The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours

Impact of microvascular invasion on 5-year overall survival of resected non-small cell lung cancer

OBJECTIVES

Non-small cell lung cancer (NSCLC) is an incidental and aggressive type of cancer. Although curative treatment can be offered, the recurrence rate is relatively high. Identifying factors that have a prognostic impact may guide changes in the staging system and recommendations for adjuvant therapy. The aim of this study was to evaluate the impact of microvascular invasion on the 5-year overall survival (OS) of patients with resected NSCLC treated at a reference cancer center.

METHODS

This retrospective, observational cohort study included patients diagnosed with early-stage NSCLC (clinical stages I-IIIA), treated with curative-intent surgery at the Brazilian National Cancer Institute between 2010 and 2016.

RESULTS

The dataset comprised 91 surgical patients, mostly females and white, with a mean age of 62 years (range between 29-83). Cases were distributed as stages I, II, and III in 55%, 29%, and 16%. Adenocarcinoma was the predominant histological subtype (67%), and microvascular invasion was present in 25% of the patients. The 5-year OS probability was 60% (95% CI, 48.3-68.9). Among all characteristics, advanced stages (p = 0.001) and the presence of microvascular invasion (p< 0.001) were related to a worse 5-year OS. After adjusting for age group and pathological stage, the presence of microvascular invasion was associated with a 4-fold increased risk of death (HR 3.9, 95% CI, 1.9-8.2).

CONCLUSION

The presence of microvascular invasion was an independent factor related to worse survival and, therefore, should be routinely assessed in resected specimens.

Histopathologic Basis for a Chest CT Deep Learning Survival Prediction Model in Patients with Lung Adenocarcinoma

Background A preoperative CT-based deep learning (DL) prediction model was proposed to estimate disease-free survival in patients with resected lung adenocarcinoma. However, the black-box nature of DL hinders interpretation of its results. Purpose To provide histopathologic evidence underpinning the DL survival prediction model and to demonstrate the feasibility of the model in identifying patients with histopathologic risk factors through unsupervised clustering and a series of regression analyses. Materials and Methods For this retrospective study, data from patients who underwent curative resection for lung adenocarcinoma without neoadjuvant therapy from January 2016 to September 2020 were collected from a tertiary care center. Seven histopathologic risk factors for the resected adenocarcinoma were documented: the aggressive adenocarcinoma subtype (cribriform, morular, solid, or micropapillary-predominant subtype); mediastinal nodal metastasis (pN2); presence of lymphatic, venous, and perineural invasion; visceral pleural invasion (VPI); and EGFR mutation status. Unsupervised clustering using 80 DL model-driven CT features was performed, and associations between the patient clusters and the histopathologic features were analyzed. Multivariable regression analyses were performed to investigate the added value of the DL model output to the semantic CT features (clinical T category and radiologic nodule type [ie, solid or subsolid]) for histopathologic associations. Results A total of 1667 patients (median age, 64 years [IQR, 57-71 years]; 975 women) were evaluated. Unsupervised patient clusters 3 and 4 were associated with all histopathologic risk factors (P < .01) except for EGFR mutation status (P = .30 for cluster 3). After multivariable adjustment, model output was associated with the aggressive adenocarcinoma subtype (odds ratio [OR], 1.03; 95% CI: 1.002, 1.05; P = .03), venous invasion (OR, 1.03; 95% CI: 1.004, 1.06; P = .02), and VPI (OR, 1.08; 95% CI: 1.06, 1.10; P < .001), independently of the semantic CT features. Conclusion The deep learning model extracted CT imaging surrogates for the histopathologic profiles of lung adenocarcinoma. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Yanagawa in this issue.

Comparison of 6th, 7th, and 8th editions of the TNM staging in non-small cell lung cancer patients: Validation of the 8th edition of TNM staging

Background

In this study, we aimed to evaluate the effects of the transition from the 6^th edition of the Tumor, Node, Metastasis (TNM) staging system to the 7^th edition, and from the 7^th edition to the 8^th edition by comparing the stage migrations. We also aimed to externally validate the 8^th edition of the TNM staging system.

Methods

Between September 2005 and June 2015, a total of 1,077 patients (986 males, 91 females; mean age: 59.6±8.3 years; range, 35 to 84 years) with non-small cell lung cancer who underwent lung resection were retrospectively analyzed. We re-staged patients according to 6^th, 7^th, and 8^th TNM staging and compared the stage migrations of cases among the three staging systems.

Results

Stage migration in the transition to the 7^th edition of the TNM staging system was observed in 368 (34.1%) patients whereas it was observed in 541 (50.2%) patients in the transition to the 8^th edition (p<0.001). The rate of upstaging in transition to the 7^th edition staging system was 50.2% (n=185), whereas it was 98.1% (n=531) for the transition to the 8^th edition (p<0.001). The survival rates of Stages 1B, 2B and 3A increased with transition to the 7^th edition and the survival rates of Stages 1B, 2A, 2B, 3A, and 3B increased with the transition to the 8^th edition. The best stratification in the survival curves in the 6th edition was between 1B-1A and 3B-3A. In the 7^th edition, it occurred between 1B-1A, 3A-2B and 3B-3A and, in the 8^th edition, between 1B-1A and 3B-3A.

Conclusion

Stratification according to the 7^th edition showed better prognostic validity compared to the 6^th edition; and that of the 8^th edition was better compared to the 7^th edition.

Relationship between survival and erythrocyte sedimentation rate in patients operated for lung cancer

Background

This study aims to investigate the relationship between preoperative erythrocyte sedimentation rate and survival in patients undergoing pulmonary resection due to lung cancer.

Methods

Between January 2011 and July 2017, a total of 575 patients (433 males, 142 females; mean age: 61.2±9.9 years; range, 29 to 82 years) who were operated due to primary lung cancer in our clinic were retrospectively analyzed. The patients were grouped according to erythrocyte sedimentation rate to analyze the relationship between erythrocyte sedimentation rate and survival.

Results

The mean overall survival time was 61.8±1.7 months in 393 patients with an erythrocyte sedimentation rate of ≤24 mm/h and 48.9±2.9 months in 182 patients with an erythrocyte sedimentation rate of ≥25 mm/h (p<0.001). Among the patients with Stage 1-2 disease, the mean survival time was 66.2±1.9 in patients with an erythrocyte sedimentation rate of ≤24 mm/h and 53.8±3.2 in patients with an erythrocyte sedimentation rate of ≥25 mm/h (p=0.008). The mean survival time in patients with adenocarcinoma was 62.4±2.4 months in patients with ≤24 mm/h erythrocyte sedimentation rate and 46.1±4.6 months in patients with ≥25 mm/h erythrocyte sedimentation rate (p=0.003).

Conclusion

The relationship between elevated erythrocyte sedimentation rate and poor prognosis in patients with the same stage of the disease is promising for the use of erythrocyte sedimentation rate as a prognostic marker.

Anti-Tumor Effect and Drug Delivery of Biomimetic Exosomes Nanoplatform Loading with Paclitaxel (PTX) for Treating Lung Adenocarcinoma

This study constructed an exosome (Exo) nanomedicine with the ability to actively penetrate into lung tumor tissue, in order to improve the anti-tumor effect of paclitaxel (PTX). For reaching this goal A549 lung adenocarcinoma cells were employed. The exosomes were collected by gradient centrifugation, and the Exo/PTX was prepared after targeted modification. Then the in vitro properties and in vivo tumor inhibitory effects of Exo/PTX were then characterized and evaluated. to conduct in vitro and in vivo study. The prepared Exo/PTX had a particle size of about 100 nm, and had a saucer-like double-layer membrane structure, which had a high encapsulation efficiency and drug loading. in vitro studies have shown that Exo/PTX can be largely taken up by lung cancer cells, thereby enhancing the drug’s effects on promoting apoptosis. The results of in vivo experiments showed that Exo/PTX can effectively inhibit the growth of tumor tissue. The results of this study showed that using exosome for drug delivery of PTX can increase the efficacy and decrease the drug toxicity and side effects.

Associations Between Morphological Phenotypes of COPD and Clinical Characteristics in Surgically Resected Patients with COPD and Concomitant Lung Cancer

Purpose

The associations between morphological phenotypes of COPD based on the chest computed tomography (CT) findings and clinical characteristics in surgically resected patients with COPD and concomitant lung cancer are unclear. The purpose of this study was to clarify the differences in clinical characteristics and prognosis among morphological phenotypes based on the chest CT findings in these patients.

Patients and Methods

We retrospectively reviewed the medical records of 132 patients with COPD and concomitant lung cancer who had undergone pulmonary resection for primary lung cancer. According to the presence of emphysema and bronchial wall thickness on chest CT, patients were classified into three phenotypes: non-emphysema phenotype, emphysema phenotype, or mixed phenotype.

Results

The mixed phenotype was associated with poorer performance status, higher score on the modified British Medical Research Council (mMRC) dyspnea scale, higher residual volume in pulmonary function, and higher proportion of squamous cell carcinoma than the other phenotypes. Univariate and multivariate Cox proportional hazards regression analyses showed that the extent of emphysema on chest CT, presented as a low attenuation area (LAA) score, was an independent determinant that predicted prognosis. In the Kaplan-Meier analysis, the Log rank test showed significant differences in survival between the non-emphysema and mixed phenotypes, and between the emphysema and mixed phenotypes.

Conclusion

The cross-sectional pre-operative LAA score can predict the prognosis in surgically resected patients with COPD and concomitant lung cancer. The COPD phenotype with both emphysema and bronchial wall thickness on chest CT was associated with poorer performance status, greater extent of dyspnea, greater impairment of pulmonary function, and worse prognosis.

Novel Inflammasome-Based Risk Score for Predicting Survival and Efficacy to Immunotherapy in Early-Stage Non-Small Cell Lung Cancer

Immune checkpoint inhibitors (ICI) for early-stage non-small cell lung cancer (NSCLC) have been approved to improve outcomes and reduce recurrence. Biomarkers for patient selection are needed. In this paper, we proposed an inflammasome-based risk score (IRS) system for prognosis and prediction of ICI response for early-stage NSCLC. Cox regression analysis was used to identify significant genes (from 141 core inflammasome genes) for overall survival (OS) in a microarray discovery cohort (n = 467). IRS was established and independently validated by other datasets (n = 1320). We evaluated the inflammasome signaling steps based on five gene sets, which were IL1B-, CASP-1-, IL18-, GSDMD-, and inflammasome-regulated genes. Gene set enrichment analysis, the Kaplan–Meier curve, receiver operator characteristic with area under curve (AUC) analysis, and advanced bioinformatic tools were used to confirm the ability of IRS in prognosis and classification of patients into ICI responders and non-responders. A 30-gene IRS was developed, and it indicated good risk stratification at 10-year OS (AUC = 0.726). Patients were stratified into high- and low-risk groups based on optimal cutoff points, and high-risk IRS had significantly poorer OS and relapse-free survival. In addition, the high-risk group was characterized by an inflamed immunophenotype and higher proportion of ICI responders. Furthermore, expression of SLAMF8 was the key gene in IRS and indicated good correlation with biomarkers associated with immunotherapy. It could serve as a therapeutic target in the clinical setting of immunotherapy.

Integrative metabolomics and transcriptomics analysis reveals novel therapeutic vulnerabilities in lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) comprises the majority (~85%) of all lung tumors, with lung adenocarcinoma (LUAD) and squamous cell carcinoma (LUSC) being the most frequently diagnosed histological subtypes. Multi-modal omics profiling has been carried out in NSCLC, but no studies have yet reported a unique metabolite-related gene signature and altered metabolic pathways associated with LUAD and LUSC.

METHODS

We integrated transcriptomics and metabolomics to analyze 30 human lung tumors and adjacent noncancerous tissues. Differential co-expression was used to identify modules of metabolites that were altered between normal and tumor.

RESULTS

We identified unique metabolite-related gene signatures specific for LUAD and LUSC and key pathways aberrantly regulated at both transcriptional and metabolic levels. Differential co-expression analysis revealed that loss of coherence between metabolites in tumors is a major characteristic in both LUAD and LUSC. We identified one metabolic onco-module gained in LUAD, characterized by nine metabolites and 57 metabolic genes. Multi-omics integrative analysis revealed a 28 metabolic gene signature associated with poor survival in LUAD, with six metabolite-related genes as individual prognostic markers.

CONCLUSIONS

We demonstrated the clinical utility of this integrated metabolic gene signature in LUAD by using it to guide repurposing of AZD-6482, a PI3Kβ inhibitor which significantly inhibited three genes from the 28-gene signature. Overall, we have integrated metabolomics and transcriptomics analyses to show that LUAD and LUSC have distinct profiles, inferred gene signatures with prognostic value for patient survival, and identified therapeutic targets and repurposed drugs for potential use in NSCLC treatment.

Patient-Reported Outcomes During Checkpoint Inhibition: Insight into Symptom Burden in Daily Clinical Practice

CONTEXT

While praised for inducing durable anti-tumour responses, immune checkpoint inhibitors (ICI) also cause immune-related adverse events (irAEs) that can vary in severity and affect health-related quality of life (HRQL).

OBJECTIVES

This study was performed to provide insight into the course of symptoms and the influence of irAEs on HRQL measured with the treatment-specific Utrecht Symptom Diary Immunotherapy (USD-I).

METHODS

In this observational cohort study, melanoma or non-small lung cancer (NSCLC) patients treated with PD(L)1-inhibitors between February 2016 and December 2018 were included. Data on symptoms, wellbeing and influence of side effects on HRQL were obtained using the patient-scored, treatment-specific USD-I, which was completed as part of routine care. Patients scored symptom intensity on a 0-10 numeric rating scale (NRS); NRS≥3 considered clinically relevant.

RESULTS

A total of 162 melanoma (55%) or NSCLC (45%) patients completed 1493 USDs (median seven per patient). Most common patient-reported clinically relevant symptoms were: inactivity, fatigue, pain, cough and sleeping problems. Symptom prevalence decreased during treatment. Patients generally reported a low influence of side effects on HRQL. A higher number of clinically relevant symptoms at a certain time point correlated with poorer wellbeing.

CONCLUSIONS

These data illustrate that ICI-treatment is generally well tolerated. However, especially the number of clinically relevant symptoms can impact patients wellbeing. Systematic use of an ICI-tailored PROM could create a window to discuss symptoms in a structured way which may promote personalized care during treatment.

Clinicopathological characteristics and prognostic significance of HDAC11 protein expression in non-small cell lung cancer: a retrospective study

Background

Although the prognosis of non-small cell lung cancer (NSCLC) can be assessed based on pathological type, disease stage and inflammatory indicators, the prognostic scoring model of NSCLC still needs to improve. HDAC11 is associated with poor prognosis of partial tumors, but its prognostic relationship with NSCLC is poorly understood. In this study, the role of HDAC11 in NSCLC was studied to evaluate relationship with disease prognosis and potential therapeutic target.

Methods

The clinicopathological and paracancerous tissues of patients with NSCLC primarily diagnosed in Tangdu Hospital from 2009 to 2013 were collected. Follow-up of patients were made every three months and the last follow-up period was December 2018. The expression of HDAC11 was assessed by immunohistochemistry (IHC). Then, weighted gene co-expression network analysis (WGCNA) was used to analyze the relationship between HDAC11 expression and the prognosis of lung adenocarcinoma (LUAD) patients. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. Kaplan-Meier plotter database was used to verify the connection between hub genes and tumor stage and prognosis. We accessed the relationship between HDAC11 expression and clinicopathological features, and impact on the prognosis.

Results

The study assessed 326 patients with NSCLC. Compared with adjacent tissues, HDAC11 expression was upregulated (HR =1.503, 95% CI: 1.172 to 1.927, P=0.001). Kaplan-Meier survival analyses showed that HDAC11 expression was closely related to OS of NSCLC patients (P=0.0011). Univariate and multivariate analyses showed that the independent risk factors of OS were clinical stage, HDAC11 expression, and HDAC11 differentiation (all P≤0.001). HDAC11 was significantly associated with prognosis in LUAD. A total of 1,174 differential genes and WGCNA were obtained to construct a co-expression network in LUAD. The GO and KEGG pathway enrichment analyses showed the relevance with staphylococcus aureus infection, NOD-like receptor signaling pathway, and others. The results of LUAD survival analysis showed that HDAC11-related genes NKX2-5 and FABP7 were significantly associated with LUAD prognosis.

Conclusions

The high expression of HDAC11 is related to the poor prognosis of LUAD, and it is expected to become a therapeutic target and prognostic evaluation therapy for LUAD in the future. However, the relevant results need to be further studied and verified.

Validation of Pretreatment Prognostic Factors and Prognostic Staging Systems for Small Cell Lung Cancer in a Real-World Data Set

Simple Summary

We present an analysis of a real-world cohort of patients with small cell lung cancer (SCLC) and examine the value of prognostic factors and scores that have been published in recent decades. In our analysis, only a few clinical (age, tumor stage) and a single laboratory parameter (alkaline phosphatase) are associated with the prognosis of patients with SCLC. We could not confirm the prognostic role of most of the published complex prognostic scores.

Abstract

Treatment decisions in patients with small cell lung cancer (SCLC) are made based on the extent of the disease. However, the outcome varies among patients at the same stage. A simple tool to predict outcomes in SCLC patients would be helpful for clinical decision-making. In recent years, several prognostic scores have been proposed. In this study, we evaluated the different prognostic factors in an unselected real-world cohort of patients. We retrospectively collected clinical, radiological and laboratory data from 92 patients diagnosed with SCLC. Univariate and multivariate cox regression analyses of survival were performed to assess the prognostic value of relevant clinical and laboratory factors for SCLC. Furthermore, we examined the association between eight published prognostic scores for SCLC and overall survival (OS). In the overall cohort, the median OS was 10.3 months (20.9 months and 9.2 months for limited disease (LD) SCLC and extensive disease (ED) SCLC, respectively). In univariate analysis, initial staging, number of metastatic sites and presence of liver, bone and adrenal gland metastases were significantly associated with worse OS. Of the established laboratory markers, albumin, alkaline phosphatase and hyponatremia but not lactate dehydrogenase (LDH) significantly predicted OS. All published prognostic scores, with the exception of the Glasgow Prognostic Score, did not significantly predict OS. In multivariate analysis, age, staging and alkaline phosphatase serum levels showed significant association with OS. We could not confirm the prognostic significance of most of the published complex prognostic scores. We therefore recommend using simple clinical and laboratory factors instead of complex scores to estimate the prognosis of SCLC patients in clinical practice.

Immunoexpression of Programmed Death-1 Receptor (PD-1) and Programmed Death-Ligand 1 (PD-L1) in Non-Small-Cell Lung Carcinoma and Its Correlation With Other Clinicopathological Parameters: A Cross-Sectional Study From North India

Aim

To study the prevalence of programmed death-1 receptor (PD-1) and programmed death-ligand 1 (PD-L1) positive cases in non-small-cell lung carcinoma (NSCLC) and their association with other clinicopathological parameters in a tertiary care setting in North India.

Material and methods

One hundred histologically proven NSCLC cases having sufficient tumor material from July 2016 to July 2018 were examined, and the prevalence of PD-1 and PD-L1 positivity in NSCLC was studied. In addition, H&E-stained sections were reviewed, and 100 consecutive cases meeting study criteria were identified as study cases. Histopathological categorization was done using a panel of immunohistochemical markers.

Statistical analysis and results

The PD-1 positivity in lymphocytes was 29% (95% CI: 20.4%-38.9%). Membranous positivity for PD-L1 in tumor cells was 27% (95% CI: 18.6%-36.8%) and in tumor-infiltrating lymphocytes was 22% (95% CI: 14.3%-31.4%). There was no statistically significant association between PD-1 or PD-L1 status with age, gender, smoking, pleural effusion, clinical stage, histological type, or lymphocyte infiltration.

Conclusion

The moderately high prevalence may justify routine testing for PD-1 or PD-L1 in NSCLC, which should preferably be carried out in all cases rather than any selected subsets. However, there was no significant correlation between PD-1 and PD-L1 with the clinical parameters studied.

Lung cancer metabolomic data from tumor core biopsies enables risk-score calculation for progression-free and overall survival

INTRODUCTION

Metabolomics has emerged as a powerful method to provide insight into cancer progression, including separating patients into low- and high-risk groups for overall (OS) and progression-free survival (PFS). However, survival prediction based mainly on metabolites obtained from biofluids remains elusive.

OBJECTIVES

This proof-of-concept study evaluates metabolites as biomarkers obtained directly from tumor core biopsies along with covariates age, sex, pathological stage at diagnosis (I/II vs. III/VI), histological subtype, and treatment vs. no treatment to risk stratify lung cancer patients in terms of OS and PFS.

METHODS

Tumor core biopsy samples obtained during routine lung cancer patient care at the University of Louisville Hospital and Norton Hospital were evaluated with high-resolution 2DLC-MS/MS, and the data were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards regression. A linear equation was developed to stratify patients into low and high risk groups based on log-transformed intensities of key metabolites. Sparse partial least squares discriminant analysis (SPLS-DA) was performed to predict OS and PFS events.

RESULTS

Univariable Cox proportional hazards regression model coefficients divided by the standard errors were used as weight coefficients multiplied by log-transformed metabolite intensity, then summed to generate a risk score for each patient. Risk scores based on 10 metabolites for OS and 5 metabolites for PFS were significant predictors of survival. Risk scores were validated with SPLS-DA classification model (AUROC 0.868 for OS and AUROC 0.755 for PFS, when combined with covariates).

CONCLUSION

Metabolomic analysis of lung tumor core biopsies has the potential to differentiate patients into low- and high-risk groups based on OS and PFS events and probability.

Ex Vivo Irradiation of Lung Cancer Stem Cells Identifies the Lowest Therapeutic Dose Needed for Tumor Growth Arrest and Mass Reduction In Vivo

Radiotherapy represents a first-line treatment for many inoperable lung tumors. New technologies offer novel opportunities for the treatment of lung cancer with the administration of higher doses of radiation in smaller volumes. Because both therapeutic and toxic treatment effects are dose-dependent, it is important to identify a minimal dose protocol for each individual patient that maintains efficacy while decreasing toxicity. Cancer stem cells sustain tumor growth, promote metastatic dissemination, and may give rise to secondary resistance. The identification of effective protocols targeting these cells may improve disease-free survival of treated patients. In this work, we evaluated the existence of individual profiles of sensitivity to radiotherapy in patient-derived cancer stem cells (CSCs) using both in vitro and in vivo models. Both CSCs in vitro and mice implanted with CSCs were treated with radiotherapy at different dose intensities and rates. CSC response to different radiation doses greatly varied among patients. In vitro radiation sensitivity of CSCs corresponded to the therapeutic outcome in the corresponding mouse tumor model. On the other side, the dose administration rate did not affect the response. These findings suggest that in vitro evaluation of CSCs may potentially predict patients’ response, thus guiding clinical decision.

Association between epidermal growth factor receptor gene mutation status and short‑term efficacy of first‑line platinum‑containing chemotherapy in advanced non‑small cell lung cancer

It remains undetermined whether there is an explicit association between the epidermal growth factor receptor (EGFR) gene mutation status and chemotherapy efficacy in non-small cell lung cancer (NSCLC) patients with advanced stages. Thus, the aim of the present retrospective study was to investigate the possible association between EGFR gene mutation status and the efficacy of first-line chemotherapy in patients with advanced NSCLC. In total, 52 patients who were diagnosed with NSCLC at Changzhou Tumor Hospital (Changzhou, China) from January 2015 to December 2018 were enrolled. All 52 patients received pemetrexed combined with platinum chemotherapy, for 21 days per cycle. After two cycles of treatment, the short-term clinical efficacy was assessed according to the Response Evaluation Criteria in Solid Tumours 1.1 guidelines. The objective response rate (ORR), disease control rate (DCR) and progression-free survival (PFS) rate were calculated at the end of the study (December 31, 2019). These patients also underwent second-generation gene sequencing before the potential association between mutations in the EGFR gene and chemotherapy efficacy was analyzed. In this group of patients, 25 cases (48.1%) were found to be harboring EGFR gene mutation, whilst 27 cases (51.9%) expressed wild-type EGFR. After receiving the first-line chemotherapy regimen, the ORR was determined to be 36.5%, the DCR was 71.2%, whereas the PFS period was 207 days. Following first-line chemotherapy, the DCR of patients with EGFR mutations (52%) was higher compared with those in patients harboring the wild-type EGFR (22%). By contrast, the PFS (260 days) of patients with EGFR mutations was longer compared with those in patients harboring wild-type EGFR (100 days). These differences were statistically significant (P<0.05). Multivariate analysis revealed that EGFR gene mutation was an independent predictor of PFS in patients with advanced NSCLC (P<0.05). To conclude, data from the present study suggest that EGFR gene mutation has independent predictive value for the efficacy of first-line chemotherapy in patients with advanced NSCLC.

Optimal Clinical Target Volume of Radiotherapy Based on Microscopic Extension around the Primary Gross Tumor in Non-Small-Cell Lung Cancer: A Systematic Review

A crucial issue in radical radiation therapy for non-small-cell lung cancer is how to define the clinical target volume (CTV). Although the scope of microscopic extension (ME) and microscopic proximal bronchial extension (PBE) from a primary tumor should be considered when defining the CTV, there has been limited research on ME and PBE. Therefore, we conducted this systematic review. The PubMed, ICHUSHI (Japanese database), and Cochrane Library databases were searched, and 816 articles were initially retrieved. After primary and secondary screenings, eight articles were ultimately selected. The results of this systematic review suggest the importance of a 0 mm margin in stereotactic radiotherapy for early-stage cancer and a 5–8 mm margin in curative irradiation for locally advanced cancer. Regarding PBE, this review yielded the conclusion that it is appropriate to consider the addition of an approximately 15 mm margin from the bronchial vasculature. Although there were few articles with a high level of evidence, this systematic review enabled us to collate results from previous studies and to provide recommendations, to some extent, regarding the CTV margin in the current clinical environment, where high-precision radiation therapy, such as image-guided radiotherapy and intensity-modulated radiotherapy, is predominant.

Survival Benefits for Pulmonary Adenocarcinoma With Malignant Pleural Effusion After Thoracoscopic Surgical Treatment: A Real-World Study

Objectives

Malignant cells in the pleural fluid or pleural metastasis are classified as stage IV non-small cell lung cancer. Radical surgery is generally considered not suitable for such patients. The aim of our study was to discuss the effectiveness of video-assisted thoracoscopic surgery (VATS) in such patients.

Methods

A retrospective analysis of the clinical records of 195 patients was performed. These patients were all diagnosed with locally advanced pulmonary adenocarcinomas with malignant pleural effusion (MPE, M1a) but no distant organ metastasis. The 195 patients included 96 patients who underwent VATS plus chemotherapy and 99 patients who received thoracic drainage plus chemotherapy. The baseline characteristics of the patients included age, gender, smoking history, Eastern Cooperative Oncology Group (ECOG) score, and number of chemotherapy cycles (2–4 cycles or &gt;4 cycles); we also analyzed clinical characteristics including the specific surgical options of the VATS group.

Results

In multivariate analysis, when compared to the thoracic drainage group, the VATS group remained significantly associated with the overall survival [HR=0.480 (95%CI 0.301-0.765)]; when compared to the lobectomy, the sub-lobectomy and the palliative surgery, remained significantly associated with the overall survival [HR=0.637 (95%CI 0.409-0.993) and HR=0.548 (95%CI 0.435-0.832), respectively]. The median survival time (MST) of patients who underwent VATS (n = 96, 49.2%) was 25 months (95% CI 22.373–27.627) whereas the patients who received thoracic drainage (n = 99, 50.8%) was 11 months (95% CI 9.978–12.022). For patients who underwent VATS, the MST of patients who received a lobectomy (n = 50, 52.1%) was 27 months (95% CI 22.432–31.568), the MST of patients who received a sub-lobectomy plus pleurodesis (n = 26, 27.1%) was 27 months (95% CI 19.157–34.843), and the MST of patients who received only pleurodesis (n = 20, 20.8%) was 12 months (95% CI 7.617–16.383).

Conclusion

For pulmonary adenocarcinomas with MPE, receiving a lobectomy or sub-lobectomy plus pleurodesis with VATS was associated with improved survival compared with patients who only received thoracic drainage and chemotherapy. Our results and previously published data may justify the use of VATS for treating pulmonary adenocarcinomas with MPE.

Rates of Guideline-Concordant Surgery and Adjuvant Chemotherapy Among Patients With Early-Stage Lung Cancer in the US ALCHEMIST Study (Alliance A151216)

Importance

Standard treatment for resectable non-small cell lung cancer (NSCLC) includes anatomic resection with adequate lymph node dissection and adjuvant chemotherapy for appropriate patients. Historically, many patients with early-stage NSCLC have not received such treatment, which may affect the interpretation of the results of adjuvant therapy trials.

Objective

To ascertain patterns of guideline-concordant treatment among patients enrolled in a US-wide screening protocol for adjuvant treatment trials for resected NSCLC.

Design, Setting, and Participants

This retrospective cohort study included 2833 patients with stage IB to IIIA NSCLC (per American Joint Committee on Cancer 7th edition criteria) who enrolled in the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial (ALCHEMIST) screening study (Alliance for Clinical Trials in Oncology A151216) from August 18, 2014, to April 1, 2019, and who did not enroll in a therapeutic adjuvant clinical trial; patients had tumors of at least 4 cm and/or with positive lymph nodes. Statistical analysis was conducted from June 1, 2020, through October 1, 2021.

Exposures

Care patterns were ascertained overall and by sociodemographic and clinical factors, including age, sex, race and ethnicity, educational level, marital status, geography, histologic characteristics, stage, genomic variant status, smoking history, and comorbidities.

Main Outcomes and Measures

Five outcomes are reported: whether patients (1) had anatomic surgical resection, (2) had adequate lymph node dissection (≥1 N1 nodal station plus ≥3 N2 nodal stations), (3) received any adjuvant chemotherapy, (4) received any cisplatin-based adjuvant chemotherapy, and (5) received at least 4 cycles of adjuvant chemotherapy.

Results

Of the 2833 patients (1505 women [53%]; mean [SD] age, 66.5 [9.2] years) included in this analysis, 2697 (95%) had anatomic surgical resection, 1513 (53%) had adequate lymph node dissection, 1617 (57%) received any adjuvant chemotherapy, 1237 (44%) received at least 4 cycles of adjuvant platinum-based chemotherapy, and 965 (34%) received any cisplatin-based adjuvant chemotherapy. Rates were similar across race and ethnicity.

Conclusions and Relevance

This cohort study found that among participants in a screening protocol for adjuvant clinical trials for resected early-stage NSCLC, just 53% underwent adequate lymph node dissection, and 57% received adjuvant chemotherapy, despite indications for such treatment. These results may affect the interpretation of adjuvant trials. Efforts are needed to optimize the use of proven therapies for early-stage NSCLC.

Trial Registration

ClinicalTrials.gov Identifier: NCT02194738.

A Proposal to Modify the 8th IASLC System: Is it Suitable for T4N2M0 Lung Adenocarcinoma to Be Placed in Stage IIIB?

PURPOSE

The International Association for the Study of Lung Cancer (IASLC) of TNM staging system has been well accepted as a precise model. However, the latest American Joint Committee on Cancer (AJCC) staging system to solve the different survival and prognosis of lung adenocarcinoma in the same period is still controversial. Therefore, it is necessary to thoroughly explore the applicability between the new system and survival prediction in terms of lung adenocarcinoma.

METHODS

We recruited 52,517 patients with lung adenocarcinoma from the Surveillence, Epidemiology, and End Results database. Cox regression analysis was performed to determine survival related factors. The mortality rate per 1000 persons per year of the T4N2M0 lung adenocarcinoma stage and other stages were compared. Survival curves were obtained using the Kaplan-Meier analysis and log-rank test.

RESULTS

The results of Cox proportional hazards regression analysis showed that age at diagnosis, race, T stage, distant metastasis, extrathoracic extension, radiotherapy, chemotherapy, and surgery are independent factors related to cancer-specific survival (CSS) and all-cause survival. Furthermore, patients with stage IIIA disease (P<0.001) and IIIB disease (P<0.001) excluding stage at T4N2M0 had a significantly lower risk of CSS and all-cause survival than those staged with T4N2M0 disease. The mortality rates per 1000 person-years with patients staged at T4N2M0 lung adenocarcinoma had higher mortality than patients in the same period. The CSS curves of patients with stage T4N2M0 reflected an obvious decline compared with those of stages IIIA disease and IIIB excluding T4N2M0, and there is no significant difference between this curve and stage IIIC patients (P>0.05).

CONCLUSION

The survival rate of patients with T4N2M0 stage was significantly lower than that of patients with IIIA and IIIB stages excluding T4N2M0, there was no significant difference between T4N2M0 and IIIC. It was suggested that this group of patients with stage T4N2M0 were upgraded in the 8th IASLC system.

Efficacy of Adjuvant Chemotherapy With Tegafur-Uracil in Patients With Completely Resected, Node-Negative NSCLC-Real-World Data in the Era of Molecularly Targeted Agents and Immunotherapy

Introduction

In Japan, adjuvant tegafur-uracil (UFT) chemotherapy is recommended for patients with completely resected, stage I NSCLC. This treatment requires real-world re-evaluation because of recent advances in target-based and immuno-oncological treatments and refinement of lung cancer staging.

Methods

The Japan Clinical Oncology Group (JCOG) 0707, a phase 3 trial comparing the benefits of UFT and S-1 (tegafur-gimeracil-oteracil) in patients with completely resected stage I NSCLC (T1 >2 cm and T2 in the TNM sixth edition), was conducted in Japan. A multicenter observational cohort study (Comprehensive Support Project for Oncology Research [CSPOR]-LC03) was also conducted for those patients excluded from JCOG 0707 during the study enrollment period. Physicians from institutions that participated in JCOG 0707 retrospectively assessed the medical records of each patient. The efficacy of UFT was evaluated in the CSPOR-LC03 cohort.

Results

In the entire study population (n = 5005), patients treated with UFT (n = 1549) had significantly longer overall survival (OS) than those without any adjuvant chemotherapy (n = 3338). There was no significant difference in OS between the patients treated with UFT (n = 1061) and those without adjuvant chemotherapy (n = 1484) in the JCOG 0707-eligible population (logrank p = 0.755). For tumors without ground-glass attenuation and size greater than 3 cm, patients treated with UFT had significantly longer survival than those without adjuvant chemotherapy, on univariate but not on multivariate analysis.

Conclusions

There was no significant difference in OS between the patients treated with UFT and those without adjuvant chemotherapy in the clinical trial-eligible population. Adjuvant UFT for patients with completely resected NSCLC may be recommended only in patients with a tumor without ground-glass attenuation and size greater than 3 cm. In patients with node-negative early NSCLC, further study is needed to select patients who will benefit from adjuvant chemotherapy.

NEIL3 Mediates Lung Cancer Progression and Modulates PI3K/AKT/mTOR Signaling: A Potential Therapeutic Target

Background. Nei endonuclease VIII-like 3 (NEIL3) is widely involved in pathophysiological processes of the body; however, its role in lung cancer has not been conclusively determined. Objective. This study is aimed at exploring the role of NEIL3 in lung cancer. Methods. The public data used in this study were downloaded from The Cancer Genome Atlas (TCGA) database. “Limma” in R was used for the analysis of differentially expressed genes. Clinical correlations and prognostic analyses were performed using the survival package in R. The proliferative abilities of lung cancer cells were evaluated by the CCK8 and colony formation assays while their invasive and migration abilities were assessed by the transwell and wound healing assays. Quantitative real-time PCR (qRT-PCR) and western blot analyses were utilized to detect RNA and protein levels. Biological differences between groups were determined by gene set enrichment analysis (GSEA). Tumor Immune Dysfunction and Exclusion (TIDE) as well as Genomics of Drug Sensitivity in Cancer (GDSC) was used for immunotherapeutic and chemotherapeutic sensitivity analyses. Results. NEIL3 was upregulated in NSCLC tissues and cell lines, implying that it is involved in lung cancer initiation and progression. Clinical correlation and prognostic analyses showed that NEIL3 was associated with worse clinical features (stage and T and N classifications) and poor prognostic outcomes. In vitro, NEIL3 significantly enhanced NSCLC proliferation, invasion, and migration. GSEA indicated that NEIL3 might be involved in PI3K/AKT/mTOR, G2/M checkpoints, and E2F target pathways. Inhibition of NEIL3 suppressed cyclinD1 and p-AKT protein levels; however, it had no effects on AKT levels, indicating that NEIL3 can partially activate the PI3K/AKT/mTOR signaling pathway. The predicted result of TIDE indicated that immunotherapeutic nonresponders had elevated NEIL3 levels. Moreover, there was a positive correlation between NEIL3 levels and chemosensitivity to cisplatin and paclitaxel. Conclusion. In general, NEIL3 mediates NSCLC progression and affects sensitivity to immunotherapy and chemotherapy; therefore, it is a potential molecular target for treatment.

Identification of sSIGLEC5 and sLAG3 as New Relapse Predictors in Lung Cancer

Lung cancer (LC) continues to be the leading cause of cancer-related deaths in both men and women worldwide. After complete tumour resection, around half of the patients suffer from disease relapse, emphasising the critical need for robust relapse predictors in this disease. In search of such biomarkers, 83 patients with non-microcytic lung cancer and 67 healthy volunteers were studied. Pre-operative levels of sSIGLEC5 along with other soluble immune-checkpoints were measured and correlated with their clinical outcome. Soluble SIGLEC5 (sSIGLEC5) levels were higher in plasma from patients with LC compared with healthy volunteers. Looking into those patients who suffered relapse, sSIGLEC5 and sLAG3 were found to be strong relapse predictors. Following a binary logistic regression model, a sSIGLEC5 + sLAG3 score was established for disease relapse prediction (area under the curve 0.8803, 95% confidence intervals 0.7955−0.9652, cut-off > 2.782) in these patients. Based on score cut-off, a Kaplan−Meier analysis showed that patients with high sSIGLEC5 + sLAG3 score had significantly shorter relapse-free survival (p ≤ 0.0001) than those with low sSIGLEC5 + sLAG3 score.Our study suggests that pre-operative sSIGLEC5 + sLAG3 score is a robust relapse predictor in LC patients.

Intestinal Haemorrhage and Colitis Induced by Treatment With Osimertinib for Non-Small-Cell Lung Carcinoma: A Case Report

Background: Osimertinib is recommended either as the first-line therapy for sensitizing EGFR-mutations (FLAURA trial) or at progression to first-/second-generation EGFR inhibitors in the presence of resistance mutation T790M (AURA 3 study). It can effectively improve the prognosis of patients with NSCLC with manageable adverse reactions. Among adverse events, intestinal haemorrhage is rare and requires extensive study on its potential lethality.

Case presentation: A 59-year-old female, diagnosed with relapsed stage IV (cT4N2M1c) NSCLC with T790M mutation of the EGFR gene, received osimertinib treatment. Eight months after osimertinib treatment, she complained of lower abdominal pain and haematochezia without haemorrhoids. Potential causes of intestinal haemorrhage other than osimertinib toxicity were ruled out. Colonoscopy examination showed severe colitis with grade 3 CTCAE. Osimertinib was discontinued, and prednisone 0.5 mg/kg was administered. Follow-up endoscopy showed no pathological findings. A novel third-generation EGFR-TKI, aumolertinib, was administrated. Five months after aumolertinib initiation, CT evaluation showed stable disease (SD), and this patient was free of colitis recurrence.

Conclusion: To our knowledge, this is the first case report of severe colitis as an adverse event associated with osimertinib. Although osimertinib is the standard treatment for NSCLC in patients with T790M mutation and has fewer side effects, colitis may occur after months of treatment. Aumolertinib, a novel third-generation EGFR-TKI, might be an effective alternative for the treatment of patients with NSCLC experiencing colitis from osimertinib.

Baseline Electrocardiographic and Echocardiographic Assessment May Help Predict Survival in Lung Cancer Patients-A Prospective Cardio-Oncology Study

Cardiovascular disease and cancer coexist and lead to exertional dyspnea. The aim of the study was to determine the prognostic significance of cardiac comorbidities, ECG and baseline echocardiography in lung cancer patients with varying degrees of reduced performance status. This prospective study included 104 patients with histopathologically confirmed lung cancer, pre-qualified for systemic treatment due to metastatic or locally advanced malignancy but not eligible for thoracic surgery. The patients underwent a comprehensive cardio-oncological evaluation. Overall survival negative predictors included low ECOG 2 (Eastern Cooperative Oncology Group) performance status, stage IV (bone or liver/adrenal metastases in particular), pleural effusion, the use of analgesics and among cardiac factors, two ECG parameters: atrial fibrillation (HR = 2.39) and heart rate >90/min (HR = 1.67). Among echocardiographic parameters, RVSP > 39 mmHg was a negative predictor (HR = 2.01), while RVSP < 21 mmHg and RV free wall strain < −30% were positive predictors (HR = 0.36 and HR = 0.56, respectively), whereas RV GLS < −25.5% had a borderline significance (HR = 0.59; p = 0.05). Logistical regression analysis showed ECOG = 2 significantly correlated with the following echocardiographic parameters: increasing RVSP, RV GLS, RV free wall strain and decreasing ACT, FAC (p < 0.05). Selected echocardiographic parameters may be helpful in predicting poor performance in lung cancer patients and, supplemented with ECG evaluation, broaden the possibilities of prognostic evaluation.

Lymph but Not Blood Vessel Invasion Is Independent Prognostic in Lung Cancer Patients Treated by VATS-Lobectomy and Might Represent a Future Upstaging Factor for Early Stages

Lung cancer is the most frequent cause of cancer-related death worldwide. The patient’s outcome depends on tumor size, lymph node involvement and metastatic spread at the time of diagnosis. The prognostic value of lymph and blood vessel invasion, however, is still insufficiently investigated. We retrospectively examined the invasion of lymph vessels and blood vessels separately as two possible prognostic factors in 160 patients who underwent a video-assisted thoracoscopic lobectomy for non-small-cell lung cancer at our institution between 2014 and 2019. Lymph vessel invasion was significantly associated with the UICC stage, lymph node involvement, tumor dedifferentiation, blood vessel invasion and recurrence. Blood vessel invasion tended to be negative prognostic, but missed the level of significance (p = 0.108). Lymph vessel invasion, on the other hand, proved to be a prognostic factor for both histological subtypes, adenocarcinoma (p < 0.001) as well as squamous cell carcinoma (p = 0.018). After multivariate analysis apart from the UICC stage, only lymph vessel invasion remained independently prognostic (p = 0.018). Remarkably, we found analogue survival curve progressions of patients with stage I, with lymph vessel invasion, compared to stage II non-small-cell lung cancer. After further validation in prospective studies, lymph vessel invasion might be considered as an upstaging factor in resectable lung cancer. Especially in the early-stage of the disease, it might represent an additional risk factor to consider adjuvant therapy after surgical resection.

Revisiting Indications for Brain Imaging During the Clinical Staging Evaluation of Lung Cancer

Introduction

Available guidelines are inconsistent as to whether patients with newly diagnosed clinical stage II NSCLC should receive routine brain imaging.

Methods

The National Cancer Database was queried for the prevalence of isolated brain metastases among patients with newly diagnosed NSCLC in 2016 and 2017. Patients with metastases in locations other than the brain were excluded. The prevalences were then stratified by clinical T and N classifications and further stratified into a summary stage, which was calculated based on T and N classifications. The summary stage represents the clinical stage that would have been available at the time of decision for brain imaging.

Results

A total of 6,949 of 149,958 patients (4.6%) with clinical stages I, II, III, or brain-limited stage IV NSCLC had dissemination limited to the brain. As T and N stages increased, prevalence of brain metastases generally increased. Among patients with node-negative (N0) NSCLC, the prevalence of brain-only metastases increased from 1.2% in patients with T1a to 3.8% among patients with T4 (p < 0.001). Among patients with T1a, the prevalence of brain-only metastases increased from 1.2% for patients with N0 to 7.9% for patients with N3 (p < 0.001). The prevalence of brain-limited metastases generally increased with increasing summary stage. The prevalence of brain-only metastases among patients with stage IA was 1.7% whereas that among patients with stage IIIA was 6.7% (p < 0.001). Of note, the prevalence of brain-limited metastases was approximately 6% for both summary stages II and III.

Conclusions

Considering the similarity in prevalence of isolated brain metastases and the potential hazards associated with brain imaging in early stage NSCLC, practitioners may consider a more liberal use of brain imaging when interpreting conflicting guidelines.

Integrative analysis of non-small cell lung cancer patient-derived xenografts identifies distinct proteotypes associated with patient outcomes

Non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths worldwide. Only a fraction of NSCLC harbor actionable driver mutations and there is an urgent need for patient-derived model systems that will enable the development of new targeted therapies. NSCLC and other cancers display profound proteome remodeling compared to normal tissue that is not predicted by DNA or RNA analyses. Here, we generate 137 NSCLC patient-derived xenografts (PDXs) that recapitulate the histology and molecular features of primary NSCLC. Proteome analysis of the PDX models reveals 3 adenocarcinoma and 2 squamous cell carcinoma proteotypes that are associated with different patient outcomes, protein-phosphotyrosine profiles, signatures of activated pathways and candidate targets, and in adenocarcinoma, stromal immune features. These findings portend proteome-based NSCLC classification and treatment and support the PDX resource as a viable model for the development of new targeted therapies.

With non-small cell lung cancer (NSCLC) being the leading cause of cancer deaths worldwide, the development of targeted therapies remains crucial. Here, the generation and multi-omics characterization of 137 NSCLC patient-derived xenografts provides a resource for potential classifications and targets.

Machine learning application in personalised lung cancer recurrence and survivability prediction

Machine learning is an important artificial intelligence technique that is widely applied in cancer diagnosis and detection. More recently, with the rise of personalised and precision medicine, there is a growing trend towards machine learning applications for prognosis prediction. However, to date, building reliable prediction models of cancer outcomes in everyday clinical practice is still a hurdle. In this work, we integrate genomic, clinical and demographic data of lung adenocarcinoma (LUAD) and squamous cell carcinoma (LUSC) patients from The Cancer Genome Atlas (TCGA) and introduce copy number variation (CNV) and mutation information of 15 selected genes to generate predictive models for recurrence and survivability. We compare the accuracy and benefits of three well-established machine learning algorithms: decision tree methods, neural networks and support vector machines. Although the accuracy of predictive models using the decision tree method has no significant advantage, the tree models reveal the most important predictors among genomic information (e.g. KRAS, EGFR, TP53), clinical status (e.g. TNM stage and radiotherapy) and demographics (e.g. age and gender) and how they influence the prediction of recurrence and survivability for both early stage LUAD and LUSC. The machine learning models have the potential to help clinicians to make personalised decisions on aspects such as follow-up timeline and to assist with personalised planning of future social care needs.

Neoadjuvant chemoradiotherapy is superior to chemotherapy alone in surgically treated stage III/N2 non-small-cell lung cancer: a retrospective single-center cohort study

BACKGROUND

There is lack of consensus whether neoadjuvant chemoradiotherapy (CHT/RT) is superior to neoadjuvant chemotherapy (CHT) alone in patients with potentially resectable stage III/N2 non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We retrospectively evaluated clinical parameters and outcomes in patients with clinical stage III/N2 NSCLC treated with neoadjuvant CHT/RT versus CHT followed by surgery. Nearest-neighbor propensity score (PS) matching was used to correct for pretreatment differences.

RESULTS

A total of 84 patients were enrolled. Thirty-four (40%) and 50 (60%) patients received CHT/RT or CHT followed by curative-intent surgery, respectively. Overall 90-day mortality and morbidity were 0% versus 0.04% and 21% versus 18%, respectively, with no significant difference between the CHT/RT and the CHT-alone cohorts (P = 0.51 and P = 0.70). In the PS-matched cohort, complete pathological response was recorded in 25% after CHT/RT versus 0% after CHT at the time of surgery. Patients receiving neoadjuvant CHT/RT exhibited significantly better 5-year disease-free survival (DFS) [45% versus 16% CHT group; hazard ratio (HR) 0.43, P = 0.04]; 5-year overall survival (OS) was 75% after CHT/RT and 21% after CHT (HR 0.37, P = 0.001). CHT/RT more often induced pathological mediastinal downstaging (P = 0.007), but CHT/RT remained the only independent factor for DFS and OS and did not depend on mediastinal downstaging.

CONCLUSIONS

In this retrospective PS-matched long-term analysis, neoadjuvant CHT/RT conferred improved DFS and OS compared with CHT alone in stage III/N2 NSCLC. These highly challenging results require confirmation in well-designed randomized controlled trials conducted at highly specialized thoracic oncology centers.

Feasibility and impact of screening for venous thromboembolism in treatment-naive lung cancer patients-Results of a prospective cohort study

BACKGROUND

Venous thromboembolism (VTE) in cancer remains underdiagnosed. This prospective study aimed to evaluate the feasibility of screening for VTE in lung cancer (LC) patients. We assess the incidence of VTE, its risk factors, and effects on overall survival (OS).

METHODS

Consecutive treatment-naive LC patients were screened for deep venous thrombosis (DVT) with compression ultrasonography and pulmonary thromboembolism (PTE) with computed tomography pulmonary angiography (CTPA) at diagnosis and after 3 months of treatment. The incidence rate of VTE (DVT and/or PTE) was calculated. Risk factors associated with VTE were assessed using logistic regression analysis. All participants were followed-up to 1 year after enrollment. OS was compared in LC subjects with and without VTE, using the Cox proportional hazard analysis.

RESULTS

Around 301 subjects with LC (stages IIIB-IV accounted for 83.1%) were enrolled, of which 16 had VTE (5.3%). The incidence rate of VTE was 90 per 1000 person-years (PY). PTE was asymptomatic in 27.3% of cases while all DVT episodes were symptomatic. The incidence rate of asymptomatic PTE identified during the screening was 17 per 1000 PY. The median duration from LC diagnosis to the VTE event was 96.5 days. Median OS was significantly less in VTE patients [161 versus 311 days; P = 0.007] and death was attributable to VTE in 50%. After adjusting for covariates, VTE (hazard ratio [HR] = 2.1), smoking (HR = 1.7), and Eastern cooperative oncology group performance status ≥2 (HR = 1.6) were independently associated with poor OS in LC.

CONCLUSIONS

VTE occurs in approximately 1 in 20 newly-diagnosed patients with LC and is associated with decreased OS. Screening for PTE may be considered even in resource-limited settings.

Efficacy of platinum agents for stage III non-small-cell lung cancer following platinum-based chemoradiotherapy: a retrospective study

BACKGROUND

Platinum-based chemoradiotherapy is the standard treatment for unresectable stage III non-small-cell lung cancer (NSCLC). However, few studies have evaluated the efficacy of subsequent chemotherapy for relapsed NSCLC following platinum-based chemoradiotherapy. This study aimed to evaluate the efficacy of platinum-doublet chemotherapy as a second-line treatment for patients with unresectable stage III NSCLC.

METHODS

We retrospectively evaluated patients with unresectable stage III NSCLC treated with cytotoxic chemotherapy following platinum-based chemoradiotherapy who were registered in a nationwide registry NSCLC database. Patients were divided into the platinum-doublet chemotherapy (platinum) group and single-agent chemotherapy (non-platinum) group based on the type of second-line chemotherapy.

RESULTS

The platinum group (n = 119) showed significantly better overall survival (OS) than the non-platinum group (n = 201) (median OS: 21.5 vs. 10.5 months, hazard ratio [HR]: 0.54, 95% confidence interval [CI]: 0.40-0.73, p < 0.001). OS from the beginning of chemoradiotherapy was also significantly better in the platinum group than in the non-platinum group (median OS: 34.9 vs. 21.8 months, HR: 0.58, 95% CI: 0.43-0.79, p = 0.001). In the multivariate analysis, platinum-doublet chemotherapy as second-line therapy, female sex, clinical stage IIIA, and duration of ≥ 8.6 months from the beginning of first-line therapy to the beginning of second-line therapy were associated with significantly better OS.

CONCLUSION

Platinum-doublet chemotherapy as a second-line therapy may prolong survival in unresectable stage III NSCLC patients following platinum-based chemoradiotherapy. Thus, re-administration of platinum agents may be a promising treatment for unresectable stage III NSCLC treated with platinum-based chemoradiotherapy.

Efficacy and safety of adjuvant EGFR-TKIs for resected non-small cell lung cancer: a systematic review and meta-analysis based on randomized control trials

Background

Postoperative adjuvant cisplatin-based chemotherapy had been the standard care in patients with completely resected high-risk stage IB to IIIA non-small cell lung cancer (NSCLC) for decades. However, the survival benefits were far from satisfactory in clinical practice. Thus, this meta-analysis was performed to compare the efficacy and safety of adjuvant epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in patients with resected NSCLC based on updated literature and research.

Methods

A systematic literature search based on random control trials (RCTs) was conducted with keywords on PubMed, Embase and the Cochrane library databases. All articles compared EGFR-TKIs to placebo or chemotherapy as adjuvant therapies for early-stage resected NSCLC. A meta-analysis was performed to generate combined hazard ratio (HR) with 95% confidence intervals (CI) for disease-free survival (DFS), overall survival (OS), and risk ratio (RR) with 95% CI for disease recurrence and adverse events (AEs). The Stata statistical software (version 14.0) was used to synthesis the data.

Results

A total of 9 RCTs comprising 3098 patients were included. Adjuvant EGFR-TKIs could significantly prolong DFS in patient with resected NSCLC harboring epidermal growth factor receptor (EGFR) mutations (HR 0.46, 95% CI 0.29–0.72), but had no impact on OS (HR 0.87, 95% CI 0.69–1.11). The subgroup analyses indicated that adjuvant EGFR-TKIs were superior in regard to DFS in most subgroups, including varied smoking status, EGFR mutations type, gender, age, Eastern Cooperative Oncology Group performance status and adenocarcinoma. Osimertinib resulted in decreased brain recurrence than first generation of EGFR-TKIs (RR 0.12, 95% CI 0.04–0.34 vs. RR 1.07, 95% CI 0.64–1.78, respectively). The AEs were generally manageable and tolerable. The incidence of high-grade (≥ 3) AEs including diarrhea (RR 5.68, 95% CI 2.94–10.98) and rash (RR 27.74, 95% CI 11.43–67.30) increased after adjuvant EGFR-TKIs treatment.

Conclusions

Adjuvant EGFR-TKIs therapy could significantly prolong DFS in patients with completely resected early-stage EGFR mutation-positive NSCLC, but had no impact on OS. Adjuvant EGFR-TKIs could be an important treatment option in patients with resected early-stage EGFR-mutant NSCLC.

[Clinical Characteristics and Prognosis of 76 Lung Adenocarcinoma Patients Harboring EGFR Mutations with Pleural Effusion at Initial Diagnosis: A Single-center Retrospective Study]

BACKGROUND

Malignant pleural effusion is one of the common clinical manifestations of patients with lung adenocarcinoma. Patients with pleural effusion at the initial diagnosis of lung adenocarcinoma usually indicate poor prognosis. Epidermal growth factor receptor (EGFR) mutations mainly occur in patients with lung adenocarcinoma. Patients with different mutant subtypes have different prognosis. The clinical characteristics and prognostic factors of patients with EGFR mutated lung adenocarcinoma of different molecular subtypes combined with pleural effusion at initial diagnosis are still unclear. This study was designed to explore the clinical characteristics and prognostic factors of these patients in order to provide management recommendations for them.

METHODS

A retrospective analysis of the clinical characteristics, treatment, outcomes and progression-free survival (PFS) of first-line treatment in patients with EGFR mutated lung adenocarcinoma combined with pleural effusion at initial diagnosis admitted to Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital from January 2012 to June 2021 was performed. Pearson's chi-square test or Fisher's exact test were performed for comparison between groups. Kaplan-Meier method was performed for survival analysis and Cox proportional risk regression model was performed for multivariate analysis.

RESULTS

76 patients met the inclusion criteria in this study. The incidences of EGFR classical mutations 19del, 21L858R and non-classical mutations were 46.0%, 38.2% and 15.8%, respectively among these patients. There was no significant difference between the three mutations in terms of gender, age, presence of dyspnea at presentation, whether other distant metastases were combined, site of pleural effusion, volume of pleural effusion, presence of other combined effusions, tumor-node-metastasis (TNM) stage, presence of other gene mutations, and treatment of pleural effusion (P>0.05). In patients with EGFR classical mutations 19del or 21L858R or non-classical mutations subtype, the proportion of chemotherapy in first-line regimens were 17.1%, 20.7% and 58.3%, respectively (P=0.001); and first-line disease control rates were 94.3%, 75.9% and 50%, respectively (P=0.003); pleural effusion control rates were 94.3%, 79.3% and 66.7%, respectively (P=0.04); PFS were 287 d, 327 d and 55 d, respectively (P=0.001). Univariate analysis showed that EGFR mutation subtype, control of pleural effusion, first-line treatment agents, and first-line treatment efficacy were significantly associated with PFS (P<0.05). Cox multifactorial analysis showed that only EGFR mutation subtype and first-line treatment efficacy were independent prognostic factors for PFS (P<0.05).

CONCLUSIONS

PFS was significantly better for classical mutations than for non-classical mutations in patients with EGFR mutated lung adenocarcinoma combined with pleural effusion at initial diagnosis. Improving the efficacy of first-line therapy is the key to improve the prognosis of these patients.

Muscle Quality Predicts Outcomes after Surgery for Early-Stage Non-Small-Cell Lung Cancer

Purpose: This study investigated the impact of skeletal muscle quality on the outcomes of patients undergoing surgery for early-stage non–small-cell lung cancer (NSCLC).

Methods: A total of 98 patients with pathological stage I–II NSCLC who underwent lobectomy or segmentectomy were retrospectively analyzed. Along with skeletal muscle quantity, muscle quality was evaluated by intramuscular adipose tissue content (IMAC) at the first lumbar vertebral level; a higher IMAC indicates lower skeletal muscle quality. Patients were divided into two groups according to the gender-specific quartiles of IMAC, and the prognostic impact of IMAC was investigated.

Results: No significant differences in the body and skeletal mass indices, which indicate skeletal muscle quantity, were observed between patients with high and those with normal IMAC. Patients with high IMAC (n = 23) showed a significantly poorer prognosis in overall and disease-specific survivals than those with normal IMAC (n = 75; P <0.001 and P = 0.048, respectively). In a bivariate analysis that included other clinicopathological factors, a high IMAC was independently associated with worse overall survival.

Conclusion: The skeletal muscle quality evaluated by IMAC could be used to predict survival risk after surgery for early-stage NSCLC.

Updated Prognostic Factors in Localized NSCLC

Lung cancer is the most common cause of cancer mortality worldwide, and non-small cell lung cancer (NSCLC) represents 80% of lung cancer subtypes. Patients with localized non-small cell lung cancer may be considered for upfront surgical treatment. However, the overall 5-year survival rate is 59%. To improve survival, adjuvant chemotherapy (ACT) was largely explored and showed an overall benefit of survival at 5 years < 7%. The evaluation of recurrence risk and subsequent need for ACT is only based on tumor stage (TNM classification); however, more than 25% of patients with stage IA/B tumors will relapse. Recently, adjuvant targeted therapy has been approved for EGFR-mutated resected NSCLC and trials are evaluating other targeted therapies and immunotherapies in adjuvant settings. Costs, treatment duration, emergence of resistant clones and side effects stress the need for a better selection of patients. The identification and validation of prognostic and theranostic markers to better stratify patients who could benefit from adjuvant therapies are needed. In this review, we report current validated clinical, pathological and molecular prognosis biomarkers that influence outcome in resected NSCLC, and we also describe molecular biomarkers under evaluation that could be available in daily practice to drive ACT in resected NSCLC.

Neoadjuvant Programmed Cell Death Protein 1 Blockade Combined With Stereotactic Body Radiation Therapy for Stage III(N2) Non-Small Cell Lung Cancer: A Case Series

The addition of radiotherapy in neoadjuvant chemotherapy did not improve event-free or overall survival in resectable non-small cell lung carcinoma (NSCLC). Neoadjuvant immunotherapy produced major pathologic response(MPR) rate of up to 45%. The potential synergy between radiotherapy and immunotherapy has been described in several studies. We reported outcomes of three cases of stage III/N2 NSCLC treated with neoadjuvant immunotherapy and stereotactic body radiation therapy (SBRT) in a single center. This explanatory trial included treatment-naive patients with stage III resectable NSCLC who received two doses of the programmed cell death protein 1 (PD-1) inhibitor toripalimab after 1 week of receiving SBRT for lung lesions. Thereafter, surgery was planned 4–6 weeks after the second dose. The primary endpoints were safety and feasibility, while the secondary endpoint was the pathologic response rate. Toripalimab combined with SBRT as a neoadjuvant treatment had well-tolerable side effects and did not lead to a delay in surgery. Among the included patients, one achieved pathologic complete response (PCR), one achieved MPR, and one with 20% residual tumor did not achieve MPR. There were few side effects of toripalimab combined with SBRT as a neoadjuvant treatment, and the treatment did not cause a delay in surgery. This study preliminarily explored the outcomes of a new neoadjuvant treatment.

Air-polluted environmental heavy metal exposure increase lung cancer incidence and mortality: A population-based longitudinal cohort study

BACKGROUND

An increased risk of lung cancer has been observed due to exposure to certain environmental heavy metals. This study elucidated the role of air-polluted heavy metals in the development of lung cancer.

METHODS

A longitudinal cohort study involving the general population was conducted to compare heavy metal content among lung cancer patients. The urine concentrations of heavy metals were measured. Questionnaire surveys were designed to collect exposure-related demographic and lifestyle data of the study subjects.

RESULTS

Participants residing near the petrochemical industrial area with higher air Cd concentration had relatively higher urinary concentration of Cd. After adjusting for sociodemographic and behavioral factors, tobacco smoking and air pollution remained as potential sources of Cd exposure. An increased prevalence of lung cancer was observed in the highly polluted zone. The risk of lung cancer incidence increased 1.25-fold for each 1 μg/g-creatinine increase in urine Cd level. Patients with lung cancer had significantly higher urinary Cd concentrations. Lung cancer patients with higher urinary Cd level had significantly poor survival (urine Cd level ≥ 1.58 vs <1.58 μg/g-creatinine; survival, medium, 192.0 vs 342.5 days, p < 0.001). At the longitudinal follow-up, participants with higher urinary Cd level had a higher risk of lung cancer incidence (urine Cd level ≥ 1.58 vs <1.58 μg/g-creatinine: 3.91% v.s. 0.87%, hazard ratio: 4.65, p < 0.001).

CONCLUSIONS

Accumulation of Cd could be a risk of lung cancer occurrence. High exposure to Cd may result in poor prognosis in lung cancer patients.

Multitask Learning Radiomics on Longitudinal Imaging to Predict Survival Outcomes following Risk-Adaptive Chemoradiation for Non-Small Cell Lung Cancer

Medical imaging provides quantitative and spatial information to evaluate treatment response in the management of patients with non-small cell lung cancer (NSCLC). High throughput extraction of radiomic features on these images can potentially phenotype tumors non-invasively and support risk stratification based on survival outcome prediction. The prognostic value of radiomics from different imaging modalities and time points prior to and during chemoradiation therapy of NSCLC, relative to conventional imaging biomarker or delta radiomics models, remains uncharacterized. We investigated the utility of multitask learning of multi-time point radiomic features, as opposed to single-task learning, for improving survival outcome prediction relative to conventional clinical imaging feature model benchmarks. Survival outcomes were prospectively collected for 45 patients with unresectable NSCLC enrolled on the FLARE-RT phase II trial of risk-adaptive chemoradiation and optional consolidation PD-L1 checkpoint blockade (NCT02773238). FDG-PET, CT, and perfusion SPECT imaging pretreatment and week 3 mid-treatment was performed and 110 IBSI-compliant pyradiomics shape-/intensity-/texture-based features from the metabolic tumor volume were extracted. Outcome modeling consisted of a fused Laplacian sparse group LASSO with component-wise gradient boosting survival regression in a multitask learning framework. Testing performance under stratified 10-fold cross-validation was evaluated for multitask learning radiomics of different imaging modalities and time points. Multitask learning models were benchmarked against conventional clinical imaging and delta radiomics models and evaluated with the concordance index (c-index) and index of prediction accuracy (IPA). FDG-PET radiomics had higher prognostic value for overall survival in test folds (c-index 0.71 [0.67, 0.75]) than CT radiomics (c-index 0.64 [0.60, 0.71]) or perfusion SPECT radiomics (c-index 0.60 [0.57, 0.63]). Multitask learning of pre-/mid-treatment FDG-PET radiomics (c-index 0.71 [0.67, 0.75]) outperformed benchmark clinical imaging (c-index 0.65 [0.59, 0.71]) and FDG-PET delta radiomics (c-index 0.52 [0.48, 0.58]) models. Similarly, the IPA for multitask learning FDG-PET radiomics (30%) was higher than clinical imaging (26%) and delta radiomics (15%) models. Radiomics models performed consistently under different voxel resampling conditions. Multitask learning radiomics for outcome modeling provides a clinical decision support platform that leverages longitudinal imaging information. This framework can reveal the relative importance of different imaging modalities and time points when designing risk-adaptive cancer treatment strategies.

Gastroesophageal reflux disease and paraneoplastic neurological syndrome associated with long-term survival in limited stage small-cell lung cancer

Introduction

Patients with small‐cell lung cancer (SCLC) have a very poor prognosis. However, a subset of SCLC achieves long‐term survival. The objective of this study was to investigate factors and pattern of long‐term survival in patients with limited‐stage small cell lung cancer (LS‐SCLC) who achieved a complete response (CR) after chemoradiotherapy.

Patient and Methods

This was a single‐center retrospective study. The analysis of hazard ratio (HR) and 95% confidence interval (CI) was performed using Cox proportional hazards model. For pattern analysis, the date of recurrence was used as the endpoint. The nominal categorical variables were analyzed by the χ² test. Survival was estimated using the Kaplan–Meier model, and the results were reported as the median and interquartile range.

Results

We identified 162 patients, median age was 64.7 (56.2–70.2) years, and 94 (58%) were females. Eighty‐one patients (50%) had recurrence during follow‐up. Gastroesophageal reflux disease (GERD) (HR, 0.65; 95% CI, 0.45–0.93; p = 0.016) and neurological paraneoplastic syndrome (PNS) (HR, 0.46; 95% CI, 0.29–0.72; p < 0.001) were independent factors associated with improved overall survival (OS). Patients with GERD had prolonged recurrence free survival (RFS) compared to patients without GERD (median, 29.1 months vs. 13.9 months, p < 0.001), whereas patients with neurological PNS had a reduced recurrence rate compared to those patients without neurological PNS (No. [%], 8 [20.5] vs. 73 [59.3], p < 0.001).

Conclusions

Patients with LS‐SCLC achieving a CR after chemoradiotherapy, GERD, and neurological PNS were associated with improved OS. GERD and neurological PNS were associated with longer RFS and lower recurrence rate, respectively.

Serum Metabolic Disturbances in Lung Cancer Investigated through an Elaborative NMR-Based Serum Metabolomics Approach

Detection of metabolic disturbances in lung cancer (LC) has the potential to aid early diagnosis/prognosis and hence improve disease management strategies through reliable grading, staging, and determination of neoadjuvant status in LC. However, a majority of previous metabolomics studies compare the normalized spectral features which not only provide ambiguous information but further limit the clinical translation of this information. Various such issues can be resolved by performing the concentration profiling of various metabolites with respect to formate as an internal reference using commercial software Chenomx. Continuing our efforts in this direction, the serum metabolic profiles were measured on 39 LC patients and 42 normal controls (NCs, comparable in age/sex) using high-field 800 MHz NMR spectroscopy and compared using multivariate statistical analysis tools to identify metabolic disturbances and metabolites of diagnostic potential. Partial least-squares discriminant analysis (PLS-DA) model revealed a distinct separation between LC and NC groups and resulted in excellent discriminatory ability with the area under the receiver-operating characteristic (AUROC) = 0.97 [95% CI = 0.89-1.00]. The metabolic features contributing to the differentiation of LC from NC samples were identified first using variable importance in projection (VIP) score analysis and then checked for their statistical significance (with p-value < 0.05) and diagnostic potential using the ROC curve analysis. The analysis revealed relevant metabolic disturbances associated with LC. Among various circulatory metabolites, six metabolites, including histidine, glutamine, glycine, threonine, alanine, and valine, were found to be of apposite diagnostic potential for clinical implications. These metabolic alterations indicated altered glucose metabolism, aberrant fatty acid synthesis, and augmented utilization of various amino acids including active glutaminolysis in LC.

SUVmax to tumor perimeter distance: a robust radiomics prognostic biomarker in resectable non-small cell lung cancer patients

OBJECTIVE

The purpose of this study was to evaluate the prognostic value of novel geometric variables obtained from pre-treatment [¹⁸F]FDG PET/CT with respect to classical ones in patients with non-small cell lung cancer (NSCLC).

METHODS

Retrospective study including stage I-III NSCLC patients with baseline [¹⁸F]FDG PET/CT. Clinical, histopathologic, and metabolic parameters were obtained. After tumor segmentation, SUV and volume-based variables, global texture, sphericity, and two novel parameters, normalized SUVpeak to centroid distance (nSCD) and normalized SUVmax to perimeter distance (nSPD), were obtained. Early recurrence (ER) and short-term mortality (STM) were used as end points. Univariate logistic regression and multivariate logistic regression with respect to ER and STM were performed.

RESULTS

A cohort of 173 patients was selected. ER was detected in 49/104 of patients with recurrent disease. Additionally, 100 patients died and 53 had STM. Age, pathologic lymphovascular invasion, lymph nodal infiltration, TNM stage, nSCD, and nSPD were associated with ER, although only age (aOR = 1.06, p = 0.002), pathologic lymphovascular invasion (aOR = 3.40, p = 0.022), and nSPD (aOR = 0.02, p = 0.018) were significant independent predictors of ER in multivariate analysis. Age, lymph nodal infiltration, TNM stage, nSCD, and nSPD were predictors of STM. Age (aOR = 1.05, p = 0.006), lymph nodal infiltration (aOR = 2.72, p = 0.005), and nSPD (aOR = 0.03, p = 0.022) were significantly associated with STM in multivariate analysis. Coefficient of variation (COV) and SUVmean/SUVmax ratio did not show significant predictive value with respect to ER or STM.

CONCLUSION

The geometric variables, nSCD and nSPD, are robust biomarkers of the poorest outcome prediction of patients with NSCLC with respect to classical PET variables.

KEY POINTS

• In NSCLC patients, it is crucial to find prognostic parameters since TNM system alone cannot explain the variation in lung cancer survival. • Age, lymphovascular invasion, lymph nodal infiltration, and metabolic geometrical parameters were useful as prognostic parameters. • The displacement grade of the highest point of metabolic activity towards the periphery assessed by geometric variables obtained from [¹⁸F]FDG PET/CT was a robust biomarker of the poorest outcome prediction of patients with NSCLC.

Prophylactic Cranial Irradiation for Extensive-Stage Small-Cell Lung Cancer: A Controversial Area

Small-cell lung cancer (SCLC) is a highly aggressive malignant tumor that is prone to lead to the development of brain metastases (BM). The application of prophylactic cranial irradiation (PCI) has been regarded as an important technological advance made in cancer therapy to reduce the occurrence of BM and improve patient survival. The benefits of PCI in the treatment of limited-stage SCLC have been confirmed. However, there has been continuous controversy about the indications and advantages of PCI for extensive-stage SCLC (ES-SCLC) because of the conflicting results from two prospective trials. In this review, we aimed to discuss the relevant controversy and progress made in the clinical application of PCI in ES-SCLC.

Prediction of overall survival of non-small cell lung cancer with bone metastasis: an analysis of the Surveillance, Epidemiology and End Results (SEER) database

Background

The prognosis of non-small cell lung cancer (NSCLC) patients with bone metastasis is extremely repulsive. The aim of this study was to potentially characterize the prevalence, associated factors and to establish a prognostic nomogram to predict the overall survival (OS) of NSCLC patients with bone metastasis.

Methods

The Surveillance, Epidemiology and End Results (SEER) database was used to collected NSCLC cases during 2010–2015. The cases with incomplete clinicopathological information were excluded. Finally, 484 NSCLC patients with bone metastasis were included in the present study and randomly divided into the training (n=340) and validation (n=144) cohorts in a ratio of 7:3 based on R software. NSCLC patients with bone metastasis were selected to investigate predictive factors for OS and cancer-specific survival (CSS) using the multivariable Cox proportional hazards regression. A nomogram incorporating these prognostic factors was developed and evaluated by a concordance index (C-index), calibration plots, and risk group stratifications.

Results

In the Cox proportional hazards model, sex, race, American Joint Committee on Cancer (AJCC) N, T stage, liver metastasis, and chemotherapy were regarded as prognostic factors of OS. The nomogram based on sex, race, AJCC N, T stage, liver metastasis and chemotherapy was developed for cancer-specific death to predict 1-, 3-, and 5-year survival rate with good performance. The C-index of established nomogram was 0.695 for cancer-specific death in the study population with an acceptable calibration.

Conclusions

The female gender, the patients with chemotherapy and not liver metastasis may indicate improved survival. However, the global prospective data with the latest tumor, node, metastasis (TNM) classification is needed to further improve this model.

Adjuvant Chemotherapy in Patients with Node-Negative Non-Small Cell Lung Cancer with Satellite Pulmonary Nodules in the Same Lobe

Background

According to the eighth TNM (tumor-node-metastasis) staging system, the presence of separate tumor nodules in the same lobe is designated as a T3 descriptor. However, it remains unclear whether adjuvant chemotherapy confers survival advantages in this setting.

Methods

We retrospectively identified 142 pathologic T3N0M0 patients with additional pulmonary nodules in the same lobe from a single-institutional database from 2004 to 2019. The main outcomes were overall survival and recurrence-free survival. Multivariable Cox regression was used to identify the benefit of adjuvant chemotherapy while adjusting for other variables.

Results

Sixty-one patients received adjuvant chemotherapy (adjuvant group) and 81 patients did not receive adjuvant therapy after surgery (surgery-only group). There were no demonstrable differences between the 2 groups regarding hospital mortality and postoperative complications, indicating that treatment selection had not significantly occurred. However, the use of adjuvant chemotherapy was associated with improved 5-year overall survival (70% vs. 59%, p=0.006) and disease-free survival (60% vs. 46%, p=0.040). A multivariable Cox model demonstrated that adjuvant chemotherapy was associated with a survival advantage (adjusted hazard ratio, 0.54; p<0.001). In exploratory analyses of subgroups, the effect of adjuvant chemotherapy seemed to be insufficient in those with small main tumors (<4 cm).

Conclusion

Adjuvant chemotherapy was associated with better survival in T3 cancers with an additional tumor nodule in the same lobe. However, the role of adjuvant chemotherapy in patient subgroups with small tumors or those without risk factors should be determined via large studies.

Efficacy of adjuvant EGFR inhibitors and impact of clinical factors in resected EGFR-mutated non-small-cell lung cancer: a meta-analysis

Background: The role of adjuvant EGFR tyrosine kinase inhibitors (TKIs) in resected EGFR-mutated non-small-cell lung cancer (NSCLC) remains unclear. Materials & methods: We evaluated pooled hazard ratio and 95% CI for disease-free survival, overall survival and prespecified subgroups. Results: Seven prospective studies with 1288 patients were included in the meta-analysis. Adjuvant EGFR TKIs significantly improved disease-free survival in EGFR-mutated resected NSCLC (HR: 0.41; 95% CI: 0.24-0.70) and in all subgroups. However, the overall survival benefit was not significant (HR: 0.65; 95% CI: 0.36-1.17). The benefit of adjuvant TKIs may be associated with TKI regimens, treatment duration, pathological stage and EGFR mutation type. Conclusion: Adjuvant EGFR TKIs significantly improved disease-free survival and nonsignificantly improved overall survival in resected EGFR-mutated NSCLC.