The dynamic pattern of recurrence in curatively resected non-small cell lung cancer patients: Experiences at a single institution

Pathological Pleural Invasion is a Risk Factor for Late Recurrence in Long-Term Survivors of Non-small Cell Lung Cancer after Complete Resection

BACKGROUND

Information regarding late recurrence after pulmonary resection for non-small cell lung cancer (NSCLC) is limited. This study aimed to analyze the risk factors for late recurrence after surgery for NSCLC in the current era.

PATIENTS AND METHODS

We conducted a retrospective study of patients who underwent complete resection for pathological I-III NSCLC between 2006 and 2015. Late recurrence was defined as a recurrence that met the following conditions: (1) the patient underwent chest computed tomography (CT) at or after 54 months after surgery and recurrence was not detected at that time, and (2) recurrence that occurred more than 5 years after surgery. The factors influencing late recurrence, relapse-free survival (RFS), and overall survival (OS) after surgery were analyzed.

RESULTS

A total of 1275 with 5-year relapse-free survival after surgery were enrolled in this study. The mean age of the patients was 66.4 years and 54% of the patients were men. The median interval between surgery and the latest follow-up examination was 98 months. In total, 35 patients (2.7%) experienced late recurrence and 138 patients have died thus far. The cumulative recurrence, RFS, and OS rates at 10 years were 3.9%, 84.9%, and 86.3%, respectively. A multivariate analysis revealed that pleural invasion was an independent risk factor for late recurrence. Pleural invasion was a poor prognostic factor for both RFS and OS.

CONCLUSIONS

Pleural invasion was a predictor of late recurrence. Age > 67 years, preoperative serum carcinoembryonic antigen (CEA) > 5 ng/ml, non-adenocarcinoma, and pleural invasion were poor prognostic factors for RFS.

Comparison of radiotherapy versus surgical resection following neoadjuvant chemoimmunotherapy in potentially resectable stage III non-small-cell lung cancer: A propensity score matching analysis

BACKGROUND

Neoadjuvant chemoimmunotherapy followed by surgery is recommended for resectable non-small-cell lung cancer (NSCLC). However, a considerable proportion of patients do not undergo surgery and opt for alternative treatments such as radiotherapy. The efficacy of radiotherapy in this context remains unclear.

METHODS

This retrospective study analyzed data from patients with stage III NSCLC who received neoadjuvant chemoimmunotherapy followed by either surgery or radiotherapy. Propensity score matching (PSM) was used to balance the heterogeneity between the groups. Efficacy outcomes, safety profiles, and disease recurrence patterns were assessed.

RESULTS

In total, 175 patients were included; 50 underwent radiotherapy, and 125 underwent surgery. Prior to matching, radiotherapy was inferior to surgery in terms of progression-free survival (PFS; Hazard ratio [HR], 2.23; P = 0.008). Following a 1:1 PSM adjustment, each group consisted of 40 patients. The median PFS was 30.8 months in the radiotherapy group and not reached in the surgery group (HR, 1.46; P = 0.390). The 12- and 24-month PFS rates were 90.4 % and 69.0 % for the radiotherapy group compared to 94.1 % and 73.9 % for the surgery group, respectively. Subgroup analyses after PSM showed that patients with stage IIIA disease tend to benefit more from surgery than those with stage IIIB disease (HR, 3.00; P = 0.074). Grade 3-4 treatment-related adverse events (TRAEs) occurred in 62.5 % of patients in the radiotherapy group and 55.0 % in the surgery group, with no grade 5 TRAEs reported. The incidence of grade 3-4 treatment-related pneumonitis or pneumonia was 7.5 % and 2.5 % in the radiotherapy and surgery groups, respectively.

CONCLUSION

Radiotherapy may be a viable alternative to surgery in patients with resectable NSCLC who do not undergo surgical resection after initial neoadjuvant chemoimmunotherapy, offering comparable efficacy and a manageable safety profile. Larger prospective studies are needed to validate these findings and optimize the treatment strategies for this patient population.

Association between number of dissected lymph nodes and survival in patients undergoing resection for clinical stage IA pure solid lung adenocarcinoma: a retrospective analysis

BACKGROUND

Lymph node dissection is essential for staging of pure solid lung adenocarcinoma and selection of treatment after surgical resection, particularly for stage I disease since the rate of lymph node metastasis can vary from 0 to 23.7%.

METHODS

We retrospectively screened all adult patients (18 years of age or older) who underwent lobectomy for pure solid cT1N0M0 lung adenocarcinoma between January 2015 and December 2017 at our center. Cox proportional hazard regression was used to assess the association between the number of dissected lymph nodes and recurrence-free survival (RFS) and to determine the optimal number of dissected lymph nodes.

RESULTS

The final analysis included 458 patients (age: 60.26 ± 8.07 years; 241 women). RFS increased linearly with an increasing number of dissected lymph nodes at a range between 0 and 9. Kaplan-Meier analysis revealed significantly longer RFS in patients with ≥ 9 vs. <9 dissected lymph nodes. In subgroup analysis, ≥ 9 dissected lymph nodes was not only associated with longer RFS in patients without lymph node metastasis (n = 332) but also in patients with metastasis (n = 126). In multivariate Cox proportional hazard regression, ≥ 9 dissected lymph nodes was independently associated with longer RFS (hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.26 to 0.73; P = 0.002).

CONCLUSIONS

≥9 Dissected lymph nodes was associated with longer RFS; accordingly, we recommend dissecting 9 lymph nodes in patients undergoing lobectomy for stage IA pure solid lung adenocarcinoma.

Hazard Function Analysis of Recurrence in Patients with Curatively Resected Lung Cancer: Results from the Japanese Lung Cancer Registry in 2010

Simple Summary

To optimize postoperative surveillance of lung cancer patients, we investigated the hazard function of tumor recurrence in patients with completely resected lung cancer. Using the records of the 2010 Japanese Joint Committee of Lung Cancer Registry, the risk of postoperative recurrence was analyzed using a cause-specific hazard function in patients who underwent lobectomy to completely resect pathological stage I–III lung cancer. The hazard function for recurrence exhibited a peak at approximately 9 months after surgery, followed by a tapered plateau-like tail extending to 60 months. The peak risk for intrathoracic recurrence was approximately two-fold higher compared with that of extrathoracic recurrence. When considered together with the results of the subgroup analysis, the characteristics of the postoperative tumor recurrence hazard in a large cohort of lung cancer patients may be useful for improving stage-related management of postoperative surveillance.

Abstract

To optimize postoperative surveillance of lung cancer patients, we investigated the hazard function of tumor recurrence in patients with completely resected lung cancer. We analyzed the records of 12,897 patients in the 2010 Japanese Joint Committee of Lung Cancer Registry who underwent lobectomy to completely resect pathological stage I–III lung cancer. The risk of postoperative recurrence was determined using a cause-specific hazard function. The hazard function for recurrence exhibited a peak at approximately 9 months after surgery, followed by a tapered plateau-like tail extending to 60 months. The peak risk for intrathoracic recurrence was approximately two-fold higher compared with that of extrathoracic recurrence. Subgroup analysis showed that patients with stage IIIA adenocarcinoma had a continuously higher risk of recurrence compared with patients with earlier-stage disease. However, the risk of recurrence in patients with squamous cell carcinoma was not significantly different compared with that more than 24 months after surgery, regardless of pathological stage. In conclusion, the characteristics of postoperative tumor recurrence hazard in a large cohort of lung cancer patients may be useful for determining the time after surgery at which patients are at the highest risk of tumor recurrence. This information may improve stage-related management of postoperative surveillance.

Recurrence dynamics after curative surgery in patients with invasive mucinous adenocarcinoma of the lung

Background

We investigated the patterns and timing of recurrence and death as well as prognostic factors based on clinicopathological and radiological factors in patients who underwent surgical treatment for invasive mucinous adenocarcinoma (IMA).

Methods

We reviewed clinicopathological findings including spread through air spaces (STAS) and CT findings of IMA such as morphology, solidity, margin, well-defined heterogeneous ground-glass opacity, CT angiogram, and air bronchogram signs from 121 consecutive patients who underwent surgical resection. Prognostic factors for disease-free survival (DFS) and overall survival (OS) were identified. Hazard rate analyses were performed for the survival dynamics.

Results

T stage (hazard ratio [HR] = 4.102, p = 0.03), N stage (N2 vs. N0, HR = 7.653, p < 0.001), and consolidative CT morphology (HR = 3.556, p = 0.008) remained independent predictors for DFS. Age (HR = 1.110, p = 0.002), smoking (HR = 12.893, p < 0.001), T stage (HR = 13.005, p = 0.006), N stage (N2 vs. N0, HR = 7.653, p = 0.004), STAS (HR = 7.463, p = 0.008), and consolidative CT morphology (HR = 6.779, p = 0.007) remained independent predictors for OS. Consolidative morphology, higher T and N stage, and presence of STAS revealed initial sharp peaks after steep decline of the hazard rate curves for recurrence or death in follow-up period.

Conclusions

Consolidative morphology, higher T and N stage, smoking, and STAS were indicators of significantly greater risk of early recurrence or death in patients with IMA. Thus, these findings could be incorporated into future surveillance strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01208-5.

[Pattern of Recurrence and Metastasis after Radical Resection of Non-small Cell Lung Cancer]

The rate of recurrence and metastasis of non-small cell lung cancer after radical resection is still very high. The risk factors for recurrence and metastasis have been extensively studied, but the dynamic pattern of postoperative recurrence hazard over time is relatively lacking. The dynamic recurrence hazard rate curve is applied to describe the rate of recurrence at any point time among the "at-risk" patients. In this article, by reviewing the previous literature, the characteristics of the dynamic recurrence and metastasis pattern after radical resection of non-small cell lung cancer and the clinical factors affecting the recurrence and metastasis pattern are summarized, in order to screen out specific populations with high recurrence risk and give them personalized follow-up strategy and diagnosis and treatment.
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Prognostic Difference of Pleural versus Distant Metastasis after Surgery for Lung Cancer

Background: Pleural metastasis in lung cancer found at diagnosis has a poor prognosis, with 5–11 months’ survival. We hypothesized that prognosis might be different for patients who have had curative-intent surgery and subsequent pleural recurrence and that survival might differ based on the location of the first metastasis (distant versus pleural). This may clarify if pleural recurrence is a local event or due to systemic disease. Methods: A database of 5089 patients who underwent curative-intent surgery for lung cancer was queried, and 85 patients were found who had biopsy-proven pleural metastasis during surveillance. We examined survival based on pattern of metastasis (pleural first versus distant first/simultaneously). Results: Median survival was 34 months (range: 1–171) from the time of surgery and 13 months (range: 0–153) from the time of recurrence. The shortest median survival after recurrence was in patients with adenocarcinoma and pleural metastasis as the first site (6 months). For patients with pleural metastasis as the first site, those with adenocarcinoma had a significantly shorter post-recurrence survival when compared with squamous cell carcinoma (6 vs. 12 months; HR = 0.34) and a significantly shorter survival from the time of surgery when compared with distant metastases first/simultaneously (25 vs. 52 months; HR = 0.49). Conclusions: Patients who undergo curative-intent surgery for lung adenocarcinoma that have pleural recurrence as the first site have poor survival. This may indicate that pleural recurrence after lung surgery is not likely due to a localized event but rather indicates systemic disease; however, this would require further study.

Identification of molecular signatures associated with early relapse after complete resection of lung adenocarcinomas

The only potentially curative treatment for lung adenocarcinoma patients remains complete resection of early-stage tumors. However, many patients develop recurrence and die of their disease despite curative surgery. Underlying mechanisms leading to establishment of systemic disease after complete resection are mostly unknown. We therefore aimed at identifying molecular signatures of resected lung adenocarcinomas associated with the risk of an early relapse. The study comprised 89 patients with totally resected stage IA–IIIA lung adenocarcinomas. Patients suffering from an early relapse within two years after surgery were compared to patients without a relapse in two years. Patients were clinically and molecular pathologically characterized. Tumor tissues were immunohistochemically analyzed for the expression of Ki67, CD45, CD4, CD8, PD1, PD-L1, PD-L2 and CD34, by Nanostring nCounter PanCancer Immune Profiling Panel as well as a comprehensive methylome profiling using the Infinium MethylationEPIC BeadChip. We detected differential DNA methylation patterns as well as significantly differentially expressed genes associated with an early relapse after complete resection. Especially, CD1A was identified as a potential biomarker, whose reduced expression is associated with an early relapse. These findings might help to develop biomarkers improving risk assessment and patient selection for adjuvant therapy as well as establish novel targeted therapeutic strategies.

Neoadjuvant PD-1 inhibitors and chemotherapy for locally advanced NSCLC: A retrospective study

BACKGROUND

Stage III non-small cell lung cancer (NSCLC) encompasses a variety of local invasion and nodal involvement and its management is still under debate. Immune checkpoint inhibitors (ICI) have been shown to improve the survival in metastatic NSCLC, but are far from being accepted as an induction therapy.

METHODS

We retrospectively collected data of all patients who received induction ICI (nivolumab or pembrolizumab) and chemotherapy (carboplatin with paclitaxel) for stage IIIA-B NSCLC followed by surgery in our unit between January 2019 and March 2020.

RESULTS

Of the 12 patients (9 males, 3 females) 6 had a squamous cell carcinoma, 3 had adenocarcinoma, 1 had an undifferentiated adenocarcinoma and 1 had adeno-squamous carcinoma. Seven patients had stage IIIA disease and 5 had stage IIIB. After induction therapy, 6 patients had stable disease and 6 had a partial response. The median tumor reduction was 3.05 cm (range 2.30-8.70). All patients, but one due to the Coronavirus Disease 2019 outbreak, had no delay in surgery. Two patients experienced myelosuppression after induction therapy, two had minor adverse effects. Three patients had postoperative complications not related to the induction therapy. All patients had a pathological response: 5 complete, 4 major and 3 partial. Eleven patients are alive (mean months of follow-up 18.17±4.97) and free of disease.

CONCLUSIONS

Induction ICI-chemotherapy may be a valid treatment in patients with locally advanced NSCLC, providing important tumor downstaging and rendering patients operable. In our experience patients had few side effects and a good pathological response.

Circulating Interleukin-4 Is Associated with a Systemic T Cell Response against Tumor-Associated Antigens in Treatment-Naïve Patients with Resectable Non-Small-Cell Lung Cancer

Simple Summary

Cytokines can increase the activity of T cells specific for tumor-associated antigens and thereby promote tumor-specific immune responses. In this study, cytokine profiles and T cell responses against 14 tumor-associated antigens were investigated in 36 treatment-naïve patients with resectable non-small cell lung cancer. Based on these results, preoperative serum interleukin-4 levels can play a role in predicting T cell responses specific for tumor-associated antigens and recurrence-free survival regardless of tumor stage. This is clinically relevant as patients with high preoperative serum interleukin-4 levels could be at high risk of postoperative tumor recurrence and, therefore, should be considered for adjuvant or neoadjuvant treatment. From this perspective, preoperative serum interleukin-4 levels may become a useful option to assess the risk of postoperative tumor recurrence in non-small-cell lung cancer.

Abstract

Spontaneous T cell responses to tumor-associated antigens (TAs) in the peripheral blood of patients with non-small-cell lung cancer (NSCLC) may be relevant for postoperative survival. However, the conditions underlying these T cell responses remain unclear. We quantified the levels of 27 cytokines in the peripheral blood and tumor tissues from treatment-naïve patients with NSCLC (n = 36) and analyzed associations between local and systemic cytokine profiles and both TA-specific T cell responses and clinical parameters. We defined T cell responders as patients with circulating T cells that were reactive to TAs and T cell nonresponders as patients without detectable TA-specific T cells. TA-specific T cell responses were correlated with serum cytokine levels, particularly the levels of interleukin(IL)-4 and granulocyte colony-stimulating factor (G-CSF), but poorly correlated with the cytokine levels in tumor tissues. Nonresponders showed significantly higher serum IL-4 levels than responders (p = 0.03); the predicted probability of being a responder was higher for individuals with low serum IL-4 levels. In multivariable Cox regression analyses, in addition to IL-4 (hazard ratio (HR) 2.8 (95% confidence interval (CI): 0.78–9.9); p = 0.116), the age-adjusted IL-8 level (HR 3.9 (95% CI: 1.05–14.5); p = 0.042) predicted tumor recurrence. However, this study included data for many cytokines without adjustment for multiple testing; thus, the observed differences in IL-4 or IL-8 levels might be incidental findings. Therefore, additional studies are necessary to confirm these results.

Prediction of Overall Survival of Patients with Completely Resected Non-Small Cell Lung Cancer: Analyses of Preoperative Spirometry, Preoperative Blood Tests, and Other Clinicopathological Data

Purpose

Risk stratification of patients with non-small cell lung cancer (NSCLC) is crucial to select the appropriate treatments, but available models for patients with complete resection are unsatisfactory. The purpose of this study was to determine a prediction model based on clinical information, routine physical and blood tests, and molecular markers.

Patients and Methods

This was a retrospective cohort study of patients who underwent surgical resection for lung cancer between 2009 to 2013. Potential prognostic factors were used to build a full prediction model based on a multivariable Cox regression analysis. A nomogram was constructed. The risk stratification cutoffs for clinical use were determined based on the model.

Results

A total of 368 NSCLC patients with R0 resection were included. The final multivariable model indicated that low diffusing capacity of the lung for carbon monoxide (HR=1.66, 95% CI: 1.18–2.34), high platelet-to-lymphocyte ratio (HR=1.42, 95% CI: 1.04–1.95), histology type of squamous cell carcinoma and others (squamous cell carcinoma vs adenocarcinoma, HR=1.40, 95% CI: 1.01–1.96; others vs adenocarcinoma, HR=2.36, 95% CI: 1.15–4.84; P trend=0.001), N>0 status (HR=1.96, 95% CI: 1.42–2.70), high serum carcinoembryonic antigen levels (HR=1.61, 95% CI: 1.13–2.27), and postoperative chemotherapy (HR=0.53, 95% CI: 0.33–0.87) were independently associated with poor OS. The patients were classified into four risk groups according to the nomogram, and the OS was different among the four groups (P<0.05).

Conclusion

A nomogram was successfully constructed based on a multivariable analysis, and the nomogram can discriminate the OS of patients with NSCLC based on risk categories, but external validation is still necessary.

Bone marrow expands the repertoire of functional T cells targeting tumor-associated antigens in patients with resectable non-small-cell lung cancer

The efficacy of cancer immunotherapy may be improved by increasing the number of circulating tumor-reactive T cells. The bone marrow is a priming site and reservoir for such T cells. The characteristics of bone marrow-derived tumor-reactive T cells are poorly understood in patients with non-small-cell lung cancer (NSCLC). To compare the responsiveness of tumor antigen-reactive T cells from the bone marrow with matched peripheral blood samples in patients with resectable NSCLC, we used flow cytometry, cytokine capture assays and enzyme-linked immunospot assays to examine the responsiveness of T cells to 14 tumor antigens in matched bone marrow and peripheral blood samples from patients with resectable NSCLC or benign tumors and tumor-free patients. T cells with reactivity to tumor antigens were detected in the bone marrow of 20 of 39 (51%) NSCLC patients. The panel of tumor antigens recognized by bone marrow-derived T cells was distinct from that recognized by peripheral blood-derived T cells in NSCLC patients. Unlike for peripheral blood T cells, the presence of tumor-reactive T cells in the bone marrow did not correlate with recurrence-free survival after curative intent resection of NSCLC. T cells with reactivity to tumor antigens are common in the bone marrow of patients with NSCLC. Tumor-reactive T cells of the bone marrow have the potential to significantly broaden the total repertoire of tumor-reactive T cells in the body. To clarify the role of tumor-reactive T cells of the bone marrow in T cell-based immunotherapy approaches, clinical studies are needed (ClinicalTrials.gov: NCT02515760).

Circulating and Tumor Myeloid-derived Suppressor Cells in Resectable Non-Small Cell Lung Cancer

RATIONALE

Myeloid-derived suppressor cell (MDSC) expansion has been found to play a role in disease progression in patients with cancer. However, the characteristics of MDSCs in lung cancer are poorly understood.

OBJECTIVES

We prospectively investigated MDSCs and inflammatory factors in tumor and peripheral blood samples from patients with resectable non-small cell lung cancer and studied their correlations with the disease prognosis.

METHODS

A complex analysis of MDSC subsets and inflammatory mediators was performed using flow cytometry and a Bio-Plex assay.

MEASUREMENTS AND MAIN RESULTS

A significant increase in the frequency of circulating monocytic (M)-MDSCs was observed in the patients with non-small cell lung cancer compared with the healthy donors (HDs). Moreover, the frequencies of M- and polymorphonuclear (PMN)-MDSCs were higher in tumors than in the peripheral blood of the same patients. This accumulation was associated with elevated concentrations of inflammatory mediators involved in MDSC migration to and activation in the tumor microenvironment. An analysis of the MDSC immunosuppressive pattern showed increased programmed death-ligand 1 expression on circulating cells from patients compared with HDs. Tumor PMN-MDSCs displayed higher programmed death-ligand 1 expression levels than the same cells in the peripheral blood. The frequency of CCR5 (C-C chemokine receptor 5) expression on circulating M-MDSCs was significantly higher in the patients than in the HDs. Clinical data analysis revealed negative correlations between recurrence-free survival and the frequencies of PMN-MDSCs and CCR5⁺ M-MDSCs in the circulation but not in tumors.

CONCLUSIONS

Our findings suggest that the level of MDSCs in the peripheral blood but not in tumor tissues predicts recurrence after surgery.

Neoadjuvant anti-programmed Death-1 immunotherapy by Pembrolizumab in resectable nodal positive stage II/IIIa non-small-cell lung cancer (NSCLC): the NEOMUN trial

Background

Immunotherapies targeting the PD1/PD-L1 pathway have had a large impact on the treatment of advanced NSCLC. Concerning multimodality tumor therapy, only few trials until today have been performed investigating neoadjuvant treatment with anti PD-1 immunotherapy prior to curative intent surgery. Aim of the NEOMUN investigator initiated trial (EudraCT-Number: 2017–000105-20; ClinicalTrials.gov Identifier: NCT03197467) is to assess feasibility and safety of pre-surgical anti PD-1 treatment in order to improve long term survival.

Methods

The study is designed as an open-label, single arm, prospective, monocenter, phase II study including 30 patients with NSCLC stage II/IIIA suitable for curative intent surgery. Investigational drug is Pembrolizumab. After 2 cycles of immunotherapy (à 200 mg q3w i.v.), tumor resection with lobectomy or bilobectomy will be performed. Primary objectives are to assess the feasibility and safety of a neoadjuvant immunotherapy and to assess antitumor activity of Pembrolizumab with regard to clinical and pathological tumor response. Secondary objective is disease free and overall survival. Exploratory objective is to analyze potential predictive biomarkers and to evaluate the therapeutic efficacy of Pembrolizumab by extended immune cell and cytokine analysis of tumor tissue.

The study protocol was approved by the local ethics committee and the federal authority. Start of patient enrollment is scheduled for June 2018.

Discussion

The NEOMUN trial will be one of the first clinical trials investigating a multimodal treatment strategy including neoadjuvant immunotherapy using Pembrolizumab as an investigational drug. Assessing the safety and therapeutic potential of neoadjuvant immunotherapy in connection with lung surgery will be of great interest for thoracic surgeons.

Trial registration

Prospectively, the NEOMUN study has been registered on www.clinicaltrials.gov; NCT03197467 (first post: June 23rd, 2017).

Evaluation of lobar lymph node metastasis in non-small cell lung carcinoma using modified total lesion glycolysis

Background

Volumetric parameters based on 3-dimensional reconstruction have recently been introduced for cancer staging. We aimed to improve the ability to diagnose hilar lymph node metastasis in patients with non-small cell lung cancer.

Methods

We evaluated 142 patients with non-small cell lung cancer who underwent right upper lobectomy and radical lymph node dissection. Metastatic involvement of right upper lobar lymph nodes was assessed using high-resolution computed tomography (HRCT) and 18F-2-floro-2-deoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT).

Results

On receiver operating characteristic (ROC) curve analysis, the area under the curves (AUC) for short axis, maximum of standardized uptake value (SUV_max), total lesion glycolysis (TLG) and modified TLG (mTLG) were 0.79, 0.77, 0.76, and 0.87, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of mTLG, using the optimal cut off value (2.45), for diagnosis of lobar lymph node metastasis were 71%, 88%, 44%, and 96%, respectively. Hilar asymmetric uptake (HAU) of FDG was larger in true-positive cases than in false-negative cases (P<0.01). Furthermore, the size of metastatic foci in the lymph node was smaller in false-negative cases (P=0.012).

Conclusions

Modified TLG is a good parameter to diagnose metastatic right upper lobar lymph nodes. Micrometastasis in the lymph node is difficult to predict using the current diagnostic method. However, more careful evaluation is required in patients with symmetric FDG accumulation at hilar region because hilar lymph nodes respond to various causes such as benign pulmonary diseases.

Histologic subtyping in pathologic stage I-IIA lung adenocarcinoma provides risk-based stratification for surveillance

Background

We hypothesize that recurrence hazard following resection for stage I-IIA lung adenocarcinoma (ADC) varies according to histologic subtype, which may provide risk stratification for surveillance better than the current uniform follow-up protocol.

Results

Presence (≥5%) of high-grade histologic subtypes (MIP and/or SOL) was associated with a significantly higher recurrence hazard: (1) presence of either MIP or SOL was associated with a significant increase in recurrence hazard during the first two years after surgery; (2) presence of SOL was associated with an increase in recurrence hazard—in particular, distant recurrence hazard—during the first year after surgery; (3) absence of high-grade subtypes (515/1,572 patients) was associated with a very low recurrence hazard (<2% risk/year) during the first ten years after surgery.

Methods

All hematoxylin and eosin–stained tumor slides from pathologic stage I-IIA lung ADC (n = 1572) were reviewed for quantification of the percentage of each histological subtype. Recurrence hazard was estimated using the Kernel-Epanechnikov smoothing procedure. The association between recurrence hazard and high-grade histologic subtypes (micropapillary [MIP] and solid [SOL]) was assessed.

Conclusions

Our findings suggest that histologic subtyping has utility for identifying recurrence hazard for surgically resected stage I-IIA lung ADC patients and provide rationale for establishing risk-based surveillance.

A surveillance method-oriented detection of post-operative spatial-temporal recurrence for non-small cell lung cancer

Background

This study evaluated spatial-temporal recurrence patterns after curative resection for non-small cell lung cancer (NSCLC) to clarify and recommend appropriate post-operative surveillance.

Methods

A total of 2,486 consecutive patients between January 2005 and December 2012 with NSCLC (stage I-IIIA) who underwent definitive surgical resection were retrospectively analyzed. We used a hazard rate curve to evaluate event dynamics. Disease-free survival (DFS) was evaluated by the Kaplan-Meier method. Univariate and multivariate analyses with Cox proportional hazards regression identified risk factors that predicted DFS.

Results

The median follow-up was 50.1 months. Recurrences were diagnosed in 852 (34.3%) patients. Four hundred eighty-nine events first occurred in the chest, 177 in the brain, 117 in the bone, and 71 in the abdomen. Of all recurrences, 78.5% occurred in the first 3 years. Univariate and multivariate analyses identified the age at diagnosis (P<0.001), histology (P=0.023), tumor size (P<0.001), pathologic N stage (P<0.001), and grade (P=0.043) as independent risk factors for intra-thoracic recurrences. Histology (P<0.001), tumor size (P<0.001), surgical method (P=0.021), pathologic N stage (P<0.001), and grade (P=0.005) were independent to predict extra-thoracic recurrences. The hazard rate curve displayed an initial surge of time to any treatment failure during 12 months after surgery. Based on sub-group analysis, both intra- and extra-recurrences increased with stage and brain recurrences in stage IIIA occurred earlier than stage II. Hazard rate curve of brain recurrences in squamous cell carcinoma showed a moderate peak during 9-15 months. Hazard rate curves of brain and bone recurrences in adenocarcinoma displayed clear peaks at 9-27 and 15-30 months, respectively.

Conclusions

Intra- and extra-thoracic recurrences correlate with different clinicopathological factors. Brain MRI and bone ECT were recommended for selected patients in particular time to early detect extra-thoracic recurrences.

Identification of an early diagnostic biomarker of lung adenocarcinoma based on co-expression similarity and construction of a diagnostic model

Background

The purpose of this study was to achieve early and accurate diagnosis of lung cancer and long-term monitoring of the therapeutic response.

Methods

We downloaded GSE20189 from GEO database as analysis data. We also downloaded human lung adenocarcinoma RNA-seq transcriptome expression data from the TCGA database as validation data. Finally, the expression of all of the genes underwent z test normalization. We used ANOVA to identify differentially expressed genes specific to each stage, as well as the intersection between them. Two methods, correlation analysis and co-expression network analysis, were used to compare the expression patterns and topological properties of each stage. Using the functional quantification algorithm, we evaluated the functional level of each significantly enriched biological function under different stages. A machine-learning algorithm was used to screen out significant functions as features and to establish an early diagnosis model. Finally, survival analysis was used to verify the correlation between the outcome and the biomarkers that we found.

Results

We screened 12 significant biomarkers that could distinguish lung cancer patients with diverse risks. Patients carrying variations in these 12 genes also presented a poor outcome in terms of survival status compared with patients without variations.

Conclusions

We propose a new molecular-based noninvasive detection method. According to the expression of the stage-specific gene set in the peripheral blood of patients with lung cancer, the difference in the functional level is quantified to realize the early diagnosis and prediction of lung cancer.

A Retrospective Long-term Follow-up Study of Stereotactic Body Radiation Therapy for Non-Small Cell Lung Cancer From a Single Institution: Incidence of Late Local Recurrence

PURPOSE

To assess the local recurrence (LR) rate and timing after stereotactic body radiation therapy (SBRT) for non-small cell lung cancer using long-term follow-up data from a single institution.

METHODS AND MATERIALS

Patients with primary or recurrent non-small cell lung cancer with or without pathologic verification, with tumors <3 cm, treated with SBRT (isocenter prescription of 48 Gy in 4 fractions) between April 1998 and August 2014, and with >6 months' follow-up were eligible. The LR rate was calculated by the cumulative incidence function, accounting for death as a competing risk. Univariate and multivariate analyses were performed to identify prognostic factors for LR.

RESULTS

A total of 216 patients and 230 tumors were analyzed. The median follow-up time of tumors without LR was 3.9 years, and the crude number of LR cases was 49 (21%). The actuarial rate of LR was 19% (95% confidence interval, 14%-25%) at 5 years. The number of LR cases in each period was 10 in year 1, 17 in year 2, 9 in year 3, 3 in year 4, 3 in year 5, and 7 after 5 years. Among 73 tumors with >5 years' follow-up, we observed 7 late LRs. The tumor histology of these late LRs was adenocarcinoma in 3, squamous cell carcinoma in 2, and unknown in 2 (1 of the unknown cases was confirmed as adenocarcinoma following salvage surgery). The median time to LR was 2.1 years (interquartile range, 1.5-4.2 years) for adenocarcinoma compared with 1.3 years (interquartile range, 1.0-2.3 years) for squamous cell carcinoma. Multivariate analysis revealed that larger tumor size, squamous cell histology compared with adenocarcinoma, and use of abdominal compression for respiratory motion management were independent negative prognostic factors for LR.

CONCLUSIONS

Long-term follow-up data demonstrated that late LR was not uncommon and that careful follow-up after SBRT is needed, especially in patients with adenocarcinoma.

Psychological distress and coping strategies among women with incurable lung cancer: a qualitative study

PURPOSE

Limited research has focused on women with lung cancer (LC) although they are recognized as the most vulnerable to psychological distress. This study explored in-depth the psychological distress experienced by women with incurable LC and analyzed the coping strategies with which they manage that distress.

METHODS

A qualitative methodology with in-depth interviews was employed for 34 women with advanced or recurrent LC. An inductive data-driven thematic analysis was applied to analyze transcripts.

RESULTS

Psychological distress was an iterative process for the women. Four themes were identified: shock regarding the diagnosis, distress regarding cancer treatment and its side effects, the facing of a recurrent or progressive disease, and persistent struggle with the life-limiting disease. Various coping strategies applied by the women to manage psychological distress were grouped into four themes: relying upon social support, focusing on positive thoughts, avoidance-based strategies, and religious faith and acceptance.

CONCLUSIONS

Women with incurable LC experienced substantial iterative psychological distress throughout the illness, regardless of length of illness at time of interview. They applied multiple forms of coping. The findings enrich the limited existing literature on this understudied population and provide direction for the future development of interventions to improve their psychological well-being.

Functional T cells targeting tumor-associated antigens are predictive for recurrence-free survival of patients with radically operated non-small cell lung cancer

In this prospective study, we examined postoperative follow-up and preoperative IFN-γ T cell responses against 14 non-small cell lung cancer (NSCLC)-associated antigens in the blood of 51 patients with NSCLC, 7 patients with benign pulmonary tumors, and 10 tumor-free patients by enzyme-linked immunospot assay. The phenotype and function of T cells specific for tumor-associated antigens (TAAs) in the blood or tumor tissue of 9 NSCLC patients were characterized in detail using TNF-α, IL-2, and IFN-γ cytokine capture assays. We found that circulating TAA-specific T cells were significantly enriched in NSCLC compared with tumor-free patients. The most frequently recognized TAAs were Aurora kinase A, HER2/neu, NY-ESO-1, and p53. TNF-α was the most abundant cytokine secreted by TAA-specific T cells in the blood as well as by in situ-activated tumor-infiltrating lymphocytes, most of which were effector memory cells. The absence of TAA-reactive T cells identified patients at higher risk of tumor recurrence, irrespective of tumor stage (OR = 8.76, 95% CI: 1.57-34.79, p = 0.008). We conclude that pre-existing TAA-reactive circulating T cells are a strong independent prognostic factor for recurrence-free survival. These data may help discriminating high-risk from low-risk patients, improving prognostication, and redirecting adjuvant therapy. Our findings suggest the therapeutic relevance of Aurora kinase A, HER2/neu, NY-ESO-1, and p53 as targets for immunotherapy. This study is registered on Clinicaltrials.gov with trial identification number: NCT02515760.

Prediction of distant recurrence in resected stage I and II lung adenocarcinoma

OBJECTIVES

Optimal procedures for adjuvant treatment and post-surgical surveillance of resected non-small-cell lung cancer remain under discussion. Pathological features are the main determinant of follow-up therapy but have limited ability to identify patients at risk of recurrence. Increasingly, molecular markers are incorporated into clinical decision-making, including measures of tumor growth. The CCP score is a quantitative, molecular measure of proliferation derived from the RNA expression of 31 cell cycle genes and a component of the molecular prognostic score (mPS). The mPS score is a linear combination of CCP score and pathological stage. CCP score and mPS are independent predictors of survival in resected lung adenocarcinoma.

MATERIALS AND METHODS

CCP scores were determined by RT-qPCR for 318 patients diagnosed with stage I-II lung adenocarcinoma. Association of mPS and CCP score with distant recurrence and lung-cancer specific survival was assessed in Cox proportional hazards regression models adjusted for age, gender, tumor size, pathological stage and pleural invasion. Distant recurrence-free survival and lung-cancer specific survival by mPS risk group were calculated by Kaplan-Meier survival analysis.

RESULTS

CCP scores were obtained for 205 stage I and 84 stage II patients. CCP score and mPS were independent markers of distant recurrence (CCP: HR 1.62, 95%CI 1.15-2.29, p=0.0055; mPS: HR 2.22, 95%CI 1.11-4.44, p=0.023). Patients with low mPS tumors were at significantly reduced risk of distant recurrence (log-rank p=4.2×10^-5). Among stage I patients, stratification by mPS identified a patient group with increased risk of distant recurrence (36%, 95%CI 28-46%, log-rank p=0.0011) CONCLUSIONS: The molecular prognostic score stratifies early-stage, resected lung cancer patients for risk of distant recurrence and could be useful to inform treatment and surveillance decisions.