2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer

Predictive model of the first failure pattern in patients receiving definitive chemoradiotherapy for inoperable locally advanced non-small cell lung cancer (LA-NSCLC)

Purpose

To analyze patterns of failure in patients with LA-NSCLC who received definitive chemoradiotherapy (CRT) and to build a nomogram for predicting the failure patterns in this population of patients.

Materials and methods

Clinicopathological data of patients with LA-NSCLC who received definitive chemoradiotherapy and follow-up between 2013 and 2016 in our hospital were collected. The endpoint was the first failure after definitive chemoradiotherapy. With using elastic net regression and 5-fold nested cross-validation, the optimal model with better generalization ability was selected. Based on the selected model and corresponding features, a nomogram prediction model was built. This model was also validated by ROC curves, calibration curve and decision curve analysis (DCA).

Results

With a median follow-up of 28 months, 100 patients experienced failure. There were 46 and 54 patients who experience local failure and distant failure, respectively. Predictive model including 9 factors (smoking, pathology, location, EGFR mutation, age, tumor diameter, clinical N stage, consolidation chemotherapy and radiation dose) was finally built with the best performance. The average area under the ROC curve (AUC) with 5-fold nested cross-validation was 0.719, which was better than any factors alone. The calibration curve revealed a satisfactory consistency between the predicted distant failure rates and the actual observations. DCA showed most of the threshold probabilities in this model were with good net benefits.

Conclusion

Clinicopathological factors could collaboratively predict failure patterns in patients with LA-NSCLC who are receiving definitive chemoradiotherapy. A nomogram was built and validated based on these factors, showing a potential predictive value in clinical practice.

International guidelines on stage III N2 nonsmall cell lung cancer: surgery or radiotherapy?

Stage III N2 nonsmall cell lung cancer (NSCLC) is a complex disease with poor treatment outcomes. For patients in whom the disease is considered technically resectable, the main treatment options include surgery (with neoadjuvant or adjuvant chemotherapy/neoadjuvant chemoradiotherapy (CRT)) or CRT followed by adjuvant immunotherapy (dependent on programmed death ligand 1 status). As there is no clear evidence demonstrating a survival benefit between these options, patient preference plays an important role. A lack of a consensus definition of resectability of N2 disease adds to the complexity of the decision-making process. We compared 10 international guidelines on the treatment of NSCLC to investigate the recommendations on preoperatively diagnosed stage III N2 NSCLC. This comparison simplified the treatment paths to multimodal therapy based on surgery or radiotherapy (RT). We analysed factors relevant to decision-making within these guidelines. Overall, for nonbulky mediastinal lymph node involvement there was no clear preference between surgery and CRT. With increasing extent of mediastinal nodal disease, a tendency towards multimodal treatment based on RT was identified. In multiple scenarios, surgery or RT-based treatments are feasible and patient involvement in decision-making is critical.

For many patients with stage III N2 NSCLC, radiotherapy or surgery are options and should be discussed with the patienthttp://bit.ly/2Z39MW5

The Role of Prophylactic Cranial Irradiation in Patients With Non-small Cell Lung Cancer: An Updated Systematic Review and Meta-Analysis

Background: The purpose of this study was to reevaluate the efficacy of prophylactic cranial irradiation (PCI) in non-small cell lung cancer (NSCLC) with the most recent published data and to identify subgroups who may be more likely to gain benefit from PCI.

Methods: We searched PubMed, Embase, and Cochrane databases for randomized trials comparing PCI with non-PCI in NSCLC patients. We pooled the data of randomized controlled trials and compared brain metastasis (BM) and overall survival (OS) between PCI group and non-PCI group.

Results: Seven studies including 1,462 patients were eligible for the current meta-analysis. Compared to non-PCI group, PCI group achieved decreased BM (RR = 0.37, 95% CI: 0.26–0.52) but similar OS (HR = 1.01, 95% CI: 0.87–1.22). In subgroup analyses of BM, PCI decreased BM for subgroups by pathology (squamous cell carcinoma or non-squamous cell carcinoma) and local treatment modality (surgery or no surgery). However, PCI failed to reduce BM for patients with poor performance status (WHO 2–3). The incidence of PCI related toxicities was low and PCI was well-tolerated by the majority of NSCLC. Low grade neurocognitive function (NCF) decline was reported in NAVLT study and greater deterioration in immediate and delayed recall was reported in RTOG 0214. No significant difference in quality of life (QOL) after PCI was reported.

Conclusion: PCI reduces the incidence of BM except for patients with poor performance status. However, PCI fails to prolong OS significantly for NSCLC. An individual patient data meta-analysis may identify patients that could achieve OS prolongation with PCI.

Long Non-Coding RNA in Drug Resistance of Non-Small Cell Lung Cancer: A Mini Review

Lung cancer is one of main causes of cancer mortality and 83% of lung cancer cases are classified as non-small cell lung cancer (NSCLC). Patients with NSCLC usually have a poor prognosis and one of the leading causes is drug resistance. With the progress of drug therapy, the emergence and development of drug resistance affected the prognosis of patients severely. Accumulating evidence reveals that long non-coding RNAs (lncRNAs), as “dark matters” of the human genome, is of great significance to drug resistance in NSCLC. Herein, we review the role of lncRNAs in drug resistance in NSCLC.

Asian Thoracic Oncology Research Group Expert Consensus Statement on Optimal Management of Stage III NSCLC

Stage III NSCLC represents a heterogeneous disease for which optimal treatment continues to pose a clinical challenge. Recent changes in the American Joint Commission on Cancer staging to the eighth edition has led to a shift in TNM stage grouping and redefined the subcategories (IIIA-C) in stage III NSCLC for better prognostication. Although concurrent chemoradiotherapy has remained standard-of-care for stage III NSCLC for almost 2 decades, contemporary considerations include the impact of different molecular subsets of NSCLC, and the roles of tyrosine kinase inhibitors post-definitive therapy and of immune checkpoint inhibitors following chemoradiotherapy. With rapid evolution of diagnostic algorithms and expanding treatment options, the need for interdisciplinary input involving multiple specialists (medical oncologists, radiation oncologists, pulmonologists, radiologists, pathologists and thoracic surgeons) has become increasingly important. The unique demographics of Asian NSCLC pose further challenges when applying clinical trial data into clinical practice. This includes differences in smoking rates, prevalence of oncogenic driver mutations, and access to health care resources including molecular testing, prompting the need for critical review of existing data and identification of current gaps. In this expert consensus statement by the Asian Thoracic Oncology Research Group, an interdisciplinary group of experts representing Hong Kong, Korea, Japan, Taiwan, Singapore, Thailand, Malaysia, and Mainland China was convened. Standard clinical practices for stage III NSCLC across different Asian countries were discussed from initial diagnosis and staging through to multi-modality approaches including surgery, chemotherapy, radiation, targeted therapies, and immunotherapy.

Postoperative Radiotherapy for Resected Stage IIIA-N2 Non-small-cell Lung Cancer: A Population-Based Time-Trend Study

INTRODUCTION

The value of postoperative radiotherapy (PORT) for resected stage IIIA-N2 non-small-cell lung cancer (NSCLC) is controversial with few studies focusing on whether PORT always plays a part in clinical practice and generates benefits to patients across different time periods. We investigated this issue using the Surveillance, Epidemiology, and End Results Database (SEER) and assessed the temporal trends spanning 27 years.

METHODS

Within SEER, we selected stage IIIA-N2 NSCLC patients who underwent a lobectomy or pneumonectomy and coded as receiving PORT or never receiving radiotherapy over three time periods: 1988 to 1996, 1997 to 2005, 2006 to 2014. For each period, survival analyses were performed and propensity score matching (PSM) was used in the potentially beneficial subgroup.

RESULTS

45.4% of 5568 eligible patients received PORT. The yearly PORT use rates varied largely from 27.8% to 74.4%. Overall survival (OS) was distinctly improved over the period. The application of PORT had a significant impact on survival only in period 1 and 3. In subgroup analysis, the OS benefit of PORT was significant in each period in patients with 50% or more lymph node ratio (LNR) both before (hazard ratios, and P values of 0.647, P = .002; 0.804, P = .008; 0.721, P < .001 for period 1, 2, 3, respectively) and after PSM (0.642, P = .006; 0.785, P = .004; 0.748, P = .003 for period 1, 2, 3, respectively).

CONCLUSIONS

The benefits of PORT are lasting and stable throughout the years in patients with LNR of 50% or more. This might provide a clue on proper patient selection for PORT application.

Immunotherapy of brain metastases: breaking a "dogma"

Until very few years ago, the oncology community dogmatically excluded any clinical potential for immunotherapy in controlling brain metastases. Therefore, despite the significant therapeutic efficacy of monoclonal antibodies to immune check-point(s) across a wide range of tumor types, patients with brain disease were invariably excluded from clinical trials with these agents. Recent insights on the immune landscape of the central nervous system, as well as of the brain tumor microenvironment, are shedding light on the immune-biology of brain metastases.Interestingly, retrospective analyses, case series, and initial prospective clinical trials have recently investigated the role of different immune check-point inhibitors in brain metastases, reporting a significant clinical activity also in this subset of patients. These findings, and their swift translation in the daily practice, are driving fundamental changes in the clinical management of patients with brain metastases, and raise important neuroradiologic challenges. Along this line, neuro-oncology undoubtedly represents an additional area of active investigation and of growing interest to support medical oncologists in the evaluation of clinical responses of brain metastases to ICI treatment, and in the management of neurologic immune-related adverse events.Aim of this review is to summarize the most recent findings on brain metastases immunobiology, on the evolving scenario of clinical efficacy of ICI therapy in patients with brain metastases, as well as on the increasing relevance of neuroradiology in this therapeutic setting.

Feasibility of postoperative adjuvant chemotherapy using carboplatin plus S-1 in completely resected non-small cell lung cancer patients

Feasibility is one of the major concerns during adjuvant chemotherapy in patients with completely resected non-small cell lung cancer. A phase II clinical trial of adjuvant chemotherapy with four courses of carboplatin (AUC 5 at day 1) and S-1 (80 mg/m²/day for 2 weeks followed by a 2-week rest) was performed to evaluate the feasibility (UMIN 9101). The primary endpoint was the completion rate and the secondary endpoints were adverse events, 2-year overall survival and disease-free rates. Thirty-five non-small cell lung cancer patients were enrolled. The adjuvant chemotherapy completion rate was 85.3% (29/34); 17/34 (50%) patients completed 4 courses without dose reduction. There were no treatment-related deaths, and Grade 3/4 adverse events included neutropenia (38.2%), leukocytopenia (14.7%), anemia (20.6%), thrombocytopenia (20.6%), anorexia (5.9%), fatigue (5.9%), and oral mucositis (2.9%). Two-year overall and disease-free survival rates were 96.3% and 53.3%, respectively. Adjuvant chemotherapy with carboplatin plus S-1 is safe and feasible.

[Definitive or neo-adjuvant chemoradiation in esophageal carcinoma?]

Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.

PET/MRI versus PET/CT in oncology: a prospective single-center study of 330 examinations focusing on implications for patient management and cost considerations

Purpose

PET/MRI has recently been introduced into clinical practice. We prospectively investigated the clinical impact of PET/MRI compared with PET/CT, in a mixed population of cancer patients, and performed an economic evaluation of PET/MRI.

Methods

Cancer patients referred for routine staging or follow-up by PET/CT underwent consecutive PET/CT and PET/MRI, using single applications of [¹⁸F]FDG, [⁶⁸Ga]Ga-DOTANOC, or [¹⁸F]FDOPA, depending on tumor histology. PET/MRI and PET/CT were rated separately, and lesions were assessed per anatomic region; based on regions, per-examination and per-patient accuracies were determined. A simulated, multidisciplinary team meeting served as reference standard and determined whether differences between PET/CT and PET/MRI affected patient management. The McNemar tests were used to compare accuracies, and incremental cost-effectiveness ratios (ICERs) for PET/MRI were calculated.

Results

Two hundred sixty-three patients (330 same-day PET/CT and PET/MRI examinations) were included. PET/MRI was accurate in 319/330 examinations and PET/CT in 277/330 examinations; the respective accuracies of 97.3% and 83.9% differed significantly (P < 0.001). The additional findings on PET/MRI—mainly liver and brain metastases—had implications for patient management in 21/263 patients (8.0%). The per-examination cost was 596.97 EUR for PET/MRI and 405.95 EUR for PET/CT. ICERs for PET/MRI were 14.26 EUR per percent of diagnostic accuracy and 23.88 EUR per percent of correctly managed patients.

Conclusions

PET/MRI enables more appropriate management than PET/CT in a nonnegligible fraction of cancer patients. Since the per-examination cost is about 50% higher for PET/MRI than for PET/CT, a histology-based triage of patients to either PET/MRI or PET/CT may be meaningful.

Pulmonary function changes following helical tomotherapy in patients with inoperable, locally advanced non-small cell lung cancer

PURPOSE

To evaluate alterations in pulmonary function indices after helical tomotherapy and explore potential associations with biologically corrected dosimetric parameters.

PATIENTS AND METHODS

In 64 patients with inoperable locally advanced non-small cell lung cancer, pulmonary function tests before and within 6 months after radiotherapy were evaluated retrospectively. In the case of concurrent chemotherapy a total dose of 67.2 Gy was delivered, otherwise 70.5 Gy was provided. In 44 patients, late pulmonary function changes (≥6 months after radiotherapy) could also be assessed.

RESULTS

In the entire patient group, there were significant declines in forced expiratory volume in 1s (FEV₁) (average change -4.1% predicted; P = 0.007), in forced vital capacity (FVC) (-4.9% predicted; P = 0.002), total lung capacity (TLC) (-5.8% predicted; P = 0.0016) and DL_CO (diffusing capacity of the lung for carbon monoxide corrected for hemoglobin level) (-8.6% predicted; P < 0.001) during the first 6 months. Corresponding FEV₁, FVC, TLC and DL_CO declines in the subgroup with late measurements (after 11.3 months on average) were -5.7, -7.4, -7.0, -9.8% predicted. A multivariate analysis including V_5 Gy, V_10 Gy, V_20 Gy, V_40 Gy, V_60 Gy, mean lung dose (MLD), gross tumor volume (GTV) and planning target volume (PTV) as potential covariates showed that GTV was the most consistent contributor, being significant for ∆FEV₁ (P = 0.003), ∆FVC (P = 0.003), ∆TLC (P = 0.001) and ∆DL_CO (P = 0.01). V_5 Gy or V_10 Gy did not contribute to any of the lung function changes.

CONCLUSIONS

The decline in pulmonary function indices after helical tomotherapy was of similar magnitude to that observed in studies reporting the effect of conformal radiotherapy on lung function. Diffusion capacity was the parameter showing the largest decrease following radiation therapy as compared to baseline and correlated with gross tumor volume. None of the alterations in pulmonary function tests were associated with the lung volume receiving low-dose radiation.

Prediction of chemotherapy adverse reactions and mortality in older patients with primary lung cancer through frailty index based on routine laboratory data

Objectives

To assess the role of a pre-chemotherapy frailty index based on routine laboratory data in predicting mortality and chemotherapy adverse reactions among older patients with primary lung cancer.

Design

Retrospective cohort study.

Setting

West China Hospital, Chengdu, China.

Participants

We included patients aged ≥60 years with primary lung cancer receiving the first course of chemotherapy.

Measurements

Data were collected from medical records, local government death databases or telephone interviews. Outcomes included chemotherapy adverse reactions and all-cause mortality. We constructed a frailty index based on 44 laboratory variables (FI-LAB) before chemotherapy, and chose the following cutoff points: robust (0.0-0.2), pre-frail (0.2-0.35) and frail (≥0.35).

Results

We included 1,020 patients (71.4% male; median age: 65 years old). Both pre-frailty and frailty was associated with any chemotherapy adverse reactions and infections during chemotherapy (OR=3.48, 95%CI: 1.77-6.87; OR=3.58, 95%CI: 1.55-8.26, respectively). Frail patients had a shorter median overall survival rate compared to robust patients (18.05 months vs 38.89 months, log-rank p<0.001). After adjusting for some potential confounding variables, the risk of all-cause mortality was dramatically increased in frail patients (HR:2.13, 95% CI:1.51-3.00) with an average follow-up of 3.9 years. Each 0.01 or per standard deviation (SD) increase in the FI-LAB value significantly increased the HR of death by 2.0% (HR:1.02, 95% CI: 1.01-1.03) and 23.0% (HR: 1.23, 95% CI: 1.13-1.34), respectively.

Conclusions

Frailty assessed by routine laboratory data indicates increased risks of chemotherapy adverse reactions and death in older patients with primary lung cancer receiving the first course of chemotherapy.

Expression of CENPE and its Prognostic Role in Non-small Cell Lung Cancer

Background

Non-small cell lung cancer (NSCLC) is one of the most important causes of death worldwide. Most patients are diagnosed in the advanced stage and have a poor prognosis. This study was to investigate the expression and significance of CENPE in NSCLC.

Method

Collecting information about CENPE in the Oncoming database, and perform a further analysis of the data in the current database to conduct a meta-analysis for its functional role in NSCLC. Patient life cycle analysis using Kaplan-Meier Plotter and GEPIA databases are used to perform patient survival analysis.

Result

A total of 12 studies involved the expression of CENPE in NSCLC cancer tissues and normal tissues, including 1195 samples. CENPE was highly expressed in NSCLC cell carcinoma compared with the control group (P < 0.05). Moreover, the expression of CENPE was correlated with the overall survival rate of CENPE. The overall survival rate of patients with high expression of CENPE was poor, and the prognosis of patients with low expression of CENPE was better (P<0.05).

Conclusion

We propose high expression of CENPE in NSLCL tissue is related to the prognosis of NSCLC, which may provide important basis for the development of tumor drugs.

Comparison of efficacy and safety between simultaneous integrated boost intensity-modulated radiotherapy and conventional intensity-modulated radiotherapy in locally advanced non-small-cell lung cancer: a retrospective study

Background

Consistent results are lacking as regards the comparative effectiveness of simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) versus conventional intensity-modulated radiotherapy in patients with locally advanced non-small-cell lung cancer (LA-NSCLC). Therefore, we conducted a retrospective analysis to demonstrate the role of SIB-IMRT for patients.

Methods

Patients who had histologically confirmed NSCLC, stage III disease and received thoracic IMRT between 2014 and 2016 were retrospectively reviewed. The survival, toxicities and dose to organs at risk (OAR) were compared among patients irradiated with different techniques. The SIB-IMRT plans were designed to deliver 45–59.4Gy (median: 50.4Gy) to PTV while simultaneously delivering 50-70Gy (median: 59.92Gy) to PGTV. As for conventional IMRT plans, a total dose of 50-70Gy (median: 60Gy) was delivered to PTV.

Results

426 patients with stage III NSCLC were eligible for analysis, including 128 with SIB-IMRT and 298 with conventional IMRT. The SIB-IMRT group had more stage IIIB disease (69.5% vs. 53%, P = 0.002), larger planning treatment volumes (median: 504 ml vs. 402 ml, P<0.001), and a larger planning treatment volume/volume of lung ratio (median, 0.18 vs. 0.12, P<0.001). The median OS of the SIB-IMRT and conventional IMRT groups were 34.5 and 31.7 months, with the 2-year rate of 60.4 and 59%, respectively (P = 0.797). No difference in PFS, LRFS or DMFS was observed between the two techniques. Patients treated with SIB-IMRT got similar lung and esophageal toxicities versus those with conventional IMRT.

Conclusions

SIB-IMRT may be an effective and safe option for patients with locally advanced NSCLC, especially for those with large mass or wide lymph node metastasis.

'Stemness' and 'senescence' related escape pathways are dose dependent in lung cancer cells surviving post irradiation

AIMS

Lung cancer is one of the main causes of cancer-related deaths worldwide and radiotherapy is a major treatment of choice. However, radioresistance is a main reason for radiotherapy failure or tumor relapse. Here, we investigated possible mechanisms associated with cancer cell radioresistance.

MATERIALS AND METHODS

We compared two newly derived cell lines, namely A549-IR3 and A549-IR6, which survived repeated (3 or 6 times) 4 Gy exposure of parental A549 lung cancer cell line. DNA repair ability, stemness and senescence were comparatively studied.

KEY FINDINGS

A549-IR3 exhibited higher proliferation ability and radioresistance compared to parental and A549-IR6 cells. Enhanced radioresistance was not accompanied by chemoresistance to cisplatin or docetaxel. DNA repair kinetics (γΗ2ΑΧ expression) were similar in all cell lines. A549-IR3 cells exhibited a significant rise in stem cell markers (CD44, CD133, OCT4, SOX2 and NANOG) whereas A549-IR6 displayed an increased senescent population.

SIGNIFICANCE

Cancer cells surviving after radiotherapy may follow two different escape pathways: selection for radioresistance resulting in regrowth, and in clinical terms relapse, or above an irradiation threshold, stem-cells die and cancer cells become senescent, leading the tumor to a state of dormancy.

Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer

Stage III non-small cell lung cancer (NSCLC) is a very heterogeneous disease that encompasses patients with resected, potentially resectable and unresectable tumours. To improve the prognostic capacity of the TNM classification, it has been agreed to divide stage III into sub-stages IIIA, IIIB and IIIC that have very different 5-year survival rates (36, 26 and 13%, respectively). Currently, it is considered that both staging and optimal treatment of stage III NSCLC requires the joint work of a multidisciplinary team of expert physicians within the tumour committee. To improve the care of patients with stage III NSCLC, different scientific societies involved in the diagnosis and treatment of this disease have agreed to issue a series of recommendations that can contribute to homogenise the management of this disease, and ultimately to improve patient care.

Delineating the pattern of treatment for elderly locally advanced NSCLC and predicting outcomes by a validated model: A SEER based analysis

INTRODUCTION

Locally advanced nonsmall-cell lung cancer (LA-NSCLC) represented a highly heterogeneous group, with more than half of the patients aged ≥65 years at the time of diagnosis. However, the optimal treatment for elderly LA-NSCLC patients was still not defined.

METHODS

A total of 33530 elderly patients (≥65 years) diagnosed with LA-NSCLC from 2004 to 2014 were identified from Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

Locally advanced nonsmall-cell lung cancer patients aged 65-74 years were more frequently treated with chemoradiotherapy (CRT) (40%), while patients aged ≥75 years received more best supportive care (BSC) (36%). For age group of 65-74 years, patients who had surgery with or without (neo)adjuvant therapy had a median survival of 28 months, CRT 15 months, radiotherapy (RT) alone 6 months, chemotherapy alone 11 months, and BSC 3 months; while for patients aged ≥ 75 years, the median OS was 20, 13, 7, 9, and 2, respectively. Besides, independent clinicopathological factors were integrated into nomograms for OS and CSS prediction, C-indexes achieved 0.692 and 0.698, respectively. Importantly, the discrimination of nomogram was superior to that of the American Joint Committee on Cancer TNM classification (0.742 vs 0.572 for training set and 0.731 vs 0.565 for validation set).

CONCLUSION

For elderly patients with LA-NSCLC, the curative-intent treatment (surgery or CRT) conferred better survival compared to chemotherapy alone, RT alone and BSC. The proposed nomograms based on independent clinicopathological variables may be practical and helpful for precise evaluation of patient prognosis, and guiding the individualized treatment for elderly LA-NSCLC.

The multifaceted roles of FOXM1 in pulmonary disease

Forkhead box M1 (FOXM1), a transcriptional regulator of G1/S and G2/M transition and M phase progression in the cell cycle, plays a principal role in many physiological and pathological processes. A growing number of studies have focused on the relationship between abnormal FOXM1 expression and pulmonary diseases, such as lung cancer, chronic obstructive pulmonary disease (COPD), asthma, acute lung injury (ALI), pulmonary fibrosis, and pulmonary arterial hypertension (PAH). These studies indicate that the FOXM1 regulatory network is a major predictor of poor outcomes, especially in lung cancer, and provide novel insight into various pulmonary diseases. For the first time, this review summarizes the mechanistic relationship between FOXM1 dysregulation and pulmonary diseases, the benefits of targeting abnormal FOXM1 expression, and the questions that remain to be addressed in the future.

[Review on Treatment Modalities for Resectable IIIa/N2 Non-small Cell Lung Cancer]

Standard treatment for resectable IIIa/N2 non-small-cell lung cancer (NSCLC) is still under debate. Optional treatments include chemotherapy, radiotherapy and surgery, other options include target therapy and immunotherapy. Multidisciplinary treatment has therefore been emphasized by various clinical trials, including bimodality strategy which has been defined as chemotherapy plus surgery or chemotherapy plus radiotherapy, and trimodality treatment which refers to chemotherapy plus surgery and radiotherapy. However, there is still no consensus on the optimal strategy on treating resectable IIIa/N2 NSCLC. Therefore, we reviewed a series of phase II and III clinical trials as well as some meta-analyses and case reports to compare the efficacy of different strategies on survival of cN2 NSCLC, and concluded that for resectable IIIa/N2 NSCLC surgery is recommended, and that strategy of chemotherapy plus surgery may not achieve better survival than that of chemotherapy plus radiotherapy. Size of tumor as well as lymph nodes should be taken into account when choosing optimal therapy, so that promising individualized strategy could be given to patients with resectable stage IIIa/N2 NSCLC.
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Developing a New qPCR-Based System for Screening Mutation

An accurate genotyping analysis is one of the critical prerequisites for lung cancer targeted therapy. Here, a quantitative polymerase chain reaction (qPCR)-based mutation detection system, mutation-selected amplification-specific system PCR (MASS-PCR), is developed. The specific primers and probes used in MASS-PCR exactly match with the mutant sequence that only allows mutant gene to emit the fluorescence peak. To determine the sensitivity of MASS-PCR, 717 lung cancer specimens, 61 formalin-fixed paraffin-embedded (FFPE) tissues, and 656 fresh reaction tissues are collected and undergo mutation detection of lung cancer driver genes (EGFR, KRAS, BRAF, HER2, MET, ALK, and ROS1). These samples are divided into two groups. Mutations in Group I, which has 631 fresh reaction tissues, are analyzed by MASS-PCR and the amplification refractory mutation system PCR (ARMS-PCR). While group II samples, 25 fresh reaction tissues and 61 FFPE tissues, are screened through MASS-PCR and next-generation sequencing (NGS). All results are verified by direct sequencing. MASS-PCR shows high consistency with ARMS-PCR (kappa value > 0.733) and NGS (kappa value = 0.79) (P < 0.001). For the samples with inconsistent MASS-PCR and ARMS-PCR results, DS results more likely support the MASS-PCR results. These data suggest that MASS-PCR is a convenient, accurate, and economical method for the detection of lung cancer driver gene mutations in clinical practice.

Unmet Clinical Need in the Management of Locally Advanced Unresectable Lung Cancer: Treatment Strategies to Improve Patient Outcomes

Stage III locally advanced non-small cell lung cancer (LA NSCLC) comprises the most heterogeneous group of patients, accounts for one-third of patients with lung cancer, and is unresectable at presentation. Multiple treatment approaches have evolved over the past few decades focusing on timing of chemoradiation (concurrent vs. sequential) and sequencing of therapy (induction vs. consolidation). Concurrent chemoradiation (CCRT) emerged as the standard of care for the majority of the patients worldwide. Despite improvements in median and overall survival (OS) using the concurrent approach, the rate of distant failure remains high. Consolidation with chemotherapy or targeted agents, adding more radiation dose, or induction chemotherapy did not improve OS. With continued research on defining optimal radiation doses and schedules and integrating novel systemic agents, immunotherapy consolidation has renewed optimism. Synergistic use of radiation and immunotherapy can prevent micrometastatic disease and reduce local failure and may have an abscopal effect in addition to survival benefits. The PACIFIC study reported an absolute progression-free survival benefit of 11.2 months with durvalumab consolidation after standard CCRT compared with placebo. The OS data with durvalumab consolidation are encouraging. Durvalumab is the only approved immunotherapy for unresectable stage III LA NSCLC. Improved survival confirms the definitive role of durvalumab as an effective adjuvant therapy after CCRT with no new safety signals. However, the potential mechanisms driving interaction between immunotherapy and chemoradiotherapy require definitive investigation. These mechanisms may help define the timing of immunotherapy initiation as neoadjuvant, adjuvant, or consolidation and maintenance therapy after progression. FUNDING: AstraZeneca Pharma India Limited.

The role of tumour volume as a prognostic factor in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy

Background

It has been shown that patients with a greater tumour volume have poorer outcomes following definitive radiotherapy but its exact role remains unclear. The purpose of this study is to investigate the role of tumour volume as a prognostic indicator in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy in a single institution over 10 years.

Methods

In total, 167 patients with NSCLC treated by definitive (chemo)radiotherapy were retrospectively reviewed between 2006 and 2015. Patient demographics, disease characteristics and tumour volume parameters were collected. Univariate analyses were carried out using Kaplan–Meier survival curves to assess the association of potential prognostic factors with the primary endpoints of overall survival (OS) rates and locoregional recurrence rates. Multivariate analyses were carried out using a Cox regression method.

Results

The median total tumour volume (TTV), defined as the gross tumour volume plus the volume of involved nodes, was 103 cm3. Patients were divided into small and large tumour groups based on this median. OS rates at 1, 3 and 5 years for smaller volumes were 69%, 24% and 13% and for larger volumes 48%, 14% and 8%, respectively. On univariate survival analyses larger TTV was significantly associated with poorer OS (p= 0·019). The concurrent use of chemotherapy significantly improved survival (p= 0·026). Nodal involvement (p= 0·03) and Eastern Cooperative Oncology Group performance status (p&lt; 0·001) were also significant independent prognostic factors of OS. On multivariate analysis TTV was strongly predictive of survival (p= 0·03; hazard ratio 1·702, 95% confidence interval 1·198–2·415). There was no association between nodal volume, tumour stages, overall stage, age, histology and radiation dose with any of the primary endpoints.

Conclusion

TTV is a significant prognostic factor in patients with advanced NSCLC treated by radical radiotherapy. In this cohort of patients TTV is more reliable at predicting survival than T stage and overall stage.

New revisions and current issues in the eighth edition of the TNM classification for non-small cell lung cancer

In the eighth edition of the TNM classification of lung cancer, the prognostic impact of tumor size is emphasized as a descriptor of all T categories. Especially in lung cancer where tumor size is 5 cm or less, the 1-cm cutoff point significantly differentiated the survival outcome. In addition, the new staging categories were assigned, namely, Tis (adenocarcinoma in situ) and T1mi (minimally invasive adenocarcinoma). Furthermore, the measurement of a radiological solid component size excluding the ground glass opacity component or pathological invasive size without a lepidic component was proposed for deciding the cT/pT categories for lung adenocarcinoma. The N descriptors were kept the same as in the eventh edition on the whole, however, quantification of nodal disease had a prognostic impact based on the number of nodal stations involved in the eighth edition, i.e. N1a as a single N1 station, N1b as a multiple N1 station, N2a1 as a single N2 station without N1 (skip metastasis), N2a2 as a single N2 station with N1 disease, and N2b as a multiple N2 station. In the M descriptors, subclassification was performed based on the location or numbers of distantly metastatic lesions, i.e. M1a as any intrathoracic metastases, M1b as a single distant metastatic lesion in one organ, and M1c as multiple distant metastases in either a single organ or multiple organs. Survival analysis of the eighth edition of the TNM classification clearly separated the distinct groups, however, unsolved issues still remain that should be discussed and further revised for the forthcoming TNM staging system.

Eosinophil peroxidase over-expression predicts the clinical outcome of patients with primary lung adenocarcinoma

Eosinophil peroxidase (EPO), a heme protein abundantly expressed in eosinophils, involves in the catalysis of cytotoxic oxidants associated with the pathogenesis of cancer, asthma, and allergic inflammatory disorders. To date, its roles in the pathogenesis of lung cancer are still not known. We determined the expression of EPO in the lung adenocarcinoma tissues and the normal adjacent lung tissues using Real-time PCR and Western blotting analysis, respectively. Also, EPO protein expression in 90 lung adenocarcinoma (AD) samples were confirmed with immunohistochemistry (IHC) using tissue microarrays. Meanwhile, we investigated the association between EPO and the clinicopathological characteristics and disease prognosis in the pulmonary adenocarcinoma patients, which demonstrated that EPO mRNA and protein were significantly higher in lung AD tissues that those of the adjacent normal lung tissues (P<0.05). EPO overexpression was significantly correlated with pathologic-tumour nodes metastasen stage (p-TNM stage, P=0.017) and lymph node metastasis (P=0.027). Patients with EPO overexpression showed shorter survival time than those with low EPO levels (P=0.017), according to the Kaplan-Meier survival curve. Furthermore, a multivariate Cox regression model was utilized to analyze the prognostic factors, which indicated that N stage (HR=0.965, 95% CI=0.328-1.359, P=0.008), p-TNM Stage (HR=3.127, 95% CI =2.463-5.015, P=0.021) and high EPO protein expression (HR=3.145, 95% CI=2.016-5.519, P=0.018) were independent factors for the prognosis of lung AD. In conclusion, increased EPO expression could be used as a biomarker for lung AD patients with poor prognosis.

Prognostic value of adjuvant therapy in T4 non-small cell lung cancer: An inverse probability of treatment weighting analysis

Background

According to the current clinical guidelines, chemoradiotherapy is considered the standard treatment for locally advanced non‐small cell lung cancer (NSCLC). We analyzed the prognostic effect of adjuvant chemotherapy (ACT) in resected patients using the new eighth tumor node metastasis (TNM) staging systems based on the Surveillance, Epidemiology and End Results database.

Methods

We identified 3008 patients with stage IIIA NSCLC (T4N0M0) who underwent sublobar resection, lobectomy, or pneumonectomy. Covariates affecting treatment selection or survival were included as part of propensity score models for matching and weighting. The effect of ACT on survival was assessed, stratified by postoperative radiation therapy (PORT) use, tumor size, and age.

Results

Analyses of 2016 patients were conducted with standardized differences in covariates < 10% after matching. ACT was associated with significantly improved five‐year overall survival (51.1% vs. 39.7%; P = 0.0260) in patients aged 21–65 with > 7 cm tumors, even after adjusting for the presence or absence of the superior sulcus (P = 0.0003). No significant outcomes were observed using other stratifications in the matched analysis. Moreover, ACT with PORT conferred a potential survival benefit in 21–65‐year‐old patients with 0–7 cm tumors (for all causes of death: hazard ratio 0.414, 95% confidence interval 0.251–0.684).

Conclusion

In this population‐based cohort, ACT prolonged the survival of patients aged 21–65 with a tumor > 7 cm, with or without PORT. Inverse probability of treatment weighting can estimate the treatment effect and is suitable for use with survival data.

Role of EBUS TBNA in Staging of Lung Cancer: A Clinician's Perspective

The treatment of non-small cell lung cancer (NSCLC) includes surgical resection with curative intent in early-stage disease and chemoradiation in the advanced stage disease. Therefore, an accurate preoperative mediastinal lymph node staging is required not only to offer the appropriate treatment but also to avoid unnecessary invasive procedures including thoracotomy. The mediastinal lymph nodes can be sampled using several techniques including mediastinoscopy, surgery (open or video-assisted thoracoscopic surgery), endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), or endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). Currently, EBUS-TBNA/EUS-FNA is the preferred modality for sampling mediastinal lymph nodes because of its minimally invasive nature and high diagnostic yield. In this review, we discuss the utility of endosonographic procedures in mediastinal lymph node staging of NSCLC.

Health Outcomes for Definite Concurrent Chemoradiation in Locally Advanced Non-Small Cell Lung Cancer: A Prospective Study

BACKGROUND

In patients with locally advanced lung cancer treated with concurrent chemoradiation, outcome measurements have been mostly limited to survival.

OBJECTIVES

We aimed to measure outcomes that matter to these patients beyond survival in a general clinical practice.

METHODS

In a prospective single-centre study, consecutive patients with locally advanced non-small cell lung cancer reported their own outcomes using the EORTC Quality of Life Questionnaire Core 30 at baseline, during therapy, at therapy stop and till 1 year after therapy end every 3 months. Survival, complications, quality of death and case-mix variables were measured.

RESULTS

There were 32 consecutive patients included prospectively from June 2013 until September 2016. Median overall survival was 24.3 months (95% CI 12.7-35.9). Severe toxicity (grade III-IV) was frequent (haematologic toxicity III-IV in 59%). Patient-reported outcomes (PROs) documented the burden on global health status and on functional domains (physical, role, social, emotional and cognitive functioning). Deterioration was pronounced during and after treatment with drops over 20 up to 40% points from baseline for physical, role and social functioning. Clinically meaningful negative effects did persist up to 6 and 9 months for physical and role functioning. Fifty-six percent of the deceased patients died in hospital.

CONCLUSIONS

The assault on health-related quality of life during concurrent chemoradiation for locally advanced lung cancer is considerable. Loss of physical and role functioning persists up to 6 and 9 months after therapy end, respectively. Measuring PROs can help to identify issues for improvement of the value of care delivered.

Short- and long-term outcomes in elderly patients with locally advanced non-small-cell lung cancer treated using video-assisted thoracic surgery lobectomy

BACKGROUND

In recent years, video-assisted thoracic surgery (VATS) lobectomy has been used to treat locally advanced non-small-cell lung cancer (LA-NSCLC). However, VATS has not been reported in elderly patients (≥70 years) with LA-NSCLC. The purpose of this study was to compare short- and long-term outcomes of patients with LA-NSCLC aged ≥70 years and 55-69 years treated with VATS.

PATIENTS AND METHODS

From January 2012 to January 2018, a total of 83 patients with LA-NSCLC who were ≥55 years of age underwent VATS. Patients were divided into ≥70 years group (37 cases) and 55-69 years group (46 cases), based on their age at the time of VATS. Short- and long-term outcomes of these two groups of patients were compared.

RESULTS

American Society of Anesthesiologists scores of ≥70 years patients were higher than those of 55-69 years patients. No significant differences were observed when comparing the general preoperative data. For short-term outcomes, there was no significant difference between the two groups of patients in length of surgery, intraoperative blood loss, conversion to thoracotomy, postoperative 30-day complication rate and severity, postoperative 30-day mortality, pathological results, compliance with adjuvant chemotherapy, or other factors. Long-term follow-up results showed that recurrence, overall survival, and disease-free survival were similar in both groups. Furthermore, multivariate analysis showed that age was not an independent predictor of overall and disease-free survival.

CONCLUSIONS

VATS in elderly patients (≥70 years) with LA-NSCLC can result in short- and long-term outcomes similar to those of 55-69 years patients with LA-NSCLC.

RETRACTED: miR-539 enhances chemosensitivity to cisplatin in non-small cell lung cancer by targeting DCLK1

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief. An Expression of Concern for this article was previously published while an investigation was conducted (see related editorial: https://doi.org/10.1016/j.biopha.2022.113812). This retraction notice supersedes the Expression of Concern published earlier. Concern was raised about the reliability of the flow cytometry data in Figures 2C, 3C and 6C, which appear to contain similar features as found in other publications, as detailed here: https://pubpeer.com/publications/96CACC6C7EAE327217D2319DC364C5; and here: https://docs.google.com/spreadsheets/d/1r0MyIYpagBc58BRF9c3luWNlCX8VUvUuPyYYXzxWvgY/edit#gid=262337249. Examples of suspected image duplication were also identified in Figures 4A+B, 6E+F, 7C. The journal requested the corresponding author comment on these concerns and provide the associated raw data. The authors did not respond to this request and therefore the Editor-in-Chief decided to retract the article.

Oral vinorelbine-based concomitant chemoradiotherapy in unresectable stage III non-small cell lung cancer: a systematic review

INTRODUCTION

Cisplatin-based chemotherapy administered concomitantly to thoracic radiotherapy is the treatment recommended by the European guidelines for fit patients with unresectable stage III non-small cell lung cancer (NSCLC). Cisplatin may be combined with etoposide, vinorelbine or other vinca alkaloids, which act also as radiation sensitizers. Initially administered intravenously, vinorelbine is also available as oral formulation and is the only orally available microtubule-targeting agent. In addition, the oral formulation avoids the risk of extravasation and phlebitis. Areas covered: A literature search has been performed for articles reporting phase II-III trials aimed to evaluate efficacy and safety of oral vinorelbine-based chemoradiotherapy in unresectable locally advanced NSCLC. Expert commentary: In a series of trials with various protocols published from 2008 to 2018, mostly phase II studies, oral vinorelbine demonstrated a significant activity in concomitant chemoradiotherapy for unresectable locally advanced NSCLC typically as part of combination schedules with cisplatin. Main toxicities were hematologic (neutropenia and anemia); non-hematological toxicities included esophagitis and gastro-duodenal adverse events. Large prospective phase III trials are needed to confirm the role of vinorelbine-based chemotherapy associated to thoracic radiotherapy in unresectable stage III NSCLC and more particularly trials with metronomic oral vinorelbine.

[Expression of KIF23 and Its Prognostic Role in Non-small Cell Lung Cancer: Analysis Based on the Data-mining of Oncomine]

背景与目的

非小细胞肺癌（non-small cell lung cancer, NSCLC）是全球引起死亡的最重要原因之一。大多数患者发现时处于中晚期，预后较差。本研究拟探讨驱动蛋白超家族23（kinesin family member 23, KIF23）在NSCLC中的表达及意义。

方法

收集Oncomine数据库中关于KIF23的信息，并对目前数据库中资料进行二次分析，对其在NSCLC中的作用进行荟萃分析。利用Kaplan-Meier Plotter进行患者生存周期分析。

结果

Oncomine数据库中共收集了447项不同类型的研究结果，其中关于KIF23表达有统计学差异的研究结果有67个，KIF23表达增高的研究有64项、表达降低的研究有3项。共有16项研究涉及KIF23在NSCLC癌组织和正常组织中的表达，共包括1, 189个样本，与对照组相比，KIF23在NSCLC细胞癌中高表达（P＜0.05）。不仅如此，KIF23表达量与NSCLC总体生存率存在相关性，高表达KIF23的患者总体生存率较差，低表达KIF23的患者预后较好（P＜0.05）。进一步亚组分析发现，KIF23表达水平对肺腺癌患者预后有显著影响，而在鳞癌患者中，其表达水平对预后无显著影响。

结论

我们通过对Oncomine基因芯片数据库中肿瘤相关基因信息的深入挖掘，提出KIF23在NSLCL组织中高表达，且与NSCLC预后有关，可能为肿瘤药物的开发提供重要理论依据。

SNAI2 and TWIST1 in lymph node progression in early stages of NSCLC patients

Lymph node metastasis is an important prognosis factor in non-small cell lung cancer (NSCLC) patients. The aim of this study was to investigate the role of epithelial to mesenchymal transition (EMT) in lymph node progression in the early stages of NSCLC. We studied a retrospective cohort of 160 consecutive surgically treated NSCLC patients with available frozen tumor samples for expression of EMT markers (CDH1, CTNNB1, CDH2, and VIMENTIN), inducers (TGFB1, c-MET, and CAIX), and transcription factors (EMT-TF: SNAI1, SNAI2, ZEB1, TWIST1, and TWIST2). Partial EMT was more frequent in N1-2 (N+) vs N0 patients (P < .01). TGFB1 (P = .02) as well as SNAI2 (P < .01) and TWIST1 (P = .04) were the most differentially expressed genes in N+ tumors. In this group, ZEB1 was correlated with all EMT inducers and other EMT-TFs were overexpressed depending on the inducers. CAIX was an independent prognostic factor for overall survival (IC 95% HR: 1.10-5.14, P = .03). Partial EMT is involved in lymph node progression of NSCLC patients and depends on the TGFβ pathway. EMT-TFs are differentially expressed depending on EMT inducers. CAIX might be a relevant prognostic marker in early stage NSCLC.

SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer

Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.

The Relationship Between Guideline-Recommended Initiation of Therapy, Outcomes, and Cost for Patients with Metastatic Non-Small Cell Lung Cancer

BACKGROUND

Guideline-recommended therapy for metastatic non-small cell lung cancer (mNSCLC) encourages evidence-based treatment; however, there is a knowledge gap regarding the influence of guideline-recommended initiation of therapy on outcomes and cost.

OBJECTIVE

To investigate if lack of guideline-recommended initiation of first-line systemic therapy was associated with worse patient outcomes and increased costs for patients with mNSCLC.

METHODS

In this retrospective analysis, 1,344 Medicare patients with mNSCLC were identified from Humana data. Performance status (PS) was imputed using procedure, diagnosis, and durable medical equipment codes pre-index. Guideline-recommended initiation of therapy was defined as ≥1 cycle of National Comprehensive Cancer Network-recommended first-line therapy based on age and PS or targeted therapies regardless of age and PS. Demographics and clinical characteristics were compared by guideline-recommended initiation of therapy. A Cox model assessed factors associated with 6-month mortality. End-of-life quality of care indicators included hospital admission and oncology infusions 30 days preceding death and were evaluated using logistic regression models. A generalized linear model assessed the relationship between guideline-recommended initiation of therapy and total health care costs in the 6 months post-index controlling for clinical, demographic, and treatment characteristics. Logistic models for inpatient stays and emergency department visits were also evaluated.

RESULTS

Guideline-recommended therapy initiation was observed in 75.5% of patients. Patients not initiating guideline-recommended therapy were older, with a mean (SD) age of 72.5 (6.7) versus 71.2 (6.2) years (P = 0.001), and more frequently identified as having a low-income subsidy (30.0% vs. 16.4%; P < 0.001). Among the 24.6% of patients who died ≤ 6 months post-index, a greater percentage had not initiated guideline-recommended therapy (28.8% vs. 23.2%; P = 0.040). In adjusted models, PS (not initiation of guideline-recommended therapy) was predictive of mortality (patients with poor PS had an 84% higher probability of death [P = 0.014]). Among decedents, 64.2% were hospitalized, and 33.9% had an oncology-related infusion within 30 days of death, with no differences by guideline-recommended initiation of therapy. These end-of-life quality indicators were not associated with guideline-recommended initiation of therapy in adjusted models. Overall, 47.5% of patients who initiated guideline-recommended therapy were hospitalized compared with 55.0% of patients who did not (P = 0.026). Patients initiating guideline-recommended therapy had higher post-index total and oncology-related health care costs and fewer hospitalizations. In models, these differences in costs and hospitalizations were not associated with initiation of guideline-recommended therapy.

CONCLUSIONS

Most patients initiated guideline-recommended therapy, with no differences in mortality and quality of care at the end of life by guideline-recommended initiation of therapy, though adherence beyond treatment initiation was not assessed. Unadjusted hospitalization rates were lower and costs were higher for patients who initiated guideline-recommended therapy. These differences were no longer observed after risk adjustment, suggesting that they may have been influenced by patient characteristics, disease progression, and subsequent treatment decisions.

DISCLOSURES

This study was sponsored by Genentech. Khoury, Michael, Parikh, and Bunce are employed by Genentech. Casebeer, Drzayich Antol, DeClue, Hopson, Li, and Stemkowski are employed by Comprehensive Health Insights, Humana, which was contracted by Genentech to conduct this study. Sehman is employed by Humana. Based on this research, 2 posters were presented at the Academy of Managed Care Pharmacy Nexus 2017 on October 16-19, 2017, in Dallas, Texas. Another poster was also presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual European Congress on October 29-November 2, 2016, in Vienna, Austria.

MEDIASTinal staging of non-small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial): study protocol of a multicenter randomised controlled trial

Background

In case of suspicious lymph nodes on computed tomography (CT) or fluorodeoxyglucose positron emission tomography (FDG-PET), advanced tumour size or central tumour location in patients with suspected non-small cell lung cancer (NSCLC), Dutch and European guidelines recommend mediastinal staging by endosonography (endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS)) with sampling of mediastinal lymph nodes. If biopsy results from endosonography turn out negative, additional surgical staging of the mediastinum by mediastinoscopy is advised to prevent unnecessary lung resection due to false negative endosonography findings. We hypothesize that omitting mediastinoscopy after negative endosonography in mediastinal staging of NSCLC does not result in an unacceptable percentage of unforeseen N2 disease at surgical resection. In addition, omitting mediastinoscopy comprises no extra waiting time until definite surgery, omits one extra general anaesthesia and hospital admission, and may be associated with lower morbidity and comparable survival. Therefore, this strategy may reduce health care costs and increase quality of life. The aim of this study is to compare the cost-effectiveness and cost-utility of mediastinal staging strategies including and excluding mediastinoscopy.

Methods/design

This study is a multicenter parallel randomized non-inferiority trial comparing two diagnostic strategies (with or without mediastinoscopy) for mediastinal staging in 360 patients with suspected resectable NSCLC. Patients are eligible for inclusion when they underwent systematic endosonography to evaluate mediastinal lymph nodes including tissue sampling with negative endosonography results. Patients will not be eligible for inclusion when PET/CT demonstrates ‘bulky N2-N3’ disease or the combination of a highly suspicious as well as irresectable mediastinal lymph node. Primary outcome measure for non-inferiority is the proportion of patients with unforeseen N2 disease at surgery. Secondary outcome measures are hospitalization, morbidity, overall 2-year survival, quality of life, cost-effectiveness and cost-utility. Patients will be followed up 2 years after start of treatment.

Discussion

Results of the MEDIASTrial will have immediate impact on national and international guidelines, which are accessible to public, possibly reducing mediastinoscopy as a commonly performed invasive procedure for NSCLC staging and diminishing variation in clinical practice.

Trial registration

The trial is registered at the Netherlands Trial Register on July 6th, 2017 (NTR 6528).

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0359-6) contains supplementary material, which is available to authorized users.

The Impact of Staging by Positron-Emission Tomography on Overall Survival and Progression-Free Survival in Patients With Locally Advanced NSCLC

INTRODUCTION

We investigated the potential impact of stage migration because of positron-emission tomography (PET) scan staging on survival in the locally advanced (stage IIIA/B) NSCLC setting.

METHODS

In PROCLAIM, 598 patients with stage IIIA/B nonsquamous NSCLC (intent-to-treat population) were randomized to either pemetrexed plus cisplatin and concurrent thoracic radiotherapy for 3 cycles followed by 4 cycles of pemetrexed consolidation or etoposide plus cisplatin and concurrent thoracic radiotherapy for 2 cycles followed by a consolidation platinum-based doublet regimen for up to 2 cycles. Baseline PET scan (PET Yes versus No) was one of the stratification factors. Subgroup analyses (PET Yes versus No) of overall survival (OS) and progression-free survival (PFS) were conducted on the intent-to-treat population regardless of treatment, as the study did not show superior efficacy for either arm.

RESULTS

Majority (491 of 598; 82.1%) of patients had a baseline PET scan staging performed. A longer median OS (PET Yes versus No: 27.2 versus 20.8; hazard ratio = 0.81, p = 0.130) and an improved median PFS (PET Yes versus No: 11.3 versus 9.2; hazard ratio = 0.73, p = 0.012) were observed for patients with PET scans compared to those with conventional staging in both treatment arms.

CONCLUSIONS

Both a significantly improved PFS and a numerically longer OS in the PET Yes subgroup, compared to patients with conventional staging, are consistent with improved survival due to stage migration. The magnitude of differences in OS and PFS based on PET scan is a reminder of the potential for factors other than the therapeutic intervention to affect outcomes.

Durvalumab: a potential maintenance therapy in surgery-ineligible non-small-cell lung cancer

Lung cancer is the most common cancer worldwide and the most common cause of cancer-related death. Non-small-cell lung cancer comprises ~87% of newly diagnosed cases of lung cancer, and nearly one-third of these patients have stage III disease. Despite improvements in the treatment of stage IV lung cancer, particularly with the introduction and dissemination of checkpoint inhibitors, very little progress has been made in the treatment of stage III lung cancer. In this article, we discuss the general staging criteria and treatment options for stage III lung cancer. We review how concurrent radiation and chemotherapy can have immunomodulatory effects, supporting the rationale for incorporating immunotherapy into existing treatment paradigms. Finally, we discuss the results of the PACIFIC trial and implications for the treatment of stage III lung cancer. In the PACIFIC trial, adding durvalumab as a maintenance therapy following the completion of chemoradiotherapy improved progression-free survival in patients with locally advanced unresectable stage III lung cancer. On the strength of these results, durvalumab has been approved by the US Food and Drug Administration for use in this setting, representing the first advance in the treatment of stage III lung cancer in nearly a decade.

Definitive radiochemotherapy versus surgery within multimodality treatment in stage III non-small cell lung cancer (NSCLC) - a cumulative meta-analysis of the randomized evidence

Randomized trials were analyzed comparing surgery with definitive radiotherapy as local curative treatment options within the framework of different multimodality treatments for patients with locally advanced non-small cell lung cancer (NSCLC). Endpoints for comparison of treatment results were overall survival, progression-free survival, and toxicity.

Hazard ratios (HR) were taken to measure treatment effects and pooled using a random effects model.

Overall survival was not significantly different between surgical and definitive radiotherapy arms (HR=0.92 [95%CI 0.82-1.04], p=0.19, χ²-test). There was heterogeneity with respect to survival at 2 years (p<0.0001, Cochran Mantel Haenszel (CMH)-test). Latter trials using concurrent radiochemotherapy (ccRT/CT) showed better survival at 2 years (risk ratio of death=0.80 [95%CI 0.73-0.88], p<0.0001, CMH-test). In the ccRT/CT trials, survival in the surgical arms tended to have an excess early mortality before 6 months of follow-up and a lesser hazard rate in comparison to definitive ccRT/CT thereafter (HR=0.78 [95%CI 0.63-0.98]). Over all trials, treatment associated mortality was higher in the surgical arms (risk ratio=3.56 [95% CI: 1.65-7.72], p=0.0005, CMH test). With respect to progression-free survival, no significant differences were found (HR=0.91 [95%CI: 0.73 - 1.13]), although the largest conducted trial found an advantage for the surgical arm (HR=0.77 [95%CI: 0.62-0.96]).

Induction therapy followed by resection or definitive radiochemotherapy represent valuable curative treatment options for patients with stage III NSCLC, the individual treatment choice deserves careful interdisciplinary evaluation and counseling. Based on the broad heterogeneity of patient groups in these stages further research on predictive factors supporting individual therapy selection is necessary.