Pulmonary emphysema and tumor microenvironment in primary lung cancer

The association of chest computed tomography-defined visual emphysema and prognosis in patients with nonsmall cell lung cancer

Background

Although computed tomography (CT)-defined emphysema is considered a predictor of lung cancer risk, it is not fully clear whether CT-defined emphysema is associated with the prognosis of lung cancer. We aimed to assess the clinical impact of CT-defined emphysema on the survival of lung cancer.

Methods

In the prospective cohort study of nonsmall cell lung cancer (NSCLC), the correlation between CT-defined emphysema and clinical variables was analysed. A multivariable Cox regression model was built to assess the association between CT-defined emphysema and overall survival (OS) for up to 8.8 years. The differences in survival analyses were derived by Kaplan-Meier analysis and log-rank testing. Low attenuation area (LAA%) was defined as the per cent of voxels below -950 HU.

Results

854 patients were included and CT-defined emphysema was present in 300 (35.1%) at diagnosis. Epidermal growth factor receptor (EGFR) wild-type (OR 1.998; p<0.001) and anaplastic lymphoma kinase (ALK) wild-type (OR 2.277; p=0.004) were associated with CT-defined emphysema. CT-defined emphysema remained a significant predictor of prognosis adjusting for age, sex, smoking history, tumour histology and Eastern Cooperative Oncology Group Performance Status (ECOG PS), whether in I-IIIA stage (adjusted hazard ratio (HR) 1.745; p=0.017) or in IIIB-IV stage (adjusted HR 1.291; p=0.022). Stratified analyses showed that OS rate among the driver oncogene groups with different CT-defined emphysema status differed significantly (log-rank p<0.001). Furthermore, patients with centrilobular emphysema (CLE) with LAA% >17% displayed poorer survival than those with LAA% ≤17% (median 432 versus 670 days; HR 1.564; p=0.020).

Conclusions

CT-defined emphysema, especially CLE with LAA%>17%, is an independent predictor of NSCLC prognosis. Moreover, prospective studies are needed to further explore this association.

Hyperinflation and reduced diffusing capacity predict prognosis in SCLC: value of extended pre-therapeutic lung function testing

BACKGROUND

Small cell lung cancer (SCLC) is characterized by aggressive growth and poor prognosis. Although SCLC affects nearly exclusively heavy smokers and leads to frequent respiratory symptoms, the impact of pre-therapeutic lung function testing in SCLC is sparely investigated until now. Therefore, we sought to examine whether we could find prognostic markers in pre-therapeutic lung function testing of SCLC patients.

PATIENTS AND METHODS

We retrospectively analysed a cohort of 205 patients with the diagnosis of SCLC between 2010 and 2018. Pre-therapeutic values of spirometry, body plethysmography and measurement of diffusing capacity was extracted from patients' charts. Comparisons between groups were performed using the Mann-Whitney U-test or by chi-square tests as appropriate. Kaplan-Meier analyses and COX-regression models were performed to correlate lung function parameters with patients' outcome.

RESULTS

Airway obstruction itself, or the diagnosis chronic obstructive pulmonary disease (COPD) based on GOLD definitions did not correlate with survival in SCLC patients. Hyperinflation measured by increased residual volume and residual volume to total lung capacity ratio (log-rank p < 0.001) and reduced diffusing capacity (log-rank p = 0.007) were associated with reduced survival. Furthermore, patients with hyperinflation as well as impairments in gas exchange representing an emphysematic phenotype had the worst outcome (log-rank p < 0.001).

CONCLUSION

We recommend including body plethysmography and measurement of diffusing capacity in the pre-therapeutic assessment of SCLC patients. Our findings suggest that reduction of hyperinflation may lead to better outcome in SCLC patients. Thus, in addition to effective tumour therapy, adequate therapy of the comorbidity of COPD should also be provided. In particular, measures to reduce hyperinflation by means of dual bronchodilation as well as respiratory physiotherapy should be further assessed in this setting.

The benefits and harms of adjuvant chemotherapy for non-small cell lung cancer in patients with major comorbidities: A simulation study

BACKGROUND

Randomized controlled trials (RCTs) have demonstrated a survival benefit for adjuvant platinum-based chemotherapy after resection of locoregional non-small cell lung cancer (NSCLC). The relative benefits and harms and optimal approach to treatment for NSCLC patients who have major comorbidities (chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], and congestive heart failure [CHF]) are unclear, however.

METHODS

We used a simulation model to run in-silico comparative trials of adjuvant chemotherapy versus observation in locoregional NSCLC in patients with comorbidities. The model estimated quality-adjusted life years (QALYs) gained by each treatment strategy stratified by age, comorbidity, and stage. The model was parameterized using outcomes and quality-of-life data from RCTs and primary analyses from large cancer databases.

RESULTS

Adjuvant chemotherapy was associated with clinically significant QALY gains for all patient age/stage combinations with COPD except for patients >80 years old with Stage IB and IIA cancers. For patients with CHF and Stage IB and IIA disease, adjuvant chemotherapy was not advantageous; in contrast, it was associated with QALY gains for more advanced stages for younger patients with CHF. For stages IIB and IIIA NSCLC, most patient groups benefited from adjuvant chemotherapy. However, In general, patients with multiple comorbidities benefited less from adjuvant chemotherapy than those with single comorbidities and women with comorbidities in older age categories benefited more from adjuvant chemotherapy than their male counterparts.

CONCLUSIONS

Older, multimorbid patients may derive QALY gains from adjuvant chemotherapy after NSCLC surgery. These results help extend existing clinical trial data to specific unstudied, high-risk populations and may reduce the uncertainty regarding adjuvant chemotherapy use in these patients.

From COPD to Lung Cancer: Mechanisms Linking, Diagnosis, Treatment, and Prognosis

Many studies have proved that the pathogenesis of the chronic obstructive pulmonary disease (COPD) and lung cancer is related, and may cause and affect each other to a certain extent. In fact, the change of chronic airway obstruction will continue to have an impact on the screening, treatment, and prognosis of lung cancer.In this comprehensive review, we outlined the links and heterogeneity between COPD and lung cancer and finds that factors such as gene expression and genetic susceptibility, epigenetics, smoking, epithelial mesenchymal transformation (EMT), chronic inflammation, and oxidative stress injury may all play a role in the process. Although the relationship between these two diseases have been largely determined, the methods to prevent lung cancer in COPD patients are still limited. Early diagnosis is still the key to a better prognosis. Thus, it is necessary to establish more intuitive screening evaluation criteria and find suitable biomarkers for lung cancer screening in high-risk populations with COPD. Some studies have indicated that COPD may change the efficacy of anti-tumor therapy by affecting the response of lung cancer patients to immune checkpoint inhibitors (ICIs). And for lung cancer patients with COPD, the standardized management of COPD can improve the prognosis. The treatment of lung cancer patients with COPD is an individualized, comprehensive, and precise process. The development of new targets and new strategies of molecular targeted therapy may be the breakthrough for disease treatment in the future.

Lung cancer in patients with COPD and factors associated with reduced survival

Background. A combination of different types of lung cancer and chronic obstructive pulmonary disease (COPD) is very common. COPD, accompanied by ventilation disorders and, often, respiratory failure, is a significant additional risk factor for mortality in these patients. Identification of risk factors for mortality in patients with lung cancer and COPD can potentially be associated with better long-term outcomes.

Materials and methods. Using a Cox regression model based on information about the outcome of the disease and life expectancy after treatment initiation, a survival analysis was performed with an assessment of the contribution of various clinical and anamnestic factors for a group of 118 COPD patients with primary diagnosed lung cancer. These patients received treatment at the Cancer Research Institute in Tomsk in 2013–2019.

Results. The study included 118 patients (87.3% men and 12.7% women). Among them, 77.97% of patients were active or former smokers with smoking index (SI) ≥ 10 pack-years, and 22% of patients had never smoked or had SI < 10 pack-years but had other risk factors for COPD. Peripheral lung cancer was detected in 45.8% of cases. Squamous cell carcinoma was noted in 54.2% of cases, adenocarcinoma – in 34.7%, large cell carcinoma – in 1.7%, small cell carcinoma – in 5.9%, and carcinoid tumors – in 2.5% of cases. Patients were characterized by varying degrees of severity of ventilation disorders in accordance with the GOLD classification: stage 1 was observed in 44% of patients, stage 2 – in 38.1 % of patients, stage 3 – in 16.9 % of patients, and stage 4 – in one patient. Threeyear mortality was 28.12%.

Conclusion. According to the results of the Cox regression analysis, factors that significantly reduced the survival rate of patients with lung cancer in combination with COPD were more severe stages in terms of the size of  the primary tumor and its localization, the prevalence of metastasis (according to TNM classification), more severe dyspnea (mMRC scale), lower oxygen saturation values, atelectasis, and episodes of pneumonia, including paracancrotic pneumonia, over the previous 12 months. The presence of certain types of metastases, such as metastatic lesions of the pleura, adrenal glands, distant non-regional lymph nodes, and bones should also be noted as negative factors for survival. It is worth noting that surgical treatment of the primary tumor was associated with an increase in the survival rate in patients with lung cancer in combination with COPD.

Quantitative Emphysema on Low-Dose CT Imaging of the Chest and Risk of Lung Cancer and Airflow Obstruction: An Analysis of the National Lung Screening Trial

BACKGROUND

Lung cancer risk prediction models do not routinely incorporate imaging metrics available on low-dose CT (LDCT) imaging of the chest ordered for lung cancer screening.

RESEARCH QUESTION

What is the association between quantitative emphysema measured on LDCT imaging and lung cancer incidence and mortality, all-cause mortality, and airflow obstruction in individuals who currently or formerly smoked and are undergoing lung cancer screening?

STUDY DESIGN AND METHODS

In 7,262 participants in the CT arm of the National Lung Screening Trial, percent low attenuation area (%LAA) was defined as the percentage of lung volume with voxels less than -950 Hounsfield units on the baseline examination. Multivariable Cox proportional hazards models, adjusting for competing risks where appropriate, were built to test for association between %LAA and lung cancer incidence, lung cancer mortality, and all-cause mortality with censoring at 6 years. In addition, multivariable logistic regression models were built to test the cross-sectional association between %LAA and airflow obstruction on spirometry, which was available in 2,700 participants.

RESULTS

The median %LAA was 0.8% (interquartile range, 0.2%-2.7%). Every 1% increase in %LAA was independently associated with higher hazards of lung cancer incidence (hazard ratio [HR], 1.02; 95% CI, 1.01-1.03; P = .004), lung cancer mortality (HR, 1.02; 95% CI, 1.00-1.05; P = .045), and all-cause mortality (HR, 1.01; 95% CI, 1.00-1.03; P = .042). Among participants with spirometry, 892 had airflow obstruction. The likelihood of airflow obstruction increased with every 1% increase in %LAA (odds ratio, 1.07; 95% CI, 1.06-1.09; P < .001). A %LAA cutoff of 1% had the best discriminative accuracy for airflow obstruction in participants aged > 65 years.

INTERPRETATION

Quantitative emphysema measured on LDCT imaging of the chest can be leveraged to improve lung cancer risk prediction and help diagnose COPD in individuals who currently or formerly smoked and are undergoing lung cancer screening.

Emphysema - The review of radiological presentation and its clinical impact in the LDCT screening era

Emphysema is one of three main lung pathologies in Chronic Obstructive Pulmonary Disease, along with chronic bronchitis and small airway obstruction. The diagnosis is based on detection of low attenuation areas in lung tissue on chest Computed Tomography, either visual by a radiologist, or automatic by the applied Computed Tomography software. Results of the studies on the association between emphysema and lung cancer incidence are mixed. Many studies have demonstrated, that chronic lung diseases, like Chronic Obstructive Pulmonary Disease, are associated with lung cancer morbidity. There is also evidence, that emphysema can be related with worse prognosis in patients with detected lung cancer. In this review article we aim to summarize current knowledge about emphysema detection and evaluation on Computed Tomography, both quantitative and qualitative. We also summarize current data on correlation between emphysema and lung cancer, as well as its potential use in selecting patients, who would most benefit from lung cancer screening.

Relationship and prognostic significance between preoperative serum albumin to globulin ratio and CT features of non-small cell lung cancer

PURPOSE

This study was conducted to assess the relationship and prognostic significance between preoperative serum albumin to globulin ratio (AGR) and high-resolution computed tomography (HRCT) features of non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Demographic parameters, laboratory values including AGR and other clinical variables were evaluated in 180 patients with NSCLC, and 72 of these patients had results of radiology parameters detected with HRCT [including emphysema, tumor disappearance rate (TDR), CT values and CT enhanced values of the tumor mass] were assessed for survival analyses. The 72 patients were divided into two groups: normal lung group and emphysema group. The discriminatory values for AGR between these two groups were assessed by Mann-Whitney U test The relationship between TDR and AGR in NSCLC patients was evaluated by Pearson correlation analysis.

RESULTS

In multivariate analysis, TDR (p = 0.033), AGR (p = 0.038), emphysema (p = 0.009), and N stage (P = 0.026) were independent predictors of overall survival (OS). AGR was higher in NSCLC patients without emphysema than NSCLC patients with emphysema (z = -2.979, P = 0.003). TDR demonstrated that there was a positive relationship with AGR (r = 0.307, p = 0.009). A nomogram with AGR, TDR, emphysema, and N stage was established to predict 5-year survival.

CONCLUSIONS

There is a relationship between CT features and AGR in NSCLC. The integrative nomogram combined with CT images, clinical and hematologic features improved survival prediction in NSCLC patients, which offers a non-invasive, comprehensive, and convenient evaluation for individualized management of NSCLC patients.

Emphysema is associated with the aggressiveness of COPD-related adenocarcinomas

OBJECTIVES

To compare the differences in radiologic and pathologic features of surgically resected chronic obstructive pulmonary disease (COPD)-related adenocarcinomas according to the presence of emphysema.

METHODS

A total of 216 smokers with surgically resected lung adenocarcinoma were included in this retrospective study, and 102 patients were diagnosed with COPD. We classified COPD patients as emphysematous or non-emphysematous group based on the emphysema severity on computed tomography (CT) and evaluated the differences in the CT and pathologic features between the two groups. The relationship between emphysema and disease-free survival was assessed using a Kaplan-Meier curve.

RESULTS

Lung adenocarcinomas in emphysema group presented a more aggressive pathologic grade and higher prevalence of solid lesions (vs subsolid lesions) on CT than those in non-emphysematous group (P = 0.006 and <0.001, respectively). After adjustment for age, sex, smoking pack-years and tumor size, emphysema group had a greater risk for higher histologic grade and higher prevalence of solid lesions than non-emphysema group (odds ratio, 3.445; 95% confidence interval, 1.124-10.564; P = 0.030, odds ratio, 6.192; 95% confidence interval, 1.804-21.254; P = 0.004, respectively). Kaplan-Meier survival curves showed that patients with emphysema had significantly impaired disease-free survival compared with those without emphysema (median disease-free survival = 37.0 vs 57.5 months, P = 0.038).

CONCLUSION

Adenocarcinomas in emphysema-present COPD had more aggressive features of pathology and CT findings, and worse disease-free survival than those without emphysema. These findings might provide an insight into the different pathobiology and prognostic implications of lung adenocarcinomas according to the presence of emphysema in patients with COPD.

Chronic Obstructive Pulmonary Disease and Lung Cancer: Underlying Pathophysiology and New Therapeutic Modalities

Chronic obstructive pulmonary disease (COPD) and lung cancer are major lung diseases affecting millions worldwide. Both diseases have links to cigarette smoking and exert a considerable societal burden. People suffering from COPD are at higher risk of developing lung cancer than those without, and are more susceptible to poor outcomes after diagnosis and treatment. Lung cancer and COPD are closely associated, possibly sharing common traits such as an underlying genetic predisposition, epithelial and endothelial cell plasticity, dysfunctional inflammatory mechanisms including the deposition of excessive extracellular matrix, angiogenesis, susceptibility to DNA damage and cellular mutagenesis. In fact, COPD could be the driving factor for lung cancer, providing a conducive environment that propagates its evolution. In the early stages of smoking, body defences provide a combative immune/oxidative response and DNA repair mechanisms are likely to subdue these changes to a certain extent; however, in patients with COPD with lung cancer the consequences could be devastating, potentially contributing to slower postoperative recovery after lung resection and increased resistance to radiotherapy and chemotherapy. Vital to the development of new-targeted therapies is an in-depth understanding of various molecular mechanisms that are associated with both pathologies. In this comprehensive review, we provide a detailed overview of possible underlying factors that link COPD and lung cancer, and current therapeutic advances from both human and preclinical animal models that can effectively mitigate this unholy relationship.

PGAM5 expression and macrophage signatures in non-small cell lung cancer associated with chronic obstructive pulmonary disease (COPD)

Background

COPD patients are at increased risk of developing non-small cell lung carcinoma that has a worse prognosis. Oxidative stress contributes to carcinogenesis and is increased in COPD patients due to mitochondrial dysfunction. We determined whether mitochondrial dysfunction is a contributing factor to the reduced survival of COPD patients with non-small cell lung carcinoma (NSCLC).

Methods

Using a transcriptomic database and outcome data of 3553 NSCLC samples, we selected mitochondrial-related genes whose levels in the tumour correlated with patient mortality. We further selected those genes showing a ≥ 2 fold expression in cancer compared to normal tissue. Cell-type specific expression of these proteins in lung tissue from NSCLC patients who were non-smokers or smokers with or without COPD (healthy smokers) was determined by immunohistochemistry. Gene set variation analysis was used in additional NSCLC datasets to determine the relative expression of specific macrophage transcriptomic signatures within lung cancer tissue.

Results

The expression of 14 mitochondrial-related genes was correlated with patient mortality and these were differentially expressed between cancer and normal lung tissue. We studied further the expression of one of these genes, PGAM5 which is a regulator of mitochondrial degradation by mitophagy. In background lung tissue, PGAM5 was only expressed in alveolar macrophages, with the highest expression in smokers with COPD compared to healthy smokers and non-smokers. In cancerous tissue, only the malignant epithelial cells and associated macrophages at the periphery of the cancer expressed PGAM5. Pre-neoplastic epithelium also showed the expression of PGAM5. There was no difference in expression in cancer tissue between COPD, healthy smoker and non-smoker groups. Macrophages at the edge of the cancer from COPD patients showed a trend towards higher expression of PGAM5 compared to those from the other groups. There was a significant correlation between PGAM5 expression in cancer tissue and the level of expression of 9 out of 49 previously-defined macrophage transcriptomic signatures with a particular one associated with patient mortality (p < 0.05).

Conclusion

PGAM5 is expressed in pre-neoplastic tissue and NSCLC, but not in normal epithelium. The association between PGAM5 expression and patient mortality may be mediated through the induction of specific macrophage phenotypes.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5140-9) contains supplementary material, which is available to authorized users.

Impact of COPD on prognosis of lung cancer: from a perspective on disease heterogeneity

Background

COPD is an important comorbidity of lung cancer, but the impact of COPD on the outcomes of lung cancer remains uncertain. Because both COPD and lung cancer are heterogeneous diseases, we evaluated the link between COPD phenotypes and the prognosis of different histological subtypes of lung cancer.

Methods

In this retrospective study, subjects with a newly and pathologically confirmed diagnosis of lung cancer were enrolled from patients preparing for lung cancer surgery. All participants underwent pulmonary function test (PFT). The diagnosis of COPD was based on GOLD criteria. Lung cancer subtypes and COPD phenotypes were categorized by WHO classification of lung tumors and computer quantitative analysis of PFT. The HRs were estimated by Cox regression analysis.

Results

Among 2,222 lung cancer patients, 32.6% coexisted with COPD. After adjustment for age, sex, body mass index (BMI), smoking status, and therapy method, COPD was significantly associated with the decreased overall survival (OS) of lung cancer (HR 1.28, 95% CI 1.05-1.57). With the increased severity of COPD, the OS of lung cancer was gradually worsened (HR 1.23, 95% CI 1.08-1.39). But surgical treatment and high BMI were independent prognostic protective factors (HR 0.46, 95% CI 0.37-0.56; HR 0.96, 95% CI 0.94-0.99). Moreover, in terms of disease heterogeneity, emphysema-predominant phenotype of COPD was an independent prognostic risk factor for squamous carcinoma (HR 2.53, 95% CI 1.49-4.30). No significant relationship between COPD phenotype and lung cancer prognosis was observed among adenocarcinoma, small cell lung cancer, large cell lung cancer, and other subtype patients.

Conclusion

These findings suggest that COPD, especially emphysema-predominant phenotype, is an independent prognostic risk factor for squamous carcinoma only.

Preoperative risk assessment with computed tomography in patients undergoing lung cancer surgery

Background

Although whole lung computed tomography (CT) is included in the routine workup before lung cancer surgery, it is not utilized to assess the preoperative pulmonary function.

Methods

Two hundred ninety patients (development cohort) who underwent lung lobectomy for cancer in our institute and another 100 patients (validation cohort) who subsequently underwent the same operation in a referral hospital were included. The total lung volume (TLV) and emphysematous lung volume (ELV) were obtained by quantitative CT.

Results

The TLV was higher in patients with a smoking history than in those without. The ELV to the TLV was higher in elderly patients than in younger patients. The regression equation for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) were developed using CT-derived variables, together with sex, age, height, and smoking habit, by a multiple regression analysis in the development cohort. The regression equation-based FVC and FEV₁ were significantly correlated with the actual FVC and FEV₁ in the development cohort, as well as in the validation cohort. The predicted postoperative FEV₁ (ppo%FEV₁) calculated based on the regression equation was also correlated with the postoperative FEV₁ value obtained by the conventional method (R=0.53), and the regression equation-based ppo%FEV₁ was a significant predictor of postoperative cardiopulmonary complications (P=0.02).

Conclusions

Whole lung CT can be used to assess the preoperative pulmonary function in patients undergoing lobectomy for cancer. This method may be helpful in preoperative risk assessment, particularly in patients who have difficulty in implementation of spirometry.

Clinical and radiological characteristics of central pulmonary adenocarcinoma: a comparison with central squamous cell carcinoma and small cell lung cancer and the impact on treatment response

Purpose

The proportion of central pulmonary adenocarcinoma (ADC) in central-type lung cancer has been gradually increasing due to the overall increasing incidence of pulmonary ADC. But the clinical and radiological characteristics of central ADCs remain unclear. In this study, we compared the clinical and radiological characteristics of central ADCs with those of small cell lung cancers (SCLCs) and squamous cell carcinomas (SQCCs) and investigated the impact of these characteristics on patients’ treatment response.

Patients and methods

The medical records of 302 consecutive patients with central lung cancer from July 2014 to September 2016 were retrospectively reviewed. There were 99 patients with ADC, 95 with SQCC and 108 with SCLC. Computed tomography images were interpreted by two radiologists. Treatment response was determined by Response Evaluation Criteria In Solid Tumors 1.1.

Results

Univariate analyses found that younger age, female sex, no history of smoking, higher levels of carcinoembryonic antigen (CEA), contralateral hilum lymphadenopathy, contralateral lung metastasis, pleural nodules and pleural metastasis to the interlobular fissure were significantly correlated with central ADC. Multivariate logistic regression analyses revealed that compared with central SQCC, female sex, younger age, no history of smoking, higher levels of CEA and contralateral hilum lymphadenopathy were the significantly independent indicators of central pulmonary ADC. Furthermore, compared with central SCLC, younger age, higher levels of CEA and cytokeratin 19 fragment (Cyfra21-1), lower levels of neuron-specific enolase, pleural nodules and lack of vascular involvement were significantly associated with central ADC. In 85 central ADC patients who received first-line platinum-based chemotherapy, both univariate and multivariate logistic regression analyses revealed that pulmonary emphysema had a negative correlation with treatment response (odds ratio=8.04, p=0.02).

Conclusion

Our study revealed that central pulmonary ADCs exhibited more aggressive clinical and radiological characteristics. Pulmonary emphysema was an independent and negative indicator for treatment response of central ADC.

Prognostic significance of CT-determined emphysema in patients with small cell lung cancer

Background

Although emphysema and small cell lung cancer (SCLC) are prevalent in smokers, no previous study has investigated the prognostic impact of computed tomography (CT)-determined emphysema in SCLC. This study was undertaken to analyze the prognostic value of emphysema scores as determined by baseline CT scans in patients with SCLC.

Methods

The data of 149 consecutive patients with SCLC were analyzed. Emphysema severity was semi-quantitatively scored on baseline chest CT images using the Goddard scoring system (possible scores for individual patients ranged from 0 to 24). Data on clinical characteristics and survival were retrospectively collected. Survivals were estimated using the Kaplan-Meier method and compared using the log-rank test. A multivariable Cox proportional hazard model was used to identify prognostic factors.

Results

Most of the 149 patients were male (85.2%) and current/ex-smokers (87.2%). The median CT emphysema score was 4 (range, 0 to 23). Univariable analysis, patients with a higher CT emphysema score (≥8) had significantly poorer overall survivals (OS) than those with lower scores (5.0 vs. 12.3 months, P<0.001). Multivariable analysis showed a higher CT emphysema score (treated as a continuous variable) was a significant independent prognostic factor of poor survival [hazard ratio (HR), 1.85; 95% confidence interval (CI), 1.14 to 3.00; P=0.012], along with extensive stage (HR, 2.27; 95% CI, 1.45-3.53; P<0.001), elevated lactate dehydrogenase (LDH) (HR, 1.52; 95% CI, 1.03-2.23; P=0.034), and supportive care only (HR, 6.46; 95% CI, 3.64-11.48; P<0.001).

Conclusions

Emphysema severity, as determined by baseline CT, is significantly associated with poor prognosis in SCLC.

Lung cancer and chronic obstructive pulmonary disease: From a clinical perspective

Chronic obstructive pulmonary disease (COPD) and lung cancer are devastating pulmonary diseases that commonly coexist and present a number of clinical challenges. COPD confers a higher risk for lung cancer development, but available chemopreventive measures remain rudimentary. Current studies have shown a marked benefit of cancer screening in the COPD population, although challenges remain, including the common underdiagnosis of COPD. COPD-associated lung cancer presents distinct clinical features. Treatment for lung cancer coexisting with COPD is challenging as COPD may increase postoperative morbidities and decrease survival. In this review, we outline current progress in the understanding of the clinical association between COPD and lung cancer, and suggest possible cancer prevention strategies in this patient population.

Regional Emphysema Score Predicting Overall Survival, Quality of Life, and Pulmonary Function Recovery in Early-Stage Lung Cancer Patients

INTRODUCTION

Pulmonary emphysema is a frequent comorbidity in lung cancer, but its role in tumor prognosis remains obscure. Our aim was to evaluate the impact of the regional emphysema score (RES) on a patient's overall survival, quality of life (QOL), and recovery of pulmonary function in stage I to II lung cancer.

METHODS

Between 1997 and 2009, a total of 1073 patients were identified and divided into two surgical groups-cancer in the emphysematous (group 1 [n = 565]) and nonemphysematous (group 2 [n = 435]) regions-and one nonsurgical group (group 3 [n = 73]). RES was derived from the emphysematous region and categorized as mild (≤5%), moderate (6%-24%), or severe (25%-60%).

RESULTS

In group 1, patients with a moderate or severe RES experienced slight decreases in postoperative forced expiratory volume in 1 second, but increases in the ratio of forced expiratory volume in 1 second to forced vital capacity compared with those with a mild RES (p < 0.01); however, this correlation was not observed in group 2. Posttreatment QOL was lower in patients with higher RESs in all groups, mainly owing to dyspnea (p < 0.05). Cox regression analysis revealed that patients with a higher RES had significantly poorer survival in both surgical groups, with adjusted hazard ratios of 1.41 and 1.43 for a moderate RES and 1.63 and 2.04 for a severe RES, respectively; however, this association was insignificant in the nonsurgical group (adjusted hazard ratio of 0.99 for a moderate or severe RES).

CONCLUSIONS

In surgically treated patients with cancer in the emphysematous region, RES is associated with postoperative changes in lung function. RES is also predictive of posttreatment QOL related to dyspnea in early-stage lung cancer. In both surgical groups, RES is an independent predictor of survival.

Prognostic significance of CT-emphysema score in patients with advanced squamous cell lung cancer

BACKGROUND

Although emphysema is a known independent risk factor of lung cancer, no study has addressed the prognostic impact of computed tomography (CT)-emphysema score in advanced stage lung cancer.

METHODS

For 84 consecutive patients with stage IIIB and IV squamous cell lung cancer that underwent palliative chemotherapy, severity of emphysema was semi-quantitatively scored using baseline chest CT images according to the Goddard scoring system (possible scores range, 0-24). The cutoff of high CT-emphysema score was determined using the maximum chi-squared test and the prognostic significance of the high CT-emphysema score was evaluated using Kaplan-Meier analysis and Cox proportional hazards analysis.

RESULTS

The median CT-emphysema score was 5 (range, 0-22). Patients with a high CT-emphysema score (≥4) tended to have poorer overall survival (OS) (median: 6.3 vs. 13.7 months) than those with a score of <4 (P=0.071). Multivariable analysis revealed that a higher CT-emphysema score was a significant independent prognostic factor for poor OS [hazard ratio (HR) =2.06; 95% confidence interval (CI), 1.24-3.41; P=0.005), along with no response to first-line therapy (P=0.009) and no second-line therapy (P<0.001).

CONCLUSIONS

CT-emphysema score is significantly associated with poor prognosis in patients with advanced squamous cell lung cancer.

Lung cancer in chronic obstructive pulmonary disease patients, it is not just the cigarette smoke

PURPOSE OF REVIEW

An important association has been described between chronic obstructive pulmonary disease (COPD) and lung cancer, where different mechanisms have been proposed. There is no unique cause for this association, as COPD is by itself a heterogeneous disease, in which their classical phenotypes (i.e., emphysema and chronic bronchitis) each play an important role in lung cancer development. We will discuss recent evidence that links these two diseases and specific characteristics found in lung cancers from patients with COPD.

RECENT FINDINGS

Molecular studies have found specific gene expressions (reduction and overexpression) in lung tumors from patients with COPD, which likely predispose to increased methylation during lung carcinogenesis, and are associated with aggressiveness. Recent evidence suggests that lung cancer risk is higher in individuals with long telomeres, and that this effect takes place well in advance of diagnosis. Lung cancer is likely to develop in areas of the lung with greater emphysema and the severity of the latter is associated with larger and more aggressive tumors.

SUMMARY

Clinical and molecular studies have found that lung cancers that develop in patients with COPD and/or emphysema appear to be more aggressive and have a distinct molecular profile when compared with tumors from patients without an underlying lung disease. This could have important implications when deciding on personalized treatments.