Application of conditional probability analysis to distant metastases from lung cancer

Clinicopathological significance of mutation profile detected by next generation sequencing in different metastatic organs of non-small cell lung cancers

BACKGROUND

The primary tumor and it's metastases show heterogeneity in molecular studies for targeted therapies in Non-Small Cell Lung Cancer(NSCLC), the leading cause of cancer-related deaths worldwide. The study aimed to identify somatic mutations in biopsies from NSCLC patients' metastatic organs using Next-Generation Sequencing(NGS) and examine their association with clinicopathological parameters.

MATERIALS AND METHODS

The study included 128 NSCLC patients and, NGS was performed on tumor biopsies from different metastatic organs at Molecular Pathology laboratory of the Department of Medical Pathology in Aydın Adnan Menderes University Faculty of Medicine. The age, gender, histopathological diagnoses, metastatic organs, smoking and mutation status were all recorded, along with the analysis results of 72 genes and 4149 primers in the panel of the NGS system.

RESULTS

53.9 % of the cases had a history of smoking and patients with brain metastases had a higher smoking rate(p=0.000). The most common occurrence(39.8 %) was lymph node metastasis, followed by brain(19.5 %). There was a strong correlation between mutation presence and metastasis in the liver(p=0.012), bone(p=0.002), and pleura(p=0.008). Smokers had a higher frequency of KRAS(p=0.000) and TP53(p=0.001) mutations. Brain metastases showed a statistically significant NF1 mutation(p=0.001), while the liver exhibited a significant BRAF mutation(p=0.000). NF1-TP53, PTEN-TP53 and NF1-PTEN were the most common concomitant mutations and, the brain was the most common metastatic organ in which they occurred.

CONCLUSION

Our results suggest prizing assessing detected mutations, in the prediction, follow-up and management of metastases, especially in patients with lung adenocarcinoma. The assessment also needs to consider the tumor's mutation status in metastatic organs. New therapeutic agents targeting NF1 mutations will be available in the future to treat NSCLC, especially in metastases.

Case report: Acute pancreatitis in lung adenocarcinoma with small cell transformation after multiple line targeted therapy

In lung cancer, metastasis to the liver, bones, brain, and adrenal glands is more commonly observed, whereas pancreatic metastasis from lung cancer is relatively rare. We present a case of a patient with an 8-year history of lung adenocarcinoma (LUAD) who was admitted to our institution exhibiting symptoms consistent with acute pancreatitis. Subsequent histopathological examination through puncture confirmed the occurrence of pancreatic metastasis originating from small cell lung cancer (SCLC). During a multidisciplinary team discussion, we reached a consensus in diagnosing the patient with post-transformation small cell carcinoma alongside moderately severe pancreatitis, which was determined to be a consequence of pancreatic metastasis. The patient received a regimen of etoposide and cisplatin chemotherapy. This unique clinical case highlights the importance of further investigating the factors contributing to pancreatic metastasis in patients with lung cancer, as the underlying mechanisms remain unclear. Understanding these exceptional metastatic events is vital in devising effective therapeutic strategies and improving patient prognosis. Our findings emphasize the need for continued surveillance and comprehensive management of lung cancer patients, particularly those with resistant forms of the disease, to promptly identify and address the progression of metastatic events to uncommon sites such as the pancreas.

Integrative bioinformatics analysis reveals ECM and nicotine-related genes in both LUAD and LUSC, but different lung fibrosis-related genes are involved in LUAD and LUSC

There are several bioinformatics studies related to lung cancer, but most of them have mainly focused on either microarray data or RNA-Seq data alone. In this study, we have combined both types of data to identify differentially expressed genes (DEGs) specific to lung cancer subtypes. We obtained six microarray datasets from the GEO and also the expression matrix of LUSC and LUAD from TCGA, which were analyzed by GEO2R tool and GEPIA2, respectively. Enrichment analyses of DEGs were performed using the Enrichr database. Protein module identification was done by MCODE plugin in cytoscape software. We identified 30 LUAD-specific, 17 LUSC-specific, and 17 DEGs shared between LUAD and LUSC. Enrichment analyses revealed that LUSC-specific DEGs are involved in lung fibrosis. In addition, DEGs shared between LUAD and LUSC are involved in extracellular matrix (ECM), nicotine metabolism, and lung fibrosis. We identified lung fibrosis-related genes, including SPP1, MMP9, and CXCL2, involved in both LUAD and LUSC, but SERPINA1 and PLAU genes involved only in LUSC. We also found an important module separately for LUAD-specific, LUSC-specific, and shared DEGs between LUSC and LUAD. S100P, GOLM, AGR2, AK1, TMEM125, SLC2A1, COL1A1, and GHR genes were significantly associated with survival. Our findings suggest that different lung fibrosis-related genes may play roles in LUSC and LUAD. Additionally, nicotine metabolism and ECM remodeling were found to be associated with both LUSC and LUAD, regardless of subtype, emphasizing the role of smoking in the development of lung cancer and ECM in the high aggressiveness and mortality of lung cancer.

Development and validation of a nomogram for predicting the overall survival in non-small cell lung cancer patients with liver metastasis

Background

Among all metastatic lesions in non-small cell lung cancer (NSCLC), liver metastasis (LM) is the most lethal site with a median survival of less than 5 months. Few studies exclusively report on prognostic factors for these unique patients. We aimed to construct and validate a practical model to predict the prognosis of NSCLC patients with LM.

Methods

Cases of NSCLC with LM diagnosed between 2010 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database, and were randomly split into training and validation cohort (7:3). The overall survival (OS) was measured from diagnosis until date of death or last follow-up. Cox regression analyses were performed to identify potential predictors of the model. A nomogram incorporating those independent factors was constructed and validated by the concordance index (C-index) and calibration plots. The decision curve analysis (DCA) and a risk stratification system were used to evaluate its clinical value.

Results

A total of 2,367 cases were selected for analysis and randomized to the training cohort (n=1,677) and the validation cohort (n=690). The patients were mainly male (59.3%), married (83.1%) and White (77.3%). Apart from LM, 54.2%, 26.7%, and 36.7% of patients also present with bone, brain, and lung metastases, respectively. The median follow-up was 4.0 months for all patients and 23 months for alive cases. The median OS was 5 months [interquartile range (IQR), 2-11 months]. Sex, age, race, grade, T stage, bone metastasis, brain metastasis, surgery, and chemotherapy were identified as the independent risk factors of the OS and used to develop the nomogram. The calibration curves exhibited excellent agreement between the predicted and actual survival in both the training and validation set, with a C-index of 0.700 [95% confidence interval (CI): 0.684-0.716] and 0.677 (95% CI: 0.653-0.701), respectively. The DCA and the risk classification system further supported that the prediction model was clinically effective.

Conclusions

This is the first study to build a prediction model for NSCLC patients with LM. It aids in treatment decisions, focused care, and physician-patient communication. The global prospective data is needed to further improve this model.

The metastatic niche formation: focus on extracellular vesicle-mediated dialogue between lung cancer cells and the microenvironment

Lung cancer is the deadliest cancer in the world, with the majority of patients presenting with advanced or metastatic disease at first diagnosis. The lungs are also one of the most common sites of metastasis from lung cancer and other tumors. Understanding the mechanisms that regulate metastasis formation from primary lung cancer and in the lungs is therefore fundamental unmet clinical need. One of the first steps during the establishment of lung cancer metastases includes the formation of the pre-metastatic niche (PMN) at distant organs, which may occur even during the early phases of cancer development. The PMN is established through intricate cross-talk between primary tumor-secreted factors and stromal components at distant sites. Mechanisms controlling primary tumor escape and seeding of distant organs rely on specific properties of tumor cells but are also tightly regulated by interactions with stromal cells at the metastatic niche that finally dictate the success of metastasis establishment. Here, we summarize the mechanisms underlying pre-metastatic niche formation starting from how lung primary tumor cells modulate distant sites through the release of several factors, focusing on Extracellular Vesicles (EVs). In this context, we highlight the role of lung cancer-derived EVs in the modulation of tumor immune escape. Then, we illustrate the complexity of Circulating Tumor Cells (CTCs) that represent the seeds of metastasis and how interactions with stromal and immune cells can help their metastatic dissemination. Finally, we evaluate the contribution of EVs in dictating metastasis development at the PMN through stimulation of proliferation and control of disseminated tumor cell dormancy. Overall, we present an overview of different steps in the lung cancer metastatic cascade, focusing on the EV-mediated interactions between tumor cells and stromal/immune cells.

Liver metastases and the efficacy of immune checkpoint inhibitors in advanced lung cancer: A systematic review and meta-analysis

Background

Liver metastasis is the most common type of lung cancer metastasis, and is a significant prognostic factor in lung cancer. However, the effect of liver metastases on the efficacy of immune checkpoint inhibitors (ICIs) remains inconsistent and controversial. The aim of this study was to explore the relationship between liver metastases and ICI efficacy in patients with advanced lung cancer based on data from randomized controlled trials (RCTs) and observational studies.

Methods

PubMed, EMBASE, Cochrane Library databases, conference proceedings, as well as grey literature websites were searched for eligible studies without language restrict ion. Study quality was assessed using Cochrane tools and the Newcastle–Ottawa Quality Assessment Scale (NOS). Outcomes of interest were overall survival (OS) and progression-free survival (PFS). The difference in efficacy between patients with and without liver metastases was calculated by pooling ratios of hazard ratios (HR), as calculated using the deft approach.

Results

A total of 16 RCTs and 14 observational trials were included. Analyses of RCTs revealed a survival benefit for ICI treatment (i.e., ICI monotherapy, ICI + Chemotherapy, dual ICI therapy and dual ICI + Chemotherapy) versus standard therapies among non-small cell lung cancer (NSCLC) patients with liver metastases (PFS HR, 0.77; 95%CI, 0.61–0.97; OS HR, 0.78; 95%CI, 0.68–0.90). NSCLC patients with liver metastases achieved less PFS benefit and comparable OS benefit from ICI treatment compared with those without liver metastases (ratios of PFS–HRs, 1.19; 95%CI, 1.02–1.39; P=0.029; Ratios of OS–HRs, 1.10; 95%CI, 0.94–1.29; P=0.24). For patients with small cell lung cancer (SCLC), ICI treatment achieved a marginal effect on patients with liver metastases as compared with standard therapies (OS HR, 0.94; 95%CI, 0.73–1.23). SCLC patients with liver metastases benefited less from ICI treatment than patients without liver metastases (ratio of OS–HRs, 1.22; 95%CI, 1.01–1.46; P=0.036). In real-world data analysis, liver metastasis could be used as an independent prognostic risk factor, increasing the risk of death by 21% in lung cancer patients receiving ICI treatment compared with those without liver metastases (OS HR, 1.21; 95%CI, 1.17–1.27; P<0.0001). Subgroup analysis confirmed that this association was not modified by race (Asian vs. Western) or number of treatment lines.

Conclusions

The presence of liver metastases does not significantly influence the OS benefit of ICIs in patients with NSCLC. However, a small amount of data shows that liver metastasis restrains the magnitude of OS benefit in patients with SCLC. Liver metastasis has potential as an independent prognostic risk factor for lung cancer patients receiving ICI treatment in clinical practice.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier (CRD42022306449).

Parotid metastases from primary lung cancer: Case series and systematic review of the features

Most parotid metastases have been reported to come from the head and neck; however, cases metastasized from the lung are extremely rare. Missed diagnoses and misdiagnoses occurred quite a few times. Thus, accurately identifying the clinical features of parotid metastasis of lung cancer is important. However, current studies about this issue are mostly case reports, and little is known about the detailed and systematic aspects. We reported three cases of parotid metastases from lung cancer and then systematically searched similar cases through “Pub-Med” and “Web of Science”. Finally, twenty-three patients were included in the study. Eighty-three percent of which were males, and 19 patients were over 50 years old. In all cases with smoking history mentioned, 93% were smokers. The predominant pathological type was small cell lung cancer (SCLC, 13 patients, 56%). Seventeen combined with other site metastasis, while more than half of which were brain metastases. The survival time ranged from 3months-17years, and as for SCLCs, it was only 3months-40months. It can be concluded that clinical features, such as sex, age, smoking history, pathological types, and metastasis patterns, could provide valuable evidence for diagnosis. The lung seems to be the most common primary site of parotid metastases except for head and neck tumors. The two circumstances, SCLC coexisting with Warthin’s tumor and parotid small cell carcinoma with lung metastasis, should be differentiated from parotid metastasis of lung cancer with caution For cases presented as SCLC, more aggressive strategies, such as chemotherapy with immunotherapy and maintenance therapy, may be more suitable. Due to the greater tendency of brain metastasis in such diseases, whole-brain radiation therapy, stereotactic radiosurgery or prophylactic cranial irradiation should be applied to corresponding patients in time. Additionally, lung cancer parotid metastases may be a marker of poor prognosis.

Distant organ metastasis patterns in lung cancer patients with pancreatic metastasis - a cluster analysis

INTRODUCTION

Pancreatic metastasis of lung cancer is rare, but the narrowing or obstruction of the biliary tract from pancreatic metastases limits the choice of antitumour agents. Lung cancer patients with pancreatic metastasis often have metastasis of other organs. For these patients, however, no studies have been conducted to evaluate distant metastasis sites as metastasis patterns. This study aims to assess whether these patients have specific metastasis patterns at the time of diagnosis of lung cancer.

MATERIAL AND METHODS

Data were collected from consecutive lung cancer patients with pancreatic metastasis between April 2012 and March 2022. Metastatic patterns were analysed using cluster analysis in patients with lung cancer.

RESULTS

During the study period, 33 (2.0%) of 1659 patients were diagnosed as having pancreatic metastasis. Of the 33 patients, 28 (84.8%) were male. Eighteen, 14, and one patient had small cell lung cancer (SCLC), lung adenocarcinoma, and large cell neuroendocrine carcinoma, respectively. They were divided into 3 groups by cluster analysis. A statistically significant difference in metastasis frequency was confirmed among these 3 groups (χ² test, p = 0.001).

CONCLUSIONS

In lung cancer patients with pancreatic metastasis, knowledge of the metastatic patterns might be useful for clinical practice in the foreseeable future because it enables more efficient detection of metastatic disease through imaging, and more effective treatment at predicted metastatic sites.

Sites of Synchronous Distant Metastases, Prognosis, and Nomogram for Small Cell Lung Cancer Patients with Bone Metastasis: A Large Cohort Retrospective Study

Background

Small cell lung cancer (SCLC) is often associated with metastases at the time of diagnosis, and the bone is one of the most common sites. The primary aim of this study was to investigate the site of synchronous distant metastasis to other organs in SCLC patients with bone metastasis (BM) and develop a robust predictive prognostic model.

Methods

We retrospectively analyzed the data from patients diagnosed with SCLC with BM in the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox analyses were used to identify independent prognostic factors. A prognostic nomogram was constructed and evaluated by calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA). Then, according to the sites of metastasis and treatment modality, all patients were stratified into several subgroups. The relationship among sites of metastasis, treatment modality, and overall survival was then analyzed.

Results

A total of 6253 patients were included. Independent prognostic factors for SCLC with BM were age, sex, primary site, radiotherapy, chemotherapy, brain metastasis, liver metastasis, and marital status. Calibration, ROC curves, and DCA indicated the excellent performance of the prognostic nomogram. The liver is the most common organ for extraskeletal metastases, followed by the lung. Patients with only BM had the longest mean survival time (9.30 ± 0.31 months). In the subgroup analysis, chemotherapy was an independent prognostic factor for all subgroups. In contrast, radiotherapy showed a positive effect on the prognosis of patients in all subgroups except those with bone and brain metastases and those with bone, lung, and brain metastases.

Conclusions

The prognostic nomogram is expected to be an accurate and personalized tool for predicting the prognosis of SCLC patients with BM. Additionally, the determination of the sites of synchronous extraskeletal metastases and the associated prognosis helps in treatment selection.

Development of metastasis-associated seven gene signature for predicting lung adenocarcinoma prognosis using single-cell RNA sequencing data

Metastasis is the primary cause of lung adenocarcinoma (LUAD)-related death. This study evaluated the metastasis-associated genes (MAGs) in single-cell RNA sequencing (scRNA-seq) data from LUAD tissues and developed a MAG signature to predict overall survival (OS) of LUAD patients. The LUAD scRNA-seq data was downloaded from the Gene Expression Omnibus (GEO) Database and MAGs were identified from LUAD scRNA-seq data. The LUAD transcriptomic and clinical data were obtained from The Cancer Genome Atlas (TCGA). Cox and LASSO regression analyses were performed to identify differentially expressed MAGs (DEMAGs) with prognostic value that were then used to construct a MAG signature and MAG-nomogram model. Finally, a functional enrichment analysis was performed via Gene Set Enrichment Analysis (GSEA). 414 MAGs and 22 prognostic DEMAGs were revealed in the study. Multivariate Cox proportional hazards regression analysis was utilized to construct a 7-MAG signature for predicting the OS of LUAD patients. Patients with high risk scores had a significantly worse OS than those with low risk scores in the training group (n = 236), and the 7-MAG signature was successfully confirmed in the testing group (n = 232) and the entire TCGA-LUAD cohort (n = 468). Furthermore, univariate and multivariate Cox regression suggested that the 7-MAG signature was an independent prognostic indicator. Additionally, based on the 7-MAG signature, a nomogram was established that could more intuitively help to predict the OS of LUAD patients. The GSEA revealed the underlying molecular mechanisms of the 7-MAG signature in LUAD metastasis. In conclusion, a 7-MAG signature was developed based on LUAD scRNA-seq data that could effectively predict LUAD patient prognosis and provide novel insights for therapeutic targets and the potential molecular mechanism of metastatic LUAD.

The role of percutaneous CT-guided biopsy of an adrenal lesion in patients with known or suspected lung cancer

PURPOSE

To determine the sensitivity, specificity, and complication rate of percutaneous adrenal biopsy in patients with known or suspected lung cancer.

METHODS

This study was approved by the Institutional Review Board at our institution as a retrospective analysis; therefore, the need for informed consent was waived. All percutaneous adrenal biopsies performed between April 1993 and May 2019 were reviewed. 357 of 582 biopsies were performed on 343 patients with known or suspected lung cancer (M:F 164:179; mean age 66 years). The biopsy results were classified into malignant, benign, or non-diagnostic. The final diagnosis was established by pathology (biopsy and/or surgical resection) or imaging follow-up on CT for at least 12 months following the biopsy. Patients with less than 12 months follow-up were excluded (n = 44). Complications were recorded.

RESULTS

The final diagnosis was metastatic lung cancer in 235 cases (77.8%), metastasis from an extrapulmonary primary in 2 cases (0.7%), pheochromocytoma in 2 cases (0.7%), and benign lesions in 63 cases (20.9%). Percutaneous adrenal gland biopsy had a sensitivity of 97% and specificity of 100% for lung cancer metastases. The non-diagnostic rate was 0.6%. Larger lesions were more likely to be malignant (p = 0.0000) and to be correctly classified as a lung metastasis (p = 0.025). The incidence of minor complications was 1.1%. There were no major complications.

CONCLUSION

Over 20% of adrenal lesions in patients with known or suspected lung cancer were not related to lung cancer. Percutaneous adrenal gland biopsy is a safe procedure, with high sensitivity and specificity for lung cancer metastases.

Impact of different patterns of metastasis in non-small-cell lung cancer patients

Aim: The aim of this study was to evaluate the frequency and median time for the development of metastases and prognosis by metastatic site after the diagnosis of non-small-cell lung cancer (NSCLC). Patients & methods: This cohort study was conducted with 1096 patients diagnosed with NSCLC between 2006 and 2014. Results: The most prevalent site of NSCLC metastases was the respiratory system. The nervous and adrenal systems presented the longest median time for the development of metastases. The 6-month survival varied from 68.2% for liver to 79.9% for the nervous system. Bone metastases were associated with a higher risk of death. Conclusion: The respiratory system was the most prevalent site of metastases. OS and risk of death varied according to the metastatic site.

Hyperattenuating adrenal lesions in lung cancer: biphasic CT with unenhanced and 1-min enhanced images reliably predicts benign lesions

OBJECTIVES

To investigate usefulness of biphasic computed tomography (CT) in characterizing hyperattenuating adrenal lesions in lung cancer.

METHODS

This retrospective study included 239 patients with lung cancer who underwent adrenal CT for hyperattenuating (> 10 Hounsfield unit) adrenal lesions. Adrenal CT comprised unenhanced and 1-min and 15-min enhanced images. We dichotomized adrenal lesions depending on benign or metastatic lesions. Reference standard for benignity was histologic confirmation or ≥ 6-month stability on follow-up CT. Two independent readers analyzed absolute (APW) or relative percentage wash-out (RPW) using triphasic CT, and enhancement ratio (ER) or percentage wash-in (PWI) using biphasic CT (i.e., unenhanced and 1-min enhanced CT). Criteria for benignity were as follows: criteria 1, (a) APW ≥ 60% or (b) RPW ≥ 40%, and criteria 2, (a) ER > 3 and (b) PWI > 200%. We analyzed area under the curve (AUC) and accuracy for benignity, and inter-reader agreement.

RESULTS

Proportion of benign adrenal lesion was 71.1% (170/239). For criteria 1 and 2, AUCs were 0.872 (95% confidence interval [CI], 0.822-0.911) and 0.886 (95% CI, 0.838-0.923), respectively, for reader 1 (p = 0.566) and 0.816 (95% CI, 0.761-0.863) and 0.814 (95% CI, 0.759-0.862), respectively, for reader 2 (p = 0.955), and accuracies were 87.9% (210/239) and 86.2% (206/239), respectively, for reader 1 (p = 0.479) and 81.2% (194/239) and 80.3% (192/239), respectively, for reader 2 (p = 0.763). Weighted kappa was 0.725 (95% CI, 0.634-0.816) for criteria 1 and 0.736 (95% CI, 0.649-0.824) for criteria 2.

CONCLUSION

Biphasic CT can reliably characterize hyperattenuating adrenal lesions in patients with lung cancer.

KEY POINTS

• Criteria from biphasic computed tomography (CT) for diagnosing benign adrenal lesions were enhancement ratio of > 3 and percentage wash-in of > 200%. • In the analysis by two independent readers, area under the curve between criteria 1 and 2 was not significantly different (0.872 and 0.886 for reader 1; 0.816 and 0.814, for reader 2; p > 0.05 for each comparison). • Wash-in characteristics from biphasic CT are helpful to predict benign adrenal lesions in lung cancer.

Analysis of bevacizumab treatments and metastatic sites of lung cancer

INTRODUCTION

Liver metastasis has not been sufficiently evaluated in lung cancer so far. We retrospectively analyzed the distant metastasis of Non-squamous non-small cell lung cancer (NSQ-NSCLC), including liver metastasis, and association between prognosis and therapeutic effect of bevacizumab treatment.

PATIENTS AND METHODS

Clinical data were collected from 1954 patients with lung cancer admitted in our hospital between 1st April 2011 and 31 March 2019. Information is extracted from the electronic medical record. Main collection data was the age, gender, smoking history, performance status, histology and driver mutation, distant metastasis site. Efficacy data of treatment including treatment duration and survival time were obtained from medical record, image data and local registry.

RESULTS

Total 366 patients receiving any chemotherapy with NSQ-NSCLC were eligible for this study. Most frequent extrathoracic metastasis is bone (N = 59) followed by brain (37), liver (18), adrenal gland (23), and OS analysis showed liver metastasis was worse prognosis compared to brain and bone metastasis (median OS: 11.6, 18.9, 15.0, respectively). Bevacizumab treatment was tend to have favorable efficacy in patients with each metastatic sites, especially, induced significant longer OS for patients with liver metastasis. CONCLUSION;: Though this study was retrospective study for small sized metastatic patients, the study suggested that liver metastasis was refractory, and that bevacizumab treatment might improve the worse prognosis.

Metastatic sites as predictors in advanced NSCLC treated with PD-1 inhibitors: a systematic review and meta-analysis

BACKGROUND

Programmed cell death protein 1 (PD-1) inhibitors are the first-line treatment for advanced non-small-cell lung cancer (NSCLC) patients. However, their efficacy in metastatic NSCLC patients remains controversial.

AIM OF THE STUDY

The aim of our study was to evaluate the prognosis of advanced metastatic NSCLC patients treated with PD-1 inhibitors, and discuss the predictive effect of metastatic site on the long-term outcome.

METHODS

The Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, and PubMed databases were systematically screened up to February 10, 2020. Twenty-five eligible studies, involving 8,067 patients that assessed the impact of metastatic sites on survival outcome were incorporated in our study. Overall survival (OS) and progression-free survival (PFS) were described as hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

Among the advanced NSCLC patients, the median proportion of brain, liver, bone, and adrenal gland metastases were 21%, 17%, 35%, and 21%, respectively. Patients with metastases to the brain, liver, and bone had worse OS compared to patients without these metastases when treated with PD-1 inhibitors. Similarly, patients with metastasis to the brain and liver were more likely to progress when treated with PD-1 inhibitors. Besides, patients with multiple metastatic sites had worse PFS compared to patients with one metastatic site, while no significant difference was found in terms of OS.

CONCLUSIONS

Based on the findings of our systematic review and meta-analysis, metastatic sites were independent predictors of the survival outcome for advanced NSCLC patients treated with PD-1 inhibitors.

Differential Efficacy of Pembrolizumab According to Metastatic Sites in Patients With PD-L1 Strongly Positive (TPS ≥ 50%) NSCLC

BACKGROUND

Pembrolizumab has shown significantly better efficacy than platinum doublet chemotherapy in patients with programmed cell death ligand 1 (PD-L1) strongly positive (tumor proportion score ≥ 50%) non-small-cell lung cancer (NSCLC). However, the predictors of response to pembrolizumab have not yet been fully elucidated for patients with PD-L1 strongly positive NSCLC.

PATIENTS AND METHODS

We retrospectively analyzed 145 patients who had been treated with pembrolizumab for PD-L1 strongly positive (TPS ≥ 50%) NSCLC without an EGFR (epidermal growth factor receptor) mutation or ALK rearrangement from February 2017 to March 2020. Various clinical characteristics, including Eastern Cooperative Oncology Group performance status, treatment line, PD-L1 expression, C-reactive protein level, neutrophil/lymphocyte ratio, and metastatic sites, and the clinical outcome of pembrolizumab treatment were examined.

RESULTS

Patients with higher PD-L1 expression (≥ 75%; n = 90) had a higher objective response rate (ORR) and longer progression-free survival (PFS) compared with those with lower expression (50%-74%; n = 55; ORR, 51% vs. 33%; P = .0305; median PFS, 13.9 months vs. 5.2 months; P = .0111). In addition, 15 patients with liver metastasis (LM) had a significantly lower ORR and shorter PFS than the 130 patients without LM (ORR, 20% vs. 47%; P = .0468; median PFS, 3.4 months vs. 9.4 months; P = .0018). A multivariate analysis indicated that PD-L1 expression and LM were significant predictors of PFS after pembrolizumab treatment (higher PD-L1 expression: hazard ratio, 0.58; 95% confidence interval, 0.38-0.91; P = .0183; presence of LM: hazard ratio, 2.05; 95% confidence interval, 1.03-3.82; P = .0420).

CONCLUSION

PD-L1 expression and LM status were predictors of the efficacy of pembrolizumab in patients with PD-L1 strongly positive NSCLC.

The Role of the ECM in Lung Cancer Dormancy and Outgrowth

The dissemination of tumor cells to local and distant sites presents a significant challenge in the clinical management of many solid tumors. These cells may remain dormant for months or years before overt metastases are re-awakened. The components of the extracellular matrix, their posttranslational modifications and their associated factors provide mechanical, physical and chemical cues to these disseminated tumor cells. These cues regulate the proliferative and survival capacity of these cells and lay the foundation for their engraftment and colonization. Crosstalk between tumor cells, stromal and immune cells within primary and secondary sites is fundamental to extracellular matrix remodeling that feeds back to regulate tumor cell dormancy and outgrowth. This review will examine the role of the extracellular matrix and its associated factors in establishing a fertile soil from which individual tumor cells and micrometastases establish primary and secondary tumors. We will focus on the role of the lung extracellular matrix in providing the architectural support for local metastases in lung cancer, and distant metastases in many solid tumors. This review will define how the matrix and matrix associated components are collectively regulated by lung epithelial cells, fibroblasts and resident immune cells to orchestrate tumor dormancy and outgrowth in the lung. Recent advances in targeting these lung-resident tumor cell subpopulations to prevent metastatic disease will be discussed. The development of novel matrix-targeted strategies have the potential to significantly reduce the burden of metastatic disease in lung and other solid tumors and significantly improve patient outcome in these diseases.

Factors Associated With Distant Metastasis in EGFR-mutated Non-small Cell Lung Cancer Patients: Logistic Analysis

BACKGROUND/AIM

The aim of this retrospective study was to identify, using logistic analysis, the factors associated with distant metastasis in non-small cell lung cancer patients carrying mutations in epidermal growth factor receptor.

PATIENTS AND METHODS

Patients who were diagnosed with distant metastasis at the time of diagnosis up to their death and during the period from April 2009 to March 2019, were included in this study. Clinical charts and imaging studies were reviewed.

RESULTS

A total of 64 patients during the research period. The factors associated with pleural metastasis were "female" and "no bone metastasis". The factor associated with brain metastasis was "lung metastasis". The factors associated with liver metastasis were "age under 70" and "Exon 19 deletion".

CONCLUSION

Knowing the factors associated with distant metastasis will provide useful information to conduct targeted and efficient imaging studies.

From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC

Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.

Incidence and Risk Factors for Bone Metastasis in Non-Small Cell Lung Cancer

Background: Bone is a frequent site of metastasis from various primary cancers including with Non-Small Cell Lung Cancer. The aim of this study was to investigate the incidence and risk factors for Bone Metastasis in patients with Non-Small Cell Lung Cancer. Methodology: A cohort study was carried out in patients diagnosed with Non-Small Cell Lung Cancer between 2006 and 2014 in a single cancer centre. A descriptive analysis of the population was compiled based on mean ± standard deviation (SD) for continuous variables and percentage (%) for categorical variables. Univariate and multivariate Cox proportional hazards regression analyses were carried out to quantify the relationship between independent variables and the outcome variable (Bone Metastasis). Results: During the study period 1025 patients were diagnosed with Non-Small Cell Lung Cancer. Bone Metastasis was detected in 136 patients (13.2%) with a mean interval between Non-Small Cell Lung Cancer diagnosis and Bone Metastasis of 8.07 months (95% CI: 7.68 8.45). Multivariate analysis revealed that younger age (HR 0.97; 95%CI, 0.95–0.99; p=0.002), adenocarcinoma (HR 1.51; 95%CI, 1.06–2.15; p=0.021) and treatment with chemotherapy, radiotherapy or chemotherapy combined with radiotherapy (HR 3.73; 95%CI, 2.30–6.05; p<0.001) were associated with the occurrence of Bone Metastasis. Conclusion: The incidence of Bone Metastasis was 13.2%. Younger age, histological subtype adenocarcinoma and treatment with chemotherapy, radiotherapy or chemotherapy combined with radiotherapy are independent risk factors for Bone Metastasis.

Lung cancer with spontaneous regression of primary and metastatic sites: A case report

Partial or complete spontaneous cancer regression is a rare phenomenon, particularly in patients with lung cancer. This is the case report of a patient with lung cancer who exhibited spontaneous regression of the primary as well as metastatic lesions, without receiving any treatment. Spontaneous regression commenced within a week of obtaining pathological specimens by transbronchial and percutaneous biopsies from the primary lesion and metastatic lymph nodes of the left side of the neck. The reason for this phenomenon is unknown; however, we hypothesized that there may be an immunological association between the stimulus of the biopsies and the spontaneous regression. This patient should be closely followed up to monitor the clinical course of this unusual case.

Metastatic sites and survival in lung cancer

OBJECTIVES

Population-based data on metastatic sites and survival in site-specific metastases are lacking for lung cancer and for any cancer because most cancer registries do not record metastases. This study uses a novel population-based approach to identify metastases from both death certificates and national inpatient data to describe metastatic pathways in lung cancer patients.

MATERIALS AND METHODS

17,431 deceased lung cancer patients diagnosed 2002-2010 were identified from the nationwide Swedish Cancer Registry, which is based on compulsory reports. The influence of age at diagnosis, sex, and histological subtype on metastatic spread was investigated. Survival in metastatic lung cancer was assessed by histology and metastatic site.

RESULTS

The most frequent metastatic sites were the nervous system, bone, liver, respiratory system, and adrenal gland. Liver (35%) and nervous system (47%) metastases were common in patients with metastases from small cell lung cancer, and bone (39%) and respiratory system (22%) metastases in adenocarcinoma. Women (43% vs. 35%) and younger patients had more metastases to the nervous system. Median survival after diagnosis was 13 months for non-metastatic and five months for metastatic lung cancer. In this novel data, liver metastases conferred the worst prognosis (three months), especially for large cell histology. Bone metastases also featured poor survival, whereas survival in respiratory and nervous system metastases was better.

CONCLUSION

Metastatic sites and survival in metastatic lung cancer is influenced by sex, histological subtype, and age at diagnosis. Liver and bone metastases signal poor survival, compared with nervous system metastases.

Modeling and predicting the occurrence of brain metastasis from lung cancer by Bayesian network: a case study of Taiwan

The Bayesian network (BN) is a promising method for modeling cancer metastasis under uncertainty. BN is graphically represented using bioinformatics variables and can be used to support an informative medical decision/observation by using probabilistic reasoning. In this study, we propose such a BN to describe and predict the occurrence of brain metastasis from lung cancer. A nationwide database containing more than 50,000 cases of cancer patients from 1996 to 2010 in Taiwan was used in this study. The BN topology for studying brain metastasis from lung cancer was rigorously examined by domain experts/doctors. We used three statistical measures, namely, the accuracy, sensitivity, and specificity, to evaluate the performances of the proposed BN model and to compare it with three competitive approaches, namely, naive Bayes (NB), logistic regression (LR) and support vector machine (SVM). Experimental results show that no significant differences are observed in accuracy or specificity among the four models, while the proposed BN outperforms the others in terms of sampled average sensitivity. Moreover the proposed BN has advantages compared with the other approaches in interpreting how brain metastasis develops from lung cancer. It is shown to be easily understood by physicians, to be efficient in modeling non-linear situations, capable of solving stochastic medical problems, and handling situations wherein information are missing in the context of the occurrence of brain metastasis from lung cancer.