Biological and clinical implications of EGFR mutations in lung cancer

Epidermal growth factor receptors unveiled: a comprehensive survey on mutations, clinical insights of global inhibitors, and emergence of heterocyclic derivatives as EGFR inhibitors

Mutations that overexpress the epidermal growth factor receptor (EGFR) are linked to cancers like breast (15-20%), head and neck (10-15%), colorectal (5-8%), and non-small cell lung cancer (10-50%), especially in East Asian populations. EGFR activation stimulates 'RAS/RAF/MEK/ERK, PI3K/Akt, and MAPK' pathways, which enhance cell division, survival, angiogenesis, and tumour growth while inhibiting apoptosis and metastasis. Secondary mutations (e.g. 'T790M', 'C797S'), off-target effects, and resistance due to alternate pathway activation reduce the efficacy of currently available EGFR inhibitors. To address these issues, 'novel heterocyclic inhibitors with structural versatility were developed to improve selectivity and binding affinity for mutant EGFR forms'. These new EGFR reduce side effects, enhance pharmacokinetics, and enhance therapeutic efficacy at low concentrations. This review focuses on 'EGFR mutations in various cancers' detailing the biochemical effects, clinical profiles, and binding interactions of globally approved EGFR inhibitors. Furthermore, it focuses into recent progress in nano-formulations and the development of heterocyclic derivatives that can successfully 'target mutant EGFRs' through varied synthesis methods. These inhibitors have the potential to have better binding affinities, selectivity's, and less side-effect. Further research required to refine the structures and develop nanoformulations of EGFR-targeted therapeutics in order to improve therapeutic efficiency and, provide more effective cancer treatments.

Effect of ground-glass opacity components on the recurrence of pathological stage IB non-small cell lung cancer harboring epidermal growth factor receptor mutations

PURPOSE

This study aimed to examine the influence of ground-glass opacity (GGO) on the prognosis of epidermal growth factor receptor (EGFR)-mutated pathological (p)-stage IB non-small cell lung cancer (NSCLC).

METHODS

Between 2009 and 2021, 115 patients underwent complete anatomical lung resection with mediastinal lymphadenectomy for p-stage IB non-squamous NSCLC harboring common EGFR mutations. The patients were classified into the part-solid and pure-solid arms based on the presence of GGO components.

RESULTS

The median follow-up time was 70.2 months. Sixty-seven patients (58%) had pure-solid tumors and 112 (97%) were diagnosed with adenocarcinoma. No patients received adjuvant EGFR-tyrosine kinase inhibitors (TKIs). The 5-year disease-free survival (DFS) rates in the pure-solid arm were significantly lower than those in the part-solid arm (5-year DFS: 45.3% vs. 86.8%, p < 0.01). The 5-year cumulative incidence of recurrence was higher in the pure-solid arm than that in the part-solid arm (49.9% vs. 9.0%, p < 0.01). A multivariable analysis revealed that pure-solid tumors were an independent prognostic predictor of disease-free survival, whereas pathological factors were not.

CONCLUSIONS

In EGFR-mutated p-stage IB NSCLC, pure-solid tumors were significant predictors of DFS. The presence of GGO components should be considered in the decision criteria for adjuvant therapy with TKIs.

Pooled Analysis of the Prognostic Significance of Epidermal Growth Factor Receptor (EGFR) Mutational Status in Combination with Other Driver Genomic Alterations in Stage I Resected Invasive Lung Adenocarcinoma for Recurrence-Free Survival: A Population-Based Study

BACKGROUND

The prognostic significance of epidermal growth factor receptor (EGFR) mutations in stage I invasive lung adenocarcinoma (LUAD) remains debated. Improving the lung cancer staging system requires further investigation into actionable mutations and their association with survival outcomes.

PATIENTS AND METHODS

A total of 410 patients with stage I invasive LUAD were analyzed for their driver mutations. Survival analysis of EGFR mutations, exon 19 deletion, L858R in exon 21, and minor genotypes were stratified by clinicopathologic characteristics. Kaplan-Meier and log-rank tests were used to determine prognostic significance. Univariate and multivariate Cox proportional hazard regression models assessed variables' impact on recurrence-free survival (RFS). Patients with further-profiled samples were divided into training and validation datasets by computer-generated random numbers. Multiple machine learning algorithms were applied to construct genomic prediction models, with C index evaluated for each.

RESULTS

EGFR mutations occurred in 210 patients (51.2%). In stage I invasive LUAD, EGFR mutations strongly correlated with poor RFS (P = 0.022), especially in never smoker (P < 0.001), female (P = 0.024), part-solid (P = 0.002), and stage IA subgroups (P = 0.020). The most frequently co-mutated gene was TP53. Moreover, patients with EGFR/TP53 co-mutations, regardless of mutant types, exhibited worse prognosis. A mutational prognostic model based on the random survival forest (RSF) algorithm achieved the highest mean C index (C index: 0.87 in training cohort versus 0.74 in validation cohort), and demonstrated strong RFS estimation performance [area under the curve (AUC):1-year, 0.87, versus 3-year, 0.92, versus 5-year, 0.92].

CONCLUSIONS

EGFR mutations are robust biomarkers for RFS estimation in stage I invasive LUAD. Combining EGFR mutations with other actionable mutations enhances individualized RFS estimation.

To establish a prognostic model of epidermal growth factor receptor mutated non-small cell lung cancer patients based on Least Absolute Shrinkage and Selection Operator regression

BACKGROUND

There is currently a shortage of effective diagnostic tools that are used for identifying long-term survival among non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) mutations. This research utilized the development of a prognostic model to assist clinicians in forecasting the survival over 24 months.

METHODS

In Phase III and IV those patients who were diagnosed with EGFR mutation from January 2018 to June 2022 were enrolled into the lung cancer group of Thoracic Surgery Department of Hebei Provincial People's Hospital. Long-run survival was stated as survival for 24 months after being diagnosed. A multivariate prognostic pattern was constructed by means of internal validation and binary logistic regression by bootstrapping. One nomogram was created with a view to boosting the explanation and applicability of the pattern.

RESULTS

A total of 603 patients with EGFR mutation were registered. Elements linked to the whole survival beyond 24 months were age (OR 6.15); female (OR 1.79); functional status (ECOG 0-1) (OR 5.26); Exon 20 insertion mutation deletion (OR 2.08); No central nervous system metastasis (OR 2.66), targeted therapy (OR 0.43); Immunotherapy (OR 0.24). The model has good internal validation.

CONCLUSION

Seven pretreatment clinicopathological variables predicted survival over 24 months. That pattern owns a great discriminative capability. It is hypothesized that this pattern is capable of assisting in selecting the optimal treatment sequence for NSCLC patients with EGFR mutations.

Clinicopathological differences between EGFR mutated and EGFR wild-type lung adenocarcinoma with papillary predominant pattern

OBJECTIVES

We aimed to reveal the clinicopathological differences between epidermal growth factor receptor (EGFR)-mutated and wild-type (WT) lung adenocarcinoma (LUAD) focusing on the predominant subtype.

METHODS

This study included 352 with EGFR mutation and 370 with WT patients in consecutive stage I LUAD classified by the predominant subtype, and their clinicopathological characteristics and prognosis were analyzed. Using the Cancer Genome Atlas Program (TCGA) cohort, we analyzed differences in gene expression between EGFR mutation and WT groups. Furthermore, we performed immunohistochemical evaluations for 46 with EGFR mutation and 47 with WT patients in consecutive stage I papillary predominant adenocarcinoma (PPA).

RESULTS

Compared to the PPA with WT [n = 115], those with EGFR mutation [n = 99] exhibited smaller invasive size (p = 0.03) and less frequent vessel invasion (p < 0.01). However, PPA with EGFR mutation showed significantly worse 5-ys recurrence-free survival (RFS) rates compared to those with WT (70.6 % versus 83.3 %, p = 0.03). Contrarily, no significant differences were observed in other predominant subtypes. In the TCGA cohort, PPA with EGFR mutation tended to show higher expression of galectin-3, which is associated with tumor metastasis and resistance to anoikis, compared to those with WT (p = 0.06). Immunohistochemical evaluation revealed that galectin-3 expression was significantly higher in PPA with EGFR mutation than in those with WT (p < 0.01).

CONCLUSIONS

The prognosis of PPA with EGFR mutation proved to be less favorable compared to that with WT, and galectin-3 is highly expressed in EGFR-mutated PPA.

Performance characteristics of a polymerase chain reaction-based assay for the detection of EGFR mutations in plasma cell-free DNA from patients with non-small cell lung cancer using cell-free DNA collection tubes

Survival rates in non-small cell lung cancer (NSCLC) are low. Detection of circulating tumor DNA in liquid biopsy (plasma) is increasingly used to identify targeted therapies for clinically actionable mutations, including EGFR mutations in NSCLC. The cobas® EGFR Mutation Test v2 (cobas EGFR test) is FDA-approved for EGFR mutation detection in tissue or liquid biopsy from NSCLC. Standard K2EDTA tubes require plasma separation from blood within 4 to 8 hours; however, Roche Cell-Free DNA (cfDNA) Collection Tubes (Roche cfDNA tube) enable whole blood stability for up to 7 days prior to plasma separation. This analysis assessed performance of Roche cfDNA tubes with the cobas EGFR test for the detection of EGFR mutations in plasma from healthy donors or patients with NSCLC. Overall, test performance was equally robust with either blood collection tube, eg, regarding limit of detection, linearity, and reproducibility, making Roche cfDNA tubes suitable for routine clinical laboratory use in this setting. Importantly, the Roche cfDNA tubes provided more flexibility for specimen handling versus K2EDTA tubes, eg, in terms of tube mixing, plasma separation, and sample stability, and do not require processing of blood within 8 hours thereby increasing the reach of plasma biopsies in NSCLC.

Current management of uncommon EGFR mutations in non-small cell lung cancer

Epidermal growth factor receptor (EGFR) mutations are frequently implicated in non-small cell lung cancer (NSCLC). Though these typically involve exon 19 in-frame deletions or L858R mutations in exon 21, uncommon EGFR mutations comprise 10-15 % of all EGFR mutations. These most frequently include G719X mutations in exon 18, L861Q mutations in exon 21, S768I mutations in exon 20, and in-frame insertions and/or duplications in exon 20. It is crucial to understand these distinct variants and their specific responses to active treatment options to optimize care. In this review, we discuss these uncommon mutations in depth and dissect the current literature regarding their treatment outcomes and subsequent evidence-based management guidelines.

Successful treatment of severe lung cancer caused by third-generation EGFR-TKI resistance due to EGFR genotype conversion with afatinib plus anlotinib

Third-generation EGFR-TKIs can be used to treat advanced non-small cell lung cancer patients with T790M resistance mutation induced by first- or second-generation EGFR-TKIs. However, it will also result in drug resistance, and the resistance mechanisms of third-generation EGFR-TKIs are complex. Here we reported a patient diagnosed with advanced lung adenocarcinoma and EGFR positive in September 2016. Following first-line targeted therapy with gefitinib, genetic testing showed EGFR T790M positive, which resulted in a change to osimertinib targeted therapy. In May 2021, troponin and creatinine levels were elevated, and the tumor hyperprogressed to severe lung cancer. Repeated genetic testing revealed that EGFR genotype converted to a non-classical mutation and EGFR T790M turned negative, which caused third-generation EGFR-TKI resistance. As a result, afatinib combined with anlotinib was selected to stabilize the patient's condition. We were inspired by the case that it reflects the significance and necessity of exploring the resistance mechanism and dynamically detecting genetic status throughout the course of treatment, which may help realize individualized precision therapy, and maximize the potential of patient.

Modified gefitinib conjugated Fe3O4 NPs for improved delivery of chemo drugs following an image-guided mechanistic study of inner vs. outer tumor uptake for the treatment of non-small cell lung cancer

Gefitinib (GEF) is an FDA-approved anti-cancer drug for the first-line treatment of patients with metastatic non-small cell lung cancer (NSCLC). However, the efficacy of anticancer drugs is limited due to their non-specificity, lower accumulation at target sites, and systemic toxicity. Herein, we successfully synthesized a modified GEF (mGEF) drug and conjugated to Iron oxide nanoparticles (Fe3O4 NPs) for the treatment of NSCLC via magnetic resonance (MR) image-guided drug delivery. A traditional EDC coupling pathway uses mGEF to directly conjugate to Fe3O4 NPs to overcom the drug leakage issues. As a result, we found in vitro drug delivery on mGEF- Fe3O4 NPs exhibits excellent anticancer effects towards the PC9 cells selectively, with an estimated IC 50 value of 2.0 μM. Additionally, in vivo MRI and PET results demonstrate that the NPs could accumulate in tumor-specific regions with localized cell growth inhibition. Results also revealed that outer tumor region exhibiting a stronger contrast than the tinner tumor region which may due necrosis in inner tumor region. In vivo biodistribution further confirms Fe3O4 NPs are more biocompatible and are excreated after the treatment. Overall, we believe that this current strategy of drug modification combined with chemical conjugation on magnetic NPs will lead to improved cancer chemotherapy as well as understanding the tumor microenvironments for better therapeutic outcomes.

Synthesis and preclinical evaluation of two osimertinib isotopologues labeled with carbon-11 as PET tracers targeting the tyrosine kinase domain of the epidermal growth factor receptor

INTRODUCTION

Osimertinib is a third-generation tyrosine kinase inhibitor (TKI) that is able to inhibit the EGFR treatment resistance mutation T790M and primary EGFR mutations Del19 and L858R. The aim of the study was to evaluate the potential of carbon-11 labeled osimertinib to be used as a tracer for the PET imaging of tumors bearing the T790M mutation.

METHODS

Osimertinib was labeled with carbon-11 at two positions, and the effect of the labeling position on the metabolism and biodistribution was studied in female nu/nu mice. The mutation status specificity of osimertinib was confirmed in vitro in a cell growth inhibition experiment, and the tumor-targeting potential of the carbon-11 isotopologues was evaluated using female nu/nu mice xenografted with NSCLC cell lines; the wild-type EGFR expressing A549, the primary Del19 EGFR mutated HCC827 and the resistance T790M/L858R mutated H1975. One of the osimertinib tracers was selected based on the results acquired and evaluated for tracer specificity and selectivity by assessment of tumor uptake in a PET study where HCC827 tumor-bearing mice were pretreated with osimertinib or afatinib.

RESULTS

[Methylindole-¹¹C]- and [dimethylamine-¹¹C]osimertinib were synthesized by ¹¹C-methylation of precursors AZ5104 and AZ7550, respectively. Rapid metabolism of both analogs of [¹¹C]osimertinib was observed. Although the tumor uptake and retention of [methylindole-¹¹C]- and [dimethylamine-¹¹C]osimertinib in tumors were similar, the tumor-to-muscle ratios appeared to be higher for [methylindole-¹¹C]osimertinib. The highest uptake, tumor-to-blood, and tumor-to-muscle ratio were observed in the Del19 EGFR mutated HCC827 tumors. However, the specificity and selectivity of [methylindole-¹¹C]osimertinib PET could not be demonstrated in HCC827 tumors. The uptake of [methylindole-¹¹C]osimertinib was not significantly higher in T790M resistance mutated H1975 xenografts compared to the negative control cell line A549.

CONCLUSIONS

Osimertinib was successfully labeled at two positions with carbon-11, yielding two EGFR PET tracers, [methylindole-¹¹C]osimertinib and [dimethylamine-¹¹C]osimertinib. The preclinical evaluation demonstrated uptake and retention in three NSCLC xenografts; A549, HCC827, and H1975. The highest uptake was observed in the primary Del19 EGFR mutated HCC827. The ability of [methylindole-¹¹C]osimertinib to distinguish between the T790M resistance mutated H1975 xenografts and the wild-type EGFR expressing A549 could not be confirmed in the ex vivo study.

Real-life comparison of afatinib and erlotinib in non-small cell lung cancer with rare EGFR exon 18 and exon 20 mutations: a Turkish Oncology Group (TOG) study

OBJECTIVES

To compare the survival of first- and second-generation tyrosine kinase inhibitors (TKIs) in patients with rare EGFR exon 18 and exon 20 mutation-positive non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We retrospectively evaluated survival characteristics of 125 patients with EGFR exon 18 and exon 20 mutated NSCLC who received erlotinib or afatinib as first line treatment between 2012 and 2021 from 34 oncology centres. Since exon 20 insertion is associated with TKI resistance, these 18 patients were excluded from the study.

RESULTS

EGFR exon 18 mutations were seen in 60%, exon 20 mutations in 16%, and complex mutations in 24% of the patients with NSCLC who were evaluated for the study. There were 75 patients in erlotinib treated arm and 50 patients in afatinib arm. Patients treated with erlotinib had progression-free survival time (PFS) of 8.0 months and PFS was 7.0 months in the afatinib arm (p = 0.869), while overall survival time (OS) was 20.0 vs 24.8 months, respectively (p = 0.190). PFS of exon 18 mutated arm was 7.0 months, exon 20 mutated arm was 4.3 months, and complex mutation positive group was 17.3 months, and this was statistically significant (p = 0.036). The longest OS was 32.5 months, seen in the complex mutations group, which was not statistically different than exon 18 and in exon 20 mutated groups (21.0 and 21.2 months, respectively) (p = 0.323).

CONCLUSION

In this patient group, especially patients with complex mutations are as sensitive to EGFR TKI treatment similar to classical mutations, and in patients with rare exon 18 and exon 20 EGFR mutation both first- and second-generation EGFR-TKIs should be considered, especially as first- and second-line options.

Advances in Lung Cancer Treatment Using Nanomedicines

Carcinoma of the lungs is among the most menacing forms of malignancy and has a poor prognosis, with a low overall survival rate due to delayed detection and ineffectiveness of conventional therapy. Therefore, drug delivery strategies that may overcome undesired damage to healthy cells, boost therapeutic efficacy, and act as imaging tools are currently gaining much attention. Advances in material science have resulted in unique nanoscale-based theranostic agents, which provide renewed hope for patients suffering from lung cancer. Nanotechnology has vastly modified and upgraded the existing techniques, focusing primarily on increasing bioavailability and stability of anti-cancer drugs. Nanocarrier-based imaging systems as theranostic tools in the treatment of lung carcinoma have proven to possess considerable benefits, such as early detection and targeted therapeutic delivery for effectively treating lung cancer. Several variants of nano-drug delivery agents have been successfully studied for therapeutic applications, such as liposomes, dendrimers, polymeric nanoparticles, nanoemulsions, carbon nanotubes, gold nanoparticles, magnetic nanoparticles, solid lipid nanoparticles, hydrogels, and micelles. In this Review, we present a comprehensive outline on the various types of overexpressed receptors in lung cancer, as well as the various targeting approaches of nanoparticles.

Effective treatment with icotinib in advanced lung adenocarcinoma harboring rare EGFR mutation G719A/L833V: A case report

RATIONALE

Mutations in epidermal growth factor receptor (EGFR) play critical roles in the pathogenesis of non-small cell lung cancer (NSCLC), and they are highly associated with sensitivity to tyrosine kinase inhibitors. Targeted therapies are approved for patients with "classical" mutations and a small number of other mutations. However, patients with rare, even double EGFR mutations have different responses to EGFR tyrosine kinase inhibitor, which brings uncertainty to clinical practice.

PATIENT CONCERNS

A 74-year-old woman, never-smoker, was presented with chest pain. Chest computed tomography scan showed a big lesion in the right upper lobe with mediastinal lymph nodes metastases. Fine-needle biopsy and pathology suggested lung adenocarcinoma. A rare G719A/L833V double mutation of EGFR was detected in both tissue and plasma samples by next-generation sequencing.Interventions and outcomes:Icotinib was used as first-line therapy and showed good efficacy. Partial response was achieved, and the progression-free survival was 8 months.

LESSONS

This is the first report of the icotinib treatment achieving long-lasting and stable disease control in an NSCLC patient with EGFR G719A/L833V mutation. Icotinib could be a first-line treatment option in NSCLC patients harboring EGFR G719A/L833V mutation.

Erlotinib with or without bevacizumab as a first-line therapy for patients with advanced nonsquamous epidermal growth factor receptor-positive non-small cell lung cancer: Exploratory subgroup analyses from the phase II JO25567 study

BACKGROUND

In the phase II JO25567 study (JapicCTI-111390), erlotinib plus bevacizumab demonstrated a significant clinical benefit in Japanese patients with epidermal growth factor receptor mutation-positive (EGFR+) non-small cell lung cancer (NSCLC). Here, we present an exploratory analysis investigating the impact of baseline pleural/pericardial effusion (PPE) on patient outcomes.

METHODS

Patients with stage IIIB/IV or postoperative recurrent EGFR+ NSCLC were randomized 1:1 to receive erlotinib (150 mg/day) plus bevacizumab (15 mg/kg every 3 weeks) or erlotinib monotherapy. Progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and safety were evaluated according to the presence or absence of baseline PPE.

RESULTS

The population comprised 152 patients, 66 with baseline PPE and 86 without. Median PFS was longer with erlotinib plus bevacizumab than with erlotinib alone, with (hazard ratio [HR] 0.45; 95% confidence interval [CI]: 0.25-0.82) or without (HR 0.62; 95% CI: 0.37-1.04) baseline PPE. Median OS was also prolonged with erlotinib plus bevacizumab relative to erlotinib regardless of the presence (HR 0.82; 95% CI: 0.46-1.47) or absence (HR 0.84; 95% CI: 0.46-1.55) of baseline PPE. ORR was higher with erlotinib plus bevacizumab (70.0%) than with erlotinib (55.6%) in patients with baseline PPE, but similar (68.9% vs. 70.7%) in patients without. Most common grade ≥3 adverse events were hypertension and rash in the erlotinib plus bevacizumab arm, and rash in the erlotinib arm, regardless of baseline PPE status.

CONCLUSIONS

Erlotinib plus bevacizumab may be a beneficial treatment strategy in patients with EGFR+ NSCLC, especially for those with baseline PPE.

Machine Learning-Based Radiomics for Prediction of Epidermal Growth Factor Receptor Mutations in Lung Adenocarcinoma

Identifying an epidermal growth factor receptor (EGFR) mutation is important because EGFR tyrosine kinase inhibitors are the first-line treatment of choice for patients with EGFR mutation-positive lung adenocarcinomas (LUAC). This study is aimed at developing and validating a radiomics-based machine learning (ML) approach to identify EGFR mutations in patients with LUAC. We retrospectively collected data from 201 patients with positive EGFR mutation LUAC (140 in the training cohort and 61 in the validation cohort). We extracted 1316 radiomics features from preprocessed CT images and selected 14 radiomics features and 1 clinical feature which were most relevant to mutations through filter method. Subsequently, we built models using 7 ML approaches and established the receiver operating characteristic (ROC) curve to assess the discriminating performance of these models. In terms of predicting EGFR mutation, the model derived from radiomics features and combined models (radiomics features and relevant clinical factors) had an AUC of 0.79 (95% confidence interval (CI): 0.77-0.82), 0.86 (0.87-0.88), respectively. Our study offers a radiomics-based ML model using filter methods to detect the EGFR mutation in patients with LUAC. This convenient and low-cost method may be of help to noninvasively identify patients before obtaining tumor sample for molecule testing.

Analysis of Molecular Biomarkers in Resected Early-Stage Non-Small Cells Lung Cancer: A Narrative Review

Simple Summary

In the last few years, the treatment of advanced NSCLC has radically changed after the development of new drugs against specific molecular targets. Moreover, multiple tumour biopsies have become mandatory in order to better select the appropriate targeted therapy. Molecular analysis using NGS in the early stage of NSCLC is still relatively widespread. The recent clinical trials that use targeted therapies in neoadjuvant and adjuvant settings also require molecular characterisation for early-stage patients. Due to the widespread use of molecular analysis in patients with early-stage NSCLC, the prognostic role of molecular biomarkers needs to be fully understood. This paper aimed to review the most recent studies associating the molecular expressions of early-stage NSCLC with survival.

Abstract

Next-generation sequencing has become a cornerstone in clinical oncology practice and is recommended for the appropriate use of tailored therapies in NSCLC. While NGS has already been standardised in advanced-stage NSCLC, its use is still uncommon in the early stages. The recent approval of Osimertinib for resected EGFR-mutated NSCLC in an adjuvant setting has launched the hypothesis that other targeted therapies used in metastatic patients can also lead to improved early-stage outcomes of NSCLC. The impact of molecular biomarkers on the prognosis of patients undergoing radical surgery for NSCLC is still unclear. Notably, the heterogeneous populations included in the studies that analysed surgical patients could be the main reason for these results. In this review, we report the most important studies that analysed the impact of principal molecular biomarkers on the survival outcomes of patients who underwent radical surgery for NSCLC.

Fused feature signatures to probe tumour radiogenomics relationships

Radiogenomics relationships (RRs) aims to identify statistically significant correlations between medical image features and molecular characteristics from analysing tissue samples. Previous radiogenomics studies mainly relied on a single category of image feature extraction techniques (ETs); these are (i) handcrafted ETs that encompass visual imaging characteristics, curated from knowledge of human experts and, (ii) deep ETs that quantify abstract-level imaging characteristics from large data. Prior studies therefore failed to leverage the complementary information that are accessible from fusing the ETs. In this study, we propose a fused feature signature (FFSig): a selection of image features from handcrafted and deep ETs (e.g., transfer learning and fine-tuning of deep learning models). We evaluated the FFSig's ability to better represent RRs compared to individual ET approaches with two public datasets: the first dataset was used to build the FFSig using 89 patients with non-small cell lung cancer (NSCLC) comprising of gene expression data and CT images of the thorax and the upper abdomen for each patient; the second NSCLC dataset comprising of 117 patients with CT images and RNA-Seq data and was used as the validation set. Our results show that our FFSig encoded complementary imaging characteristics of tumours and identified more RRs with a broader range of genes that are related to important biological functions such as tumourigenesis. We suggest that the FFSig has the potential to identify important RRs that may assist cancer diagnosis and treatment in the future.

Prognosis of epidermal growth factor receptor-mutated stage I lung adenocarcinoma with radiologically solid features

OBJECTIVES

The prognostic role of the epidermal growth factor receptor (EGFR) mutation remains controversial, especially in early-stage lung adenocarcinoma with a solid appearance. We evaluated the oncological outcomes of clinical stage I (c-stage I) radiologically invasive lung adenocarcinoma by EGFR mutation status.

METHODS

Between 2008 and 2013, the data from 463 surgically resected c-stage I radiologically invasive, i.e. solid-dominant lung adenocarcinomas subjected to EGFR mutant analysis, were evaluated. Oncological outcomes were assessed using multivariable Cox regression analysis. Recurrence-free survival (RFS) was estimated using Kaplan-Meier analysis and the log-rank test.

RESULTS

A total of 229 (49%) samples harboured the EGFR-mutant adenocarcinoma. Overall, the 5-year RFS did not differ significantly between the EGFR-mutant and EGFR wild-type groups (67.3% vs 64.9%; P = 0.639). However, among the clinical T1c/T2a tumour subset (n = 177), a multivariable Cox hazard model revealed that radiologically pure-solid tumour (P = 0.024), EGFR-mutant (P = 0.027) and pathological stage II/III (P < 0.001) were significant predictors of a poor RFS. Furthermore, in the c-T1c/T2a radiologically pure-solid lung adenocarcinoma subset, the EGFR-mutant group showed marginally lower 5-year RFS compared to that with the EGFR wild-type group (n = 134; 34.9% vs 53.0%; P = 0.062). Among them, multivariable Cox regression analysis revealed that EGFR mutant (P = 0.037) and pathological stage II/III (P = 0.011) were independently and significantly prognostic for worse RFS.

CONCLUSIONS

Among the c-stage I radiologically invasive lung adenocarcinomas, the EGFR mutation-positive type was correlated with an increased risk of recurrence in the c-T1c/T2a radiologically pure-solid tumour subset. When considering the prognostic value of EGFR mutations in early-stage lung adenocarcinoma, it is necessary to stratify them based on the presence of a ground-glass opacity component.

Clinicopathologic features and prognostic value of epidermal growth factor receptor mutation in patients with pT1a and pT1b invasive lung adenocarcinoma after surgical resection

Background

Previous studies have evaluated the prognostic value of epidermal growth factor receptor (EGFR) mutation in different subgroups of lung adenocarcinoma, but there remains controversial on this issue. We conduct this study aimed to reveal the prognostic value of EGFR mutation in patients with pT1a and pT1b invasive lung adenocarcinoma.

Methods

From August 2009 to February 2015, 338 patients with pT1a and pT1b invasive lung adenocarcinoma who underwent EGFR mutation analysis were enrolled into this study. According to clinicopathologic and radiologic characteristics, survival analysis was conducted in different subgroups using Kaplan-Meier methods and Cox regression models.

Results

EGFR mutation was detected in 216 (63.9%) patients. In the entire cohort, EGFR mutation was significantly frequent in female (P=0.011), never smoking (P=0.014) patients, patients with part-solid nodules (P=0.005) and patients with lepidic pattern-predominant adenocarcinoma (LPA)/acinar pattern-predominant adenocarcinoma (APA)/papillary pattern-predominant adenocarcinoma (PPA) (P=0.005). No difference in recurrence-free survival (RFS) was seen between patients harboring EGFR mutation and patients without EGFR mutation in the entire cohort (P=0.664) and the subgroup cohorts. Patients with EGFR mutation had a longer overall survival (OS) compared with patients without EGFR mutation in the entire cohort (P=0.005) and the subgroups of N0 stage cohort (P=0.013), N1–2 stage cohort (P=0.033), APA/PPA/invasive mucinous adenocarcinoma (IMA) cohort (P=0.011) and pT1b cohort (P=0.002). Tyrosine kinase inhibitors (TKIs) could significantly prolong the OS in patients with EGFR mutation after recurrence (P=0.04).

Conclusions

EGFR mutation was not a risk factor for recurrence of patients with pT1a and pT1b invasive lung adenocarcinoma.

Prognostic model of long-term advanced stage (IIIB-IV) EGFR mutated non-small cell lung cancer (NSCLC) survivors using real-life data

BACKGROUND

There is a lack of useful diagnostic tools to identify EGFR mutated NSCLC patients with long-term survival. This study develops a prognostic model using real world data to assist clinicians to predict survival beyond 24 months.

METHODS

EGFR mutated stage IIIB and IV NSCLC patients diagnosed between January 2009 and December 2017 included in the Spanish Lung Cancer Group (SLCG) thoracic tumor registry. Long-term survival was defined as being alive 24 months after diagnosis. A multivariable prognostic model was carried out using binary logistic regression and internal validation through bootstrapping. A nomogram was developed to facilitate the interpretation and applicability of the model.

RESULTS

505 of the 961 EGFR mutated patients identified in the registry were included, with a median survival of 27.73 months. Factors associated with overall survival longer than 24 months were: being a woman (OR 1.78); absence of the exon 20 insertion mutation (OR 2.77); functional status (ECOG 0-1) (OR 4.92); absence of central nervous system metastases (OR 2.22), absence of liver metastases (OR 1.90) or adrenal involvement (OR 2.35) and low number of metastatic sites (OR 1.22). The model had a good internal validation with a calibration slope equal to 0.781 and discrimination (optimism corrected C-index 0.680).

CONCLUSIONS

Survival greater than 24 months can be predicted from six pre-treatment clinicopathological variables. The model has a good discrimination ability. We hypothesized that this model could help the selection of the best treatment sequence in EGFR mutation NSCLC patients.

EML4-ALK-mediated activation of the JAK2-STAT pathway is critical for non-small cell lung cancer transformation

BACKGROUND

The echinoderm microtubule-associated protein-like-4 anaplastic lymphoma kinase (EML4-ALK) fusion gene was identified in a subset of non-small cell lung cancer (NSCLC) patients. They responded positively to ALK inhibitors. This study aimed to characterize the mechanisms triggered by EML4-ALK to induce NSCLC transformation.

METHODS

HEK293 and NIH3T3 cells were transfected with EML4-ALK variant 3 or pcDNA3.1-NC. H2228 cells were transfected with siRNA-EML4-ALK or siRNA-NC. Cell viability and proliferation were measured by the CCK-8 and EdU methods, respectively. Flow cytometry revealed apoptosis. Gene expression profiles were generated from a signaling pathway screen in EML4-ALK-regulated lung cancer cells and verified by qPCR and Western blotting. The co-immunoprecipitation and immunohistochemistry/ immunofluorescence determined the interaction and colocalization of JAK2-STAT pathway components with EML4-ALK.

RESULTS

Microarray identified several genes involved in the JAK2-STAT pathway. JAK2 and STAT6 were constitutively phosphorylated in H2228 cells. EML4-ALK silencing downregulated phosphorylation of STAT6. Expression of EML4-ALK in HEK293 and NIH3T3 cells activated JAK2, STAT1, STAT3, STAT5, and STAT6. In EML4-ALK-transfected HEK293 cells and EML4-ALK-positive H2228 cells, activated STAT6 and JAK2 colocalized with ALK. STAT3 and STAT6 were phosphorylated and translocated to the nucleus of H2228 cells following IL4 or IL6 treatment. Apoptosis increased, while cell proliferation and DNA replication decreased in H2228 cells following EML4-ALK knockdown. In contrast, HEK293 cell viability increased following EML4-ALK overexpression, while H2228 cell viability significantly decreased after treatment with ALK or JAK-STAT pathway inhibitors.

CONCLUSIONS

Our data suggest that the aberrant expression of EML4-ALK leads to JAK2-STAT signaling pathway activation, which is essential for the development of non-small cell lung cancer.

First-Line EGFR-TKIs Treatment in Stage I Non-Small-Cell Lung Cancer Patients Harboring EGFR Gene Mutations with Postoperative Intrapulmonary Recurrence

Background

The epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is an effective treatment for advanced lung cancer harboring EGFR gene mutations, and has improved progression-free survival in several clinical trials.

Methods

We investigated 30 stage I non-small-cell lung cancer patients harboring EGFR gene mutations with postoperative intrapulmonary recurrence. Progression-free survival and response rate were analyzed.

Results

Partial response was achieved in 23 patients and stable disease was found in 7 patients. The objective response rate was 76.7% and disease control rate was 100%. The median progression-free survival (PFS) time was 24.5 months. The median PFS in patients with only intrapulmonary recurrence was significantly superior to patients with both intrapulmonary recurrence and metastasis (32.0 months vs 14.0 months, P = 0.003). The median PFS observed in patients who underwent icotinib treatment was significantly longer than in patients who underwent gefitinib treatment (30.5 months vs 12.0 months, p = 0.005). There were no statistical differences in median PFS between patients with tumors harboring exon 21 mutation and exon 19 deletion, age <65 and ≥65, male and female, smoker and non-smoker.

Conclusion

Our result reveals that first-line EGFR-TKIs treatment for stage I non-small-cell lung cancer patients harboring EGFR gene mutations with postoperative intrapulmonary recurrence is effective and could be a useful option in practical setting.

A practical and adaptive approach to lung cancer screening: a review of international evidence and position on CT lung cancer screening in the Singaporean population by the College of Radiologists Singapore

Lung cancer is the leading cause of cancer-related death around the world, being the top cause of cancer-related deaths among men and the second most common cause of cancer-related deaths among women in Singapore. Currently, no screening programme for lung cancer exists in Singapore. Since there is mounting evidence indicating a different epidemiology of lung cancer in Asian countries, including Singapore, compared to the rest of the world, a unique and adaptive approach must be taken for a screening programme to be successful at reducing mortality while maintaining cost-effectiveness and a favourable risk-benefit ratio. This review article promotes the use of low-dose computed tomography of the chest and explores the radiological challenges and future directions.

Clinicopathological characteristics of lung adenocarcinoma with compound EGFR mutations

The extensive clinical applications of next-generation sequence analyzers have made uncommon and compound EGFR mutations more prevalent than previously described. However, clinicopathological impacts of compound EGFR mutations in lung adenocarcinoma remain unclear. We earlier examined the presence of compound EGFR mutations primarily in the cis allele by EGFR exon sequencing and droplet digital polymerase chain reaction in 462 completely resected EGFR-mutated adenocarcinomas of the lung and identified 64 tumors with compound mutations. We evaluated clinicopathological characteristics of lung adenocarcinomas with compound EGFR mutations in comparison with cases with common or uncommon single mutations. Among 64 compound EGFR mutations, L858R/E709G (9%) was the most frequent mutation type, followed by L858R/S768I (8%), L858R/T790M (8%), and L858R/L833V (6%). We observed both single and compound mutations frequently in women, never or light smokers; their adenocarcinomas showed thyroid transcription factor-1 immunoreactivity. In contrast, compound mutations were significantly associated with lymph node metastases (p = 0.0242; single vs. compound cases) and the presence of tumor cells with clear cytoplasm (p = 0.0014; single vs. compound cases). Furthermore, patients with compound mutations had significantly poorer prognoses than cases with single EGFR mutations (p = 0.043). Overall, clinicopathological features of common, uncommon, and compound EGFR mutations are similar; however, tumors with compound mutations may be characterized by aggressive behavior and histological findings of clear cell features.

Prognostic value of epidermal growth factor receptor gene mutation in resected lung adenocarcinoma

BACKGROUND

Mutation of the EGFR gene is known as a predictor for the response to EGFR tyrosine kinase inhibitor. Although EGFR mutation status is proposed to be incorporated in the Ninth Edition of the Lung Cancer Staging system, its prognostic value for surgically resected lung adenocarcinoma remains controversial.

METHODS

Data on 1512 patients with completely resected lung adenocarcinoma who underwent EGFR mutation analysis between 2008 and 2015 were collected. The prognostic value of EGFR mutations was determined in patients with lung adenocarcinoma stratified by clinicopathologic and radiologic characteristics. Independent prognostic factors were identified by multivariate analysis using the Cox proportional hazards model. Competing risk model was used to estimate the cumulative incidence.

RESULTS

EGFR mutations were identified in 935 patients (61.8%). In the entire cohort, there was no difference in recurrence-free survival between the EGFR-mutated group and the wild-type group (P = .266). However, Cox multivariate analyses revealed that EGFR mutation was a strong independent prognostic factor for worse recurrence-free survival in patients with radiologic solid tumors (hazard ratio, 1.485; 95% confidence interval, 1.208-1.826; P < .001), histologic acinar pattern-predominant adenocarcinoma/papillary pattern-predominant adenocarcinoma/invasive mucinous adenocarcinoma (hazard ratio, 1.684; 95% confidence interval, 1.330-2.132; P < .001), and pathologic stage II and III (hazard ratio, 1.417; 95% confidence interval, 1.115-1.801; P = .004). Patients with EGFR mutations developed significantly more brain (hazard ratio, 1.827; 95% confidence interval, 1.213-2.766; P = .004) and bone (hazard ratio, 1.724; 95% confidence interval, 1.131-2.631; P = .011) metastases compared with the wild-type cohort.

CONCLUSIONS

EGFR mutation was a strong poor prognostic factor in patients with radiologic solid, histologic acinar pattern-predominant adenocarcinoma/papillary pattern-predominant adenocarcinoma/invasive mucinous adenocarcinoma, and pathologic stage II and III lung adenocarcinomas. After surgery, distinct metastatic patterns were revealed according to EGFR mutation status. These findings have implications for the upcoming new lung cancer staging system.

The Correlation between EGFR Mutation Status and DNA Content of Lung Adenocarcinoma Cells in Pleural Effusion

Objectives: Lung adenocarcinomas with or without epidermal growth factor receptor (EGFR) mutations have shown different drug effects against EGFR inhibitors. But it is not very clear if EGFR mutation status affects the biological behavior of lung adenocarcinoma, because tumor gene regulation is very complicated and can be affected by many factors. We aimed to explore if EGFR mutation status is related with tumor malignant degree by investigating the relevance of EGFR mutation status with DNA content and aneuploid peaks of lung adenocarcinoma cells in pleural fluids without using EGFR-TKIs.

Materials and Methods: 591 cases of lung adenocarcinoma patients in Hebei Tumor Hospital who had undergone EGFR gene detection and DNA quantitative analysis were collected from January 2012 to August 2018.They were divided into two groups: EGFR mutant group and non-mutant group. EGFR mutations were detected by Amplification Refractory Mutation System (ARMS) and ABI 7500 Fluorescence quantitative PCR with pleural effusions. DNA content and aneuploid peaks were detected by LD DNA image cytometry (DNA-ICM). Rank-sum test of SPSS 16 was used for statistical analysis.

Results: The maximum DI, the mean DI of the first 20 cells greater than 5C, the percentage of cells greater than 5C and the number of cells greater than 9C of the first 20 cells in the mutant group were all higher than those in the non-mutant group, having statistical significance (p<0.001); the peaks of aneuploid cells in the mutant group occurred more often than those in the non-mutant group, having statistical significance (p<0.001).

Conclusions: Our study has shown that advanced lung adenocarcinomas with EGFR-mutations had higher DI values, more aneuploid cells and more frequent aneuploid peaks compared with those without EGFR-mutations, suggesting that advanced lung adenocarcinomas with EGFR mutations are more aggressive than those without EGFR mutations.

Heregulin expression and its clinical implication for patients with EGFR-mutant non-small cell lung cancer treated with EGFR-tyrosine kinase inhibitors

Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are standard therapy for EGFR-mutant non-small cell lung cancer (NSCLC). Preclinically, HER3 ligand heregulin induces resistance to EGFR-TKIs, whereas the pan-human EGFR family inhibitor afatinib remains effective. Here, we examined whether soluble heregulin levels have clinical implications for EGFR-mutant NSCLC treated with EGFR-TKIs. Soluble heregulin was immunologically measured in plasma from EGFR-mutant NSCLC patients. Cutoff values were determined by 1-year PFS ROC curve. The relationship between soluble heregulin and PFS following EGFR-TKI therapy was analyzed by Cox proportional hazards model. Seventy-three patients were enrolled: 44 were treated with 1^st-generation and 29 with 2^nd-generation EGFR-TKIs. Soluble heregulin levels varied (range: 274-7,138 pg/mL, median: 739 pg/mL). Among patients treated with 1^st-generation EGFR-TKIs, those with high heregulin (n = 20, >800 pg/mL) had a tendency for shorter PFS than those with low heregulin (n = 24, <800 pg/mL), with median PFS of 322 and 671 days, respectively. Cox proportional hazards model also indicated a trend toward resistance against 1^st-generation EGFR-TKIs (HR: 1.825, 95% CI: 0.865-4.318) but not against 2^nd-generation EGFR-TKIs. Soluble heregulin potentially correlates with resistance to EGFR-TKIs but not 2^nd-generation EGFR-TKIs in patients with EGFR-mutant NSCLC.

Cost-Effectiveness Analysis Of EGFR Mutation Testing And Afatinib Versus Gemcitabine-Cisplatin As First-Line Therapy For Advanced Non-Small-Cell Lung Cancer In China

Objective

The purpose of this study was to evaluate the cost-effectiveness of the combined use of afatinib and epidermal growth factor receptor (EGFR) testing versus gemcitabine-cisplatin as the first-line treatment for patients with non-small cell lung cancer (NSCLC) in China.

Methods

A decision-analytic model, based on clinical phase III trials, was developed to simulate patient transitions. Direct costs were estimated from the perspective of the Chinese healthcare system. Quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER) were calculated over a 5-year lifetime horizon. Model robustness was conducted in sensitivity analyses.

Results

For the base case, EGFR mutation testing followed by afatinib treatment for advanced NSCLC increased 0.15 QALYs compared with standard chemotherapy at an additional cost of $5069.12. The ICER for afatinib maintenance was $33,416.39 per QALY gained. The utility of PFS and the cost of afatinib had the most important impact on the ICER. Scenario analyses suggested that when a patient assistance program (PAP) was available, ICER decreased to $22,972.52/QALY lower than the willingness-to-pay (WTP) threshold of China ($26,508/QALY).

Conclusion

Our results suggest that gene-guided maintenance therapy with afatinib with the PAP might be a cost-effective treatment option compared with gemcitabine – cisplatin in China.

Zebrafish Xenograft Model of Human Lung Cancer for Evaluating Osimertinib Resistance

About half of NSCLC patients with EGFR mutation had secondary mutation T790M after treatment with a first-generation tyrosine kinase inhibitor (TKI), Gefitinib. The third-generation of EGFR-TKI Osimertinib is suitable for patients with EGFR mutation and T790M mutation. However, drug screening for NSCLC patients after the emergence of acquired resistance has become a difficult problem for clinicians. In this study, we established drug-resistant cell lines of Gefitinib and Osimertinib to evaluate cell proliferation in vitro. And we investigated the inhibitory effect of different drug concentration gradients on cancer cells. Zebrafish with high homology to human genes were selected as xenotransplantation models to compare the effects of different concentrations of Osimertinib on the proliferation and angiogenesis of zebrafish tumors after transplantation of different lung cancer cell lines. It was confirmed that Osimertinib could inhibit the proliferation of tumor cells with EGFR mutation and T790M resistance mutation in zebrafish, which was consistent with the clinical research conclusion.

Frequency and significance of epidermal growth factor receptor mutations detected by PCR methods in patients with non-small cell lung cancer

Epidermal growth factor receptor (EGFR) is the most important driver gene of non-small cell lung cancer (NSCLC) as EGFR mutations determine the efficacy of EGFR tyrosine kinase inhibitor (EGFR-TKI) therapy. In the present study, the comprehensive ability of widely used polymerase chain reaction (PCR) methods to detect EGFR mutations was determined. Among the 35 EGFR mutations detected via the direct sequencing of 73 patients with NSCLC, 11 types were identified in exons 18, 19 and 21. Among the 11 mutation types, all exon 18 and 21 mutations were identified by 2 widely used PCR methods, namely, Scorpion-Amplification Refractory Mutation System and cobas v2. However, among the 9 different exon 19 deletions, 3 types were not identified by the 2 methods. In addition, 25 samples with EGFR mutations were analyzed by the 2 methods, including a sample from a patient with an unidentified exon 19 deletion, the T751_I759 deletion and insertion S; this patient had long-term disease control as a result of EGFR-TKI therapy. The 2 methods could not detect this unidentified deletion, whereas sizing capillary electrophoresis for the comprehensive detection of exon 19 deletions detected this deletion. It is generally thought that patients with exon 19 mutations have higher response rates to EGFR-TKI therapy than patients with exon 21 mutations. The present study confirmed the EGFR mutation status by comparing the mutations with the Catalog Of Somatic Mutations In Cancer, which is the world's largest and most comprehensive resource for analyzing the effects of somatic mutations in human cancers. The predicted frequency of EGFR mutations identified by the 2 methods was 85%. The frequency of mutations detectable by the 2 methods was less for exon 19 than exon 21. Therefore, the results of the present study suggest that decreasing false-negative detection of exon 19 deletions is crucial for the clinical testing of EGFR mutations.

Treatment of uncommon EGFR mutations in non-small cell lung cancer: new evidence and treatment

Sensitizing mutations in epidermal growth factor receptor (EGFR) are associated with positive responses to anti-EGFR-targeted therapy, leading to a new era of treatment for non-small cell lung cancer (NSCLC). Exon 19 deletions and exon 21 L858R substitutions are the most common mutations, accounting for approximately 90% mutations in NSCLC; these are termed classic mutations and result in high sensitivity to tyrosine kinase inhibitors (TKIs). Other EGFR mutations are termed uncommon EGFR mutations, of which G719X, S768I, L861Q, exon 20 insertions, and complex mutations are the most frequent. G719X, S768I, and L861Q are point mutations and those that exist with complex mutations are sensitive to first-generation TKIs. A prospective analysis demonstrated that afatinib, a second-generation TKI, led to a better prognosis in some patients with NSCLC compared to first-generation TKIs. Chemotherapy used to be the traditional choice for patients carrying exon 20 insertions; however, with the development of novel targeted drugs, the role of chemotherapy is changing. Tremendous progress has also been made in clinical trials on immunotherapy treatment of uncommon EGFR mutations. The treatment for patients with NSCLC harboring uncommon EGFR mutations remains a subject of debate and the sensitivity of uncommon EGFR mutations to TKIs is still unclear. Here, we summarized recent data in the literature and provide an overview of the clinical characteristics, incidence, and outcomes of patients harboring G719X, S768I, L861Q, exon 20 insertions, and complex mutations who were treated with TKIs, chemotherapy, or immunotherapy.

Correlation of Thyroid Transcription Factor-1 Expression with EGFR Mutations in Non-Small-Cell Lung Cancer: A Meta-Analysis

OBJECTIVES

This meta-analysis investigated the relationship between thyroid transcription factor-1 (TTF-1) expression and epidermal growth factor receptor (EGFR) mutations in non-small-cell lung cancer (NSCLC) to clarify whether TTF-1 can be a potential surrogate marker for EGFR mutation status in advanced NSLCL.

METHODS

A systematic searching of databases, including PubMed, EMBASE, Cochrane Library, and Google Scholar, was performed to identify studies assessing the correlation of TTF-1 expression with EGFR mutations. From 17 studies, 9764 patients were included in the combined analysis of odds ratio (OR) for the correlation between TTF-1 expression and EGFR mutations.

RESULTS

Compared with NSCLCs showing negative TTF-1 expression, tumors harboring TTF-1 overexpression showed a significantly higher rate of EGFR mutations (OR = 5.19, 95% confidence interval: 3.60⁻7.47, p < 0.00001). This correlation was observed in both subgroups of East Asian (OR = 4.33, 95% CI: 3.46⁻5.41, p < 0.00001) and European patients (OR = 4.64, 95% CI: 1.41⁻15.28, p < 0.01). In addition, TTF-1 expression was significantly associated with EGFR mutations in exon 19 (OR = 4.63, 95% CI: 2.89⁻7.41, p < 0.00001) as well as exon 21 (OR = 3.16, 95% CI: 1.04⁻9.60, p = 0.04).

CONCLUSIONS

This meta-analysis demonstrates a significant correlation between TTF-1 expression and EGFR mutations in patients with NSCLC. The status of TTF-1 expression may be a biomarker to guide anticancer treatment in patients with NSCLC and unknown EGFR mutation status.

Genetic and epigenetic alterations of the EGFR and mutually independent association with BRCA1, MGMT, and RASSF1A methylations in Vietnamese lung adenocarcinomas

Genetic and epigenetic alterations importantly contribute to the pathogenesis of lung cancer. In the study, we measured the frequency and distribution of molecular abnormalities of EGFR as well as the aberrant promoter methylations of BRCA1, MGMT, MLH1, and RASSF1A in Vietnamese lung adenocarcinomas. We investigated the association between genetic and epigenetic alteration, and between each abnormality with clinicopathologic parameters. Somatic EGFR mutation that was found in 49/139 (35.3%) lung adenocarcinomas showed a significant association with young age, female gender, and non-smokers. EGFR overexpression was identified in 82 tumors (59.0%) and statistical relationships with EGFR or BRCA1 methylation but not EGFR mutation. In addition, EGFR, BRCA1, MGMT, MLH1, and RASSF1A methylations were found in 33 (23.7%), 41 (29.5%), 46 (33.1%), 28 (20.1%), and 41 (29.5%) cases of a total of 139 lung adenocarcinomas, respectively. The RASSF1A methylation was found to be linked to the smoking habit. Methylations in MGMT and RASSF1A were also found to correlate with metastasis status. Furthermore, the distribution of EGFR mutation and that of BRCA1, MGMT or RASSF1A methylation were significantly exclusive in lung adenocarcinomas. The main finding of our study demonstrate that epigenetic abnormalities might play a critical role for the lung tumorigenesis in patients with smoking history and metastasis, and partly affect the predictive value of EGFR mutations through blocking expression due to promoter EGFR hypermethylation. Mutually exclusive distribution of genetic and epigenetic alterations reflects differently biological characteristics in the etiology of lung adenocarcinomas.

Comparative mutational evaluation of multiple lung cancers by multiplex oncogene mutation analysis

In patients presenting with synchronous or metachronous multiple lung cancer (MLC), it is important to distinguish between multiple primary lung cancer (MP) and intrapulmonary metastasis (IM). The present study was aimed at investigating the mutational profiles of synchronous/metachronous MLC and to compare the classification of paired tumors by multiplex gene mutation analysis with the histopathological evaluation. We carried out targeted sequencing of 20 lung cancer-related oncogenes using next-generation sequencing (NGS) in 82 tumors from 37 MLC patients who underwent surgical resection at our department. The patients were diagnosed as MP or IM cases based on the Martini and Melamed criteria, histopathological and gene mutational evaluations. Matching mutations between paired tumors was observed in 20 (54%) patients, who were diagnosed as IM cases by mutational evaluation. Patients who could not be clearly diagnosed by histopathological evaluation were classified as equivocal cases. Among the histopathological IM cases (n = 7), six (86%) were confirmed as IM cases also by mutational evaluation, and most of the paired tumors of these cases (n = 5) harbored multiple matching mutations. Among the histopathological MP cases (n = 17), mutational evaluation yielded a discordant diagnosis in eight (47%) cases. Of these, the paired tumors of four cases harbored multiple matching mutations, suggesting that the mutational diagnosis might be more suitable in these patients. Our findings suggest that multiplex mutational analysis could be a useful complementary tool for distinguishing between MP and IM in addition to histopathological evaluation.

EGFR-TKI-sensitive mutations in lung carcinomas: are they related to clinical features and CT findings?

Background

Epidermal growth factor receptor (EGFR) mutation testing is restricted to several limitations. In this study, we examined the relationship between EGFR mutation status and clinicoradiological characteristics in a Chinese cohort of patients.

Materials and methods

The data of patients who were diagnosed with lung carcinoma and underwent both EGFR testing and chest computed tomography (CT) at our hospital between January 1, 2011, and November 31, 2015, were retrospectively analyzed. The age, sex, and smoking index of the patients, the size, margin, and density of the tumor, and the presence of specific signs visible on the CT images were assessed.

Results

The results showed a higher rate of EGFR-tyrosine kinase inhibitor (TKI)-sensitive group than nonsensitive group in female patients and patients with a low smoking index (P<0.001, both). In logistic regression analyses, tumor size (P<0.001), smooth margins (P=0.015), and angular margins (P<0.001) were independent negative predictors of EGFR-TKI-sensitive group. Pleural indentation (P<0.001) and air bronchogram (P=0.025) were independent positive predictors of EGFR-TKI-sensitive group. Patients with squamous cell carcinoma had fewer sensitive mutations than those with either adenocarcinoma (P<0.001) or adenosquamous carcinoma (P<0.001).

Conclusion

Clinical and CT characteristics differed significantly between EGFR-TKI-sensitive and nonsensitive groups. Our findings may be useful in deciding therapeutic strategies for patients in whom EGFR testing is not possible.

Clinicopathological and genetic characteristics associated with brain metastases from lung adenocarcinoma and utility as prognostic factors

Brain metastases (BM) are common in patients with lung adenocarcinoma, and represent a significant cause of morbidity in the disease. A more comprehensive understanding of the clinicopathological characteristics that serve as prognostic factors for survival in patients with BM from lung adenocarcinoma may aid in informing treatment strategies for this patient population. In the present study, clinicopathological factors, including EGFR mutation status, were evaluated in 59 patients who were diagnosed with BM from lung adenocarcinoma, and underwent BM resection between January 1985 and December 2014 at Fukuoka University Hospital. The most frequent subtype of BM from lung adenocarcinoma was solid adenocarcinoma (57.6%), followed by papillary adenocarcinoma (22.0%) and acinar adenocarcinoma (18.6%). A total of 14 patients (23.7%) exhibited EGFR mutations, which were significantly associated with female sex (9/14, 64.3%), non-smoker status (8/14, 57.1%), BM in the frontal lobes (9/14, 64.3%) and papillary adenocarcinoma (5/14, 35.7%). Statistical analysis revealed a significant association between non-smoker status and BM in the frontal lobes, and more favorable disease prognosis. The results of the present study suggest that histological and genetic analysis of tissue from BM provides information useful for managing treatment of patients with resectable BM arising from lung adenocarcinoma.

In Vivo Molecular Imaging for Biomedical Analysis and Therapies

In vivo molecular imaging is a powerful tool to analyze the human body. Precision medicine is receiving high attention these days, and molecular imaging plays an important role as companion diagnostics in precision medicine. Nuclear imaging with PET or SPECT and optical imaging technologies are used for in vivo molecular imaging. Nuclear imaging is superior for quantitative imaging, and whole-body analysis is possible even for humans. Optical imaging is superior due to its ease of use, and highly targeted specific imaging is possible with activatable agents. However, with optical imaging using fluorescence, it is difficult to obtain a signal from deep tissue and quantitation is difficult due to the attenuation and scattering of the fluorescent signal. Recently, to overcome these issues, optoacoustic imaging has been used in in vivo imaging. In this article, we review in vivo molecular imaging with nuclear and optical imaging and discuss their utility for precision medicine.

Pulmonary Adenocarcinoma, Harboring Both an EGFR Mutation and ALK Rearrangement, Presenting a Stable Disease to Erlotinib and a Partial Response to Alectinib

A 63-year-old woman with pulmonary adenocarcinoma (stage IIIB) that was positive for an epidermal growth factor receptor (EGFR) mutation and an anaplastic lymphoma kinase (ALK) rearrangement was treated with erlotinib as the first-line treatment, resulting in a stable disease. Due to skin rashes, fatigue and anorexia, erlotinib was suspended on erlotinib day 44. Alectinib was administered as the second-line treatment, exhibiting a partial response. On alectinib day 56, drug-induced lung injury forced suspension of alectinib, which was cured with corticosteroid therapy. ALK-tyrosine kinase inhibitors may be more effective for patients positive for both EGFR mutation and ALK rearrangement than other agents.

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

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

Erlotinib as single agent first line treatment in locally advanced or metastatic activating EGFR mutation-positive lung adenocarcinoma (CEETAC): an open-label, non-randomized, multicenter, phase IV clinical trial

Background

Erlotinib is approved for the first line treatment of epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer. Since the number of prospective studies in Caucasian patients treated in routine clinical setting is limited we conducted a multicenter, phase IV clinical trial to determine the efficacy and safety of erlotinib and to demonstrate the feasibility of the validated standardized companion diagnostic method of EGFR mutation detection.

Methods

651 chemonaive, cytologically or histologically verified advanced stage lung adenocarcinoma patients from Hungary, Turkey and Latvia were screened for exon19 microdeletions and exon21 L858R EGFR mutations using the companion diagnostic EGFR test. EGFR mutation-positive, locally advanced or metastatic lung adenocarcinoma patients received as first line treatment erlotinib at 150 mg/day. The primary endpoint was progression-free survival (PFS).

Results

62 EGFR mutation-positive patients (9.5% of screened) were included in the safety/intent-to-treat cohort. Median PFS was 12.8 months (95%CI, 9.9–15.8), objective response rate and one-year survival was 66.1% and 82.5%, respectively. Most frequent treatment related adverse events were diarrhoea and rash. Eastern Oncology Cooperative Group Performance Status (ECOG PS), smoking status and M1a/M1b disease stage were significant prognosticators of PFS (p = 0.017, p = 0.045 and p = 0.002, respectively). There was no significant difference in PFS between the subgroups stratified by gender, age or exon19 vs exon21 mutation.

Conclusions

Our study confirmed the efficacy and safety of first line erlotinib monotherapy in Caucasian patients with locally advanced or metastatic lung adenocarcinoma carrying activating EGFR mutations based on the screening with the approved companion diagnostic procedure.

Trial registration

ClinicalTrials.gov Identifier: NCT01609543.

Rapid point-of-care testing for epidermal growth factor receptor gene mutations in patients with lung cancer using cell-free DNA from cytology specimen supernatants

Epidermal growth factor receptor (EGFR) mutations are associated with responses to EGFR tyrosine kinase inhibitors (EGFR-TKIs) in non-small-cell lung cancer (NSCLC). Our previous study revealed a rapid point-of-care system for detecting EGFR mutations. This system analyzes cell pellets from cytology specimens using droplet-polymerase chain reaction (d-PCR), and has a reaction time of 10 min. The present study aimed to validate the performance of the EGFR d-PCR assay using cell-free DNA (cfDNA) from supernatants obtained from cytology specimens. Assay results from cfDNA supernatant analyses were compared with those from cell pellets for 90 patients who were clinically diagnosed with, or suspected of having, lung cancer (80 bronchial lavage fluid samples, nine pleural effusion samples and one spinal fluid sample). EGFR mutations were identified in 12 and 15 cases using cfDNA supernatants and cell pellets, respectively. The concordance rates between cfDNA-supernatant and cell‑pellet assay results were 96.7% [kappa coefficient (K)=0.87], 98.9% (K=0.94), 98.9% (K=0.79) and 98.9% (K=0.79) for total EGFR mutations, L858R, E746_A750del and T790M, respectively. All 15 patients with EGFR mutation-positive results, as determined by EGFR d-PCR assay using cfDNA supernatants or cell pellets, also displayed positive results by conventional EGFR assays using tumor tissue or cytology specimens. Notably, EGFR mutations were even detected in five cfDNA supernatants for which the cytological diagnoses of the corresponding cell pellets were 'suspicious for malignancy', 'atypical' or 'negative for malignancy.' In conclusion, this rapid point-of-care system may be considered a promising novel screening method that may enable patients with NSCLC to receive EGFR-TKI therapy more rapidly, whilst also reserving cell pellets for additional morphological and molecular analyses.

Polymer nanofiber-based microchips for EGFR mutation analysis of circulating tumor cells in lung adenocarcinoma

Background

Circulating tumor cells (CTCs) detection, an approach considered to be “liquid biopsy”, is a potential alternative method in clinical use for early diagnosis of solid tumor progression.

Methods

In this study, we developed a poly (lactic-co-glycolic acid) (PLGA) – nanofiber (PN)-NanoVelcro chip as an efficient device for simple and rapid capture of CTCs from peripheral blood. We evaluated the device performance by assessing the capture efficiency and purity. Single CTC was isolated via laser microdissection system for subsequent genetic analysis, with an aim to find the concordance of epidermal growth factor receptor (EGFR) mutations between tumor tissue and CTCs.

Results

PN-NanoVelcro chip exhibits great performance in capture efficiency and high purity. The genetic analysis results showed that most EGFR mutation in tumor tissue could also be detected in CTCs.

Conclusion

Compared to computed tomography image results, CTC detection can be implemented throughout the course of diseases and provides an accurate and earlier diagnosis of tumor progression, which make it possible for patients to acquire suitable and timely treatment.

The prognostic value of CSCs biomarker CD133 in NSCLC: a meta-analysis

The prognostic value of cancer stem cells (CSCs) marker CD133 in non-small-cell lung cancer (NSCLC) remains controversial. We performed this meta-analysis of 32 eligible studies to clarify the prognostic value of CD133 and provide evidence for CSCs hypothesis. We calculated pooled hazard ratio (HR) for survival outcomes and pooled odds ratio (OR) for clinical parameters associated with CD133 in total 3595 NSCLC patients by STATA. Our results showed that NSCLC patients with higher CD133 expression had shorter overall survival time only in Asian patients (HR = 3.80, 95% CI: 3.12-4.04, p < 0.001; I2 = 32%) but not in Caucasian patients (HR = 1.15, 95% CI: 0.88-1.52, p = 0.307; I2 = 0%), suggesting that differential prognostic value of CD133 in distinct ethnic group. We speculated that the intrinsic EGFR gene status of CSCs might be responsible for this racial difference. Additionally, we found that higher expression of CD133 was associated with poor differentiation (OR = 2.03, 95% CI: 1.32-3.14, p = 0.001) and lymph node metastasis (OR = 2.39, 95% CI: 1.62-3.52, p < 0.001) but there was no significant difference of CD133 expression between adenocarcinoma and squamous carcinoma (OR = 1.13, 95% CI: 0.93-1.38, p = 0.3) in NSCLC patients. These results may provide a new therapeutic perspective on the treatment of NSCLC patients according to the expression of CD133 in distinct ethnic group.