Lung cancer screening

Start of an era: circulating cell-free DNA for early detection of cancers

Effective screening modalities are currently available for only a small subset of cancers, and they generally have suboptimal performance with complicated procedures. Therefore, there is an urgent need to develop simple, accurate, and non-invasive methods for early detection of cancers. Genetic and epigenetic alterations in plasma circulating cell-free DNA (cfDNA) have shown the potential to revolutionize methods of early detection of cancers and facilitate subsequent diagnosis to improve survival of patients. The medical interest in cfDNA assays has been inspired by emerging single- and multi-early detection of cancers studies. This review summarizes current technological and clinical advances, in the hopes of providing insights into the development and applications of cfDNA assays in various cancers and clinical scenarios. The key phases of clinical development of biomarkers are highlighted, and the future developments of cfDNA-based liquid biopsies in early detection of cancers are outlined. It is hoped that this study can boost the potential integration of cfDNA-based early detection of cancers into the current clinical workflow.

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Liquid biopsy, characterized by minimal invasiveness and user friendliness, can identify multiple cancers at the early stage and localize the tissue of origin

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The state-of-the-art technology facilitates the application of circulating cell-free DNA (cfDNA) assays in the early detection of cancers

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cfDNA assays are expected to be integrated into the clinical workflow after technological refinement and clinical trial validation

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The development and application strategies of cfDNA assays in various cancers and clinical scenarios can vary, and the harm-and-benefit should be balanced carefully

A Comprehensive Prognostic and Immune Analysis of Ferroptosis-Related Genes Identifies SLC7A11 as a Novel Prognostic Biomarker in Lung Adenocarcinoma

Lung adenocarcinoma (LUAD) is still one of the illnesses with the greatest mortality and morbidity. As a recently identified mode of cellular death, the activation of ferroptosis may promote the effectiveness of antitumor therapies in several types of tumors. However, the expression and clinical significance of Ferroptosis-associated genes in LUAD are still elusive. The RNA sequencing data of LUAD and relevant clinical data were downloaded from The Cancer Genome Atlas (TCGA) datasets. Subsequently, potential prognostic biomarkers were determined by the use of biological information technology. The R software package “ggalluvial” was applied to structure Sanguini diagram. Herein, our team screened 14 dysregulated ferroptosis-associated genes in LUAD. Among them, only four genes were associated with clinical outcome of LUAD patients, including ATP5MC3, FANCD2, GLS2, and SLC7A11. In addition, we found that high SLC7A11 expression predicted an advanced clinical progression in LUAD patients. Additionally, 8 immune checkpoint genes and 7 immune cells for LUAD were recognized to be related to the expression of SLC7A11. KEGG assays indicated that high expression of SLC7A11 might participate in the modulation of intestinal immune network for IgA generation and Staphylococcus aureus infection. Overall, our findings revealed that SLC7A11 might become a potentially diagnostic biomarker and SLC7A11 might serve as an independent prognosis indicator for LUAD.

Identification of Tumor Antigens and Immune Subtypes in Lung Adenocarcinoma for mRNA Vaccine Development

Cancer vaccines are emerging as a viable strategy for cancer treatment. In the current study, we screened for genes associated with the prognosis of patients with lung adenocarcinoma and positively correlated with antigen-presenting cell infiltration and identified KLRG1 and CBFA2T3 as potential tumor antigens for mRNA vaccines in lung adenocarcinoma (LUAD). Further analyses of immune subtypes revealed that patients with early-stage LUAD, high immune cell infiltration, high immune checkpoint expression, and low tumor mutation burden might benefit from mRNA vaccination. Moreover, we identified four biomarkers that can be used to assess mRNA vaccination suitability. We also identified potentially sensitive anti-cancer drugs for populations not suitable for vaccination by means of anti-cancer drug susceptibility prediction. Overall, we provided a new perspective for mRNA vaccine treatment strategies for LUAD and emphasized the importance of precise and personalized treatments.

Application of circulating genetically abnormal cells in the diagnosis of early-stage lung cancer

PURPOSE

Lung cancer is the leading cause of cancer-related death worldwide. The early detection of lung cancer is crucial for the diagnosis of this disease. Therefore, an effective and noninvasive method for the early diagnosis of lung cancer is urgently needed.

METHODS

To evaluate the diagnostic performance of circulating genetically abnormal cells (CACs) in early lung cancer, a total of 63 participants who completed CAC detection by Zhuhai SanMed Biotech Inc. and obtained pathological results from January to December 2020 were included in our study; 50 patients had lung cancer and 13 patients had benign lung disease. The levels of lung cancer-related markers in peripheral blood and the chest computed tomography (CT) imaging characteristics of these patients were collected before pathological acquisition.

RESULTS

The positive rate of CAC was 90.0% in the lung cancer group and 23.1% in the benign lung disease group, and the difference was statistically significant (P < 0.01). The area under the receiver operating characteristic (ROC) curve of CAC was 0.837, the sensitivity was 90%, and the specificity was 76.9%. The area under the ROC curve and sensitivity were both higher than those of the combined or single serum tumor marker test.

CONCLUSIONS

This study preliminarily concludes that the CAC test, as a noninvasive test, has high sensitivity and specificity for the early diagnosis of lung cancer. This test is expected to help with the early detection of disease in lung cancer patients.

The additional value of lung cancer screening program in identifying unrecognized diseases

Background

A systematic examination of low-dose CT (LDCT) scan, beside lung nodules, may disclose the presence of undiagnosed diseases, improving the efficacy and the cost/efficacy of these programs. The study was aimed at evaluating the association between LDCT scan findings and non-oncologic and oncologic diseases.

Methods

The LDCT scan of participants to the “Un Respiro per la vita”^® lung cancer screening program were checked and abnormal findings, beside lung nodules, recorded. First admission to the acute care because of cardiovascular (CD), respiratory (RD) and oncological diseases (OD) in the following three years were retrieved. The association of LDCT scan abnormal findings with CD, RD and OD was assessed through univariable and multivariable logistic regression models.

Results

Mean age of 746 participants was 62 years (SD:5), 62% were male. 11 (1.5%) received a diagnosis of lung cancer. 16.1% participants were admitted to the acute care in the following three years: 8.6% for CD, 4.3% for RD and 5.2% for OD. Valve calcification (OR 2.02, p:0.02) and mucus plugs (OR 3.37, p:0.04) were positively associated with CD, while sub-pleural fibrosis had a protective role (OR 0.47, p:0.01). Lung nodules > 8 mm (OR 5.54, p: < 0.01), tracheal deviation (OR 6.04, p:0.01) and mucus plugs (OR 4.00, p:0.04) were positively associated with OD admissions. Centrilobular emphysema OR for RD admissions was 1.97 (p:0.06).

Conclusions

The observed association between selected LDCT findings and ensuing CD, RD and OD suggests that the information potential of LCDT goes beyond the screening of lung cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01826-1.

Clinical Significance and Immune Landscape of Recurrence-Associated Ferroptosis Signature in Early-Stage Lung Adenocarcinoma

BACKGROUND

The prevalence of patients newly diagnosed with early-stage lung adenocarcinoma (LUAD) is growing alongside significant advances in screening approaches. This study aimed to construct ferroptosis-related gene score (FRGscore) for predicting recurrence, explore immune-molecular characteristics, and determine the benefit of immunotherapy in distinct ferroptosis-based patterns and FRGscore-defined subgroups.

METHODS

A total of 1,085 early-stage LUAD patients from four independent cohorts were included. Consensus clustering analysis was performed using 217 co-expressed FRGs to explore different ferroptosis-mediated patterns. An FRG scoring system was established to predict relapse, quantify ferroptosis-mediated patterns, and evaluate the response to immunotherapy in individual patients based on Lasso-penalized and stepwise Cox regression analyses. Immune landscape involving multiple parameters was further evaluated, stratified by cluster subtypes and FRGscore subgroups.

RESULTS

Two ferroptosis-mediated patterns were identified and verified, which were characterized by significantly distinct prognosis and immune profiles. Analyses of immune characteristics showed that identified ferroptosis patterns were characterized as immune-inflamed phenotype and immune-exhausted phenotype. The FRG scoring model based on 11 FRG-derived signatures panel classified patients into the FRGscore-high and FRGscore-low subgroups. Significantly longer recurrence-free survival (RFS) and overall survival (OS) were observed in the FRGscore-low subgroup. FRGscore-low patients were characterized by higher tumor mutational burden (TMB), immunoscore, immunophenoscore, and PD-L1 expression level and were associated with lower Tumor Immune Dysfunction and Exclusion (TIDE) score, whereas the opposite was observed in FRGscore-high patients. Immune-active pathways were remarkably enriched in the FRGscore-low subgroup. This scoring model remained highly predictive of prognosis across different clinical, molecular, and immune subgroups. Further analysis indicated that FRGscore-low patients exhibited higher response to anti-PD-1/PD-L1 immunotherapy and better clinical benefits based on two independent immunotherapy cohorts.

CONCLUSION

The proposed FRGscore could highly distinguish the recurrence patterns and molecular and immune characteristics and could predict immunotherapy prognosis, potentially representing a powerful prognostic tool for further optimization of individuated treatment and management strategies in early-stage LUAD.

Computer-aided diagnosis system versus conventional reading system in low-dose (< 2 mSv) computed tomography: comparative study for patients at risk of lung cancer

BACKGROUND

Computer-aided diagnosis in low-dose (≤ 3 mSv) computed tomography (CT) is a potential screening tool for lung nodules, with quality interpretation and less inter-observer variability among readers. Therefore, we aimed to determine the screening potential of CT using a radiation dose that does not exceed 2 mSv.

OBJECTIVE

We aimed to compare the diagnostic parameters of low-dose (< 2 mSv) CT interpretation results using a computer-aided diagnosis system for lung cancer screening with those of a conventional reading system used by radiologists.

DESIGN AND SETTING

We conducted a comparative study of chest CT images for lung cancer screening at three private institutions.

METHODS

A database of low-dose (< 2 mSv) chest CT images of patients at risk of lung cancer was viewed with the conventional reading system (301 patients and 226 nodules) or computer-aided diagnosis system without any subsequent radiologist review (944 patients and 1,048 nodules).

RESULTS

The numbers of detected and solid nodules per patient (both P < 0.0001) were higher using the computer-aided diagnosis system than those using the conventional reading system. The nodule size was reported as the maximum size in any plane in the computer-aided diagnosis system. Higher numbers of patients (102 [11%] versus 20 [7%], P = 0.0345) and nodules (154 [15%] versus 17 [8%], P = 0.0035) were diagnosed with cancer using the computer-aided diagnosis system.

CONCLUSIONS

The computer-aided diagnosis system facilitates the diagnosis of cancerous nodules, especially solid nodules, in low-dose (< 2 mSv) CT among patients at risk for lung cancer.

FYB methylation in peripheral blood as a potential marker for the early-stage lung cancer: a case-control study in Chinese population

BACKGROUND

Lung cancer (LC) is the leading cause of cancer-related morbidity and mortality in China. Exploring novel biomarkers for the early detection of LC is important.

MATERIALS AND METHODS

We quantified DNA methylation levels of three CpG sites of FYB gene in peripheral blood in 163 early-stage LC cases (88.3% at stage I) and 187 age- and gender-matched healthy controls. Covariates-adjusted odds ratios (ORs) for -10% methylation were calculated by binary logistic regression.

RESULTS

With multiple testing corrections, hypomethylation of FYB_CpG_4 was significantly associated with LC (OR = 2.04, p = 4.50E-04) even with LC at stage I (OR = 1.41, p = 0.003) without obvious bias between genders, but it mainly affected the subjects older than 55 years (OR = 2.04, p = 0.015). Hypomethylation of FYB_CpG_2 was also associated with LC, but only for the males (OR = 1.76, p = 0.018). FYB_CpG_3 methylation had no association with LC, but interestingly its methylation level in the males was only half of that in the females.

DISCUSSION AND CONCLUSIONS

We proposed a novel association between blood-based abnormal FYB methylation and very early-stage LC. The age- and gender-related DNA methylation patterns also revealed the diversity and precision of epigenetic regulations.

Increased Disparities in Patients Diagnosed with Metastatic Lung Cancer Following Lung CT Screening in the United States

OBJECTIVES

We sought to determine if implementation of low dose computed tomography (LDCT) screening for lung cancer in the United States had led to changes in patients being diagnosed with metastatic lung cancer over time.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Result (SEER) database was utilized to determine the proportion of lung cancers diagnosed as stage I to III and stage IV from 2009-2018. Changes in lung cancer stage distribution were compared in the overall population and by race.

RESULTS

From 2009 to 2018, the proportion of stage I to III lung cancers increased from 52% (51.3%-53.2%) in 2009 to 56% (54.0%-55.8%) in 2018 (P < .001). Correspondingly, the proportion of lung cancers diagnosed in stage IV decreased from 48% (46.8%-48.7%) in 2009 to 45% (44.2%-46.0%) (P < .001) in 2018. For white patients, the proportion increased from 53% (51.6%-53.7%) to 56% (55.1%-57.1%) (P < .001). However, for black patients, no trend was present, with the proportion being 51% (47.9%-53.4%) in 2009 and 52% (49.0%-54.2%) in 2018 (P = .303).

CONCLUSION

Since the implementation of LDCT screening, the proportion of early-stage lung cancers increased in the general population. These changes in stage distribution were not present in black patients.

Global Burden of Respiratory Diseases Attributable to Ambient Particulate Matter Pollution: Findings From the Global Burden of Disease Study 2019

Background: Exposure to ambient particulate matter pollution (APMP) is a global health issue that directly affects the human respiratory system. Thus, we estimated the spatiotemporal trends in the burden of APMP-related respiratory diseases from 1990 to 2019. Methods: Based on the Global Burden of Disease Study 2019, data on the burden of APMP-related respiratory diseases were analyzed by age, sex, cause, and location. Joinpoint regression analysis was used to analyze the temporal trends in the burden of different respiratory diseases over the 30 years. Results: Globally, in 2019, APMP contributed the most to chronic obstructive pulmonary disease (COPD), with 695.1 thousand deaths and 15.4 million disability-adjusted life years (DALYs); however, the corresponding age-standardized death and DALY rates declined from 1990 to 2019. Similarly, although age-standardized death and DALY rates since 1990 decreased by 24% and 40%, respectively, lower respiratory infections (LRIs) still had the second highest number of deaths and DALYs attributable to APMP. This was followed by tracheal, bronchus, and lung (TBL) cancer, which showed increased age-standardized death and DALY rates during the past 30 years and reached 3.78 deaths per 100,000 persons and 84.22 DALYs per 100,000 persons in 2019. Among children aged < 5 years, LRIs had a huge burden attributable to APMP, whereas for older people, COPD was the leading cause of death and DALYs attributable to APMP. The APMP-related burdens of LRIs and COPD were relatively higher among countries with low and low-middle socio-demographic index (SDI), while countries with high-middle SDI showed the highest burden of TBL cancer attributable to APMP. Conclusions: APMP contributed substantially to the global burden of respiratory diseases, posing a significant threat to human health. Effective actions aimed at air pollution can potentially avoid an increase in the PM2.5-associated disease burden, especially in highly polluted areas.

Integrating microRNA expression, miRNA-mRNA regulation network and signal pathway: a novel strategy for lung cancer biomarker discovery

Background

Since there are inextricably connections among molecules in the biological networks, it would be a more efficient and accurate research strategy to screen microRNA (miRNA) markers combining with miRNA-mRNA regulatory networks. The independent regulation mode is more “fragile” and “influential” than the co-regulation mode. miRNAs can be used as biomarkers if they can independently regulate hub genes with important roles in the PPI network, simultaneously the expression products of the regulated hub genes play important roles in the signaling pathways of related tissue diseases.

Methods

We collected miRNA expression of non-small cell lung cancer (NSCLC) from The Cancer Genome Atlas (TCGA) database and the Gene Expression Omnibus (GEO) database. Volcano plot and signal-to-noise ratio (SNR) methods were used to obtain significant differentially expressed (SDE) miRNAs from the TCGA database and GEO database, respectively. A human miRNA-mRNA regulatory network was constructed and the number of genes uniquely targeted (NOG) by a certain miRNA was calculated. The area under the curve (AUC) values were used to screen for clinical sensitivity and specificity. The candidate markers were obtained using the criteria of the top five maximum AUC values and NOG ≥ 3. The protein–protein interaction (PPI) network was constructed and independently regulated hub genes were obtained. Gene Ontology (GO) analysis and KEGG pathway analysis were used to identify genes involved in cancer-related pathways. Finally, the miRNA which can independently regulate a hub gene and the hub gene can participate in an important cancer-related pathway was considered as a biomarker. The AUC values and gene expression profile analysis from two external GEO datasets as well as literature validation were used to verify the screening capability and reliability of this marker.

Results

Fifteen SDE miRNAs in lung cancer were obtained from the intersection of volcano plot and SNR based on the GEO database and the TCGA database. Five miRNAs with the top five maximum AUC values and NOG ≥ 3 were screened out. A total of 61 hub genes were obtained from the PPI network. It was found that the hub gene GTF2F2 was independently regulated by miR-708-5p. Further pathway analysis indicated that GTF2F2 participates in protein expression by binding with polymerase II, and it can regulate transcription and accelerate tumor growth. Hence, miR-708-5p could be used as a biomarker. The good screening capability and reliability of miR-708-5p as a lung cancer marker were confirmed by AUC values and gene expression profiling of external datasets, and experimental literature. The potential mechanism of miR-708-5p was proposed.

Conclusions

This study proposes a new idea for lung cancer marker screening by integrating microRNA expression, regulation network and signal pathway. miR-708-5p was identified as a biomarker using this novel strategy. This study may provide some help for cancer marker screening.

Incidental Adrenal Mass in a Patient With Surgically Treated Lung Adenocarcinoma

Adrenal metastases are not uncommon in patients with widespread metastatic lung cancer. Isolated metachronous adrenal metastases in cases of surgically treated lung cancer without long-term evidence of disease are rare and may pose a diagnostic and treatment dilemma. The current literature suggests that in such cases, adrenalectomy provides better median and overall survival rates. This case presents an incidentally discovered isolated adrenal mass in a patient with a past medical history of lung adenocarcinoma that was surgically removed three years before metastasis discovery. The patient successfully underwent adrenalectomy and was disease-free with no apparent complications at her three-month follow-up visit. The case highlights the importance of long-term radiographic surveillance after surgical resection of lung adenocarcinoma for the prompt diagnosis and timely treatment of metachronous metastases.

Prediction Model for Lung Cancer in High-Risk Nodules Being Considered for Resection: Development and Validation in a Chinese Population

Background

Determining benign and malignant nodules before surgery is very difficult when managing patients with pulmonary nodules, which further makes it difficult to choose an appropriate treatment. This study aimed to develop a lung cancer risk prediction model for predicting the nature of the nodule in patients’ lungs and deciding whether to perform a surgical intervention.

Methods

This retrospective study included patients with pulmonary nodules who underwent lobectomy or sublobectomy at Tianjin Medical University General Hospital between 2017 and 2020. All subjects were further divided into training and validation sets. Multivariable logistic regression models with backward selection based on the Akaike information criterion were used to identify independent predictors and develop prediction models.

Results

To build and validate the model, 503 and 260 malignant and benign nodules were used. Covariates predicting lung cancer in the current model included female sex, age, smoking history, nodule type (pure ground-glass and part-solid), nodule diameter, lobulation, margin (smooth, or spiculated), calcification, intranodular vascularity, pleural indentation, and carcinoembryonic antigen. The final model of this study showed excellent discrimination and calibration with a concordance index (C-index) of 0.914 (0.890–0.939). In an independent sample used for validation, the C-index for the current model was 0.876 (0.825–0.927) compared with 0.644 (0.559–0.728) and 0.681 (0.605–0.757) for the Mayo and Brock models. The decision curve analysis showed that the current model had higher discriminatory power for malignancy than the Mayo and the Brock models.

Conclusions

The current model can be used in estimating the probability of lung cancer in nodules requiring surgical intervention. It may reduce unnecessary procedures for benign nodules and prompt diagnosis and treatment of malignant nodules.

Seven tumor-associated autoantibodies as a serum biomarker for primary screening of early-stage non-small cell lung cancer

Objective

The purpose of this study was to analyze the levels of tumor‐associated autoantibodies (TAAbs) in lung diseases and determine their diagnostic efficiency in early‐stage non‐small cell lung cancer (NSCLC).

Methods

We retrospectively analyzed the levels of 7‐TAAbs in 177 newly diagnosed early‐stage NSCLC patients, 202 patients with lung benign diseases and 137 healthy cases. The levels of a panel of 7‐TAAbs, including p53, GAGE7, PGP9.5, CAGE, MAGE A1, SOX2, GBU4‐5, were measured by ELISA.

Results

The serum levels of p53, GAGE7, PGP9.5, CAGE, MAGE A1, SOX2, and GBU4‐5 were not statistically different among NSCLC, benign and healthy groups (p > 0.05). The area under the curve (AUC) of 7‐TAAbs was all lower than 0.70. The sensitivity of combined detection was the highest (23.73%), while the specificity was the lowest (88.79%). The positive rates of PGP9.5, SOX2, and combined detection were significantly different among the three groups (p < 0.05). Among them, PGP9.5 and combined detection were significantly different between the NSCLC and benign groups (p < 0.05), PGP9.5, SOX2 and combined detection were significantly different between the NSCLC and healthy groups (p < 0.05).

Conclusions

The diagnostic efficiency of 7‐TAAbs in early‐stage NSCLC was not high, so it cannot be used alone as a screening method for NSCLC.

Guideline-Recommended Lung Cancer Screening Adherence Is Superior With a Centralized Approach

BACKGROUND

To recognize fully the benefit of lung cancer screening (LCS), annual adherence must approach the high levels seen in the National Lung Screening Trial. Emerging data suggest that annual adherence is poor and that a centralized approach to screening improves adherence.

RESEARCH QUESTIONS

Do differences in adherence exist between a centralized and decentralized approach to LCS within a hybrid program and what are predictors of adherence?

STUDY DESIGN

A retrospective evaluation of a single-center hybrid LCS program was conducted to compare outcomes including patient eligibility and adherence between the centralized and decentralized approaches.

METHODS

Patient demographics and outcomes were compared between those screened with a centralized and decentralized approach and between adherent and nonadherent patients using two-sample t tests, χ ² tests, or analyses of variance, as appropriate. Annual adherence analysis was conducted using data from patients who remained eligible for screening with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2. Logistic regression was used to estimate the association between adherence and the primary exposure, adjusting for potential confounders.

RESULTS

A cohort of 1,117 patients underwent baseline low-dose CT imaging. Two hundred eleven patients (19%) were ineligible by United States Preventative Services Task Force criteria and most (90%) were screened with the decentralized approach. After exclusions, 765 patients with Lung-RADS score of 1 or 2 remained eligible for annual screening. Overall adherence was 56%; however, adherence in the centralized program was 70%, compared with 41% with the decentralized approach (P < .001). Individuals screened in a decentralized approach were 73% less likely to be adherent (OR, 0.27; 95% CI, 0.19-0.37). A greater proportion of patients with three or more comorbidities were screened outside the centralized program.

INTERPRETATION

Those screened using a centralized approach were more likely to meet eligibility criteria for LCS and more likely to return for annual screening than those screened using a decentralized approach.

Early Diagnosis and Screening for Lung Cancer

Cancer interception refers to actively blocking the cancer development process by preventing progression of premalignancy to invasive disease. The rate-limiting steps for effective lung cancer interception are the incomplete understanding of the earliest molecular events associated with lung carcinogenesis, the lack of preclinical models of pulmonary premalignancy, and the challenge of developing highly sensitive and specific methods for early detection. Recent advances in cancer interception are facilitated by developments in next-generation sequencing, computational methodologies, as well as the renewed emphasis in precision medicine and immuno-oncology. This review summarizes the current state of knowledge in the areas of molecular abnormalities in lung cancer continuum, preclinical human models of lung cancer pathogenesis, and the advances in early lung cancer diagnostics.

Long non-coding RNA DLX6-AS1 knockdown suppresses the tumorigenesis and progression of non-small cell lung cancer through microRNA-16-5p/BMI1 axis

BACKGROUND

Non-small cell lung cancer (NSCLC) is a huge threat to sufferers' life and overall health. Long non-coding RNA (lncRNA) distal-less homeobox 6 antisense RNA 1 (DLX6-AS1) has been revealed to function as a carcinogenesis factor in some cancers. This research aimed to scrutinize the role and mechanism underlying DLX6-AS1 in NSCLC tumorigenesis and progression.

METHODS

The levels of DLX6-AS1, microRNA-16-5p (miR-16-5p), and BMI1 mRNA were estimated via reverse transcription-quantitative PCR (RT-qPCR) assay. The protein levels were disclosed by western blot assay. Cell proliferative potential was estimated by colony formation and Cell Counting Kit-8 (CCK-8) assays. Cell migration was estimated by Transwell and wound healing assay. A Transwell assay was executed to estimate cell invasion. The relationships of DLX6-AS1, miR-16-5p, and BMI1 were forecasted by bioinformatics analysis, and confirmed by luciferase reporter assay and RNA immunoprecipitation (RIP) assay. A xenograft mice model was employed to to inspect the function of DLX6-AS1 knockdown on NSCLC tumorigenesis in vivo.

RESULTS

DLX6-AS1 was overexpressed in NSCLC tissues and cells, and was inextricably linked with the poor prognosis of NSCLC patients. Depletion of DLX6-AS1 oppressed cell proliferation, migration, invasion, epithelial-mesenchymal transition (EMT) but promoted apoptosis in NSCLC. MiR-16-5p is a target of DLX6-AS1 and directly targets BMI1. Moreover, the anti-tumor impacts of miR-16-5p were overturned by overexpression of DLX6-AS1 or BMI1 in NSCLC cells. Additionally, DLX6-AS1 silencing inhibited tumor growth of NSCLC in vivo.

CONCLUSIONS

In conclusion, lncRNA DLX6-AS1 downregulation suppressed the tumorigenesis and progression of NSCLC via miR-16-5p/BMI1 axis in vitro and in vivo, elucidating the vital roles and downstream targets of DLX6-AS1 in NSCLC.

Knockdown of LncRNA LINC00958 Inhibits the Proliferation and Migration of NSCLC Cells by MiR-204-3p/KIF2A Axis

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. Increasing evidence suggests that long non-coding RNAs (lncRNAs) function in the tumorigenesis of NSCLC. LINC00958, a newly identified lncRNA, has been reported to be closely linked to tumorigenesis in several cancers. However, its specific role in NSCLC remains unclear. In this study, we determined the expression of LINC00958 in NSCLC by RT-qPCR analysis and evaluated cell proliferation and migration by CCK-8 and transwell assays, respectively. We established a xenograft tumor model to examine the effect of LINC00958 on tumor growth in vivo. Luciferase reporter assays were performed to determine the interaction between LINC00958 and miR-204-3p and the interaction between miR-204-3p and KIF2A. We found that LINC00958 was up-regulated in NSCLC tissues and cell lines. Down-regulation of LINC00958 inhibited cell proliferation and migration in vitro and suppressed tumor growth in vivo. Besides, miR-204-3p was identified as a target of LINC00958 and miR-204-3p inhibitor could reverse the inhibitory effect of LINC00958 knockdown on proliferation and migration of NSCLC cells. We also validated that KIF2A, a direct target of miR-204-3p, was responsible for the biological role of LINC00958. KIF2A antagonized the effect of miR-204-3p on NSCLC cell proliferation and migration and was regulated by LINC00958/miR-204-3p. Taken together, these data indicate that the LINC00958/miR-204-3p/KIF2A axis is critical for NSCLC progression, which might provide a potential therapeutic target of NSCLC.

Cross-Scale Integration of Nano-Sized Extracellular Vesicle-Based Biomarker and Radiomics Features for Predicting Suspected Sub-Solid Pulmonary Nodules

Sub-solid nodules (SSN) are common radiographic findings. Due to possibility of malignancy, further evaluation is urgentlyneeded for prevention and management of lung cancer (LC). This current study enrolled patients with SSN, including LC, benign nodules (BN), and healthy individuals as a control, to discover small extracellular vesicles (sEVs) differentially expressed miRNAs (DEMs) as biomarker by next-generation sequencing (NGS) and validation by RT-qPCR. Through cross-scale integration of validated small-molecule and macro-imaging, the prediction model was developed by logistic algorithms and further interpreted into an easy-to-use Nomogram by Cox-proportional hazards modeling. Present study has discovered various sEVs DEMs and sEVs-miR-424-5p that were selected and validated as novel potential biomarkers for cancerous nodule, namely LC. Furthermore, the 10 radiomics signs and 4 clinical features of SSN were merged with sEVs-miR-424-5p and proceeded in multivariate logistic regression analysis to develop the cross-scale integrated modeling, which yielded a significantly higher area under the curve (AUC). Finally, visualization of an easy-to-use nomogram was invented to potentially predict suspected SSN. sEVs-miR-424-5p could be a novel biomarker for distinguishing SSN from LC and BN populations. Its association with cross-scale fusion of radiomics-clinical features will provide great potential to be an errorless prediction of malignant SSN.

Chronic obstructive pulmonary disease as a risk factor in primary care: a Canadian retrospective cohort study

Chronic obstructive pulmonary disease (COPD) is a complex disease that is predicted to be the third most common cause of death by 2030. In Canada, the care and management of chronic conditions is largely provided by primary care providers. Although there is emerging research and initiatives that describe the prevalence of COPD in Canadian primary care settings, to our knowledge, there have been no efforts to use a large pan-Canadian database to analyze COPD as a risk factor for other common chronic conditions managed in primary care. We report the risk of developing comorbidities after the onset of COPD, that is, the extent to which COPD is a risk factor for developing common chronic conditions (heart failure, depression, anxiety, coronary artery disease, diabetes, anemia, hypertension, ischemic heart disease, underweight, and osteoporosis). After adjusting for age, sex, urban vs rural residence, and smoking status, the relative risks for patients with COPD at baseline were significantly higher for subsequent incidence of anemia, anxiety, diabetes, depression, heart failure, ischemic heart disease, lung cancer, osteoporosis, sleep apnea, underweight, and hypertension than patients without COPD. Using a cut-point of a 200% increase in relative risk as indicative of particular clinical relevance, COPD has a statistically and clinically significant association with developing lung cancer, becoming underweight, and developing heart failure.

The biogenesis and biological function of PIWI-interacting RNA in cancer

Small non-coding RNAs (ncRNAs) are vital regulators of biological activities, and aberrant levels of small ncRNAs are commonly found in precancerous lesions and cancer. PIWI-interacting RNAs (piRNAs) are a novel type of small ncRNA initially discovered in germ cells that have a specific length (24-31 nucleotides), bind to PIWI proteins, and show 2'-O-methyl modification at the 3'-end. Numerous studies have revealed that piRNAs can play important roles in tumorigenesis via multiple biological regulatory mechanisms, including silencing transcriptional and posttranscriptional gene processes and accelerating multiprotein interactions. piRNAs are emerging players in the malignant transformation of normal cells and participate in the regulation of cancer hallmarks. Most of the specific cancer hallmarks regulated by piRNAs are involved in sustaining proliferative signaling, resistance to cell death or apoptosis, and activation of invasion and metastasis. Additionally, piRNAs have been used as biomarkers for cancer diagnosis and prognosis and have great potential for clinical utility. However, research on the underlying mechanisms of piRNAs in cancer is limited. Here, we systematically reviewed recent advances in the biogenesis and biological functions of piRNAs and relevant bioinformatics databases with the aim of providing insights into cancer diagnosis and clinical applications. We also focused on some cancer hallmarks rarely reported to be related to piRNAs, which can promote in-depth research of piRNAs in molecular biology and facilitate their clinical translation into cancer treatment.

Limitations and perceived delays for diagnosis and staging of lung cancer in Portugal: A nationwide survey analysis

BACKGROUND

We aimed to identify the perception of physicians on the limitations and delays for diagnosing, staging and treatment of lung cancer in Portugal.

METHODS

Portuguese physicians were invited to participate an electronic survey (Feb-Apr-2020). Descriptive statistical analyses were performed, with categorical variables reported as absolute and relative frequencies, and continuous variables with non-normal distribution as median and interquartile range (IQR). The association between categorical variables was assessed through Pearson's chi-square test. Mann-Whitney test was used to compare categorical and continuous variables (Stata v.15.0).

RESULTS

Sixty-one physicians participated in the study (45 pulmonologists, 16 oncologists), with n = 26 exclusively assisting lung cancer patients. Most experts work in public hospitals (90.16%) in Lisbon (36.07%). During the last semester of 2019, responders performed a median of 85 (IQR 55-140) diagnoses of lung cancer. Factors preventing faster referral to the specialty included poor articulation between services (60.0%) and patients low economic/cultural level (44.26%). Obtaining National Drugs Authority authorization was one of the main reasons (75.41%) for delaying the begin of treatment. The cumulative lag-time from patients' admission until treatment ranged from 42-61 days. Experts believe that the time to diagnosis could be optimized in around 11.05 days [IQR 9.61-12.50]. Most physicians (88.52%) started treatment before biomarkers results motivated by performance status deterioration (65.57%) or high tumor burden (52.46%). Clinicians exclusively assisting lung cancer cases reported fewer delays for obtaining authorization for biomarkers analysis (p = 0.023). Higher waiting times for surgery (p = 0.001), radiotherapy (p = 0.004), immunotherapy (p = 0.003) were reported by professionals from public hospitals.

CONCLUSIONS

Physicians believe that is possible to reduce delays in all stages of lung cancer diagnosis with further efforts from multidisciplinary teams and hospital administration.

Comprehensive mutational analysis of background mucosa in patients with Lugol-voiding lesions

Somatic mutations including the background mucosa in patients with Lugol-voiding lesions (LVLs) are still not well known. The aim of this study was to evaluate the somatic mutations of the background mucosa in patients with LVLs (Squamous cell carcinoma (SCC), intraepithelial neoplasia (IN), and hyperplasia). Twenty-five patients with LVLs (9 with SCC, 6 with IN, and 10 with hyperplasia) were included. A targeted sequence was performed for LVLs and background mucosa using an esophageal cancer panel. Each mutation was checked whether it was oncogenic or not concerning OncoKB. In LVLs, TP53 was the most dominant mutation (80%). Furthermore, 72% of TP53 mutations was putative drivers. In background mucosa, NOTCH1 was the most dominant mutation (88%) and TP53 was the second most dominant mutation (48%). Furthermore, 73% of TP53 mutations and 8% of NOTCH1 mutations were putative drivers. Putative driver mutations of TP53 had significantly higher allele frequency (AF) in SCC than in IN and hyperplasia. Conversely, putative driver mutations of NOTCH1 did not have a significant accumulation of AF in the progression of carcinogenesis. Furthermore, in SCC, AF of TP53 mutations was significantly higher in LVLs than in background mucosa, but not in IN and hyperplasia. Regarding NOTCH1, a significant difference was not observed between LVLs and background mucosa in each group. The background mucosa in patients with LVLs already had putative driver mutations such as TP53 and NOTCH1. Of these two genes, TP53 mutation could be the main target gene of carcinogenesis in esophageal SCC. Clinical Trials registry: UMIN000034247.

Urinary detection of lung cancer in mice via noninvasive pulmonary protease profiling

Lung cancer is the leading cause of cancer-related death, and patients most commonly present with incurable advanced-stage disease. U.S. national guidelines recommend screening for high-risk patients with low-dose computed tomography, but this approach has limitations including high false-positive rates. Activity-based nanosensors can detect dysregulated proteases in vivo and release a reporter to provide a urinary readout of disease activity. Here, we demonstrate the translational potential of activity-based nanosensors for lung cancer by coupling nanosensor multiplexing with intrapulmonary delivery and machine learning to detect localized disease in two immunocompetent genetically engineered mouse models. The design of our multiplexed panel of sensors was informed by comparative transcriptomic analysis of human and mouse lung adenocarcinoma datasets and in vitro cleavage assays with recombinant candidate proteases. Intrapulmonary administration of the nanosensors to a Kras- and Trp53-mutant lung adenocarcinoma mouse model confirmed the role of metalloproteases in lung cancer and enabled accurate detection of localized disease, with 100% specificity and 81% sensitivity. Furthermore, this approach generalized to an alternative autochthonous model of lung adenocarcinoma, where it detected cancer with 100% specificity and 95% sensitivity and was not confounded by lipopolysaccharide-driven lung inflammation. These results encourage the clinical development of activity-based nanosensors for the detection of lung cancer.

Comprehensive analysis of competitive endogenous RNA associated with immune infiltration in lung adenocarcinoma

To identify the prognostic biomarker of the competitive endogenous RNA (ceRNA) and explore the tumor infiltrating immune cells (TIICs) which might be the potential prognostic factors in lung adenocarcinoma. In addition, we also try to explain the crosstalk between the ceRNA and TIICs to explore the molecular mechanisms involved in lung adenocarcinoma. The transcriptome data of lung adenocarcinoma were obtained from The Cancer Genome Atlas (TCGA) database, and the hypergeometric correlation of the differently expressed miRNA-lncRNA and miRNA-mRNA were analyzed based on the starBase. In addition, the Kaplan–Meier survival and Cox regression model analysis were used to identify the prognostic ceRNA network and TIICs. Correlation analysis was performed to analysis the correlation between the ceRNA network and TIICs. In the differently expressed RNAs between tumor and normal tissue, a total of 190 miRNAs, 224 lncRNAs and 3024 mRNAs were detected, and the constructed ceRNA network contained 5 lncRNAs, 92 mRNAs and 10 miRNAs. Then, six prognostic RNAs (FKBP3, GPI, LOXL2, IL22RA1, GPR37, and has-miR-148a-3p) were viewed as the key members for constructing the prognostic prediction model in the ceRNA network, and three kinds of TIICs (Monocytes, Macrophages M1, activated mast cells) were identified to be significantly related with the prognosis in lung adenocarcinoma. Correlation analysis suggested that the FKBP3 was associated with Monocytes and Macrophages M1, and the GPI was obviously related with Monocytes and Macrophages M1. Besides, the LOXL2 was associated with Monocytes and Activated mast cells, and the IL22RA1 was significantly associated with Monocytes and Macrophages M1, while the GPR37 and Macrophages M1 was closely related. The constructed ceRNA network and identified Monocytes, Macrophages M1 and activated Mast cells are all prognostic factors for lung adenocarcinoma. Moreover, the crosstalk between the ceRNA network and TIICs might be a potential molecular mechanism involved.

Comorbidity Profiles and Lung Cancer Screening among Older Adults: U.S. Behavioral Risk Factor Surveillance System 2017 to 2019

RATIONALE

Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) is now recommended for those meeting standard risk factor-based eligibility criteria, the role of comorbidity in the uptake of LCS with LDCT in an older real-world U.S. population is not well established.

OBJECTIVE

To examine the relationships between comorbidity, functional status and LCS utilization in the United States.

METHODS

Using population-based data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), we examined the association of comorbid conditions and functional limitations regarding activities of daily living with LCS utilization among participants that met the LCS criteria based on the US Preventive Service Taskforce guidelines. We employed multivariable weighted logistic regression models to evaluate these associations, both overall and within subgroups defined by age (<65 vs. ≥65 years), gender, and smoking history.

RESULTS

Of 11,214 participants that met the eligibility criteria for LCS, 1731 (16%) underwent LCS with LDCT. The majority were white (90%), male (55%), former smokers (52%) and living with at least one chronic comorbid condition (77%). Over 28% had 3 or more comorbid conditions and approximately 40% of participants reported having some form of functional limitations. In the multivariable models, the likelihood of undergoing LCS with LDCT within the past year was positively associated with higher levels of comorbidity (≥5 vs. 0: aOR=2.34, 95% CI=1.22,4.48) but not with functional limitations (≥3 vs. 0: aOR=1.00, 95% CI=0.66, 1.50).

CONCLUSION

The presence of comorbid conditions is associated with a higher likelihood of undergoing LCS with LDCT. Because poor health status may diminish the benefits of screening, future research is needed to precisely characterize the health status of LCS-eligible individuals.

A novel recurrence-associated metabolic prognostic model for risk stratification and therapeutic response prediction in patients with stage I lung adenocarcinoma

OBJECTIVE

The proportion of patients with stage I lung adenocarcinoma (LUAD) has dramatically increased with the prevalence of low-dose computed tomography use for screening. Up to 30% of patients with stage I LUAD experience recurrence within 5 years after curative surgery. A robust risk stratification tool is urgently needed to identify patients who might benefit from adjuvant treatment.

METHODS

In this first investigation of the relationship between metabolic reprogramming and recurrence in stage I LUAD, we developed a recurrence-associated metabolic signature (RAMS). This RAMS was based on metabolism-associated genes to predict cancer relapse and overall prognoses of patients with stage I LUAD. The clinical significance and immune landscapes of the signature were comprehensively analyzed.

RESULTS

Based on a gene expression profile from the GSE31210 database, functional enrichment analysis revealed a significant difference in metabolic reprogramming that distinguished patients with stage I LUAD with relapse from those without relapse. We then identified a metabolic signature (i.e., RAMS) represented by 2 genes (ACADM and RPS8) significantly related to recurrence-free survival and overall survival times of patients with stage I LUAD using transcriptome data analysis of a training set. The training set was well validated in a test set. The discriminatory power of the 2 gene metabolic signature was further validated using protein values in an additional independent cohort. The results indicated a clear association between a high risk score and a very poor patient prognosis. Stratification analysis and multivariate Cox regression analysis showed that the RAMS was an independent prognostic factor. We also found that the risk score was positively correlated with inflammatory response, the antigen-presenting process, and the expression levels of many immunosuppressive checkpoint molecules (e.g., PD-L1, PD-L2, B7-H3, galectin-9, and FGL-1). These results suggested that high risk patients had immune response suppression. Further analysis revealed that anti-PD-1/PD-L1 immunotherapy did not have significant benefits for high risk patients. However, the patients could respond better to chemotherapy.

CONCLUSIONS

This study is the first to highlight the relationship between metabolic reprogramming and recurrence in stage I LUAD, and is the first to also develop a clinically feasible signature. This signature may be a powerful prognostic tool and help further optimize the cancer therapy paradigm.

Pyroptosis: mechanisms and diseases

Currently, pyroptosis has received more and more attention because of its association with innate immunity and disease. The research scope of pyroptosis has expanded with the discovery of the gasdermin family. A great deal of evidence shows that pyroptosis can affect the development of tumors. The relationship between pyroptosis and tumors is diverse in different tissues and genetic backgrounds. In this review, we provide basic knowledge of pyroptosis, explain the relationship between pyroptosis and tumors, and focus on the significance of pyroptosis in tumor treatment. In addition, we further summarize the possibility of pyroptosis as a potential tumor treatment strategy and describe the side effects of radiotherapy and chemotherapy caused by pyroptosis. In brief, pyroptosis is a double-edged sword for tumors. The rational use of this dual effect will help us further explore the formation and development of tumors, and provide ideas for patients to develop new drugs based on pyroptosis.

Intergroupe francophone de cancérologie thoracique, Société de pneumologie de langue française, and Société d'imagerie thoracique statement paper on lung cancer screening

Following the American National Lung Screening Trial results in 2011 a consortium of French experts met to edit a statement. Recent results of other randomized trials gave the opportunity for our group to meet again in order to edit updated guidelines. After literature review, we provide here a new update on lung cancer screening in France. Notably, in accordance with all international guidelines, the experts renew their recommendation in favor of individual screening for lung cancer in France as per the conditions laid out in this document. In addition, the experts recommend the very rapid organization and funding of prospective studies, which, if conclusive, will enable the deployment of lung cancer screening organized at the national level.

Photon-counting detectors in computed tomography: from quantum physics to clinical practice

Over the last decade, a fundamentally new type of computed tomography (CT) detectors has proved its superior capabilities in both physical and preclinical evaluations and is now approaching the stage of clinical practice. These detectors are able to discriminate single photons and quantify their energy and are hence called photon-counting detectors. Among the promising benefits of this technology are improved radiation dose efficiency, increased contrast-to-noise ratio, reduced metal artifacts, improved spatial resolution, simultaneous multi-energy acquisitions, and the prospect of multi-phase imaging within a single acquisition using multiple contrast agents. Taking the conventional energy-integrating detectors as a reference, the authors demonstrate the technical principles of this new technology and provide phantom and patient images acquired by a whole-body photon-counting CT. These images serve as a basis for discussing the potential future of clinical CT.

When Is a Harm a Harm? Discordance between Patient and Medical Experts' Evaluation of Lung Cancer Screening Attributes

BACKGROUND

A shared decision-making (SDM) process for lung cancer screening (LCS) includes a discussion between clinicians and patients about benefits and potential harms. Expert-driven taxonomies consider mortality reduction a benefit and consider false-positives, incidental findings, overdiagnosis, overtreatment, radiation exposure, and direct and indirect costs of LCS as potential harms.

OBJECTIVE

To explore whether patients conceptualize the attributes of LCS differently from expert-driven taxonomies.

DESIGN

Cross-sectional study with semistructured interviews and a card-sort activity.

PARTICIPANTS

Twenty-three Veterans receiving primary care at a Veterans Affairs Medical Center, 55 to 73 y of age with 30 or more pack-years of smoking. Sixty-one percent were non-Hispanic African American or Black, 35% were non-Hispanic White, 4% were Hispanic, and 9% were female.

APPROACH

Semistructured interviews with thematic coding.

MAIN MEASURES

The proportion of participants categorizing each attribute as a benefit or harm and emergent themes that informed this categorization.

KEY RESULTS

In addition to categorizing reduced lung cancer deaths as a benefit (22/23), most also categorized the following as benefits: routine annual screening (8/9), significant incidental findings (20/23), follow-up in a nodule clinic (20/23), and invasive procedures (16/23). Four attributes were classified by most participants as a harm: false-positive (13/22), overdiagnosis (13/23), overtreatment (6/9), and radiation exposure (20/22). Themes regarding the evaluation of LCS outcomes were 1) the value of knowledge about body and health, 2) anticipated positive and negative emotions, 3) lack of clarity in terminology, 4) underlying beliefs about cancer, and 5) risk assessment and tolerance for uncertainty.

CONCLUSIONS

Anticipating discordance between patient- and expert-driven taxonomies of the benefits and harms of LCS can inform the development and interpretation of value elicitation and SDM discussions.

N6-Methyladenosine RNA Methylation Regulator-Related Alternative Splicing (AS) Gene Signature Predicts Non-Small Cell Lung Cancer Prognosis

Aberrant N6-methyladenosine (m6A) RNA methylation regulatory genes and related gene alternative splicing (AS) could be used to predict the prognosis of non-small cell lung carcinoma. This study focused on 13 m6A regulatory genes (METTL3, METTL14, WTAP, KIAA1429, RBM15, ZC3H13, YTHDC1, YTHDC2, YTHDF1, YTHDF2, HNRNPC, FTO, and ALKBH5) and expression profiles in TCGA-LUAD (n = 504) and TCGA-LUSC (n = 479) datasets from the Cancer Genome Atlas database. The data were downloaded and bioinformatically and statistically analyzed, including the gene ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses. There were 43,948 mRNA splicing events in lung adenocarcinoma (LUAD) and 46,020 in lung squamous cell carcinoma (LUSC), and the data suggested that m6A regulators could regulate mRNA splicing. Differential HNRNPC and RBM15 expression was associated with overall survival (OS) of LUAD and HNRNPC and METTL3 expression with the OS of LUSC patients. Furthermore, the non-small cell lung cancer prognosis-related AS events signature was constructed and divided patients into high- vs. low-risk groups using seven and 14 AS genes in LUAD and LUSC, respectively. The LUAD risk signature was associated with gender and T, N, and TNM stages, but the LUSC risk signature was not associated with any clinical features. In addition, the risk signature and TNM stage were independent prognostic predictors in LUAD and the risk signature and T stage were independent prognostic predictors in LUSC after the multivariate Cox regression and receiver operating characteristic analyses. In conclusion, this study revealed the AS prognostic signature in the prediction of LUAD and LUSC prognosis.

Evaluation of the association between vitamin D and lung cancer skin metastasis: A protocol for systematic review

BACKGROUND

This study aims to investigate the association between vitamin D (VD) and lung cancer skin metastasis (LCSM).

METHODS

The following databases will be retrieved from the beginning to the present of each database without language limitation: PUBMED, EMBASE, Cochrane Library, Web of Science, CBM, and CNKI. The reference lists of included trials and other sources will also be checked. Two researchers will independently undertake literature selection, data collection, and study quality evaluation. We will utilize a fixed or random-effect model to pool the data according to the heterogeneity test. The RevMan 5.3 software will be used to analyze the data and perform meta-analysis.

RESULTS

This study will summarize high quality study to explore the association between VD and LCSM.

CONCLUSION

The findings of this study will help to judge whether there is association between VD and LCSM.

ETHICS AND DISSEMINATION

No research ethical approval is required in this study, because it will only analyze published data. It is expected to disseminate through a peer-reviewed journal.

STUDY REGISTRATION

osf.io/ph2au.

Comparison of clinical diagnostic value of spiral CT with different dose in patients with early-stage peripheral lung cancer

PURPOSE

To compare the clinical diagnostic value of spiral CT scan with different dose in patients with early-stage peripheral lung cancer.

METHODS

A total of 163 cases of patients with early-stage peripheral lung cancer who came to People's Hospital of Rizhao for treatment from June 2014 to January 2017 were retrospectively analyzed. A total of 78 cases of patients who received low-dose CT scanning were the low-dose group, another 84 cases of patients who received routine dose CT scanning were the routine dose group. Multislice helical CT (MSCT) scanning was performed in both groups, with tube voltage of 120 kV. Tube current was 25 m A in the low-dose group and 250 m A in the routine dose group. In addition, a total of 80 patients with lobar pneumonia were added as the control group of diagnostic sensitivity, specificity and accuracy. Pathological diagnosis was taken as the gold standard to compare the diagnostic sensitivity, specificity and accuracy of the two groups.

RESULTS

The image quality, nodules and signs of the two groups were compared, and the results of radiation dose of the two groups were compared. The diagnostic sensitivity, specificity and accuracy of the low-dose group were 82.05%, 87.50% and 84.81%, respectively. The diagnostic sensitivity, specificity and accuracy of the routine dose group were 85.71%, 86.25% and 85.97%, respectively. The diagnostic value of the two groups was not statistically significant (p > 0.05). However, the radiation dose in the low-dose group was significantly lower than that in the routine group.

CONCLUSION

Low-dose MSCT scanning can meet the clinical requirements for imaging diagnosis of peripheral lung cancer, and can reduce the radiation dose of patients.

Lobectomy is superior to segmentectomy for peripheral high grade non-small cell lung cancer ≤2 cm

Background

Current practice guidelines recommend the following criteria for segmentectomy for non-small cell lung cancer (NSCLC): size ≤2 cm, margins ≥2 cm and no lymph node involvement. We sought to further stratify the selection criteria for segmentectomy for small peripheral high-grade tumors.

Methods

This retrospective database study was conducted using the Surveillance, Epidemiology and End Results (SEER) database. We queried for patients with high-grade (poorly differentiated/undifferentiated) pathological (p)T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy between 2004 and 2015. Patients with node-positive disease or those who received any form of induction or adjuvant treatments were excluded.

Results

A total of 4,332 patients met the inclusion criteria, with 3,977 patients (91.8%) treated with lobectomy and 355 patients (8.2%) who underwent segmentectomy. In a propensity matched pair analysis of 640 patients, lobectomy (n=320) showed significantly improved 5-year survival of 45.9% vs. 33.8% for segmentectomy (n=320), P<0.01. In a multivariate Cox regression analysis, lobectomy was associated with significantly improved survival (HR: 0.84, 95% CI: 0.714–0.989, P=0.036). Interestingly, married status, adenocarcinoma histology, number of lymph nodes sampled were associated with better survival (P<0.05), while advanced age and male gender had worse survival outcomes (P<0.05).

Conclusions

For small peripheral NSCLC ≤2 cm and high grades of tumor differentiation, lobectomy is associated with better long-term survival outcomes as compared to segmentectomy. Additional data is needed to further stratify various NSCLC histologies with their respective grades to allow for better selection for segmentectomy.

Lung cancer screening by nodule volume in Lung-RADS v1.1: negative baseline CT yields potential for increased screening interval

Objectives

The 2019 Lung CT Screening Reporting & Data System version 1.1 (Lung-RADS v1.1) introduced volumetric categories for nodule management. The aims of this study were to report the distribution of Lung-RADS v1.1 volumetric categories and to analyse lung cancer (LC) outcomes within 3 years for exploring personalized algorithm for lung cancer screening (LCS).

Methods

Subjects from the Multicentric Italian Lung Detection (MILD) trial were retrospectively selected by National Lung Screening Trial (NLST) criteria. Baseline characteristics included selected pre-test metrics and nodule characterization according to the volume-based categories of Lung-RADS v1.1. Nodule volume was obtained by segmentation with dedicated semi-automatic software. Primary outcome was diagnosis of LC, tested by univariate and multivariable models. Secondary outcome was stage of LC. Increased interval algorithms were simulated for testing rate of delayed diagnosis (RDD) and reduction of low-dose computed tomography (LDCT) burden.

Results

In 1248 NLST-eligible subjects, LC frequency was 1.2% at 1 year, 1.8% at 2 years and 2.6% at 3 years. Nodule volume in Lung-RADS v1.1 was a strong predictor of LC: positive LDCT showed an odds ratio (OR) of 75.60 at 1 year (p < 0.0001), and indeterminate LDCT showed an OR of 9.16 at 2 years (p = 0.0068) and an OR of 6.35 at 3 years (p = 0.0042). In the first 2 years after negative LDCT, 100% of resected LC was stage I. The simulations of low-frequency screening showed a RDD of 13.6–21.9% and a potential reduction of LDCT burden of 25.5–41%.

Conclusions

Nodule volume by semi-automatic software allowed stratification of LC risk across Lung-RADS v1.1 categories. Personalized screening algorithm by increased interval seems feasible in 80% of NLST eligible.

Key Points

• Using semi-automatic segmentation of nodule volume, Lung-RADS v1.1 selected 10.8% of subjects with positive CT and 96.87 relative risk of lung cancer at 1 year, compared to negative CT.

• Negative low-dose CT by Lung-RADS v1.1 was found in 80.6% of NLST eligible and yielded 40 times lower relative risk of lung cancer at 2 years, compared to positive low-dose CT; annual screening could be preference sensitive in this group.

• Semi-automatic segmentation of nodule volume and increased screening interval by volumetric Lung-RADS v1.1 could retrospectively suggest a 25.5–41% reduction of LDCT burden, at the cost of 13.6–21.9% rate of delayed diagnosis.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07275-w) contains supplementary material, which is available to authorized users.

National health screening may reduce cardiovascular morbidity and mortality among the elderly

OBJECTIVES

Since 2007, the Korean government has provided a free health screening to the elderly starting at the age of 66 years. The purpose of this study was to evaluate the association between this general health screening and the incidences of stroke and myocardial infarction and mortality.

STUDY DESIGN

The study design used in this study is a retrospective cohort study.

METHODS

The study was conducted using the universe of insurance claims data of Korea and followed a cohort of individuals aged 66 years in 2009 from 2006 through 2016 (n = 354,194). We assessed the association between receipt of the national health screening and health outcomes using propensity matching and Cox proportional hazard models.

RESULTS

We found that the receipt of the national health screening was associated with a reduction in negative health outcomes. The hazard ratio for stroke was 0.89 (P < 0.001), 0.88 (P < 0.001) for myocardial infarction and 0.58 for death (P < 0.001).

CONCLUSION

Korea's national health screening was associated with reductions in cardiovascular morbidity and mortality in the elderly.

Utility of red cell distribution width as a diagnostic and prognostic marker in non-small cell lung cancer

An increasing number of studies have indicated that red blood cell distribution width (RDW) may be a novel biomarker for the diagnosis and prognosis of various malignancies. However, to date, data on the association of RDW with non-small cell lung cancer (NSCLC) are unclear. Our present study aimed to explore the value of RDW in NSCLC patients. A total of 338 NSCLC patients, 109 small cell lung cancer (SCLC) patients, and 302 healthy participants were retrospectively analyzed between January 2016 and December 2018. In the present study, we found that RDW was significantly increased in NSCLC patients. Receiver-operating characteristic (ROC) analysis showed that the area under the ROC curve (AUC) of RDW was 0.753 in discriminating NSCLC patients from healthy participants, the optimal cut-off value of RDW was 12.95, and the specificity and sensitivity were 76.33% and 76.16%, respectively. Further analysis found that RDW can enhance the diagnostic performance of Cyfra21-1 and NSE in discriminating NSCLC patients from healthy participants or SCLC patients. Among NSCLC patients, RDW was significantly correlated with TNM stage, T stage, N stage, M stage, and Cyfra21-1, indicating that RDW may be helpful for predicting the prognosis of NSCLC patients. Our findings suggest that RDW can be used as an auxiliary marker for the diagnosis and prognosis of NSCLC.

Predicting Lung Cancer Risk of Incidental Solid and Subsolid Pulmonary Nodules in Different Sizes

Objective

Malignancy prediction models for pulmonary nodules are most accurate when used within nodules similar to those in which they were developed. This study was to establish models that respectively predict malignancy risk of incidental solid and subsolid pulmonary nodules of different size.

Materials and Methods

This retrospective study enrolled patients with 5-30 mm pulmonary nodules who had a histopathologic diagnosis of benign or malignant. The median time to lung cancer diagnosis was 25 days. Four training/validation datasets were assembled based on nodule texture and size: subsolid nodules (SSNs) ≤15 mm, SSNs between 15 and 30 mm, solid nodules ≤15 mm and those between 15 and 30 mm. Univariate logistic regression was used to identify potential predictors, and multivariate analysis was used to build four models.

Results

The study identified 1008 benign and 1813 malignant nodules from a single hospital, and by random selection 1008 malignant nodules were enrolled for further analysis. There was a much higher malignancy rate among SSNs than solid nodules (rate, 75% vs 39%, P<0.001). Four distinguishing models were respectively developed and the areas under the curve (AUC) in training sets and validation sets were 0.83 (0.78-0.88) and 0.70 (0.61-0.80) for SSNs ≤15 mm, 0.84 (0.74-0.93) and 0.72 (0.57-0.87) for SSNs between 15 and 30 mm, 0.82 (0.77-0.87) and 0.71 (0.61-0.80) for solid nodules ≤15 mm, 0.82 (0.79-0.85) and 0.81 (0.76-0.86) for solid nodules between 15 and 30 mm. Each model showed good calibration and potential clinical applications. Different independent predictors were identified for solid nodules and SSNs of different size.

Conclusion

We developed four models to help characterize subsolid and solid pulmonary nodules of different sizes. The established models may provide decision-making information for thoracic radiologists and clinicians.

AHNAK2 Is Associated with Poor Prognosis and Cell Migration in Lung Adenocarcinoma

BACKGROUND

Lung adenocarcinoma (LUAD), as the main subtype of lung cancer, is one of the common causes of cancer-related deaths worldwide. The AHNAK family is correlated with cell structure and migration, cardiac calcium channel signaling, and tumor metastasis. Previous studies showed AHNAK2 could promote tumor progression and cell migration in melanoma and renal clear cell carcinoma. However, the role of AHNAK2 in LUAD remains unknown.

METHODS

We examined the levels of AHNAK2 in pathological specimens and the database of Clinical Proteomic Tumor Analysis Consortium-Lung adenocarcinoma (CPTAC-LUAD), The Cancer Genome Atlas-Lung Adenocarcinoma (TCGA-LUAD), Gene Expression Omnibus dataset (GSE72094, GSE26939), and The Genotype-Tissue Expression (GTEx) of lung tissue samples. Univariate Cox regression, multivariate Cox regression, and Kaplan-Meier survival analysis were performed to reveal the relationship between AHNAK2 and prognosis. A nomogram was constructed to predict 2- or 3-year overall survival and validated via calibration curves, receiver operating characteristic (ROC) analysis, and decision curve analysis (DCA). Furthermore, Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis were used to explore the functional role of AHNAK2 in lung adenocarcinoma. Finally, by transfecting siRNA, we examined the regulatory effect of AHNAK2 on cell migration.

RESULTS

The expression of AHNAK2 was upregulated in tumor samples and correlated with poor prognosis in LUAD patients. Nomogram with AHNAK2 and clinical parameters showed a good prediction in overall survival (OS), especially the 2-year OS. In addition, functional analyses and wound healing assay suggested that AHNAK2 might be involved in the regulation of migration in LUAD.

CONCLUSION

In summary, our study showed that AHNAK2 might be a novel biomarker in LUAD and revealed the potential mechanism of AHNAK2 in LUAD progression which could provide new insights for target therapy.

Implementation of the cloud-based computerized interpretation system in a nationwide lung cancer screening with low-dose CT: comparison with the conventional reading system

OBJECTIVES

We aimed to compare the CT interpretation before and after the implementation of a computerized system for lung nodule detection and measurements in a nationwide lung cancer screening program.

METHODS

Our screening program started in April 2017, with 14 participating institutions. Initially, all CTs were interpreted using interpretation systems in each institution and manual nodule measurement (conventional system). A cloud-based CT interpretation system, equipped with semi-automated measurement and CAD (computer-aided detection) for lung nodules (cloud-based system), was implemented during the project. Positive rates and performances for lung cancer diagnosis based on the Lung-RADS version 1.0 were compared between the conventional and cloud-based systems.

RESULTS

A total of 1821 (M:F = 1782:39, mean age 62.7 years, 16 confirmed lung cancers) and 4666 participants (M:F = 4560:106, mean age 62.8 years, 31 confirmed lung cancers) were included in the conventional and cloud-based systems, respectively. Significantly more nodules were detected in the cloud-based system (0.76 vs. 1.07 nodule/participant, p < .001). Positive rate did not differ significantly between the two systems (9.9% vs. 11.0%, p = .211), while their variability across institutions was significantly lower in the cloud-based system (coefficients of variability, 0.519 vs. 0.311, p = .018). The Lung-RADS-based sensitivity (93.8% vs. 93.5%, p = .979) and specificity (90.9% vs. 89.6%, p = .132) did not differ significantly between the two systems.

CONCLUSION

Implementation of CAD and semi-automated measurement for lung nodules in a nationwide lung cancer screening program resulted in increased number of detected nodules and reduced variability in positive rates across institutions.

KEY POINTS

• Computer-aided CT reading detected more lung nodules than radiologists alone in lung cancer screening. • Positive rate in lung cancer screening did not change with computer-aided reading. • Computer-aided CT reading reduced inter-institutional variability in lung cancer screening.

Impact of the Percepta Genomic Classifier on Clinical Management Decisions in a Multicenter Prospective Study

BACKGROUND

The Percepta genomic classifier has been clinically validated as a complement to bronchoscopy for lung nodule evaluation.

RESEARCH QUESTION

The goal of this study was to examine the impact on clinical management decisions of the Percepta result in patients with low- and intermediate-risk lung nodules.

STUDY DESIGN AND METHODS

A prospective "real world" registry was instituted across 35 US centers to observe physician management of pulmonary nodules following a nondiagnostic bronchoscopy. To assess the impact on management decisions of the Percepta genomic classifier, a subset of patients was analyzed who had an inconclusive bronchoscopy for a pulmonary nodule, a Percepta result, and an adjudicated lung diagnosis with at least 1 year of follow-up. In this cohort, change in the decision to pursue additional invasive procedures following Percepta results was assessed.

RESULTS

A total of 283 patients met the study eligibility criteria. In patients with a low/intermediate risk of malignancy for whom the clinician had designated a plan for a subsequent invasive procedure, a negative Percepta result down-classified the risk of malignancy in 34.3% of cases. Of these down-classified patients, 73.9% had a change in their management plan from an invasive procedure to surveillance, and the majority avoided a procedure up to 12 months following the initial evaluation. In patients with confirmed lung cancers, the time to diagnosis was not significantly delayed when comparing Percepta down-classified patients vs patients who were not down-classified (P = .58).

INTERPRETATION

The down-classification of nodule malignancy risk with the Percepta test decreased additional invasive procedures without a delay in time to diagnosis among those with lung cancer.

Possible role of circulating tumor cells in early detection of lung cancer

The prognosis of lung cancer varies highly depending on the disease stage at diagnosis, from a 5-year survival rate close to 90% in stage I, to 10% or less in stage IV disease. The enhancement of early diagnosis of this malignancy is mandatory to improve prognosis, because lung cancer patients stay long asymptomatic or few symptomatic after disease onset. Nowadays, liquid biopsy has emerged as a minimally-invasive tool to address the urgent need for real time monitoring, stratification, and personalized treatment of malignancies, including lung cancer. Liquid biopsy refers to a class of biomarkers, including circulating tumor cells (CTCs), cell-free circulating tumor DNA (ctDNA) and tumor-derived extracellular vesicles (tdEV). Since CTCs represent a crucial step in disease progression and metastasis, we reviewed here the scientific literature about the use of CTCs in early diagnosis of lung cancer; different techniques, and different strategies (e.g., source of analysis sample or high-risk groups of patients) were discussed showing the potential of implementing liquid biopsy in the clinical routine of non-metastatic lung cancer.

Evaluating the efficacy of bronchoscopy for the diagnosis of early stage lung cancer

Novel diagnostic techniques for lung cancer are rapidly evolving. Specifically, several novel changes to bronchoscopy are reaching clinical evaluation. It is critical to think about historical standards for evaluating new diagnostic testing, and put those concepts into the framework of lung cancer. Often a thorough evaluation of new technology is not performed as a part of regulatory marketing clearance. Therefore, we must consider how to best study novel testing beyond these regulatory minimums. There are several methodological principles that can achieve this goal such as using a control arm, more thorough reporting of enrolled patients, consecutive patient enrollment, and adequate sample size. We hope clinicians, particularly those performing bronchoscopy for lung nodules, will feel empowered to critically appraise the evaluation of new diagnostic testing for lung cancer moving forward.

Surgery or stereotactic body radiotherapy for metachronous primary lung cancer? A propensity score matching analysis

OBJECTIVE

We compared outcomes after surgery or stereotactic body radiotherapy (SBRT) among patients with metachronous primary lung cancer (MPLC).

METHODS

Patients with MPLC were treated with either surgery (2008-2018) or SBRT (2010-2018). We used propensity score matching (PSM) to reduce bias from various clinicopathological factors. MPLC was defined by the Martini and Melamed criteria.

RESULTS

Of 77 patients, 51 underwent surgery and 26 received SBRT. Most median clinicopathological characteristics did not significantly differ between the surgery and SBRT groups (male sex: 67% vs 65%; age: 73 vs 77 years; time after first surgery: 6.2 vs 4.7 years; lobectomy as first procedure: 82% vs 85%; second tumor size: 11 vs 12 mm; clinical stage I: 96% vs 100%; CEA: 2.9 vs 3.0 ng/ml). However, the surgery group had significantly more ipsilateral second tumors (n = 71, 58%, P = 0.003), better performance status (P = 0.03), and preserved lung function (P = 0.02). Surgery, thus, tended to be selected for patients with good physical function and for the MPLC in the contralateral side. Five-year overall survival did not significantly differ between the surgery and SBRT groups, either before PSM (86.5% vs 65.8%, P = 0.24, log-rank) or after PSM (100% vs 84.4%, P = 0.73).

CONCLUSIONS

Surgery and SBRT for MPLC patients are safe and feasible treatments with similar outcomes. However, this finding should be verified by a random controlled trial with a larger study cohort.

Ventilation Heterogeneity and Its Association with Nodule Formation Among Participants in the National Lung Screening Trial-A Preliminary Investigation

RATIONALE AND OBJECTIVES

We have developed a technique to measure ventilation heterogeneity (VH) on low dose chest CT scan that we hypothesize may be associated with the development of lung nodules, and perhaps cancer. If true, such an analysis may improve screening by identifying regional areas of higher risk.

MATERIALS AND METHODS

Using the National Lung Screening Trial database, we identified a small subset of those participants who were labeled as having a positive screening test at 1 year (T1) but not at baseline (T0). We isolated the region in which the nodule would form on the T0 scan ("target region") and measured VH as the standard deviation of the linear dimension of a virtual cubic airspace based on measurement of lung attenuation within the region.

RESULTS

We analyzed 24 cases, 9 with lung cancer and 15 with a benign nodule. We found that the VH of the target region was nearly statistically greater than that of the corresponding contralateral control region (0.168 [0.110-0.226] vs. 0.112 [0.083-0.203], p = 0.051). The % emphysema within the target region was greater than that of the corresponding contralateral control region (1.339 [0.264-4.367] vs. 1.092 [0.375-4.748], p = 0.037). There was a significant correlation between the % emphysema and the VH of the target region (rho = +0.437, p = 0.026).

CONCLUSION

Our study provides the first data in support of increased local VH being associated with subsequent lung nodule formation. Further work is necessary to determine whether this technique can enhance screening for lung cancer by low dose chest CT scan.

Clinical Implementation of Deep Learning in Thoracic Radiology: Potential Applications and Challenges

Chest X-ray radiography and computed tomography, the two mainstay modalities in thoracic radiology, are under active investigation with deep learning technology, which has shown promising performance in various tasks, including detection, classification, segmentation, and image synthesis, outperforming conventional methods and suggesting its potential for clinical implementation. However, the implementation of deep learning in daily clinical practice is in its infancy and facing several challenges, such as its limited ability to explain the output results, uncertain benefits regarding patient outcomes, and incomplete integration in daily workflow. In this review article, we will introduce the potential clinical applications of deep learning technology in thoracic radiology and discuss several challenges for its implementation in daily clinical practice.

Atrial invasion and showering phenomenon in primary lung cancer: A case report

Advanced lung cancer can have numerous extra-pulmonary complications. Due to the proximity to the heart, cardiac invasion and the subsequent seeding of the tumor into the vascular system present numerous challenges in physician team care coordination. Here we have a 55-year-old male who presented with stroke symptoms in the setting of undiagnosed advanced lung cancer complicated by direct tumor invasion into the left atria and mixed embolic showering phenomenon and thrombotic hypercoagulability. Review of both the embolic showering phenomenon and hypercoagulability will be discussed as both can result in embolic occlusion or metastatic seeding at distant sites. Fewer than ten cases of spontaneous tumor embolization resulting from lung cancer invasion of the pulmonary vein have been reported. Poor prognosis of advanced lung cancer requires delicate, yet pragmatic conversations between care teams and the patient.

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Lung cancer has potential sequelae that extend well beyond confines of pulmonary pleura.

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Caution is needed when differentiating between tumor extension and metastatic seeding for atrial masses in the setting of lung cancer.

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The showering phenomenon of tumor emboli should be considered when presented with stroke symptoms that cannot be attributed to a unilateral deficit or when multiple areas of the brain are affected.