Distribution of distant metastases from newly diagnosed non-small cell lung cancer

Imaging in Lung Cancer Staging

Lung cancer remains one of the leading causes of mortality worldwide, as well as in the United States. Clinical staging, primarily with imaging, is integral to stratify patients into groups that determine treatment options and predict survival. The eighth edition of the tumor, node, metastasis (TNM-8) staging system proposed in 2016 by the International Association for the Study of Lung Cancer remains the current standard for lung cancer staging. The system is used for all subtypes of lung cancer, including non-small cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoid tumors.

Therapeutic role of EGFR - Tyrosine kinase inhibitors in non-small cell lung cancer with leptomeningeal metastasis

Leptomeningeal metastasis (LM) is a significant complication that advances fast and has a poor prognosis for patients with advanced non-small cell lung cancer (NSCLC) who have epidermal growth factor receptor (EGFR) mutations. Current therapies for LM are inconsistent and ineffective, and established techniques such as radiation, chemotherapy, and surgery continue to fall short of potential outcomes. Nonetheless, EGFR tyrosine kinase inhibitors (TKIs) exhibit potent anti-tumor activity and hold considerable promise for NSCLC patients with EGFR mutations. Thus, assessing EGFR-TKIs effectiveness in treating these central nervous system (CNS) problems is crucial. This review integrates current literature on the intracranial efficacy of EGFR-TKIs to explore the varying impacts of approved EGFR-TKIs in LM patients and the therapeutic possibilities presented by other EGFR-TKIs in development. To delineate the optimal clinical treatment strategy, further exploration is needed regarding the optimal sequencing of EGFR-TKIs and the selection of alternative therapy options following initial treatment failure with EGFR-TKIs.

Lung Cancer Staging: Imaging and Potential Pitfalls

Lung cancer is the leading cause of cancer deaths in men and women in the United States. Accurate staging is needed to determine prognosis and devise effective treatment plans. The International Association for the Study of Lung Cancer (IASLC) has made multiple revisions to the tumor, node, metastasis (TNM) staging system used by the Union for International Cancer Control and the American Joint Committee on Cancer to stage lung cancer. The eighth edition of this staging system includes modifications to the T classification with cut points of 1 cm increments in tumor size, grouping of lung cancers associated with partial or complete lung atelectasis or pneumonitis, grouping of tumors with involvement of a main bronchus regardless of distance from the carina, and upstaging of diaphragmatic invasion to T4. The N classification describes the spread to regional lymph nodes and no changes were proposed for TNM-8. In the M classification, metastatic disease is divided into intra- versus extrathoracic metastasis, and single versus multiple metastases. In order to optimize patient outcomes, it is important to understand the nuances of the TNM staging system, the strengths and weaknesses of various imaging modalities used in lung cancer staging, and potential pitfalls in image interpretation.

Is there any prognostic significance in pleural involvement and/or effusion in patients with ALK-positive NSCLC?

PURPOSE

Anaplastic lymphoma kinase (ALK) mutations occurs in approximately 3-5% of patients with non-small cell lung cancer (NSCLC). Pleural involvement/effusion is common in ALK-positive patients with NSCLC at baseline. The aim of the study was to evaluate the characteristics of ALK-positive patients who have Ple-I/E.

METHODS

In this multicenter study, patients with ALK-positive NSCLC who have Ple-I/E were retrospectively analyzed. Clinical and demographic characteristics of the disease, response rates, median progression-free survival (PFS), and overall survival (OS) were evaluated in 362 ALK-positive patients with NSCLC.

RESULTS

Of the patients, 198 (54.7%) were male. The median age at the time of diagnosis was 54 (range 21-85) years. All patients' histology was adenocarcinoma (100%). At baseline, 57 (15.7%) patients had Ple-I/E. There was no association between Ple-I/E and gender, lung metastasis, or distant lymphadenopathy (LAP) metastasis. The frequencies of liver, brain, and bone metastases were significantly higher in ALK-positive patients without Ple-I/E compared to those with Ple-I/E (respectively 18.2% vs 4.8%, p = 0.008; 19.1% vs 4.8%, p = 0.001; 20.6% vs 8.9%, p = 0.002). The median PFS was longer in ALK-positive patients who had Ple-I/E (18.7 vs 10.6 months, p = 0.017). Similarly, the median OS was longer in ALK-positive patients who had Ple-I/E (44.6 vs 22.6 months, p = 0.051).

CONCLUSION

Brain, liver, and bone metastases were lower in ALK-positive patients with Ple-I/E. Patients presented with Ple-I/E were prone to have better PFS and OS.

The yield and impact of pulmonologist-performed EUS-B-FNA of subdiaphragmatic lesions-an institutional experience

INTRODUCTION

Pulmonologists can biopsy structures below the diaphragm using the convex curvilinear ultrasound bronchoscope via the esophagus (EUS-B). The literature with respect to the value of EUS-B, rapid on-site evaluation, and final diagnostic yield for structures below the diaphragm is limited. We review our institutional experience.

MATERIALS AND METHODS

Our database was queried retrospectively for EUS-B fine needle aspirations (FNAs) from 2013 to 2021. All procedures involving EUS-B-FNA of subdiaphragmatic structures were selected for analysis. The following data elements were collected for each patient: age, gender, clinical indication, sample site, on-site adequacy (OSA), preliminary and final diagnoses, and sufficiency of cell block for ancillary studies.

RESULTS

A total of 75 subdiaphragmatic sites were biopsied in 74 patients. Of which, 87% of samples subjected to rapid on-site evaluation were deemed to contain adequate material (OSA+). There were no false-positive OSAs. Six cases remained nondiagnostic at the final diagnosis. The final diagnostic yield (with cell block) was 92% (69/75 cases). Cell block was sufficient for immunohistochemistry or special stains in all applicable cases (n = 36). Molecular testing was requested for 11 cases and successful in 10 (91%). Sampling of subdiaphragmatic sites changed the stage in 67% (38/57) of lung cancer patients.

CONCLUSIONS

Pulmonologists can perform EUS-B-FNA of subdiaphragmatic sites with high OSA and final diagnostic yield when assisted by cytopathologists. Strong correlations exist between OSA, cell block adequacy, and subsequent capacity to perform ancillary testing. EUS-B below the diaphragm can make an important contribution to the diagnosis of lung cancer, nonpulmonary malignancies, and other diseases.

Bone-modifying agents for non-small-cell lung cancer patients with bone metastases during the era of immune checkpoint inhibitors: A narrative review

During the course of lung cancer progression, bone metastases occur in about 40% of patients. Common complications associated with bone metastases in lung cancer patients include musculoskeletal pain, pathologic fractures, spinal cord compression, and hypercalcemia. We discuss the efficacy of bone-modifying agents (BMAs) in reducing skeletal-related events (SREs) and improving cancer-related outcomes, particularly in patients with stage IV non-small-cell lung cancer with bone metastases. In addition, the combined effects of BMAs with radiotherapy or immunotherapy in reducing SREs in patients with lung cancer and bone metastases are explored.

Proteomic analysis of brain metastatic lung adenocarcinoma reveals intertumoral heterogeneity and specific alterations associated with the timing of brain metastases

BACKGROUND

Brain metastases are associated with considerable negative effects on patients' outcome in lung adenocarcinoma (LADC). Here, we investigated the proteomic landscape of primary LADCs and their corresponding brain metastases.

MATERIALS AND METHODS

Proteomic profiling was conducted on 20 surgically resected primary and brain metastatic LADC samples via label-free shotgun proteomics. After sample processing, peptides were analyzed using an Ultimate 3000 pump coupled to a QExactive HF-X mass spectrometer. Raw data were searched using PD 2.4. Further data analyses were carried out using Perseus, RStudio and GraphPad Prism. Proteomic data were correlated with clinical and histopathological parameters and the timing of brain metastases. Mass spectrometry-based proteomic data are available via ProteomeXchange with identifier PXD027259.

RESULTS

Out of the 6821 proteins identified and quantified, 1496 proteins were differentially expressed between primary LADCs and corresponding brain metastases. Pathways associated with the immune system, cell-cell/matrix interactions and migration were predominantly activated in the primary tumors, whereas pathways related to metabolism, translation or vesicle formation were overrepresented in the metastatic tumors. When comparing fast- versus slow-progressing patients, we found 454 and 298 differentially expressed proteins in the primary tumors and brain metastases, respectively. Metabolic reprogramming and ribosomal activity were prominently up-regulated in the fast-progressing patients (versus slow-progressing individuals), whereas expression of cell-cell interaction- and immune system-related pathways was reduced in these patients and in those with multiple brain metastases.

CONCLUSIONS

This is the first comprehensive proteomic analysis of paired primary tumors and brain metastases of LADC patients. Our data suggest a malfunction of cellular attachment and an increase in ribosomal activity in LADC tissue, promoting brain metastasis. The current study provides insights into the biology of LADC brain metastases and, moreover, might contribute to the development of personalized follow-up strategies in LADC.

Clinicopathological Profile of Non-small Cell Lung Cancer and the Changing Trends in Its Histopathology: Experience From a Tertiary Care Cancer Center in Kashmir, India

Background The overall frequency and incidence of different cancers across the globe, including lung cancer, are marked by ethnic and geographical variations. Lung cancer is the most commonly diagnosed cancer worldwide that inflicts most of the cancer deaths. Non-small cell lung cancer (NSCLC) constitutes most lung cancer cases. The aim of this study was to find the frequency and clinicopathological characteristics of NSCLC in high incidence zone of Kashmir, an ethnically and geographically distinct area in Northern India. Material and methods The study was conducted to evaluate the clinicopathological profile of NSCLC at a tertiary care cancer center, Sher-I-Kashmir Institute of Medical Sciences (SKIMS). The patients and case records were analyzed for clinical presentation and demographic features, smoking status, radiological features, histopathological type, and stage of their disease at presentation. Results The study included 1557 NSCLC patients registered over a period of seven years, i.e., 2008-2014. Most of the patients belonged to rural areas (70%). The median age of the whole cohort was 58.0 years (ranges 22-95 years), and the male-to-female ratio was 3.7:1 (male = 1231 and female = 326). Smokers comprised 77.39% of cases, and Hookah was the most common form of smoking (65.06%). The ratio of squamous cell carcinoma and adenocarcinoma was 3.7:1 (67.5% vs. 24.9%). Stage III and IV disease accounted for 93% of cases (30.6% and 62.7%, respectively). Squamous cell carcinoma histopathology was dominant in smokers (74.3%) compared to adenocarcinoma (19%), while squamous cell carcinoma and adenocarcinoma histopathology ran parallel in nonsmokers (45.1% and 44%, respectively). Most of the patients had an Eastern Cooperative Oncology Group (ECOG) performance status between 1 and 2 (79%).  Conclusion We conclude Kashmir region is a very high-risk area for lung cancer, with NSCLC showing a high incidence. Most of our patients present in advanced stages, and the frequency of adenocarcinoma is showing an increasing trend over the years from 2008-2014.

Isolated Pancreatic Metastasis from a Lung Adenocarcinoma Primary: A Case Report and Literature Review

Isolated pancreatic metastasis is a rare occurrence and is commonly misdiagnosed as primary pancreatic malignancy. We present a case of a 65-year-old female patient with a history of stage IIIA lung adenocarcinoma, who developed significant epigastric pain 27 months after diagnosis and treatment of a primary lung adenocarcinoma. This patient was found to have a pancreatic head lesion initially suspected to be a primary pancreatic neoplasm but eventually discovered to be a metastatic lesion from the previously treated primary lung adenocarcinoma.

New prognostic system specific for epidermal growth factor receptor-mutated lung cancer brain metastasis

Introduction

Brain metastases (BM) from lung cancer are heterogeneous, and accurate prognosis is required for effective treatment strategies. This study aimed to identify prognostic factors and develop a prognostic system exclusively for epidermal growth factor receptor (EGFR)-mutated lung cancer BM.

Methods

In total, 173 patients with EGFR-mutated lung cancer from two hospitals who developed BM and received tyrosine kinase inhibitor (TKI) and brain radiation therapy (RT) were included. Univariate and multivariate analyses were performed to identify significant EGFR-mutated BM prognostic factors to construct a new EGFR recursive partitioning analysis (RPA) prognostic index. The predictive discrimination of five prognostic scoring systems including RPA, diagnosis-specific prognostic factors indexes (DS-GPA), basic score for brain metastases (BS-BM), lung cancer using molecular markers (lung-mol GPA) and EGFR-RPA were analyzed using log-rank test, concordance index (C-index), and receiver operating characteristic curve (ROC). The potential predictive factors in the multivariable analysis to construct a prognostic index included Karnofsky performance status, BM at initial lung cancer diagnosis, BM progression after TKI, EGFR mutation type, uncontrolled primary tumors, and number of BM.

Results and discussion

In the log-rank test, indices of RPA, DS-GPA, lung-mol GPA, BS-BM, and EGFR-RPA were all significant predictors of overall survival (OS) (p ≤ 0.05). The C-indices of each prognostic score were 0.603, 0.569, 0.613, 0.595, and 0.671, respectively; The area under the curve (AUC) values predicting 1-year OS were 0.565 (p=0.215), 0.572 (p=0.174), 0.641 (p=0.007), 0.585 (p=0.106), and 0.781 (p=0.000), respectively. Furthermore, EGFR-RPA performed better in terms of calibration than other prognostic indices.BM progression after TKI and EGFR mutation type were specific prognostic factors for EGFR-mutated lung cancer BM. EGFR-RPA was more precise than other models, and useful for personal treatment.

Peritoneal carcinomatosis secondary to metastatic lung cancer complicated with acute suppurative appendicitis: A case report and literature review

RATIONALE

Lung cancer (LC) is a malignant tumor with the highest morbidity and mortality in the world. The most common metastatic sites of LC are the brain (47%), bone (36%), liver (22%), adrenal glands (15%), thoracic cavity (11%) and distant lymph nodes (10%). Peritoneal carcinomatosis (PC) is a rare clinical event in LC patients. Considering the rarity and nonspecific clinical symptoms of peritoneal metastasis among LC patients, a case of peritoneal metastasis secondary to LC incidentally observed by laparoscopic appendectomy is unusual.

PATIENT CONCERNS

Here, we present a 53-year-old never-smoker woman who presented to the emergency department with a 2-day history of pain in the right abdominal quadrant. Later, laparoscopy revealed acute suppurative appendicitis accompanied by a peritoneal metastatic mass.

DIAGNOSIS

The patient was diagnosed with PC secondary to metastatic LC complicated with acute suppurative appendicitis by immunohistochemistry. Positron emission tomography computed tomography (PET CT) findings further strengthen the evidence of PC from LC.

OUTCOMES

Based on the results of genomic analysis, the patient received targeted therapy with osimertinib 80 mg/d.

LESSONS

Due to the discovery of new targets, the use of molecular therapies improved progression-free survival (PFS) and overall survival (OS), which increases the chance of identifying peritoneal metastasis of LC. For LC patients with abdominal symptoms, clinicians should be aware of the possibility of peritoneal metastasis from LC, especially for patients diagnosed with lung adenocarcinoma or with pleural effusion.

Imaging of Lung Cancer Staging

Lung cancer is a leading cause of cancer-related mortality worldwide. Imaging is integral in accurate clinical staging to stratify patients into groups to predict survival and determine treatment. The eighth edition of the tumor, node, and metastasis (TNM-8) staging system proposed by the International Association for the Study of Lung Cancer in 2016, accepted by both the Union for International Cancer Control and the American Joint Committee on Cancer, is the current standard method of staging lung cancer. This single TNM staging is used for all histologic subtypes of lung cancer, including nonsmall cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoid tumor, and it addresses both clinical and pathologic staging. Familiarity with the strengths and limitations of imaging modalities used in staging, the nuances of TNM-8, its correct nomenclature, and potential pitfalls are important to optimize patient care. In this article, we discuss the role of computed tomography (CT) and positron emission tomography/CT in lung cancer staging, as well as current imaging recommendations pertaining to TNM-8.

Patterns of Extrathoracic Metastasis in Lung Cancer Patients

Metastasis is a major cause of death in lung cancer patients. Therefore, a deeper understanding of the metastatic mechanisms is important for developing better management strategies for lung cancer patients. This study evaluated the patterns of extrathoracic metastases in lung cancer. We retrieved data for 25,103 lung cancer patients from an institutional database and then evaluated the impacts of clinicopathologic factors on metastasis patterns. We found that 36.5% of patients had extrathoracic metastasis. Younger patients had a significantly higher extrathoracic metastasis rate in most histologic subtypes. Metastases to the bone (58.3%), central nervous system (CNS) (44.3%), liver (26.6%) and adrenal gland (18.3%) accounted for 85.5% of all extrathoracic metastases. Patients with nonmucinous adenocarcinoma had significantly higher bone metastasis rate. Patients with small cell carcinoma and large cell neuroendocrine carcinoma (LCNEC) had significantly higher liver metastasis rates. Further, patients with LCNEC also had a significantly lower bone metastasis rate, and patients with squamous cell carcinoma had a significantly lower CNS metastasis rate. Patients with multiple cancers had similar patterns of metastasis compared to patients with only lung cancer. In conclusion, different histologic subtypes of lung cancer have different metastatic patterns. Our study might help clinicians decide on follow-up strategies.

Clinical risk factors of carbohydrate antigen-125, cytokeratin fragment 19, and neuron-specific enolase in liver metastases from elderly lung cancer patients

Objective: Lung cancer is a common malignant tumor characterized by challenging detection and lack of specificity in clinical manifestations. To investigate the correlation of tumor markers in the serum with liver metastasis and prognosis of lung cancer.

Methods: A total of 3,046 elderly lung cancer patients were retrospectively studied between September 1999 and July 2020. Divided into liver metastasis group and non-liver metastasis group. We compared a series of serum biomarkers between the two groups of elderly patients to predict the prognosis in patients with lung cancer by fluorescence in situ hybridization (FISH), advanced flow cytometry (FCM) and multi tumor marker protein chip, including tumor markers in the serum included alkaline phosphatase (ALP), serum calcium, hemoglobin (HB), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), cytokeratin fragment 19 (Cyfra21-1), carbohydrate antigen-125 (CA-125), carbohydrate antigen-153 (CA-153), carbohydrate antigen-199 (CA-199), and free prostate specific antigen (free PSA). We used binary logistic regression analysis to determine risk factors, and used receiver operating curve (ROC) analysis to evaluate the diagnostic value of liver metastases in elderly patients with lung cancer.

Results: The proportion of lung cancer in the liver metastasis group was higher than that observed in the non-liver metastases group. The expression levels of CA-125, Cyfra21-1, and NSE in the liver metastasis group of lung cancer were significantly higher than those reported in the non-liver metastases group (p < 0.05). ROC curve analysis shows that the area under the curve of CA-125, Cyfra21-1, and NSE are 0.614, 0.616 and 0.608, respectively. The sensitivity and specificity of CA-125 were 45.70% and 76.20%, the sensitivity and specificity of Cyfra21-1 were 60.10% and 57.10%, and the sensitivity and specificity of NSE were 44.10% and 75.00%, respectively.

Conclusion: High levels of CA-125, Cyfra21-1, and NSE in the serum may be associated with liver metastasis in elderly patients with lung cancer. CA-125 and NSE are factors influencing the prognosis of elderly patients with liver metastasis of lung cancer.

The Efficacy of PD-1/PD-L1 Inhibitors in Patients with Liver Metastasis of Non-Small Cell Lung Cancer: A Real-World Study

BACKGROUND

A controversy exists regarding the efficacy of programmed death-1 (PD-1)/ programmed death ligand-1 (PD-L1) inhibitors for patients with non-small cell lung cancer (NSCLC) and liver metastases. Our study retrospectively evaluated the efficacy of PD-1/PD-L1 inhibitors in NSCLC patients with liver metastases.

METHODS

This retrospective study included 1627 lung cancer patients who received immunotherapy. Among 648 patients who had advanced NSCLC and received PD-1/PD-L1 inhibitors, 61 had liver metastases and 587 did not have. We analyzed patient characteristics, progression-free survival (PFS) and overall survival (OS). An exploratory analysis of biomarkers including CD4, CD8 and CD68 for efficacy in patients with liver metastases was also performed.

RESULTS

In liver metastasis patients receiving PD-1/PD-L1 inhibitors, the objective response rate (ORR) was 29.5%, the disease control rate (DCR) was 72.1%, PFS was 6.4 months and OS was 15.2 months, which were all worse than those of patients without liver metastases (ORR: 35.8%; DCR: 81.8%; PFS: 7.9 months, p = 0.001; OS: 20.6 months, p = 0.008). When compared to non-liver lesions, the ORR (26.2 vs. 39.3%) and DCR (75.4 vs. 88.5%) of liver lesions were lower. During the analysis of PD-L1 expression, 27 PD-L1-positive patients had a longer PFS than 21 patients in the negative group (p = 0.012). Being PD-L1 positive was the independent prognostic indicators for PFS (p = 0.006). Additionally, the PD-L1 and CD8 dual-positive group responded favorably to PD-1/PD-L1 inhibitors.

CONCLUSIONS

PD-1/PD-L1 inhibitors are effective in liver metastasis-NSCLC patients. However, the efficacy is inferior when compared to those of patients without liver metastases. In NSCLC patients with liver metastases, PD-L1 expression and CD8+ T cell infiltration can predict the response of PD-1/PD-L1-directed immunotherapy.

Effects of 2,2',4'‑trihydroxychalcone on the proliferation, metastasis and apoptosis of A549 human lung cancer cells

The aim of the present study was to evaluate the antitumor effects of 2,2′,4′-trihydroxychalcone (7a) on the A549 human lung cancer cell line. A549 cells were treated with different concentrations of 7a for different time periods. Cells without 7a were used as the negative control group. Cell proliferation, invasion, vasculogenic mimicry (VM) formation, heterogeneous adhesion and apoptosis were measured using Cell Counting Kit-8, Transwell invasion, VM, adhesion and flow cytometric assays, respectively. In addition, the expression of related proteins was determined using western blot analysis or ELISA. The present study found that 7a had a significant inhibitory effect on the survival rate of the A549 lung cancer cells but almost no effect on BEAS-2B human lung epithelial cells or human venous endothelial cells. The migration rate, VM length, invasion rate and heterogeneous adhesion number of cells treated with 7a significantly decreased as the concentration increased, while the apoptosis rate increased. Western blot analysis showed that 7a treatment significantly increased the expression levels of E-cadherin, cleaved poly (ADP-ribose) polymerase, Bax and caspase-3 and simultaneously decreased the expression levels of metalloproteinase-2/9, Bcl-2, phosphorylated (p)-PI3K, p-AKT, p-mTOR, vascular endothelial growth factor (VEGF), E-selectin and N-cadherin. At the same time, the ELISA results showed that the level of the pro-angiogenic factor VEGF in the culture media was reduced in the presence of 7a. In addition, 7a could also reduce the nuclear NF-κB protein expression, which could inhibit the gene transcription of tumor apoptosis and metastasis-related proteins. Therefore, 7a may exert inhibitory effects on A549 cells by inhibiting cell proliferation, migration, VM formation and heterogeneous adhesion, as well as by inducing apoptosis through the suppression of the PI3K/AKT/NF-κB signaling pathway; these findings suggested that 7a may be a promising agent for the treatment of lung cancer.

Isolated Splenic Metastasis of Primary Lung Cancer Presented as Metachronous Oligometastatic Disease—A Case Report

Modern oncology practice and new antitumor drugs prolonged disease-free intervals in patients with lung cancer. Patients with distant metastatic disease are treated only with palliative intent. The International Association for the Study of Lung Cancer, in the 8th edition of the TNM classification, for the first time includes oligometastatic disease as a clinical state that describes the patients with distant metastasis, limited in number and organ sites, who may have more indolent biology. In this paper, we present a case of a 56-year-old man who was admitted to our clinic regarding a radiologically diagnosed splenic lesion of uncertain nature, and who underwent a left upper lobectomy for primary lung cancer 12 years before. After a detailed radiological diagnosis, it was concluded that it is highly suspected metastatic lesion of the spleen and the patient underwent a splenectomy. While no definitive protocols exist on the management of isolated splenic metastasis from lung cancer, splenectomy, in suitable patients, with reasonable survival expectations, improves patient disease-free survival and can prevent potentially life-threatening complications, such as splenic rupture. 18F-FDG PET has very high sensitivity and specificity for differentiating benign and malignant splenic lesions especially in patients who are in the follow up protocol due to primary malignancy.

Construction of methylation-associated nomogram for predicting the recurrence-free survival risk of stage I-III lung adenocarcinoma

Aim: The aim of our study was to investigate a methylation-associated predictor for prognosis in patients with stage I-III lung adenocarcinoma (LUAD). Methods: A DNA methylation-based signature was developed via univariate, least absolute shrinkage and selection operator and multivariate Cox regression models. Results: We identified a 14-site methylation signature that was correlated with recurrence-free survival of stage I-III lung adenocarcinoma patients. By receiver operating characteristic analysis, we showed the high ability of the 14-site methylation signature for predicting recurrence-free survival. In addition, the nomogram result showed a satisfactory predictive value. Conclusion: We successfully identified a DNA methylation-associated nomogram which can predict recurrence-free survival in patients with stage I-III lung adenocarcinoma.

A narrative review on tumor microenvironment in oligometastatic and oligoprogressive non-small cell lung cancer: a lot remains to be done

Objective

In this review, we aim to collect and discuss available data about the role and composition of tumor microenvironment (TME) in oligometastatic (OMD) and oligoprogressive (OPD) non-small cell lung cancer (NSCLC). Furthermore, we aim to summarize the ongoing clinical trials evaluating as exploratory objective the TME composition, through tissue and/or blood samples, in order to clarify whether TME and its components could explain, at least partially, the oligometastatic/oligoprogressive process and could unravel the existence of predictive and/or prognostic factors for local ablative therapy (LAT).

Background

OMD/OPD NSCLC represent a heterogeneous group of diseases. Several data have shown that TME plays an important role in tumor progression and therefore in treatment response. The crucial role of several types of cells and molecules such as immune cells, cytokines, integrins, protease and adhesion molecules, tumor-associated macrophages (TAMs) and mesenchymal stem cells (MSCs) has been widely established. Due to the peculiar activation of specific pathways and expression of adhesion molecules, metastatic cells seem to show a tropism for specific anatomic sites (the so-called “seed and soil” hypothesis). Based on this theory, metastases appear as a biologically driven process rather than a random release of cancer cells. Although the role and the function of TME at the time of progression in patients with NSCLC treated with tyrosine-kinase inhibitors and immune checkpoint inhibitors (ICIs) have been investigated, limited data about the role and the biological meaning of TME are available in the specific OMD/OPD setting.

Methods

Through a comprehensive PubMed and ClinicalTrials.gov search, we identified available and ongoing studies exploring the role of TME in oligometastatic/oligoprogressive NSCLC.

Conclusions

Deepening the knowledge on TME composition and function in OMD/OPD may provide innovative implications in terms of both prognosis and prediction of outcome in particular from local treatments, paving the way for future investigations of personalized approaches in both advanced and early disease settings.

Pancreatic metastasis from squamous cell lung cancer: computed tomography and magnetic resonance imaging findings

Metastatic lesions of the pancreas are uncommon. The incidence of pancreatic involvement with squamous cell carcinoma is the lowest among the different histological subtypes of lung cancer. We present the clinical data, pathological findings, and imaging features of two cases of pancreatic metastasis from squamous cell lung cancer with a literature review. A 75-year-old man and a 67-year-old man were both diagnosed with metastatic pancreatic tumors from squamous cell lung cancer during a multidisciplinary team discussion. Both patients were misdiagnosed as having a neuroendocrine tumor of the pancreas by imaging examination before surgery. Squamous cell lung cancer metastasis to the pancreas is extremely rare, and the atypical clinical and radiological presentations make it difficult to distinguish metastatic tumors from primary pancreatic tumors.

EML4-ALK positive lung adenocarcinoma with skeletal muscle metastasis in the right calf which was treatable with lorlatinib after resistance to treatment with alectinib

This report concerns a patient with skeletal muscle metastases due to lung adenocarcinoma harbouring an echinoderm microtubule-associated protein-like-4 (EML4)-anaplastic lymphoma kinase (ALK) rearrangement, who was successfully treated with lorlatinib after resistance to alectinib. A right lower lobectomy based on a diagnosis of lung adenocarcinoma was performed on a 77-year-old Japanese woman. After 7 months of surgical resection, a mass in the right calf was observed. A fine-needle aspiration biopsy from the mass was performed and the mass was diagnosed as metastatic adenocarcinoma harbouring EML4-ALK rearrangement. Alectinib was administered for 10 months. Then, administration of lorlatinib, an ALK tyrosine kinase inhibitor classified as third generation, was initiated after resistance to treatment with alectinib. After starting treatment with lorlatinib, the gastrocnemius tumour diminished and has maintained a stable condition. Our case suggests that EML4-ALK positive lung adenocarcinoma is treatable with lorlatinib after resistance to treatment with alectinib.

Impact of docetaxel plus ramucirumab on metastatic site in previously treated patients with non-small cell lung cancer: a multicenter retrospective study

Background

Docetaxel (DOC) plus ramucirumab (RAM) has been recommended as an optimal therapy for previously treated patients with non-small cell lung cancer (NSCLC). In a clinical setting, there are few reports about DOC plus RAM, therefore its effect on factors such as Eastern Cooperative Oncology Group (ECOG) performance status (PS) and metastatic sites is still unknown.

Methods

We recruited NSCLC patients who received DOC plus RAM in four medical facilities in Japan from June 2016 to March 2020. We retrospectively investigated the overall response rate (ORR), disease control rate (DCR), and progression-free survival (PFS) of DOC plus RAM and conducted univariate and multivariate analyses using PFS as a dependent factor. Patients were followed up until June 30, 2020.

Results

A total of 237 patients were consecutively enrolled. For all patients, the ORR, DCR, and median PFS were 25.2%, 63.9%, and 4.5 months, respectively. The ORR and DCR for malignant pleural effusion (MPE), lung metastasis, and liver metastasis were 7.7% and 53.8%, 30.3% and 77.5%, and 48.6% and 71.4%, respectively. In the multivariate analysis, MPE, lung metastasis, and liver metastasis were not prognostic factors for poor PFS. However, ECOG-PS 2 or more [hazard ratio (HR): 1.66, 95% confidence interval (CI): 1.14–2.40, P=0.008] and brain metastasis (HR: 1.71, 95% CI: 1.23–2.37, P=0.001) were significant and independent factors associated with shorter PFS.

Conclusions

DOC plus RAM could be an optimal therapy for previous treated NSCLC patients with lung and liver metastasis, and furthermore, should be used carefully for patients with poor ECOG-PS or brain metastasis.

Keywords

Docetaxel and ramucirumab; non-small cell lung cancer (NSCLC); metastatic site; poor performance status

Peripheral Nerve Resident Macrophages and Schwann Cells Mediate Cancer-Induced Pain

Although macrophages (MΦ) are known to play a central role in neuropathic pain, their contribution to cancer pain has not been established. Here we report that depletion of sciatic nerve resident MΦs (rMΦ) in mice attenuates mechanical/cold hypersensitivity and spontaneous pain evoked by intraplantar injection of melanoma or lung carcinoma cells. MΦ-colony stimulating factor (M-CSF) was upregulated in the sciatic nerve trunk and mediated cancer-evoked pain via rMΦ expansion, transient receptor potential ankyrin 1 (TRPA1) activation, and oxidative stress. Targeted deletion of Trpa1 revealed a key role for Schwann cell TRPA1 in sciatic nerve rMΦ expansion and pain-like behaviors. Depletion of rMΦs in a medial portion of the sciatic nerve prevented pain-like behaviors. Collectively, we identified a feed-forward pathway involving M-CSF, rMΦ, oxidative stress, and Schwann cell TRPA1 that operates throughout the nerve trunk to signal cancer-evoked pain. SIGNIFICANCE: Schwann cell TRPA1 sustains cancer pain through release of M-CSF and oxidative stress, which promote the expansion and the proalgesic actions of intraneural macrophages. GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/81/12/3387/F1.large.jpg.

Early Gastrointestinal Progression to Immunotherapy in Lung Cancer: A Report of Two Cases

Intestinal and pancreatic metastases are rare and often challenging to recognize and manage. Lung cancer patients with enteric involvement usually display poor outcomes. Hyperprogression to immunotherapy represents a concern, even though there is currently no agreement on its exact definition. Gastrointestinal hyperprogression to immune checkpoint inhibitors has not been described so far. In these cases, distinguishing disease-related symptoms from immune-related adverse events may represent a diagnostic conundrum. Here, we report two cases of non-small-cell lung cancer experiencing a rapid pancreatic and colic progression to immunotherapy, respectively. While further investigations to identify biomarkers associated with hyperprogression are warranted, clinicians should be aware of the potential unusual clinical presentations of this phenomenon.

A novel model for extrapleural cavity metastasis assessment in patients with lung cancer

Aim: To investigate the clinical value of tumor markers in extrapleural tumor metastasis assessment of newly diagnosed lung cancer patients. Materials & methods: This study retrospectively analyzed 306 patients diagnosed with lung cancer accompanied by tumor metastasis. Patients were grouped into extrapleural tumor metastasis and intrapleural tumor metastasis. Seven serum tumor markers were included for analysis. Results: The area under curves of receiver operating characteristic curve based on binning decision tree algorithm were above 0.8 in both training and validation sets. A scorecard with a score below 3 suggested extrapleural tumor metastasis in newly diagnosed lung cancer patients. Conclusion: The serum tumor marker-derived model is a convenient and fast approach for extrapleural cavity metastasis assessment, which may provide positive implications in newly diagnosed lung cancer patients.

Adenocarcinoma of the Lung With Inguinal Lymph Node Metastasis

Adenocarcinoma of the lung can present with distant metastasis, with major metastasis sites being mediastinal lymph nodes, liver, brain, and adrenal glands. Inguinal lymph nodes are an unusual site for distant metastasis of adenocarcinoma of the lung. We discuss the case of a 73-year-old Caucasian female with a medical history significant for hypertension, chronic obstructive pulmonary disease (COPD) who was seen in the primary care clinic for ongoing shortness of breath, worsening cough, and wheezing. She was prescribed a short course of steroids and antibiotics for possible COPD exacerbation. Despite these measures, the patient had worsening pulmonary symptoms and got evaluated in the emergency room. A CT scan of the chest showed right upper lobe bilobed masses and bulky mediastinal lymph nodes resulting in the partial collapse of the lung's right upper lobe. She got admitted to the hospital for further evaluation, and pulmonary service was consulted for possible endobronchial ultrasound-guided biopsy (EBUS) of the mediastinal nodes. During the physical exam, she was found to have a large fungating mass in the right groin. Upon further questioning, she reported that the mass began as a small swelling in the groin three months ago and was evaluated by the primary care physician and received antibiotics for two weeks. During this time, she did not have any worsening pulmonary symptoms. She underwent bedside excisional biopsy of the lymph node; the pathology came back positive for metastatic adenocarcinoma of pulmonary origin. Unfortunately, the patient had a significant worsening of her respiratory distress; she transitioned to comfort measures and passed away three days later. In this article, we report a case of metastatic lung adenocarcinoma with the inguinal lymph nodes' involvement as the site of distant metastasis, followed by a brief review of the occurrence of adenocarcinoma with the inguinal lymph nodes' involvement.

The role of percutaneous CT-guided biopsy of an adrenal lesion in patients with known or suspected lung cancer

PURPOSE

To determine the sensitivity, specificity, and complication rate of percutaneous adrenal biopsy in patients with known or suspected lung cancer.

METHODS

This study was approved by the Institutional Review Board at our institution as a retrospective analysis; therefore, the need for informed consent was waived. All percutaneous adrenal biopsies performed between April 1993 and May 2019 were reviewed. 357 of 582 biopsies were performed on 343 patients with known or suspected lung cancer (M:F 164:179; mean age 66 years). The biopsy results were classified into malignant, benign, or non-diagnostic. The final diagnosis was established by pathology (biopsy and/or surgical resection) or imaging follow-up on CT for at least 12 months following the biopsy. Patients with less than 12 months follow-up were excluded (n = 44). Complications were recorded.

RESULTS

The final diagnosis was metastatic lung cancer in 235 cases (77.8%), metastasis from an extrapulmonary primary in 2 cases (0.7%), pheochromocytoma in 2 cases (0.7%), and benign lesions in 63 cases (20.9%). Percutaneous adrenal gland biopsy had a sensitivity of 97% and specificity of 100% for lung cancer metastases. The non-diagnostic rate was 0.6%. Larger lesions were more likely to be malignant (p = 0.0000) and to be correctly classified as a lung metastasis (p = 0.025). The incidence of minor complications was 1.1%. There were no major complications.

CONCLUSION

Over 20% of adrenal lesions in patients with known or suspected lung cancer were not related to lung cancer. Percutaneous adrenal gland biopsy is a safe procedure, with high sensitivity and specificity for lung cancer metastases.

Difficult differential diagnosis of bladder pedicled masses about metastasis from non-small cell lung cancer: A case report

Differential diagnoses of primary bladder tumors from metastasis ones can be difficult, for the symptom and imaging findings are pretty similar. Here, we reported a case of bladder metastasis from lung adenocarcinoma. A 73-year-old female patient who was diagnosed with bladder metastasis from lung adenocarcinoma presented as gross hematuria and multiple pedicled masses in the bladder on MRI scan. Such clinical manifestations were easily misdiagnosed as primary bladder malignancy. Additionally, the tumor samples of this case were further harvested and processed for histopathological analysis and gene detections to confirm this case as a metastasis tumor that was refractory to the subsequent therapy. Diagnosis of bladder metastasis should be paid more consideration in patients with a history of cancer despite the fact that primary bladder malignancy accounts for the majority of bladder masses.

How to handle oligometastatic disease in nonsmall cell lung cancer

Patients with nonsmall cell lung cancer and limited metastatic disease have been defined as oligometastatic if local ablative therapy of all lesions is amenable. Evidence from different clinical retrospective series suggests that this subgroup harbours better prognosis than other stage IV patients. However, most reports have included patients with inconsistent numbers of metastases in different locations treated by a variety of invasive and noninvasive therapies. As long as further results from randomised clinical trials are awaited, treatment decision follows an interdisciplinary debate in each individual case. Surgery and radiotherapy should capture a dominant role in the treatment course offering the option of a curative-intended local therapy in combination with a systemic therapy based on an interdisciplinary decision. This review summarises the current treatment standard in oligometastatic lung cancer with focus on an ablative therapy for both lung primary and distant metastases in prognostically favourable locations.

Progress towards non-small-cell lung cancer models that represent clinical evolutionary trajectories

Non-small-cell lung cancer (NSCLC) is the leading cause of cancer-related deaths worldwide. Although advances are being made towards earlier detection and the development of impactful targeted therapies and immunotherapies, the 5-year survival of patients with advanced disease is still below 20%. Effective cancer research relies on pre-clinical model systems that accurately reflect the evolutionary course of disease progression and mimic patient responses to therapy. Here, we review pre-clinical models, including genetically engineered mouse models and patient-derived materials, such as cell lines, primary cell cultures, explant cultures and xenografts, that are currently being used to interrogate NSCLC evolution from pre-invasive disease through locally invasive cancer to the metastatic colonization of distant organ sites.

Analysis of bevacizumab treatments and metastatic sites of lung cancer

INTRODUCTION

Liver metastasis has not been sufficiently evaluated in lung cancer so far. We retrospectively analyzed the distant metastasis of Non-squamous non-small cell lung cancer (NSQ-NSCLC), including liver metastasis, and association between prognosis and therapeutic effect of bevacizumab treatment.

PATIENTS AND METHODS

Clinical data were collected from 1954 patients with lung cancer admitted in our hospital between 1st April 2011 and 31 March 2019. Information is extracted from the electronic medical record. Main collection data was the age, gender, smoking history, performance status, histology and driver mutation, distant metastasis site. Efficacy data of treatment including treatment duration and survival time were obtained from medical record, image data and local registry.

RESULTS

Total 366 patients receiving any chemotherapy with NSQ-NSCLC were eligible for this study. Most frequent extrathoracic metastasis is bone (N = 59) followed by brain (37), liver (18), adrenal gland (23), and OS analysis showed liver metastasis was worse prognosis compared to brain and bone metastasis (median OS: 11.6, 18.9, 15.0, respectively). Bevacizumab treatment was tend to have favorable efficacy in patients with each metastatic sites, especially, induced significant longer OS for patients with liver metastasis. CONCLUSION;: Though this study was retrospective study for small sized metastatic patients, the study suggested that liver metastasis was refractory, and that bevacizumab treatment might improve the worse prognosis.

The Combination of CA125 and NSE Is Useful for Predicting Liver Metastasis of Lung Cancer

Purpose

Liver metastasis is the final stage of cancer progression and is associated with poor prognosis. Although numerous indicators have been identified as having prognostic value for lung cancer and liver metastasis, liver metastases are still not diagnosed by imaging in many patients. To provide a more accurate method for clinical prediction of liver metastasis, we analyzed multiple factors to identify potential predictive factors for liver metastasis of lung cancer.

Methods

Patients first diagnosed with lung cancer between 2002 and 2016 (n = 1746) were divided into two groups, with and without liver metastasis. Serum concentrations of calcium, carcinoembryonic antigen (CEA), cancer antigen-125 (CA125), cancer antigen-153 (CA153), carbohydrate antigen-199 (CA199), cytokeratin fraction 21-1 (CYFRA21-1), total prostate-specific antigen (TPSA), and neuron-specific enolase (NSE) were analyzed in both patient groups.

Results

There was no significant difference in age or sex between the two groups. CA125 and NSE were significantly associated with liver metastasis. Compared with CA125, NSE was more specific, while it was less sensitive (P < 0.001). Further analysis of NSE concentrations was conducted in patients with non-small-cell lung cancer and indicated that NSE concentration differed significantly between those with and without liver metastasis (P = 0.023). We conducted analysis with NSE and CA125 combined, resulting in acceptable sensitivity (51.2%), specificity (72.6%), and area under the curve (0.64) values; sensitivity and area under the curve values were higher than those for individual factors, while specificity was higher than that for CA125.

Conclusions

The combination of CA125 and NSE can assist prediction of liver metastasis of lung cancer, providing improved diagnostic accuracy.

Retroperitoneal Metastasis, with Marked Fibrosis, of Lung Adenocarcinoma after Afatinib Treatment: An Autopsy Case Report

A 73-year-old woman was admitted to our hospital for treatment of vomiting. Four months previously, she had been diagnosed with lung adenocarcinoma (cT3N3M1a stage IVA) and started receiving afatinib as first-line treatment. On admission, the primary tumor had shrunk, but abdominal computed tomography revealed a new retroperitoneal lesion causing duodenal obstruction and hydronephrosis. She underwent gastrojejunostomy, and a biopsy of the peritoneum revealed adenocarcinoma. She was treated with second-line chemotherapy but developed cerebral infarction and died 104 days after admission. An autopsy revealed marked fibrosis with scattered tumor cells in the retroperitoneum. The underlying mechanism of the metastasis is discussed.

Pearls and pitfalls in lung cancer staging

Lung cancer is the third most common cancer in the UK and is the leading cause of death. Radiology plays a central role in the diagnostic work-up of patients with suspected and known lung cancer. Tumour assessment includes both local staging, as well as distant staging. Local staging objectives include the assessment of technical resectability with regard to the evaluation of tumour size and invasion of surrounding structures. Distant staging objectives aim to identify distant metastasis in lymphatic and extra lymphatic tissues. CT, positron emission tomography/CT, MRI, and ultrasound are routinely used imaging techniques for staging in patients with lung cancer. In this review, we will consider the pitfalls of these examinations that radiologists potentially face during the work-up of patients with lung cancer.

The Role of the ECM in Lung Cancer Dormancy and Outgrowth

The dissemination of tumor cells to local and distant sites presents a significant challenge in the clinical management of many solid tumors. These cells may remain dormant for months or years before overt metastases are re-awakened. The components of the extracellular matrix, their posttranslational modifications and their associated factors provide mechanical, physical and chemical cues to these disseminated tumor cells. These cues regulate the proliferative and survival capacity of these cells and lay the foundation for their engraftment and colonization. Crosstalk between tumor cells, stromal and immune cells within primary and secondary sites is fundamental to extracellular matrix remodeling that feeds back to regulate tumor cell dormancy and outgrowth. This review will examine the role of the extracellular matrix and its associated factors in establishing a fertile soil from which individual tumor cells and micrometastases establish primary and secondary tumors. We will focus on the role of the lung extracellular matrix in providing the architectural support for local metastases in lung cancer, and distant metastases in many solid tumors. This review will define how the matrix and matrix associated components are collectively regulated by lung epithelial cells, fibroblasts and resident immune cells to orchestrate tumor dormancy and outgrowth in the lung. Recent advances in targeting these lung-resident tumor cell subpopulations to prevent metastatic disease will be discussed. The development of novel matrix-targeted strategies have the potential to significantly reduce the burden of metastatic disease in lung and other solid tumors and significantly improve patient outcome in these diseases.

Non-Small Cell Lung Cancer With Synchronous Peritoneal Adenocarcinoma: A Rare Independent Combination

Lung cancer is one of the most common malignancies worldwide, and metastasis occurs in more than one-third of cases. Common sites of metastatic disease are the brain, spine, nerve, adrenal glands, bone, liver, and pleura. Peritoneal involvement, however, is rare, and peritoneal involvement found in lung cancer is presumed to be metastatic until proven otherwise. This is due to the fact that primary peritoneal adenocarcinoma is uncommon and difficult to distinguish from the metastatic spread.  Here, we report on a case of a 73-year-old woman who presented with ascites. Evaluation of ascitic fluid was consistent with adenocarcinoma. Subsequent CT of the chest revealed a 4.3-cm mass in the lower lobe of the left lung, which was determined to be poorly differentiated squamous cell carcinoma on histopathology. This is a rare case of two synchronous primary cancers: adenocarcinoma and poorly differentiated squamous cell carcinoma.  To conclude, physicians should be familiar with an independent presentation of squamous cell carcinoma of the lung and peritoneal carcinomatosis in the same patient, as the outcome of independent tumors is poor in most cases.

Isolated Pancreatic Metastasis From Squamous Cell Lung Cancer Mimicking Primary Pancreatic Ductal Adenocarcinoma on FDG PET/CT

Isolated pancreatic metastasis from lung cancer is rare. We present a case of isolated pancreatic metastasis from squamous cell lung cancer. The pancreatic tumor showed hypovascularity on enhanced MRI and intense FDG uptake on FDG PET/CT mimicking primary pancreatic ductal adenocarcinoma. This case indicates pancreatic metastasis should be considered as a differential diagnosis in patients with a history of extrapancreatic cancer and hypermetabolic pancreatic lesion.

Metachronous bilateral breast metastases of a lung neuroendocrine tumor: A case report

Breast metastases of primary lung neuroendocrine tumors are rarely reported. The current report presents the case of a 41-year old female with no history of smoking who initially underwent surgery for a breast fibroadenoma, during which a neuroendocrine tumor of the right lung was detected via chest X-ray. The patient underwent surgery for the tumor and developed right breast nodules after adjuvant chemotherapy. Histological and immunohistochemical examinations of biopsies from these nodules indicated breast metastasis of the primary lung neuroendocrine tumor. The patient underwent mastectomy of the right breast but subsequently developed metastases in the left breast, for which local radiotherapy was administered. The observed metachronous bilateral breast metastases indicated that the contralateral breast should be considered during an investigation of metastasis.

Systemic Therapy Plus Thermal Ablation Versus Systemic Therapy Alone for Oligometastatic Liver Metastases from Non-small Cell Lung Cancer

PURPOSE

This study assessed and compared the efficacy and long-term outcomes of systemic therapy plus image-guided thermal ablation versus systemic therapy alone for oligometastatic liver metastases (LMs) from non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board. Written informed consent was waived due to the retrospective design. From November 2012 to December 2017, 61 patients (mean age 59.0 years; 35 males) with oligometastatic LMs from NSCLC (≤ 5 metastatic lesions) who received systemic therapy with (n = 21, group A) or without (n = 40, group B) thermal ablation were analyzed. Progression-free survival (PFS) and overall survival (OS) were estimated by Kaplan-Meier curves.

RESULTS

The demographic and clinical characteristics were not significantly different between the groups (all P ≥ .05). In total, 28 LMs were entirely ablated, rendering a technical success rate of 100%, without major complications. The overall 6-month response rate was significantly higher in group A than in group B [57.1% (12/21) vs. 26.3% (10/38); P = .026]. The median PFS in group A was significantly longer than in group B [11.0 (95% CI 7.9-16.2) months vs. 5.2 (95% CI 3.7-7.9) months; P = .001]. However, the median OS was not significantly different [27.7 (95% CI 20.6-44.4) months vs. 17.7 (95% CI 14.5-27.5) months; P = .152].

CONCLUSION

Systemic therapy plus thermal ablation may prolong PFS but not OS in oligometastatic LMs from NSCLC.

Microwave ablation for non-small cell lung cancer with synchronous solitary extracranial metastasis

AIMS

Local therapy including surgery or radiotherapy has been reported for the treatment of non-small cell lung cancer (NSCLC) with synchronous solitary metastasis, while studies with other local ablative treatment are rare. Here, we summarized our single-center experience of microwave ablation (MWA) for both primary and metastatic lesions in NSCLC patients with synchronous solitary extracranial metastases.

PATIENTS AND METHODS

We retrospectively screened our institute database from January 2014 to Jun 2019. NSCLC patients with synchronous extracranial solitary metastasis with primary and metastatic lesions that were treated with MWA were identified and analyzed.

RESULTS

Of the 1472 stage IV NSCLC patients found, 38 were diagnosed with synchronous extracranial solitary metastasis and 29 of them received MWA for primary and metastatic lesions. The most common distant metastases were contralateral lung metastases (14 cases), followed by bone (6), liver (4), adrenal gland (3) and pleura metastases (1). Median OS and PFS was 21.5 and 12.5 months, respectively. Patients with N0 had significantly longer PFS (median 18.5 vs. 8.0 months) and OS (median 42.7 vs. 19.0 months). In addition, systemic therapy was showed to be a prognostic factor for better PFS (12.9 vs. 7.5 months). Clinical pathological factors including age, histology, T stage, PS score, and metastasis locations are not significantly associated with survival.

CONCLUSIONS

MWA may serve as an alternative treatment for NSCLCs with synchronous solitary extracranial metastases.

A Robust Signature Based on Autophagy-Associated LncRNAs for Predicting Prognosis in Lung Adenocarcinoma

Objective

To construct a predictive signature based on autophagy-associated lncRNAs for predicting prognosis in lung adenocarcinoma (LUAD). Materials and Methods. Differentially expressed autophagy genes (DEAGs) and differentially expressed lncRNAs (DElncRNAs) were screened between normal and LUAD samples at thresholds of ∣log₂Fold Change∣ > 1 and P value < 0.05. Univariate Cox regression analysis was conducted to identify overall survival- (OS-) associated DElncRNAs. The total cohort was randomly divided into a training group (n = 229) and a validation group (n = 229) and a validation group (

Results

A total of 30 DEAGs and 2997 DElncRNAs were identified between 497 LUAD tissues and 54 normal tissues; however, only 1183 DElncRNAs were related to the 30 DEAGs. A signature consisting of 13 DElncRNAs was built to predict OS in lung adenocarcinoma, and the survival analysis indicated a significant OS advantage of the low-risk group over the high-risk group in the training group, with a 5-year OS AUC of 0.854. In the validation group, survival analysis also indicated a significantly favorable OS for the low-risk group over the high-risk group, with a 5-year OS AUC of 0.737. Univariate and multivariate Cox regression analyses indicated that only positive surgical margin (vs negative surgical margin) and high-risk group (vs low-risk group) based on the predictive signature were independent risk factors predictive of overall mortality in LUAD.

Conclusions

This study investigated the association between autophagy-associated lncRNAs and prognosis in LUAD and built a robust predictive signature of 13 lncRNAs to predict OS.

Comparable outcomes of nivolumab in patients with advanced NSCLC presenting with or without brain metastases: a retrospective cohort study

OBJECTIVE

This study aimed to determine whether there is a difference in the efficacy of nivolumab in patients with advanced non-small cell lung cancer (NSCLC) presenting with or without brain metastases.

MATERIALS AND METHODS

Patients with advanced NSCLC treated with nivolumab monotherapy were retrospectively analyzed. They were divided into two cohorts according to the presence or absence of brain metastases. The differences between the two cohorts in objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), duration of response (DOR) and overall survival (OS) were investigated, and the intracranial efficacy, including intracerebral objective response rate (IORR), intracranial disease control rate (IDCR) and intracranial progression-free survival (iPFS), were examined in the brain metastasis (BM) cohort.

RESULTS

Seventy-three patients (32 with brain metastases and 41 without) were included. The ORRs of the BM cohort and the non-brain metastasis (non-BM) cohort were 25.0% and 19.5% (p = 0.574), DCRs were 53.1% and 56.1% (p = 0.800), respectively. Their median PFS were 2.8 and 4.9 months (p = 0.204), median DORs were 9.8 and 28.8 months (p = 0.003), and median OS were 14.8 and 20.2 months (p = 0.114), respectively. According to the Cox multivariate regression analysis, BM was not an independent prognostic factor. The IORR and IDCR of the BM cohort were 28.1% and 46.9%, respectively, with a median iPFS of 2.2 months.

CONCLUSIONS

The efficacy of nivolumab is comparable in patients with NSCLC presenting with and without brain metastases, but the results must be verified in large-scale prospective studies.

A case of medial pterygoid muscle metastasis of lung cancer presenting with trismus

A man in his 60s with severe trismus was referred to our hospital. Based on computed tomography (CT), positron emission tomography/computed tomography (PET/CT), and biopsy, his initial diagnosis at another hospital was oropharyngeal cancer with cervical lymph node and distant metastases. After the review of the contrast-enhanced CT and reevaluated PET/CT images, we updated his diagnosis to left primary lung cancer that had metastasized to the cervical lymph nodes, bones, and skeletal muscles including the right medial pterygoid muscle. Since metastasis from primary lung cancer to the contralateral cervical lymph node is relatively rare, cervical lymph node metastases were thought to have originated from the metastatic lesion in the right medial pterygoid muscle. As metastases in the masticator muscles from lung cancer are rare, it is sometimes necessary to differentiate from primary head and neck lesions. Here, we report a rare case of lung cancer with the onset of trismus due to metastasis to the masticator muscle and perineural spread along the mandibular nerve.

Lipopolysaccharide-anchored macrophages hijack tumor microtube networks for selective drug transport and augmentation of antitumor effects in orthotopic lung cancer

Objective: Engineered immune cells (e.g., therapeutic T cells) provide a revolutionary approach to combat cancer. Certain activated immune cells can exquisitely sense and respond to the tumor microenvironment. Here, we propose a paradigm based on engineering macrophages to allow selective intercellular drug delivery and augmentation of antitumor activities by hijacking tumor microtube networks. Methods: Macrophages were engineered via anchoring lipopolysaccharides on the plasma membrane (LM). The tumor tropism of LM encapsulating doxorubicin (LM-Dox) was monitored by a real-time cell migration assay and small animal in vivo imaging. Monocyte chemoattractant protein-1 (CCL2) was measured by quantitative PCR and ELISA. Intercellular conduit formation was characterized by confocal laser scanning microscopy and scanning electron microscopy. LM-Dox activation of tumor-associated macrophages to release TNF-α was evaluated by western blot and immunofluorescence assays. The potential therapeutic effects of LM-Dox in a 3D tumor-immune model and a murine orthotopic lung cancer model were tested. Results: LM-Dox exhibited tumor tropism in response to CCL2 produced by A549 lung tumor cells and lung tumor tissues resulting in a remarkably higher amount of tumor accumulation than the case of Lipo-Dox (~ 4-fold). Intriguingly, LM-Dox accumulated at tumor sites hijacked the established tumor microtube networks and even stimulated microtube formation with tumor cells but not with normal cells to enable selective and rapid transport of the drug to tumor cells. Simultaneously, LM-Dox induced secretion of TNF-α in tumor-associated macrophages, which increased the antitumor activity of Dox. Thus, LM-Dox increased the inhibitory effects on tumor growth and metastasis in a mouse orthotopic lung cancer model and minimized the side effects of Dox-induced tumor invasion. Conclusion: Lipopolysaccharide-anchored macrophages that can hijack tumor microtube networks for selective drug transport may serve as versatile bioactive carriers of anticancer drugs. In the clinical context, these engineered microphages represent a personalized medicine approach that can be translated into potential use of patient-derived monocytes/macrophages for drug delivery by means of cell-to-cell communication.

The Impact of Lung Carcinoma Histology on the Frequency of Bone Metastases

Objective  Lung cancer is the leading cause of death by cancer, and the bones are one of the most common sites of metastasis from this condition. This study aimed to evaluate the influence of lung carcinoma histology on the frequency of bone metastases. Methods  This retrospective study evaluated the medical records of 407 patients diagnosed with lung cancer between 2003 and 2012. The prevalence of bone metastases and their association with histological subtypes were evaluated using chi-squared tests, odds ratios (ORs) and 95% confidence intervals (CIs). The overall survival was evaluated using the Kaplan-Meier method. Results  The prevalence of bone metastases was 28.2% ( n  = 115), and the spine was the most frequently affected site (98 metastases; 32.1%). Adenocarcinoma was the most common histological subtype of lung carcinoma (46.7%), and it was significantly more frequent among patients with bone metastases (58.3% versus 42.1%; p  = 0.003; OR = 1.92; 95% CI: 1.29-2.97). Squamous cell carcinoma was significantly less frequent among patients with bone metastases (13.0% versus 29.8%; p  = 0.0004; OR = 0.35; 95% CI: 0.19-0.64). The median survival time after the first bone metastasis diagnosis was 4 months. Conclusion  Adenocarcinoma was the most common histological subtype of lung carcinoma, and it was significantly associated with a higher risk of developing bone metastases.

ALK rearrangement: a high-frequency alteration in ovarian metastasis from lung adenocarcinoma

Background

Ovarian metastatic tumors from lung adenocarcinoma are rare, and a serial study of these tumors is lacking to date. Additionally, a better understanding of the clinicopathological and molecular characteristics of metastatic tumors is needed.

Methods

Seven cases of ovarian metastasis from lung adenocarcinoma from 2013 to 2017 at our institute were investigated. The results were combined with those found in literature review. A total of 16 cases were analyzed in the present study. We examined clinicopathological and immunohistochemical characteristics, further detected ALK rearrangement by FISH (fluorescence in situ hybridization), and assessed EGFR and KRAS mutations using Sanger sequencing or the amplification refractory mutation system (ARMS).

Results

The mean age of the patients was 44.6 years (range, 33–56 years). Eleven of sixteen patients developed ovarian tumors within a mean time of 18.5 months (range, 5–48 months) from the initial diagnosis of lung adenocarcinoma; 5 patients had lung tumors and ovarian masses simultaneously. Five tumors (5/16, 31%) occurred in the bilateral ovaries, and the others were unilateral ovarian tumors (11/16, 69%). All seven cases from our institute were positive for TTF-1 and Napsin A but negative for PAX8. In four cases, ALK (D5F3) was diffusely and strongly expressed, with ALK rearrangements (4/7, 57%). Overall, ALK rearrangement was found by FISH or immunohistochemistry in 11/16 (69%) cases. In two cases, EGFR mutations in exons 19 and 21, respectively, were found. One patient did not detected EGFR or ALK mutation in the metastatic tumor, but the primary lung adenocarcinoma did harbor an EGFR mutation. Two cases had no alterations in three genes above. Although the mean survival time of the patients with ALK rearrangement was longer than those without (mean survival time 25 m vs. 20 m), no statistical significance of the difference was found.

Conclusions

As the largest case series of ovarian metastasis from lung adenocarcinoma, our findings indicate that ALK rearrangement is the most common molecular alteration. Although patients with ALK rearrangement appear to have a better prognosis than do those without ALK rearrangement, more cases with longer follow-up and multivariant analysis are needed to clarify this point.

Isolated Rare Urethral Metastasis From Primary Lung Adenocarcinoma: Case Report and Literature Review

Background: Lung adenocarcinoma is a common respiratory malignancy, however urethral metastasis of lung adenocarcinoma has not yet been reported. This study aims to present a rare case of isolated urethral metastasis in a male patient with a history of primary lung adenocarcinoma.

Case Presentation: A 69 year-old male patient was admitted complaining of dysuria and nocturia for 3 months, with a history of lung adenocarcinoma after surgery. The patient was diagnosed as benign prostatic hyperplasia (BPH) and received holmium laser enucleation of the prostate, an effective transurethral procedure to treat bladder outflow obstruction due to BPH. Four months after surgery for BPH, the patient had no improvement in symptoms and continued to complain of dysuria and perineum pain. An MRI of the pelvis indicated posterior urethral mass without any regional lymphadenopathy or other sites of lesion. Urethrocystoscopy found the mass in the membranous urethra near the verumontanum, and pathology combined with immunohistochemical staining confirmed the isolated urethral metastasis of lung adenocarcinoma. The further therapeutic regimen consisting of chemotherapy (pemetrexed combined with nedaplatin) and bevacizumab was well-tolerated, and obviously relieved the patient from dysuria and perineum pain.

Conclusion: This study reported the first case of isolated rare urethral metastasis from primary lung adenocarcinoma and underlined the necessity for clinicians to remain vigilant to metastasis during follow-up of primary cancer.

Isolated Renal Metastasis from Primary Lung Squamous Cell Carcinoma with Synchronous Small Cell Lung Cancer

Synchronous multiple primary lung cancer is a unique type of lung carcinomas that are diagnosed with more than two different pathological types in the same or different lung lobes. Isolated metastasis to the kidney is considered rare. Herein, we present a case of a 58-year-old male with a history of chronic obstructive pulmonary disease (COPD) and 40 pack-year of cigarette smoking, who was diagnosed with synchronous small cell lung cancer (SCLC) and squamous cell carcinoma (SCC) with isolated metastasis to the kidney. Isolated kidney metastasis from lung cancer is an infrequent finding; it should be considered when the patient is diagnosed with lung cancer. In the absence of disseminated disease and contraindications, nephrectomy is an option for treatment with chemotherapy or as a palliative measure if the patient is symptomatic.