Impact of metastatic status on the prognosis of EGFR mutation-positive non-small cell lung cancer patients treated with first-generation EGFR-tyrosine kinase inhibitors

Top advances of the year: Targeted therapy for lung cancer

The past year has offered significant advancements in the field of non-small cell lung cancer (NSCLC), both in the early and advanced disease settings. The identification of guideline-recommended actionable targets has provided the foundation for developing multiple new therapeutic agents. There has been a focus on developing drugs designed to overcome acquired resistance, a limitation of tyrosine kinase inhibitor-based therapy in lung cancer. In addition, there is an emerging trend toward combination therapies for patients in the first-line setting with the goal of preventing or delaying resistance. Another promising area of development has been the use of antibody-drug conjugates, where there are the initial reports of central nervous system efficacy and activity in patients with genomic alterations. Over the past year, numerous publications and presentations have highlighted multiple therapeutic advances, offering new treatment options for patients with NSCLC. The focus of this review is to summarize the most impactful findings, emphasizing their significance in the evolving treatment landscape for NSCLC. Several landmark trials in lung cancer with practice-changing clinical implications have been presented and published in 2023. This article reviews a selection of these trials as they relate to early and advanced-stage oncogene-driven lung cancer. The ADAURA and ALINA trials, in which targeted therapy given in the adjuvant setting has demonstrated improved clinical outcomes, are reviewed. In the advanced-stage setting, recent trials in the context of specific oncogene drivers are reviewed, including EGFR, ALK, ROS1, RET, ERBB2 (HER2), BRAF, MET exon 14 skipping (METex14), and KRAS alterations. Also discussed are the results of several trials that have evaluated the use of combination therapies and resistance-mechanism agnostic treatment strategies. PLAIN LANGUAGE SUMMARY: Targeted therapy plays an important role for patients with early and advanced-stage non-small cell lung cancer carrying specific genetic alterations. New strategies that combine multiple therapies are now being studied in randomized clinical trials, with the goal of enhancing the effectiveness of targeted therapy for patients with advanced lung cancer.

Risk factors for rib metastases of lung cancer patients with high-uptake rib foci on 99Tcm-MDP SPECT/CT

BACKGROUND

99Tcm-MDP SPECT/CT is widely used to diagnose early bone metastasis. Ribs are high-risk bone metastasis sites, while few study is related to ribs. The study is to investigate the risk factors of rib metastases in lung cancer patients.

METHODS

We retrospectively analyzed the patients' clinical characteristics and SPECT/CT imaging features. The patients were divided into a rib metastasis group (108 cases) and a non-rib metastasis group (103 cases).

RESULTS

In 211 patients, rib metastases were closely related to tumor markers, T stage, N stage, clinical staging, lymph node (LN) involvement, number of rib foci, localization on rib and foci type (P<0.05). In 93 patients with pure rib foci, rib metastases were affected by clinical staging, LN involvement, localization on the rib and primary lung cancer localization (P<0.001, 0.038,<0.001, 0.034, respectively). In 100 patients with a solitary rib focus, rib metastases were associated with clinical staging, localization on the rib, and LN involvement (P<0.001, 0.001, and 0.014, respectively). In all 633 rib foci, localization on the rib was an effective risk factor for rib metastases (P<0.001).

CONCLUSIONS

Patients with increased tumor markers, stage IV lung adenocarcinoma and multiple rib foci located ipsilaterally with the primary lung tumor, or rib foci accompanied other bone foci are more likely to develop rib metastasis. Patients with pure rib foci or a solitary rib focus, especially in the anterior rib with negative LN involvement, have a low probability of rib metastasis.

Prognostic value of venous thromboembolism in patients with advanced pancreatic cancer: a systematic review and meta-analysis

Objective

This study aimed to investigate the relationship between the incidence of VTE and the prognosis of patients with advanced pancreatic cancer, as there is currently a lack of systematic research on this topic, despite the prevalence of venous thromboembolism (VTE) in patients with pancreatic cancer.

Methods

Databases including PubMed, Embase, Web of Science, and Cochrane Library were searched until April 9, 2023, to identify studies that explored the relationship between VTE and the prognosis of advanced pancreatic cancer. Duplicate publications, studies without full text or sufficient information for data extraction, animal experiments, reviews, and systematic reviews were excluded. The extracted data were analyzed using STATA 15.1.

Results

The pooled results indicated a significant association between the incidence of VTE and poorer overall survival (HR=1.38, 95% CI: 1.24 - 1.53, p < 0.001) and disease-free survival (HR=2.42, 95% CI: 1.94 - 3.04, p < 0.001) among patients with advanced pancreatic cancer. Additionally, early VTE showed a significant impact on overall survival (HR=2.03, 95% CI: 1.33 - 3.12, p = 0.001), whereas late VTE did not demonstrate a significant association with poor overall survival (HR=1.22, 95% CI: 0.96 - 1.54, p = 0.099).

Conclusions

This study found that advanced pancreatic cancer patients with VTE had poorer overall and disease-free survival than those without. Meanwhile, the patients with early VTE had a significantly poorer prognosis, whereas late VTE did not. The findings highlight the importance of timely detection of VTE for patients with advanced pancreatic cancer patients and offer a partial theoretical basis for future clinical endeavors.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023427043, identifier CRD42023427043.

Pre-treatment Neutrophil-to-Lymphocyte Ratio significantly affects progression free survival in positive EGFR mutation advanced lung adenocarcinoma with EGFR-TKI treatment in Bali, Indonesia

Introduction: Today, recommendations about initial Response Evaluation Criteria in Solid Tumor (RECIST) and its frequency still vary, while early diagnosis of progression affects patient's prognosis and subsequent treatment options. Methods: This study aims to examine Progression Free Survival (PFS) of positive EGFR mutations advanced lung adenocarcinoma receiving Tyrosine Kinase Inhibitor (TKI) and factors that influence it. This was an observational study with retrospective cohort design conducted at Prof IGNG Ngoerah Hospital from January to December 2021. Sample was data from Epidermal Growth Factor Receptor (EGFR) positive mutation advanced lung adenocarcinoma patient who were treated with EGFR-TKI at Prof IGNG Ngoerah Hospital, Denpasar, Bali from January 2017 to February 2021. Total sample was 63. Results: Median PFS was 12 months (95% CI 10.28-13.71) and minimum PFS was 3 months. In univariate analysis, Hazard Ration (HR) of older age, smoker, distant metastasis, brain metastasis, increased Neutrophil-to-Lymphocyte Ration (NLR), and exon 21 mutation to shorter PFS was 0.99 (95% CI 0.95-1.02); 1.03 (95% CI 0.57-1.85); 1.45 (95% CI 0.85-2.49); 2.14 (95% CI 1.02-4.49); 1.08 (95% CI 1.03-1.13); and 1.21 (95% CI 0.67-2.18). Multivariate analysis showed only increased NLR affected PFS significantly with HR 1.06 (95% CI 1.007-1.13). Conclusion: Median PFS of EGFR positive mutation advanced lung adenocarcinoma patients who received TKI was 12 months and minimum value was 3 months. Increased age, smoking, distant metastases, brain metastases, and exon 21 mutations were not associated with PFS. NLR significantly affected PFS.

Risk factor analysis of bone metastasis in patients with non-small cell lung cancer

OBJECTIVE

Bone tissue is the most common metastatic location besides lung and liver. 30%~40% of patients with non-small cell lung cancer (NSCLC) will have bone metastasis (BM) in the development of the disease. This study aims to explore the relevant risk factors through multivariate analysis, in order to provide basis for the prevention of BM and bone related events of NSCLC.

METHODS

We analyzed 152 patients, with 67 in BM group and 85 in non-BM group. The general clinical data and laboratory indicators (mainly coagulation function) of patients were compared through univariate and multivarijate analysis. Finally, the independent risk factors of BM in patients with NSCLC were screened out.

RESULTS

The results of univariate analysis show that thrombosis, clinical stage, tumor-node-metastasis (TNM) stage, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (FIB), D-Dimer (D-D), platelet (PLT) and alkaline phosphatase (AKP) are the risk factors of BM in patients with NSCLC (p<0.05). Further multivariate logistic regression analysis suggests that the independent risk factors of BM in patients with NSCLC are clinical stage III-IV, TNM stage T1-T3, TNM stage N2-N3, FIB, APTT, D-D and AKP (P<0.05).

CONCLUSION

Clinical stage III-IV, TNM stage T1-T3, TNM stage N2-N3, FIB, APTT, D-D and AKP are the independent risk factors of BM in patients with NSCLC. Meanwhile, patients with these risk factors should be screened in time, which is of great significance to prevent bone related events and relieve pain.

High Tumor Mutation Burden Is Associated with Poor Clinical Outcome in EGFR-Mutated Lung Adenocarcinomas Treated with Targeted Therapy

This study aimed to determine the association between TMB and treatment outcomes in patients with epidermal growth factor receptor (EGFR)-mutated lung cancer that were treated with tyrosine kinase inhibitors (TKIs). The TMB was assessed using a 409-gene targeted next-generation sequencing panel. We compared the response rate (RR), progression-free survival (PFS), overall survival (OS), and frequency of secondary T790M mutations among the different TMB groups. The median TMB of the study population (n = 88) was 3.36/megabases. We divided 52 (59%) and 36 (41%) patients into the low and high TMB groups, respectively. A high TMB level was significantly associated with liver metastasis and more advanced stage (all p < 0.05). RR was significantly lower in the high TMB group than that of the low TMB group (50.0% vs. 80.7%, all p = 0.0384). In multivariate analysis, high TMB was independently associated with a shorter PFS (hazard ratio [HR] = 1.80, p = 0.0427) and shorter OS (HR = 2.05, p = 0.0397) than that of the low TMB group. Further, high TMB was independently associated with decreased T790M mutation development. These results suggest that high TMB may be a predictive biomarker for adverse treatment outcomes and represent a patients’ subgroup warranting tailored therapeutic approaches.

Efficacy of osimertinib in epidermal growth factor receptor-mutated non-small-cell lung cancer patients with pleural effusion

Background

Osimertinib is a standard first-line treatment for advanced non-small-cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR) mutations. Although malignant pleural effusion (PE) is a common clinical problem in NSCLC, information about the efficacy of osimertinib in patients with PE is limited, especially regarding its efficacy in EGFR T790M-negative patients with PE remains unclear.

Methods

We retrospectively reviewed the medical records of patients with NSCLC harboring EGFR mutations who were treated with osimertinib in our institution between May 2016 and December 2020.

Results

A total of 63 patients with EGFR mutated NSCLC were treated with osimertinib; 33 (12 with PE) had no EGFR T790M mutation, while 30 (12 with PE) had EGFR T790M mutation. In EGFR T790M-negative NSCLC, the progression-free survival (PFS) of the patients with PE was comparable to that of the patients without PE (median PFS 19.8 vs. 19.8 months, p = 0.693). In EGFR T790M- positive NSCLC, the PFS and overall survival (OS) of the patients with PE were significantly shorter than those of the patients without PE (median PFS 16.8 vs. 8.3 months, p = 0.003; median OS 44.9 vs. 14.2 months, p = 0.007). In the multivariate analysis, the presence of PE was independently associated with shorter PFS and OS in EGFR T790M-positive NSCLC patients, but not EGFR T790M-negative patients.

Conclusions

These data suggest the efficacy of osimertinib may differ between EGFR T790M-positive and -negative NSCLC patients with PE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09701-2.

Sequence-dependent synergistic effect of aumolertinib-pemetrexed combined therapy on EGFR-mutant non-small-cell lung carcinoma with pre-clinical and clinical evidence

BACKGROUND

Inevitably developed resistance of the third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) limited its clinical benefit on non-small cell lung cancer (NSCLC). Upfront combination therapy is promising to prevent this resistance. Compelling clinical evidence indicated the failure of third-generation EGFR TKIs combined with either immunotherapy or antiangiogenic agents. In comparison, combined treatment of third-generation EGFR TKIs and chemotherapy might be a favorable choice. Herein, we systematically analyzed and compared the effects of pemetrexed and a novel third-generation EGFR TKI aumolertinib combined in different sequences, subsequently revealed the potential mechanisms and proved the optimal combination schedule with clinical retrospective study.

METHODS

Three combination schedules involving pemetrexed and aumolertinib in different sequences were developed. Their inhibition effects on cell proliferation and metastasis were firstly compared upon three human NSCLC cell lines in vitro, by cell counting kit-8, colony formation, wound healing and transwell assays respectively. Further evaluation in vivo was proceeded upon H1975 and HCC827 xenograft model. Gene and protein expression were detected by Q-PCR and western blot. Drug concentration was determined by LC-MS/MS. VEGF secretion was determined by ELISA. Tumor vessel was visualized by immunofluorescence. Lastly, a clinical retrospective study was raised with 65 patients' data.

RESULTS

The combination of pemetrexed and aumolertinib exhibited a sequence-dependent and EGFR mutant-dependent synergistic effect in vitro and in vivo. Only treatment with aumolertinib following pemetrexed (P-A) exhibited synergistic effect with stronger anti-tumor growth and anti-metastasis ability than monotherapy and also other combination sequences. This synergism could exclusively be observed in H1975 and HCC827 but not A549. Pathway analysis showed that P-A significantly enhanced the suppression of EGFR pathway. In addition, our results intriguingly found an obvious reduction of VEGF secretion and the accompanying normalization of the intratumor vessel, consequently increasing intratumoral accumulation of pemetrexed in P-A group. Finally, the clinical retrospective study verified the synergistic effect of P-A combination by significantly superior tumor response than aumolertinib monotherapy.

CONCLUSION

Aumolertinib-pemetrexed combined therapy is promising for EGFR mutant NSCLC but only in right administration sequence. P-A could become an advantageous combination strategy in clinical with synergistic inhibition of tumor growth and metastasis.

ADAURA: The Splash of Osimertinib in Adjuvant EGFR-Mutant Non-small Cell Lung Cancer

The introduction of tyrosine kinase inhibitors (TKI) for the treatment of metastatic non-small cell lung cancer (NSCLC) harbouring sensitizing epidermal growth factor receptor (EGFR) gene mutations revolutionized the diagnostic and treatment algorithm of this subset of patients almost two decades ago. Since then, a number of trials have evaluated the role of TKI therapy in early-stage disease, with encouraging disease-free survival (DFS) results but lack of a survival advantage. ADAURA, a phase III trial evaluating 3 years of adjuvant osimertinib versus placebo in patients harbouring EGFR mutations with completely resected stage IB–IIIA NSCLC, recently reported a profound DFS benefit (hazard ratio 0.21), favourable quality of life and reduction in the risk of brain metastases. These results led to osimertinib’s fast track approval by the US Food and Drug Administration, with this drug thus becoming the first EGFR-TKI approved for the treatment of early-stage disease. However, the key endpoint of overall survival remains immature and questions around indication (i.e. stage, need for adjuvant chemotherapy), optimal treatment duration, biomarkers of response and cost-effectiveness remain to be answered. In this article, we critically appraise the findings of ADAURA and discuss future challenges.

Prognostic Impact of Pleural Effusion in Patients with Malignancy: A Systematic Review and Meta-Analysis

The exact role of pleural effusion in the prognosis of cancer patients remains unclear. We aimed to systematically review the prognostic value of pleural effusion in patients with cancer. We performed a systematic review and meta‐analysis with a systematic literature search. All cohort studies with available overall survival (OS) and progression‐free survival (PFS) results for patients with cancer with or without pleural effusion were included. The Mantel–Haenszel method was used to calculate the pooled hazard ratios (HRs) and 95% confidence intervals (CIs). Heterogeneity and publication bias were examined. Subgroup analysis and sensitivity analysis were performed. A total of 47 studies with 146,117 patients were included in the analysis. For OS, pleural effusion was a prognostic factor associated with a poor prognosis for patients with cancer (HR, 1.58, 95% CI, 1.43–1.75; I² 94.8%). In the subgroup analysis, pleural effusion was a prognostic factor associated with poor survival for patients with lung cancer (HR, 1.44, 95% CI, 1.35–1.54; I² 60.8%), hematological cancer (HR, 2.79, 95% CI, 1.63–4.77; I² 29.4%) and other types of cancer (HR, 2.08, 95% CI, 1.43–3.01; I² 55.1%). For PFS, pleural effusion was a prognostic factor associated with a poor prognosis for patients with cancer (HR, 1.61, 95% CI, 1.28–2.03; I² 42.9%). We also observed that massive pleural effusion was a prognostic factor associated with a poorer prognosis compared to minimal pleural effusion. Pleural effusion had prognostic value in both OS and PFS of patients with cancer, except for patients with malignant pleural mesothelioma, regardless of whether the malignant effusion was confirmed histologically or cytologically. However, future evidence of other pleural effusion characteristics is still needed.

Advancing Treatment of Bone Metastases through Novel Translational Approaches Targeting the Bone Microenvironment

Bone metastases represent a lethal condition that frequently occurs in solid tumors such as prostate, breast, lung, and renal cell carcinomas, and increase the risk of skeletal-related events (SREs) including pain, pathologic fractures, and spinal cord compression. This unique metastatic niche consists of a multicellular complex that cancer cells co-opt to engender bone remodeling, immune suppression, and stromal-mediated therapeutic resistance. This review comprehensively discusses clinical challenges of bone metastases, novel preclinical models of the bone and bone marrow microenviroment, and crucial signaling pathways active in bone homeostasis and metastatic niche. These studies establish the context to summarize the current state of investigational agents targeting BM, and approaches to improve BM-targeting therapies. Finally, we discuss opportunities to advance research in bone and bone marrow microenvironments by increasing complexity of humanized preclinical models and fostering interdisciplinary collaborations to translational research in this challenging metastatic niche.

An RFC4/Notch1 signaling feedback loop promotes NSCLC metastasis and stemness

Notch signaling represents a key mechanism mediating cancer metastasis and stemness. To understand how Notch signaling is overactivated to couple tumor metastasis and self-renewal in NSCLC cells, we performed the current study and showed that RFC4, a DNA replication factor amplified in more than 40% of NSCLC tissues, directly binds to the Notch1 intracellular domain (NICD1) to competitively abrogate CDK8/FBXW7-mediated degradation of NICD1. Moreover, RFC4 is a functional transcriptional target gene of Notch1 signaling, forming a positive feedback loop between high RFC4 and NICD1 levels and sustained overactivation of Notch signaling, which not only leads to NSCLC tumorigenicity and metastasis but also confers NSCLC cell resistance to treatment with the clinically tested drug DAPT against NICD1 synthesis. Furthermore, together with our study, analysis of two public datasets involving more than 1500 NSCLC patients showed that RFC4 gene amplification, and high RFC4 and NICD1 levels were tightly correlated with NSCLC metastasis, progression and poor patient prognosis. Therefore, our study characterizes the pivotal roles of the positive feedback loop between RFC4 and NICD1 in coupling NSCLC metastasis and stemness properties and suggests its therapeutic and diagnostic/prognostic potential for NSCLC therapy.

The Prognostic Value of Baseline Distant Metastasis in Icotinib-Treated Patients with EGFR-Mutated Stage IV Non-Small Cell Lung Cancer

Purpose

Several studies have revealed the prognostic value distant metastasis in non-small-cell lung cancer (NSCLC) patients receiving first-line epidermal growth factor receptor (EGFR) inhibitors. However, the question of whether the specific metastatic site could predict survival outcomes remain elusive. This study evaluated the prognostic value of specific metastatic site at diagnosis in first-line icotinib-treated patients with EGFR-mutated advanced NSCLC.

Methods

A total of 216 patients with EGFR-mutated stage IV NSCLC who received first-line icotinib treatment were retrospectively enrolled. The associations between the presence of distant metastasis to certain organs at diagnosis and survival outcomes were analyzed.

Patients and methods

The presence of distant metastases was not associated with progression-free survival. Patients with liver metastasis showed a significantly shorter OS than those without liver metastasis (14.6m vs 33.0m, p=0.024). Patients with brain metastasis showed a marginally shorter OS than those without brain metastasis (26.5m vs 33.8m, p=0.051). Patients with lung metastasis showed a significantly longer OS than those without lung metastasis (36.0m vs 28.6m, p=0.038). Multivariable Cox regression analysis showed the presence of liver metastasis (HR [hazard ratio]: 2.265, 95% CI [confidence interval]: 1.239-4.139, p=0.008) and brain metastasis (HR: 1.493, 95% CI: 1.012-2.202, p=0.043) were independent predictors for unfavorable OS, while lung metastasis (HR: 0.669, 95% CI: 0.460-0.971, p=0.034) was an independent predictor for favorable OS.

Conclusion

The presence of liver and brain metastasis predicted unfavorable OS, while the presence of lung metastasis predicted favorable OS in first-line icotinib-treated patients with EGFR-mutated stage IV NSCLC.

The incidence, risk factors and predictive nomograms for early death among patients with stage IV gastric cancer: a population-based study

Background

Although advances in the treatment of stage IV gastric cancer (GC) patients, some patients were observed to die within 3 months of initial diagnosis. The present study aimed to explore the early mortality and risk factors for stage IV GC and further develop nomograms.

Methods

A total of 2,174 eligible stage IV GC patients were selected from the Surveillance, Epidemiology, and End Results database. Logistic regression analyses were used to determine the risk factors and develop the nomograms to predict all-cause early death and cancer-specific early death. The predictive performance of the nomograms was assessed by receiver operating characteristic curves (ROC), calibration plots and decision curve analyses (DCA) in both training and validation cohorts.

Results

Of 2,174 patients enrolled, 708 died within 3 months of initial diagnosis (n=668 for cancer-specific early death). Early mortality remained stable from 2010-2015. Non-Asian or Pacific Islander (API) race, poorer differentiation, middle sites of the stomach, no surgery, no radiotherapy, no chemotherapy, lung metastases and liver metastases were associated with high risk of both all-causes early death and cancer-specific early death. The nomograms constructed based on these factors showed favorable sensitivity, with the area under the ROC range of 0.816-0.847. The calibration curves and DCAs also exhibited adequate fit and ideal net benefit in prediction and clinical application.

Conclusions

Approximately one-third of stage IV GC patients experienced early death. These associated risk factors and predictive nomograms may help clinicians identify the patients at high risk of early death and be the reference for treatment choices.

The Co-Expression of Programmed Death-Ligand 1 (PD-L1) in Untreated EGFR-Mutated Metastatic Lung Adenocarcinoma

Epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) is the standard first-line therapy for metastatic lung adenocarcinoma harboring sensitive EGFR mutations. Tumor surface programmed death-ligand 1 (PD-L1) is expressed in some metastatic EGFR-mutated lung adenocarcinoma, but its impact on the efficacy of EGFR-TKIs is unclear. We retrospectively investigated 117 untreated metastatic lung EGFR mutated adenocarcinoma patients with a PD-L1 immunohistochemistry test. The PD-L1 expression level was classified by tumor proportion scores (TPS). Forty-five patients had negative expression (TPS < 1%), 45 had a weak expression (TPS 1–49%), and 27 had a strong expression (≥50%). All patients recruited in this study received EGFR-TKIs as a first-line therapy. No significant differences were observed for objective response rates (68.9% versus 62.2% versus 73.1%, p = 0.807) and median time to treatment failure (TTF) (12.17 versus 13.17 versus 11.0 months, p = 0.443) of first-line EGFR-TKIS among the three groups of patients (negative versus weak versus strong). The median overall survival was 21.27 versus 20.63 versus 19.43 months among the three groups of patients (p = 0.77). Our results demonstrated that PD-L1 did not affect the efficacy of first-line EGFR-TKIs in metastatic EGFR mutated lung adenocarcinoma. Thus, EGFR-TKIs are suggested as the preferred clinical therapy for these patients, despite their PD-L1 levels.

Epidermal Growth Factor Receptor (EGFR) Pathway, Yes-Associated Protein (YAP) and the Regulation of Programmed Death-Ligand 1 (PD-L1) in Non-Small Cell Lung Cancer (NSCLC)

The epidermal growth factor receptor (EGFR) pathway is a well-studied oncogenic pathway in human non-small cell lung cancer (NSCLC). A subset of advanced NSCLC patients (15–55%) have EGFR-driven mutations and benefit from treatment with EGFR-tyrosine kinase inhibitors (TKIs). Immune checkpoint inhibitors (ICIs) targeting the PD-1/PDL-1 axis are a new anti-cancer therapy for metastatic NSCLC. The anti-PD-1/PDL-1 ICIs showed promising efficacy (~30% response rate) and improved the survival of patients with metastatic NSCLC, but the role of anti-PD-1/PDL-1 ICIs for EGFR mutant NSCLC is not clear. YAP (yes-associated protein) is the main mediator of the Hippo pathway and has been identified as promoting cancer progression, drug resistance, and metastasis in NSCLC. Here, we review recent studies that examined the correlation between the EGFR, YAP pathways, and PD-L1 and demonstrate the mechanism by which EGFR and YAP regulate PD-L1 expression in human NSCLC. About 50% of EGFR mutant NSCLC patients acquire resistance to EGFR-TKIs without known targetable secondary mutations. Targeting YAP therapy is suggested as a potential treatment for NSCLC with acquired resistance to EGFR-TKIs. Future work should focus on the efficacy of YAP inhibitors in combination with immune checkpoint PD-L1/PD-1 blockade in EGFR mutant NSCLC without targetable resistant mutations.

Cucurbitacin E inhibits the Yes‑associated protein signaling pathway and suppresses brain metastasis of human non‑small cell lung cancer in a murine model

Human non-small cell lung cancer (NSCLC) is associated with an extremely poor prognosis especially for the 40% of patients who develop brain metastasis, and few treatment strategies exist. Cucurbitacin E (CuE), an oxygenated tetracyclic triterpenoid isolated from plants particularly of the family Cucurbitaceae, has shown anti-tumorigenic properties in several types of cancer, yet the mechanism remains unclear. Yes-associated protein (YAP), a main mediator of the Hippo signaling pathway, promotes tumorigenesis, drug resistance and metastasis in human NSCLC. The present study was designed to ascertain whether CuE inhibits YAP and its downstream gene expression in the human NSCLC cell lines H2030-BrM3 (K-ras^G12C mutation) and PC9-BrM3 (EGFR^Δexon19 mutation), which have high potential for brain metastasis. The efficacy of CuE in suppressing brain metastasis of H2030-BrM3 cells in a murine model was also investigated. It was found that after CuE treatment in H2030-BrM3 and PC9-BrM3 cells, YAP protein expression was decreased, and YAP signaling GTIIC reporter activity and expression of the downstream genes CTGF and CYR61 were significantly (P<0.01) decreased. CuE treatment also reduced the migration and invasion abilities of the H2030-BrM3 and PC9-BrM3 cells. Finally, our in vivo study showed that CuE treatment (0.2 mg/kg) suppressed H2030-BrM3 cell brain metastasis and that mice treated with CuE survived longer than the control mice treated with 10% DMSO (P=0.02). The present study is the first to demonstrate that CuE treatment inhibits YAP and the signaling downstream gene expression in human NSCLC in vitro, and suppresses brain metastasis of NSCLC in a murine model. More studies to verify the promising efficacy of CuE in inhibiting brain metastasis of NSCLC and various other cancers may be warranted.

First-line afatinib for the treatment of EGFR mutation-positive non-small-cell lung cancer in the 'real-world' clinical setting

Afatinib is an ErbB family blocker that is approved for the treatment of epidermal growth factor receptor (EGFR) mutation-positive non-small-cell lung cancer (NSCLC). Pivotal randomized clinical studies demonstrated that afatinib significantly prolonged progression-free survival compared with platinum-based chemotherapy (LUX-Lung 3, LUX-Lung 6), and with gefitinib (LUX-Lung 7), with manageable side effects. However, these results were derived from controlled studies conducted in selected patients and are not necessarily representative of real-world use of afatinib. To gain a broader understanding of the effectiveness and safety of first-line afatinib, we have undertaken a literature review of real-world studies that have assessed its use in a variety of patient populations. We focused on patients with uncommon EGFR mutations, brain metastases, or those of advanced age, as these patients are often excluded from clinical studies but are regularly seen in routine clinical practice. The available real-world studies suggest that afatinib has clinical activity, and is tolerable, in diverse patient populations in an everyday clinical practice setting. Moreover, consistent with LUX-Lung 7, several real-world comparative studies indicate that afatinib might confer better efficacy than first-generation EGFR tyrosine kinase inhibitors. Tolerability-guided dose adjustment, undertaken in 21-68% of patients in clinical practice, did not appear to reduce the efficacy of afatinib. Taken together, these findings provide further support for the use of afatinib as a treatment option in patients with EGFR mutation-positive NSCLC.

Prognostic impact of pleural effusion in EGFR-mutant non-small cell lung cancer patients without brain metastasis

Background

In epidermal growth factor receptor (EGFR)‐mutant non‐small cell lung cancer (NSCLC), brain metastasis is known as a poor prognosis factor. However, prognostic factors in the patients without brain metastasis remain unclear. In this study, we aimed to clarify the differences between metastatic site and prognosis in common EGFR‐mutant NSCLC patients without brain metastasis.

Methods

Chemotherapy‐naïve, advanced EGFR‐mutant NSCLC patients without brain metastasis diagnosed between January 2010 and March 2016 were enrolled. We evaluated prognosis according to the presence or absence of bone metastases, liver metastasis, and pleural effusion.

Results

A total of 50 EGFR‐mutant NSCLC patients without brain metastasis were enrolled. The median progression‐free survival and overall survival were significantly shorter in patients with pleural effusion than in those patients without (progression‐free survival 7.0 months, 95% confidence interval [CI] 3.7–13.0 vs. 13.0 months, 95% CI 9.1–21.7, hazard ratio [HR] 2.29, 95% CI 1.11–4.73, P = 0.020; overall survival 19.5 months, 95% CI 5.7–28.8 vs. 55.3 months, 95% CI 24.0–not evaluable, HR 3.00, 95% CI 1.35–6.68, P = 0.005). Pleural effusion was an independent factor of poor prognosis for progression‐free survival (HR 3.44, 95% CI 1.50–7.88, P = 0.003) and overall survival (HR 2.34, 95% CI 1.00–5.44, P = 0.049).

Conclusion

Pleural effusion might be a poor prognosis factor for advanced EGFR‐mutant NSCLC patients without brain metastasis treated with first‐generation EGFR‐tyrosine kinase inhibitors. Further precision medicine according to the metastatic site is required.

[Risk Factors of Non-small Cell Lung Cancer with Bone Metastasis after Therapy]

背景与目的

肺癌目前是死亡率最高的肿瘤, 非小细胞肺癌(non-small cell lung cancer, NSCLC)患者在手术后通常会发生远处转移, 如骨转移、脑转移、肺转移等。本研究旨在探究NSCLC患者术后发生骨转移的危险因素。

方法

选择本院于2009年5月-2011年5月确诊收治的NSCLC患者176例, 按照是否发生骨转移将患者分为两组, 即骨转移组和无骨转移组。对比两组患者的一般临床病理资料, 并通过多因素分析对比发生骨转移的独立危险因素。

结果

NSCLC患者的一般临床病理资料中血栓与否, 肿瘤-淋巴结-转移(tumor-node-metastasis, TNM)分期与是否发生骨转移关系密切, 有统计学意义(均P < 0.01);在两组患者的凝血功能指标中发现凝血酶原时间、活化部分凝血酶活酶时间、纤维蛋白原、凝血酶时间、血小板计数、D-二聚体以及碱性磷酸酶之间存在明显的差异性, 有统计学意义(均P < 0.05);Logistic回归分析发现纤维蛋白原、碱性磷酸酶、T4期、N3期和D-二聚体为NSCLC患者发生骨转移的独立危险因素。

结论

纤维蛋白原、活化部分凝血酶活酶时间、碱性磷酸酶、T3期、N2期和D-二聚体为NSCLC患者发生骨转移的独立危险因素。

Serum peptide expression and treatment responses in patients with advanced non-small-cell lung cancer

Epidermal growth factor receptor (EGFR) mutation is an important predictor for response to personalized treatments of patients with advanced non-small-cell lung cancer (NSCLC). However its usage is limited due to the difficult of obtaining tissue specimens. A novel prediction system using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has been reported to be a perspective tool in European countries to identify patients who are likely to benefit from EGFR tyrosine kinase inhibitor (TKI) treatment. In the present study, MALDI-TOF MS was used on pretreatment serum samples of patients with advanced non-small-cell lung cancer to discriminate the spectra between disease control and disease progression groups in one cohort of Chinese patients. The candidate features for classification were subsequently validated in a blinded fashion in another set of patients. The correlation between plasma EGFR mutation status and the intensities of representative spectra for classification was evaluated. A total of 103 patients that were treated with EGFR-TKIs were included. It was determined that 8 polypeptides peaks were significant different between the disease control and disease progression group. A total of 6 polypeptides were established in the classification algorithm. The sensitivity of the algorithm to predict treatment responses was 76.2% (16/21) and the specificity was 81.8% (18/22). The accuracy rate of the algorithm was 79.1% (34/43). A total of 3 polypeptides were significantly correlated with EGFR mutations (P=0.04, P=0.03 and P=0.04, respectively). The present study confirmed that MALDI-TOF MS analysis can be used to predict responses to EGFR-TKI treatment of the Asian population where the EGFR mutation status differs from the European population. Furthermore, the expression intensities of the three polypeptides in the classification model were associated with EGFR mutation.