predicted longer PFS. The overall survival (OS) was highly associated with elevated CYFRA21-1 and CA125 (median OS 25.1 mo vs 52.5 mo, P=0.003; 22.7 mo vs 55.0 mo, P<0.001, respectively), while independent of CEA.

CONCLUSIONS

High level of baseline CEA and decline 1 month after treatment could predict the efficacy of EGFR-TKIs in patients with advanced lung adenocarcinoma. While high levels of baseline CYFRA21-1 and CA125 indicated shortened survival.