Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

The Impact of Preoperative Invasive Nodal Staging on Unexpected Mediastinal Upstaging in Early-Stage Non-small Cell Lung Cancer

INTRODUCTION

Preoperative invasive nodal staging is standard of care for early-stage non-small cell lung cancer (NSCLC). Complications and delays in care are not negligible and diagnostic accuracy varies. In our system, invasive nodal staging is performed for clear radiographic indications (node > 1.0 cm short axis or standardized uptake value > 3.0, tumor > 4.0 cm). This study assessed whether unexpected mediastinal upstaging was less common in patients receiving preoperative invasive nodal staging.

METHODS

This retrospective study evaluated nodal upstaging, defined as pathological N2 or IIIA+ disease, based on receipt or non-receipt of invasive nodal staging. Clinical stage I-II NSCLC patients who underwent resection (2009-2019) were identified from our cancer registry. Stage and preoperative nodal staging information were confirmed through chart review. Associations between patient characteristics, invasive nodal staging receipt, and clinical to pathological stage changes were analyzed.

RESULTS

Among 2576 patients, 18.7% (n = 481) underwent invasive nodal staging. After resection, 6.2% of all patients had nodal upstaging and 24.9% had TNM upstaging. Only 0.3% (n = 9) were upstaged to N2 and 0.5% (n = 13) were upstaged to IIIA+. Lack of preoperative nodal sampling was not associated with N2 or IIIA+ upstaging. Findings were consistent in subanalyses of patients with surgical specimens meeting Commission on Cancer nodal sampling criteria and with clinical IB+ disease.

CONCLUSIONS

Although most patients did not undergo invasive nodal staging, <1% had unexpected N2 on surgical pathology. There was no association between lack of preoperative invasive nodal sampling and N2 nodal upstaging. Preoperative invasive nodal staging did not increase pathologic N2 nodal upstaging in early-stage NSCLC patients in our integrated health system.

Impact of tumor size by clinical N subclassification and histology in trimodality-treated N2 non-small cell lung cancer

The evolving TNM classification has emphasized the tumor size's role in NSCLC prognosis, reclassifying stage IIIA patients from the previous edition as stage IIIB (T3-4N2M0, 8th edition). However, the prognostic implications of tumor size and survival in stage III NSCLC patients undergoing neoadjuvant therapy remain unexplored. Therefore, we investigated the association between tumor size and mortality in N2 non-small cell lung cancer (NSCLC) patients undergoing neoadjuvant concurrent chemoradiotherapy followed by surgery (trimodality therapy), considering the number of metastatic N2 stations and histology. We analyzed 756 patients with stage III (T1-3N2) NSCLC who underwent trimodality therapy, excluding those with T3 tumors with invasion components or additional nodules (2003-2019). Overall survival was compared using the Cox-proportional hazards model, while the tumor size-survival relationship was estimated using restricted cubic splines. Using 8th TNM edition, 32.1%, 48.5%, and 19.3% were clinical T1, T2, and T3. During a median follow-up of 53.5 months, 398 patients died. The adjusted hazard ratios for overall survival comparing T2 and T3 to T1 were 1.46 (95% confidence interval, 1.14-1.85) and 1.48 (1.10-1.99). For the extent of clinical N2, large tumor size increased the mortality risk in patients with N2b but not in N2a. Tumor size did not increase mortality risk in squamous cell carcinoma patients; however, the mortality risk was increased with larger tumors in adenocarcinoma. These findings raise the importance of considering tumor size in treatment planning and suggesting tailored strategies.

Directional interactions from non-small cell lung cancer to brain glucose metabolism revealed by total-body PET imaging

PURPOSE

Imaging markers for lung-brain interaction and brain metastasis of non-small cell lung cancer (NSCLC) are lacking. This study aimed to explore the effect of NSCLC on brain glucose metabolism using total-body positron emission tomography (PET) imaging.

METHODS

Fifty-six healthy controls (HCs) and 42 NSCLC patients underwent total-body PET imaging. Concentrations of serum tumor markers were obtained for NSCLC patients. Pseudo-time series data of NSCLC were generated based on the tumor, node, metastasis (TNM) staging system. A novel causal metabolic covariance network (CaMCN) between NSCLC and brain glucose metabolism was conducted with maximum and mean of standardized uptake value (SULmax and SULmean), serum tumor markers as the seed series, respectively. Reliability was evaluated by reverse CaMCN analysis. Finally, post-hoc analysis was performed on brain regions that exhibited causality from NSCLC.

RESULTS

CaMCN analysis demonstrated significant causality from NSCLC to glucose uptake of the posterior fossa regions, the anatomic "watershed areas" and the gray-white matter junction in the frontal, temporal and occipital lobes. Reverse CaMCN analysis demonstrated significant distinctions from the original CaMCN results. Post-hoc analysis revealed that glucose uptake in the inferior temporal gyrus, thalamus, superior frontal gyrus, precentral gyrus and postcentral gyrus exhibited significant differences among HCs and different stages of NSCLC.

CONCLUSION

The proposed method can capture causal relationships from NSCLC to brain metabolism, providing pathophysiological insights into the lung-brain interaction in NSCLC. Moreover, the identified brain regions were the areas where NSCLC brain metastases frequently occur, holding the promise as biomarkers for brain metastases of NSCLC.

Finding patterns in lung cancer protein sequences for drug repurposing

Proteins are fundamental biomolecules composed of one or more chains of amino acids. They are essential for all living organisms, contributing to various biological functions and regulatory processes. Alterations in protein structures and functions are closely linked to diseases, emphasizing the need for in-depth study. A thorough understanding of these associations is crucial for developing targeted and more effective therapeutic strategies.Computational analyses of biomedical data facilitate the identification of specific patterns in proteins associated with diseases, providing novel insights into their biological roles. This study introduces a computational approach designed to detect relevant sequence patterns within proteins. These patterns, characterized by specific amino acid arrangements, can be critical for protein functionality. The proposed methodology was applied to proteins targeted by drugs used in lung cancer treatment, a disease that remains the leading cause of cancer-related mortality worldwide. Given that non-small cell lung cancer represents 85-90% of all lung cancer cases, it was selected as the primary focus of this study.Significant sequence patterns were identified, establishing connections between drug-target proteins and proteins associated with lung cancer. Based on these findings, a novel computational framework was developed to extend this pattern-based analysis to proteins linked to other diseases. By employing this approach, relationships between lung cancer drug-target proteins and proteins associated with four additional cancer types were uncovered. These associations, characterized by shared amino acid sequence features, suggest potential opportunities for drug repurposing. Furthermore, validation through an extensive literature review confirmed biological links between lung cancer drug-target proteins and proteins related to other malignancies, reinforcing the potential of this methodology for identifying new therapeutic applications.

No detectable impact of short-term treatment delays on lung cancer survival

Timely initiation of treatment is a core principle of oncologic care, especially for aggressive cancers such as lung cancer. However, the real-world impact of short-term delays in treatment initiation on survival outcomes in lung cancer remains unclear. This meta-analysis evaluates the association between treatment delays of 4, 8, and 12 weeks and all-cause mortality in lung cancer patients. A systematic search was conducted in PubMed, Scopus, and Web of Science for studies published between 2000 and 2025. Of 5360 screened records, 15 studies were included, comprising 16 cohorts for overall survival of lung cancer patients. Hazard ratios (HRs) for 4-, 8-, and 12-week treatment delays were estimated using random-effects meta-analyses. Heterogeneity was measured with the I2 statistic, and publication bias was assessed using funnel plots and Egger's test. No significant association was found between treatment delay and survival at any of the time points. Pooled HRs were 1.00 (95% CI, 0.99-1.02) for a 4-week delay, 1.01 (95% CI, 0.99-1.03) for an 8-week delay, and 1.01 (95% CI, 0.98-1.05) for a 12-week delay. Despite high heterogeneity (I2 = 97%), no evidence of publication bias was detected. This meta-analysis found no significant impact of short-term treatment delays (up to 12 weeks) on mortality in lung cancer patients. These findings challenge the assumption that brief delays universally worsen outcomes and underscore the importance of individualized treatment planning and prioritization.

Real-World Clinical Characteristics, Treatment Patterns, and Clinical Outcomes in US Patients with Stage I-III Resected NSCLC Without Known EGFR Mutations: The RESECT Study

BACKGROUND

Immunotherapy has altered the treatment landscape for resectable non-small cell lung cancer, increasing the complexity of treatment planning. Understanding treatment patterns and outcomes prior to the advent of immunotherapy can provide context for assessing the benefit of immunotherapies and other novel agents.

OBJECTIVE

We aimed to characterize real-world demographics, clinical characteristics, treatment patterns, and clinical outcomes of patients with early-stage non-small cell lung cancer before widespread immunotherapy use.

METHODS

Analyses included patients from the US CancerLinQ Discovery® database diagnosed with stage I-III non-small cell lung cancer between 2014 and 2020 without known EGFR mutations who underwent surgical resection within 140 days of diagnosis. The primary outcome was treatment patterns by disease stage.

RESULTS

Analyses included 3077 patients with stage I (n = 1673), II (n = 853), and III (n = 551) disease. Most (92.8%, 52.3%, and 36.5% of stage I, II, and III patients) received surgery without systemic therapy. Among stage I, II, and III patients, 7.2%, 44.8%, and 46.6% received adjuvant therapy only. Of stage II and III patients, 2.0% and 10.2% received neoadjuvant therapy only, and 0.9% and 6.7% received both (stage I patients who received neoadjuvant only or perioperative therapy were excluded because of low numbers [n = 4]). Five-year overall survival rates were 73.4%, 61.9%, and 50.5% in stage I, II, and III patients; 5-year real-world relapse-free survival rates were 35.4%, 23.1%, and 14.0%. In an exploratory multivariate analysis, neoadjuvant treatment was associated with improved overall survival and real-world relapse-free survival in stage II-III patients (stage I patients not evaluable). Adjuvant treatment was associated with improved real-world relapse-free survival, but not overall survival, in stage II-III patients.

CONCLUSIONS

Most patients received surgery alone, though the proportion receiving systemic treatment increased with disease stage. Modest 5-year, real-world relapse-free survival rates indicate a need for more effective neoadjuvant or adjuvant treatments in this setting.

Real-world outcomes of subsequent treatment strategies after durvalumab consolidation in stage III unresectable non-small cell lung cancer

BACKGROUND

The PACIFIC trial established chemoradiation followed by 1-year durvalumab consolidation as standard of care for unresectable locally advanced non-small cell lung cancer (LA-NSCLC). This study aims to investigate therapeutic strategies and clinical outcomes after durvalumab failure in the real-world.

MATERIALS AND METHODS

Patients with stage III LA-NSCLC from 23 Italian centres were retrospectively enrolled at durvalumab progression. Subsequent treatments (Sub-Tx) were prospectively collected and classified as follows:chemo-immunotherapy (subgroup-1), platinum-based chemotherapy (subgroup-2), non-platinum-based chemotherapy (subgroup-3), and targeted therapy (subgroup-4). Durvalumab progression free survival (Dur-PFS) and overall survival (Dur-OS), as well as outcomes of Sub-Tx (Sub-PFS and Sub-OS) were estimated by using the Kaplan-Meier approach.

RESULTS

A total of 122 patients were enrolled. Median Dur-PFS was 9.3 months (95 % CI: 7.1 - 11.4) and median Dur-OS 24.2 months (95 % CI: 18.7 - 29.7). Out of 93 patients receiving a Sub-Tx, 21.5 %, 43.0 %, 28.0 %, and 7.5 % were in the subgroup 1, 2, 3, and 4, respectively. Median Sub-PFS were 12.0, 4.1, 2.7, and 6.0 months, respectively. Patients who completed 12 months of durvalumab were 65.0 %, 27.5 %, 19.2 %, and 42.9 % across the four subgroups. In univariate analysis, the duration of durvalumab therapy was an independent factor for selecting Sub-Tx (p < 0.007). Median time to next treatment (TTNT) was 6.7 months with chemo-immunotherapy and 2.1 with chemotherapy (p = 0.009). Out of 15 patients with a TTNT > 1 year, 40 % were rechallenged with immunotherapy.

CONCLUSION

Platinum-based chemotherapy was the predominant treatment after durvalumab consolidation. Immunotherapy rechallenge was associated with the best survival outcome in selected cases, warranting further investigation.

Mastering CT-based radiomic research in lung cancer: a practical guide from study design to critical appraisal

Radiomics is a health technology that has the potential to extract clinically meaningful biomarkers from standard of care imaging. Despite a wealth of exploratory analysis performed on scans acquired from patients with lung cancer and existing guidelines describing some of the key steps, no radiomic-based biomarker has been widely accepted. This is primarily due to limitations with methodology, data analysis, and interpretation of the available studies. There is currently a lack of guidance relating to the entire radiomic workflow from study design to critical appraisal. This guide, written with early career lung cancer researchers, describes a more complete radiomic workflow. Lung cancer image analysis is the focus due to some of the unique challenges encountered such as patient movement from breathing. The guide will focus on CT imaging as these are the most common scans performed on patients with lung cancer. The aim of this article is to support the production of high-quality research that has the potential to positively impact outcome of patients with lung cancer.

Percutaneous Cryoablation of Non-small Cell Lung Cancer in Patients with Recurrence After Stereotactic Body Radiation Therapy

PURPOSE

Evaluate safety and efficacy of lung cancer cryoablation in patients with stereotactic body radiation therapy (SBRT) recurrence.

MATERIALS AND METHODS

Between 9/2018 and 11/2023, all patients with non-small cell lung cancer (NSCLC) treated with lung cryoablation after SBRT recurrence were retrospectively identified. Histories of smoking, COPD, post-procedural pneumothorax, adverse events requiring immediate post-procedural hospitalization, and initiation/worsening of home oxygen requirements 3-6 months later were obtained. Technical success was defined as ability to envelope the targeted tumor with an ice-ball without premature cessation of the cryoablation protocol. Outcome measures included local control, local progression-free survival, and overall survival at 6 months, 1 year, 2 years, and 3 years.

RESULTS

29 patients with NSCLC recurrence after SBRT underwent percutaneous cryoablation with 35 treatment sessions. Mean lesion size and standard deviation was 2.8 ± 1.5 cm (Range, 1.0-7.4 cm). Pneumothorax and hospitalization rates were 44.4% (16/36) and 36.1% (14/36). The mean number of ablation probes was 2.5 ± 1.5 (Range, 1-6). Twenty-six patients had COPD (92.9%), of which 3.8% (1/26) had new or worsened home oxygen requirements. All (36/36) cryoablations achieved technical success. Local control, local progression-free survival, and overall survival were 100%/92.9%/92.9% at 6 months, 76.2%/70.8%/92.9% at 1 year, 64.9%/60.3%/62.3% at 2 years, and 31.5%/22.6%/35.4% at 3 years.

CONCLUSION

Percutaneous cryoablation of non-small cell lung cancer may be a safe and effective treatment alternative for recurrence after SBRT without worsening pulmonary function.

ctDNA can detect minimal residual disease in curative treated non-small cell lung cancer patients using a tumor agnostic approach

BACKGROUND

Circulating tumor DNA (ctDNA) has the potential to become a reliable biomarker for identifying minimal residual disease (MRD) and predicting recurrence in patients with non-small cell lung cancer (NSCLC) following curative treatment. However, there is a lack of studies that investigate the clinical validity of ctDNA using a tumor-agnostic approach, which can provide significant clinical benefits.

METHODS

We analyzed samples from 45 NSCLC patients recruited in a prospective national multicenter study, all of whom had undergone curative treatment. A total of 38 pre-treatment plasma samples and 76 post-treatment plasma samples were examined using a commercially available cancer personalized profiling by deep sequencing (CAPP-seq) strategy, and a tumor-agnostic approach. Post-treatment samples were collected at two distinct landmark time points: Follow-up 1 (0.5-4.5 months post-treatment) and Follow-up 2 (4.5-7.5 months post-treatment).

RESULTS

Detectable ctDNA post-treatment was significantly associated with increased risk of tumor recurrence and shorter recurrence-free survival (RFS). Using only a single blood sample taken from Follow-up 2, we correctly identified MRD in 50% of the patients who later experienced recurrence. However, subgroup analysis further revealed that in patients treated with radiotherapy or chemoradiotherapy (CRT), ctDNA detection was significantly linked to shorter RFS in the MRD analysis from Follow-up 2, but not in the MRD analysis from Follow-up 1.

CONCLUSION

These findings suggest that post-treatment ctDNA, detected using a tumor-agnostic approach, is a reliable biomarker for predicting recurrence in NSCLC patients following curative treatment. However, the optimal timing for blood sampling to detect MRD appears to depend on the type of curative treatment received.

Liquid biopsy in lung cancer

Precision medicine based on biomarkers, such as genetic abnormalities and PD-L1 expression, has been established for the treatment of nonsmall cell lung cancer. Recently, liquid biopsy has emerged as a valuable and minimally invasive alternative. This method analyzes blood and other bodily fluids to detect cancer-related genetic abnormalities and molecular residual disease (MRD). Liquid biopsy, which includes testing for circulating tumor cells, circulating tumor DNA (ctDNA), and microRNA (miRNA), offers several advantages over conventional methods. It is minimally invasive, can be performed repeatedly, and provides crucial information for early cancer diagnosis, genotyping, and treatment monitoring. Elevated ctDNA levels and miRNA markers show promise for early diagnosis. Liquid biopsy complements traditional tissue biopsy during genotyping, particularly when tumor samples are insufficient. Tests such as Cobas® EGFR Mutation Test v2 and Guardant360® CDx have been shown to be effective in detecting genetic mutations and guiding treatment decisions. Although the accuracy of liquid biopsy is still lower than that of tissue biopsy, its clinical utility continues to improve. For cancer prediction recurrence and treatment monitoring, ctDNA analysis can detect MRD earlier than conventional imaging, offering potential benefits for treatment adjustment and early relapse detection. The continuous development and validation of liquid biopsy methods are essential for improving personalized lung cancer treatment strategies.

Evaluation of a motion correction algorithm in lung cancer PET/CT: Phantom validation and patient studies

BACKGROUND

Data-driven gating (DDG) is an emerging technology that can reduce the respiratory motion artifacts in positron emission tomography (PET) images.

PURPOSE

The aim of this study is to use phantom and patient data to validate the performance of DDG with a motion correction algorithm based on the reconstruct, register, and average (RRA) method.

METHODS

A customized motion platform drove the phantom (five spheres with diameters of 10-28 mm) using a periodic motion that had a duration of 3-5 s and amplitudes of 2-4 cm. Normalized ratio of ungated and RRA PET relative to the ground-truth static PET was calculated for RSUVmax, RSUVmean, RSUVpeak, RVolume, and relative contrast-to-noise ratio (RCNR). Additionally, 30 lung cancer patients with 76 lung lesions less than 3 cm in diameter were prospectively studied. The overall image quality of patient examination was scored using a 5-point scale by two radiologists. SUVmax, SUVmean, SUVpeak, volume, and CNR of lesions measured in ungated and RRA PET were compared, and subgroup analysis was conducted.

RESULTS

In RRA PET images, motion artifacts of the spheres in the phantom were effectively mitigated, regardless of changes in movement amplitudes or duration. For all spheres with different ranges of motion and cycles, RSUVmax, RSUVmean, RSUVpeak, and RCNR increased significantly (p ≤ 0.001) and RVolume decreased significantly (p < 0.001) in RRA PET images. The average radiologist scores of image quality were 3.90 ± 0.86 with RRA PET, and 3.03 ± 1.19 with ungated PET. In RRA PET images, the SUVmax (p < 0.001), SUVmean (p < 0.001), SUVpeak (p < 0.001), and CNR (p < 0.001) of the lesions increased, while the volume (p < 0.001) of the lesions decreased. Δ%SUVmax, Δ%SUVmean, Δ%SUVpeak, and Δ%CNR of the lesions increased by 3.9%, 6.5%, 5.6%, and 4.3%, respectively, while Δ%Volume of the lesions decreased by 18.4%. Subgroup analysis showed that in lesions in the upper and middle lobes, only SUVpeak (p < 0.001) significantly increased by 5.6% in RRA PET, while their volume (p < 0.001) notably decreased by 12.4% (p < 0.001).

CONCLUSION

DDG integrated with RRA motion correction algorithm can effectively mitigate motion artifacts, thus enhancing the quantification accuracy and visual quality of images in lung cancer PET/CT.

Surveillance With Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography of Patients With Stage I-to-III Lung Cancer After Completion of Curative treatment (SUPE_R): A Randomized Controlled Trial

INTRODUCTION

Post-treatment surveillance is recommended for NSCLC owing to a high risk of recurrence, but evidence on the optimal surveillance method is lacking. This trial evaluates fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) versus contrast-enhanced CT (ceCT) for surveillance in patients with NSCLC.

METHODS

In this multicenter, randomized controlled trial (SUPE_R, ClinicalTrials.gov NCT03740126), patients with stage IA-to-IIIC NSCLC were randomized one-to-one to standard surveillance (ceCT) or surveillance with [18F]FDG PET/CT after completion of curative treatment. The primary outcome was the proportion of recurrences treated with curative intent. Secondary outcomes included time to recurrence (TTR) and overall survival (OS).

RESULTS

Between February 2019 and February 2022, 750 patients were randomized to PET/CT (n = 373) or CT (n = 377). Recurrences occurred in 164 patients (22%). The proportion of recurrences treated with curative intent was identical in the PET group (42/87) and CT group (37/77), both 48% (p = 0.98). More recurrences were detected through scheduled follow-up in the PET group (90%) than in the CT group (77%; p = 0.02). There were no significant differences in TTR (hazard ratio 1.12, 95% confidence interval 0.82-1.52, p = 0.48) or OS (hazard ratio 0.97, 95% confidence interval 0.66-1.43, p = 0.89) between groups.

CONCLUSIONS

Surveillance with [18F]FDG PET/CT did not improve rates of curatively treated recurrences, TTR, or OS compared with ceCT in patients with NSCLC after curative treatment. These findings do not support the routine use of [18F]FDG PET/CT for post-treatment surveillance in this patient population.

Is SBRT the optimal first-line treatment for operable early-stage NSCLC in elderly patients?

The introduction of screening programs and the increase in life expectancy in developed countries have significantly raised the incidence of early-stage non-small cell lung cancer (ES-NSCLC). Surgery remains the standard of care for ES-NSCLC; however, stereotactic body radiotherapy (SBRT) has become the treatment of choice for patients with inoperable ES-NSCLC. Despite its growing use, there is a lack of robust data from randomized phase III trials comparing SBRT to surgery, mostly due to challenges in recruitment. This gap is particularly pronounced in the elderly, who are often excluded from clinical studies. With the rising incidence of ES-NSCLC and an aging population, non-invasive therapies like SBRT may offer significant advantages by minimizing treatment-related morbidity while effectively controlling the disease. This review critically evaluates the current literature on managing ES-NSCLC in elderly patients and assesses the potential benefits and limitations of SBRT as a standard of care in this complex population.

Circulating tumor DNA- and cancer tissue-based next-generation sequencing reveals comparable consistency in targeted gene mutations for advanced or metastatic non-small cell lung cancer

BACKGROUND

Molecular subtyping is an essential complementarity after pathological analyses for targeted therapy. This study aimed to investigate the consistency of next-generation sequencing (NGS) results between circulating tumor DNA (ctDNA)-based and tissue-based in non-small cell lung cancer (NSCLC) and identify the patient characteristics that favor ctDNA testing.

METHODS

Patients who diagnosed with NSCLC and received both ctDNA- and cancer tissue-based NGS before surgery or systemic treatment in Lung Cancer Center, Sichuan University West China Hospital between December 2017 and August 2022 were enrolled. A 425-cancer panel with a HiSeq 4000 NGS platform was used for NGS. The unweighted Cohen's kappa coefficient was employed to discriminate the high-concordance group from the low-concordance group with a cutoff value of 0.6. Six machine learning models were used to identify patient characteristics that relate to high concordance between ctDNA-based and tissue-based NGS.

RESULTS

A total of 85 patients were enrolled, of which 22.4% (19/85) had stage III disease and 56.5% (48/85) had stage IV disease. Forty-four patients (51.8%) showed consistent gene mutation types between ctDNA-based and tissue-based NGS, while one patient (1.2%) tested negative in both approaches. Patients with advanced diseases and metastases to other organs would be suitable for the ctDNA-based NGS, and the generalized linear model showed that T stage, M stage, and tumor mutation burden were the critical discriminators to predict the consistency of results between ctDNA-based and tissue-based NGS.

CONCLUSION

ctDNA-based NGS showed comparable detection performance in the targeted gene mutations compared with tissue-based NGS, and it could be considered in advanced or metastatic NSCLC.

Microwave ablation of non-small cell lung cancer enhances local T-cell abundance and alters monocyte interactions

BACKGROUND

Minimally invasive thermal therapies show great prospect in non-small cell lung cancer (NSCLC) treatment. However, changes in immune cell populations following microwave ablation (MWA) in NSCLC microenvironment are not fully revealed.

OBJECTIVE

The present study was conducted to identify changes in immune cell populations and analyse dysregulated genes in immune cells after MWA in NSCLC microenvironment.

METHODS

The patients received fractionated MWA in two treatments separated by 3 weeks. Tumor biopsy samples were obtained through core-needle biopsy before each fractionated MWA procedure at the same site and used for single-cell RNA sequencing with the 10x Genomics pipeline.

RESULTS

A total of 9 major cell types were identified after MWA, which include neutrophils, T cells, B cells, monocytes, epithelial cells, chondrocytes, macrophages, tissue stem cells, and endothelial cells. After MWA, the tumor tissue exhibited an increased proportion of T cells. MWA altered gene expression in each cell cluster at the single-cell level. Cell trajectory analysis revealed that the cells at the starting point were most like T helper cells, naïve T cells, and regulatory T cells; they then developed into anergic T cells, T follicular cells, natural killer T cells, T memory cells, and exhausted T cells, and finally ended as γδ T cells and cytotoxic T cells. Moreover, after MWA, more interaction between monocytes and T cells (or B cells) were identified.

CONCLUSIONS

MWA increases local T-cell abundance and alters monocyte interactions, thereby reshaping the tumor microenvironment. This study lays a foundation for investigating dysregulated genes that may contribute to the MWA-induced immune response in NSCLC.

WHAT IS ALREADY KNOWN ON THIS TOPIC

Thermal ablation may change the immune profiles of patients by activating various steps in the cancer immunity cycle. However, changes in immune cell populations following MWA of NSCLC have not been fully reported.

WHAT THIS STUDY ADDS

After MWA, an increase in interactions between monocytes and T cells intratumorally was observed, which promoted antitumor immunity.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The current study illuminates the MWA-caused systemic immune response in NSCLC, which may help to identify the dysregulated genes involved in the MWA-caused immune response.

The evolving landscape of stage III unresectable non-small cell lung cancer "between lights and shadows"

Despite PACIFIC set a new milestone in the clinical management of unresectable stage III non-small cell lung cancer (NSCLC), it left some critical questions pending for clinical research: the efficacy of durvalumab in the real-world setting; the activity of less intensive regimens for frail populations; the role of targeted therapies in oncogene-addicted tumors; the selection of subsequent strategies at immunotherapy failure; the efficacy of novel and intensified treatments; the role of molecular biomarkers for patients' selection. This review aims to describe the evolving landscape of unresectable stage III NSCLC and provides an updated overview of the available evidence, analyzing lights and shadows emerging from recent clinical trials and discussing the most relevant challenges of post-PACIFIC era.

Recurrence prediction using circulating tumor DNA in patients with early-stage non-small cell lung cancer after treatment with curative intent: A retrospective validation study

BACKGROUND

Despite treatment with curative intent, many patients with localized non-small cell lung cancer (NSCLC) develop recurrence. The current challenge is to identify high-risk patients to guide adjuvant treatment. Identification of residual disease by detection of circulating tumor DNA (ctDNA) may allow more accurate clinical decision-making, but its reliability in NSCLC is not established. We aimed to build on previous data to validate a tissue-informed personalized ctDNA assay, to predict recurrence in patients with early-stage disease.

METHODS AND FINDINGS

Tumor tissue and plasma was collected from patients with stage 0-III NSCLC enrolled to LEMA (Lung cancer Early Molecular Assessment trial, NCT02894853). Serial plasma was collected before and after definitive treatment, with the latter including key timeframes of interest (1-3 days post-treatment, between 14 and 122 days after treatment end, and ≥14 days after treatment end). Somatic mutations identified by tumor exome sequencing were used to design patient-specific assays, to analyze ctDNA. Results were compared and combined with an independent dataset (LUCID; LUng Cancer CIrculating Tumour Dna study, NCT04153526). In LEMA, 130 patients (57% male; median age 66 years (range 44-82); 69% adenocarcinoma, 22% squamous cell carcinoma (SCC); 3%/49%/19%/29% with stage 0/I/II/III) were treated with curative intent. Tumor tissue originated from surgical resection or diagnostic biopsy in 118 and 12 patients respectively. LUCID included 88 patients (51% male; median age 72 years (range 44-88); 63% adenocarcinoma, 31% SCC; 49%/28%/23% with stage I/II/III). Before treatment, ctDNA was detected in 48% LEMA and 51% LUCID patients. Sensitivity, specificity, positive and negative predictive value of ctDNA detection post-treatment (≥1 positive sample ≥14 days after treatment end) to predict recurrence were 61%, 97%, 92% and 84% for LEMA and 64%, 96%, 90% and 83% for LUCID. In the combined cohort, ctDNA detection after treatment was associated with shorter recurrence-free survival (hazard ratio (HR) 11.4 (95% confidence interval (CI) [7.0,18.7]; p < 0.001)) and overall survival (HR 8.1 (95% CI [4.6,14.2]; p < 0.001)), accounting for guarantee-time bias. Of note, a key limitation of this work was the irregular sample collection schedules, during routine follow-up visits, of both studies.

CONCLUSIONS

ctDNA detection predicted recurrence in independent retrospective cohorts with notable reproducibility, including near-identical detection rates and predictive values, confirming its ability to differentiate patients at high- versus low risk of recurrence. Our results support the potential of tissue-informed ctDNA analysis as a decision-support tool for adjuvant therapy in NSCLC.

Clinical TNM Lung Cancer Staging: A Diagnostic Algorithm with a Pictorial Review

Lung cancer is a prevalent malignant disease with the highest mortality rate among oncological conditions. The assessment of its clinical TNM staging primarily relies on contrast-enhanced computed tomography (CT) of the thorax and proximal abdomen, sometimes with the addition of positron emission tomography/CT scans, mainly for better evaluation of mediastinal lymph node involvement and detection of distant metastases. The purpose of TNM staging is to establish a universal nomenclature for the anatomical extent of lung cancer, facilitating interdisciplinary communication for treatment decisions and research advancements. Recent studies utilizing a large international database and multidisciplinary insights indicate a need to update the TNM classification to enhance the anatomical categorization of lung cancer, ultimately optimizing treatment strategies. The eighth edition of the TNM classification, issued by the International Association for the Study of Lung Cancer (IASLC), transitioned to the ninth edition on 1 January 2025. Key changes include a more detailed classification of the N and M descriptor categories, whereas the T descriptor remains unchanged. Notably, the N2 category will be split into N2a and N2b based on the single-station or multi-station involvement of ipsilateral mediastinal and/or subcarinal lymph nodes, respectively. The M1c category will differentiate between single (M1c1) and multiple (M1c2) organ system involvement for extrathoracic metastases. This review article emphasizes the role of radiologists in implementing the updated TNM classification through CT imaging for correct clinical lung cancer staging and optimal patient management.

Current insights into the clinico-pathologic characteristics of lung cancer in women

INTRODUCTION

Lung cancer is responsible for premature cancer deaths in women and is the first cause of cancer deaths in women in many countries. The problem of lung cancer in women seems to be underestimated in many aspects, including low participation in clinical trials and screening tests.

AREAS COVERED

Current research progress has contributed to a better understanding of the issue and makes it possible to describe the problem in a new light. In our paper, the problem of lung cancer in women was discussed in a broad aspect, taking into account women's health, the harmful effects of smoking and the current diagnostic and treatment process. The results of treatment also differ in relation to sex. All these aspects of the diversity of women's lung cancer were presented on the basis of newest and most comprehensive literature.

EXPERT OPINION

Lung cancer in women is and will remain an important health problem worldwide, which is justified by epidemiological data, basic research and treatment results.

The efficacy and safety of neoadjuvant immunochemotherapy in resectable stage I-III non-small cell lung cancer: a systematic review and network meta-analysis

BACKGROUND

Neoadjuvant immunochemotherapy (NICT) is a new treatment method for resectable non-small-cell lung cancer (NSCLC). Network meta-analysis assessed efficacy, safety, and optimal treatment.

METHODS

We searched for randomized controlled trials (RCTs) comparing NICT with neoadjuvant chemotherapy (NCT) in PubMed, Embase, Web of Science, Cochrane Library, and international conferences. Outcomes were surgical resection rate, pathological complete response(pCR),event-free survival (EFS), and Grade 3-5 treatment-related adverse events (TRAEs).

RESULTS

RCTs of 3,387 patients, six treatment combinations, and two modalities were included. Meta-analysis showed that NICT yielded higher pCR and EFS rates than NCT. The toripalimab-chemotherapy combination had the highest surgical resection rate (OR = 1.68, 95% CI: 1.05-2.73), pCR (OR = 38.84, 95% CI: 11.05-268.19) and EFS (HR = 0.40, 95% CI: 0.28-0.58).This regimen worked well for patients with low programmed death-ligand 1 (PD-L1) expression or squamous cell pathology. For high PD-L1 expression and patients with NSCLC, neoadjuvant nivolumab with chemotherapy had the most efficacy. The incidence of treatment-related adverse events increased with longer treatment cycles, with perioperative nivolumab combined with chemotherapy showing the worst safety profile (RR = 1.32, 95% CI: 1.00-1.76), while neoadjuvant nivolumab combined with chemotherapy alone had the best safety profile (RR = 0.91, 95% CI: 0.68-1.21). Indirect comparison showed no survival benefit for neoadjuvant-adjuvant immunotherapy (HR = 0.93, 95% CI: 0.65-1.35). In the indirect comparison between the two immune checkpoint inhibitors(ICIs), although there was no significant difference in EFS (HR = 0.81, 95% CI: 0.61-1.08), PD-1 inhibitors may still be the most effective treatment option.

CONCLUSIONS

NICT effectively and safely treats resectable NSCLC. The optimal treatment combination is typically toripalimab and chemotherapy. Treatment based on PD-L1 expression and pathological type is recommended.

Real-World Treatment Patterns and Associated Outcomes in Patients With Resectable Early-Stage Non-Small Cell Lung Cancer: The THASSOS International Study

BACKGROUND

THASSOS-INTL (NCT04808050), a multinational, retrospective study, evaluated treatment patterns and associated outcomes in patients with early-stage non-small cell lung cancer (NSCLC) from seven countries in the Asia-Pacific and the Middle-East and Africa.

METHODS

Eligible adult patients (≥ 18 years) with resectable clinical stage (CS) IA-IIIB NSCLC (7th AJCC) diagnosed from 01/01/2013 to 31/12/2017 were followed until death, last recorded clinical visit, or 31/12/2020 (data cut-off).

RESULTS

Of 755 patients (CS I: 30.6%, CS II: 35.0%, CS III: 34.2%) with a median age of 62 [range: 56-69] years enrolled, 69.3% were male, and 75.0% were current/ex-smokers. Of 24.2% of patients tested for EGFR, 28.4% (52/183) were positive, while 23/44 patients tested (52.3%) had PD-L1 expression (≥ 1%: 16; unknown: 7). Overall, 82.9% had surgery, of whom 39.1% (245/626) had surgery alone; 21.1% received neoadjuvant therapy, 51.1% received adjuvant therapy, and 5.8% received both; 11.2% (58/519) patients received targeted therapy (adjuvant: 47 patients; neoadjuvant: 11 patients), and 4.6% (24/519) received immunotherapy (adjuvant: 22 patients; neoadjuvant: 2 patients). The 3-year survival was 77.4% with a median overall survival (mOS) of 7.5 (95% confidence interval [CI]: 6.7-NE) years, with the highest mOS recorded with adjuvant therapy (7.5 [95% CI: 7.0-NE] years).

CONCLUSIONS

This real-world study showed > 50% use of adjuvant therapy per guideline recommendations but poor use of neoadjuvant therapy. Biomarker testing at diagnosis was low, reflecting the study period being before targeted and immunotherapies. With recent approvals of newer (neo)adjuvant agents, a multidisciplinary approach is needed for better treatment decisions to improve the prognosis of early-stage NSCLC.

Up-Regulation of MELK Promotes Cell Growth and Invasion by Accelerating G1/S Transition and Indicates Poor Prognosis in Lung Adenocarcinoma

Maternal embryonic leucine zipper kinase (MELK) is an oncogene in many tumors, although its contribution to lung adenocarcinoma (LUAD) is unclear. We examined MELK expression in patient LUAD tissue and matched healthy lung tissues. We investigated the connection between MELK expression and tumor differentiation, lymph node metastasis, and patient survival. We downregulated MELK expression using small-hairpin RNA to assess its impact on LUAD cell proliferation, clonogenicity, and invasion. We also investigated the molecular mechanism underlying these effects. MELK expression was significantly heightened in LUAD tissue as opposed to the matching healthy lung tissues. LUAD patients who had MELK overexpression had a worse prognosis. Suppression of MELK hinders proliferation, clonogenicity, and invasion of LUAD cells. The MELK suppression led to the arrest of the cell cycle's G1/S phase by reducing the cyclin E1 and cyclin D expression. Our outcomes manifest that MELK can function as a beneficial prognostic indication and a new therapy target for LUAD. MELK has an essential function in progressing LUAD, manifesting potential as a viable target for therapeutic intervention in this disease management.

A machine learning-based 18F-FDG PET/CT multi-modality fusion radiomics model to predict Mediastinal-Hilar lymph node metastasis in NSCLC: a multi-centre study

AIM

To develop and validate a machine learning (ML) model based on positron emission tomography/computed tomography (PET/CT) multi-modality fusion radiomics to improve the prediction efficiency of mediastinal-hilar lymph node metastasis (LNM).

MATERIALS AND METHODS

Eighty-eight non-small cell lung cancer (NSCLC) patients with 559 LNs from centre 1 were divided into training and internal validation cohorts (7:3 ratio), and 75 patients with 543 LNs from centre 2 were assigned as external validation cohorts. PET and CT images were fused by wavelet transform. Multi-modality fusion radiomics features from six images of lymph nodes were extracted. The multi-modality fusion radiomics (MFR), multi-modality fusion radiomics + metabolic parameters (MFRM), CT, PET and PET + CT models were developed based on the best one among the 11 ML algorithms. The receiver operating characteristic (ROC) curve and the Delong test were used to assess and compare the performance of the models.

RESULTS

The CatBoost algorithm was chosen, and the MFR, MFRM, CT, PET and PET + CT models were constructed. The MFR and MFRM models showed a high AUC for predicting LNM in centre 1 (AUC = 0.950 and 0.952) and centre 2 (AUC = 0.923 and 0.927), and there were significant differences in centre 2 (P=0.036). The diagnostic efficacy of MFR and MFRM models was significantly higher than CT, PET, PET + CT models and SUVmax≥3.5 (P<0.001). The MFRM prediction was statistically different from the MFR prediction in the hilar/interlobar zone.

CONCLUSION

Both the MFR and MFRM models based on multi-modality fusion radiomics showed great potential for non-invasively predicting mediastinal-hilar LNM in NSCLC.

Real-World Evaluation of Immune-Related Endocrinopathies in Metastatic NSCLC Patients Treated with ICIs in Romania

(1) Background: Exploring real-world data (RWD) regarding immune-related adverse events (irAEs) is crucial to better understand the efficacy and safety of immunotherapy in cancer patient populations excluded from clinical trials. An analysis was conducted to evaluate the presumptive predictive causality between endocrine irAEs and the efficacy of immune check-point inhibitors (ICIs) in metastatic non-small-cell lung cancer (mNSCLC) patients treated in daily practice in Romania. (2) Methods: This was a retrospective cohort study of mNSCLC patients treated with ICIs in a tertiary level hospital in Romania for a period of almost seven years, from November 2017 till July 2024. Endocrine irAEs were well defined as any occurring autoimmune endocrinopathy during ICIs and related to immunotherapy. The hospital endocrinologist (M.C.C.O) diagnosed, treated, and followed these endocrine irAEs in a multidisciplinary approach. We investigated multiple medical variables to assess their impact on ICI effectiveness. Descriptive and statistical analyses were performed. (3) Results: Of 487 cancer patients treated with ICIs, we identified 215 mNSCLC patients who were evaluated for endocrine irAEs and co-medications during ICI therapy. Forty-seven (21.8%) patients experienced endocrine irAEs, thyroiditis being the most frequent and prevalent autoimmune endocrinopathy in 60% of cases. Endocrine irAEs were statistically significant, correlated with ICI efficacy (p = 0.002) for survival analysis. Steroids and proton-pump inhibitors used as co-medication during ICIs had a negative impact on response to therapy. (4) Conclusions: Endocrine irAEs might be considered predictive biomarkers for successful immunotherapy in mNSCLC patients. Co-medication during ICIs had a major influence on the effectiveness of these cutting-edge therapies. RWD plays an important role for oncology daily practice whenever clinical trial evidence is not available to guide decision.

Mediastinal staging lymph node probability map in non-small cell lung cancer

BACKGROUND

Mediastinal lymph node (LN) staging is routinely performed using PET/CT and EBUS-TBNA. Promising predictive algorithms for lymph nodes have been reported for each technique, both individually and in combination. This study aims to develop a predictive algorithm that combines EBUS, PET/CT and clinical data to provide a probability of malignancy.

METHODS

A retrospective study was conducted on consecutive patients with non-small cell lung carcinoma staged using PET/CT and EBUS-TBNA. Lymph nodes were identified by level (N1, N2, and N3) and anatomical region (AR) (subcarinal, paratracheal, and hilar). A Standardized Uptake Value (SUV) was determined for each sampled LN. The ultrasound features collected included diameter in the short axis (DSA), morphology, border, echogenicity and the presence of the vascular hilum. A robust logistic regression model was used to construct an algorithm to estimate the probability of malignancy of the lymph node.

RESULTS

A total of 116 patients with a mean age of 66, 93% of whom were men, were included. 358 lymph nodes were evaluated, 51% of which exhibited adenocarcinoma and 35% were squamous, while 14% were classified as non-small-cell lung carcinoma. The model estimated the probability of malignancy for each lymph node using age, DSA, SUVmax, and AR. The Area Under the ROC curve, was 0.89. A user-friendly application was also developed ( https://ubidi.shinyapps.io/lymma/ .) CONCLUSIONS: The integration of patient clinical characteristics, EBUS features, and PET/CT findings may generate a pre-sampling malignancy probability map for each lymph node. The model requires prospective and external validation.

Revolutionizing lung cancer treatment: harnessing exosomes as early diagnostic biomarkers, therapeutics and nano-delivery platforms

Lung cancer, known for its high morbidity and mortality rates, remains one of the most critical health challenges globally. Conventional treatment options, such as chemotherapy and surgery, are often limited by high costs, significant side effects, and often yield a poor prognosis. Notably, recent research has shed light on the potential therapeutic roles of exosomes, which essentially influence lung cancer's development, diagnosis, treatment, and prognosis. Exosomes have been revealed for their exceptional properties, including natural intercellular communication, excellent biocompatibility, minimal toxicity, prolonged blood circulation ability, and biodegradability. These unique characteristics position exosomes as highly effective drug delivery systems, nanotherapeutics, and potential diagnostic and prognostic biomarkers in lung cancer. This review provides a comprehensive review of the physiological and pathological roles of exosomes in lung cancer, emphasizing their potential as innovative diagnostic biomarkers, therapeutics, and delivery platforms. By harnessing their unique properties, exosomes are poised to revolutionize the diagnosis and treatment of lung cancer, offering a promising avenue for more personalized and effective therapies.

Timing of Adjuvant Chemotherapy After Surgical Resection for Non-small Cell Lung Cancer: A Target Trial Emulation Using Nationwide Swedish Registry Data

BACKGROUND

We investigated the impact of time to adjuvant chemotherapy (AC) on survival after surgical resection (<8 weeks or 8-16 weeks) for patients with non-small cell lung cancer (NSCLC) by applying a target-trial emulation.

MATERIAL AND METHODS

We used Swedish population-based healthcare registries to emulate a hypothetical target trial, with treatment arms of 'initiate AC <8 weeks postoperatively' and 'initiate AC 8-16 weeks postoperatively'. The clone-censor-weight approach was used in which all patients were cloned and all clones were assigned to each treatment arm. Clones were then censored when the assigned treatment was no longer compatible with the actual treatment.

RESULTS

We included 510 patients in the hypothetical target trial, of whom 51% received AC and 150 (57%) started AC within 8 weeks. More than half of the patients were female (52.5%) and the mean age was 69 years. The 5-year disease-free survival (DFS) in the emulated trial for the group who initiated AC <8 weeks postoperatively was 50.3% and the 5-year overall survival (OS) was 58.1%. For the group who initiated AC 8-16 weeks postoperatively, the emulated trial showed a 5-year DFS and OS of 49.1% and 57.1%, respectively.

CONCLUSION

By using target trial emulation, our study supports earlier data on timing for AC after surgical resection for NSCLC. However, further research is needed and our data indicate that a randomized controlled trial could be conducted without major harm to the experimental group (>8 weeks).

Molecular residual disease analysis of adjuvant osimertinib in resected EGFR-mutated stage IB-IIIA non-small-cell lung cancer

Osimertinib-a third-generation epidermal growth factor receptor-tyrosine kinase inhibitor-is recommended as adjuvant therapy for resected stage IB-IIIA epidermal growth factor receptor-mutated non-small-cell lung cancer, based on significant disease-free survival (DFS) and overall survival improvement shown in the previously reported phase 3 ADAURA trial. A trend toward an increased DFS event rate after completion of 3 years adjuvant treatment in ADAURA suggests that some patients may benefit from longer adjuvant osimertinib treatment. We therefore explored whether tumor-informed, circulating tumor DNA-based, molecular residual disease (MRD) could predict recurrence in an exploratory post hoc analysis of 220 patients (n = 112 osimertinib; n = 108 placebo) from ADAURA. MRD preceded imaging DFS events in this study by a median of 4.7 (95% confidence interval, 2.2-5.6) months. DFS and MRD event-free rate at 36 months was 86% versus 36% for patients in the osimertinib versus placebo groups (hazard ratio, 0.23 (95% confidence interval, 0.15-0.36)). In the osimertinib group, DFS or MRD events were detected in 28 (25%) patients; most events occurred following osimertinib cessation (19 of 28, 68%) and within 12 months of stopping osimertinib (11 of 19, 58%). At 24 months after osimertinib, the DFS and MRD event-free rate was 66%. In this study, MRD preceded DFS events in most patients across both arms. DFS and MRD event-free status was maintained for most patients during adjuvant osimertinib treatment and posttreatment follow-up, with most MRD or DFS events occurring after osimertinib treatment discontinuation or completion. MRD detection could potentially identify patients who may benefit from longer adjuvant osimertinib, although this requires clinical confirmation. ClinicalTrials.gov identifier: NCT02511106 .

Non-Small Cell Lung Cancer Patients with Skip-N2 Metastases Have Similar Survival to N1 Patients-A Multicenter Analysis

Introduction: Nodal involvement is one of the most important prognostic factors in NSCLC. Skip-N2 metastasis (N0N2), which is N2 metastasis in the absence of N1 metastasis, occurs in approximately 20-30% of patients. According to the International Association for the Study of Lung Cancer, N1 and N0N2 patients may have comparable long-term survival, considering their similar tumor stages. However, this conclusion remains controversial. Therefore, we carried out this multicenter study to examine the long-term survival and disease-free interval (DFI) of N0N2- and N1 patients. Methods: One-, three-, and five-year survival rates were measured. Kaplan-Meier curves and a Cox proportional hazards model assessed survival and were used to identify prognostic factors for overall survival. Results: Between January 2010 and December 2020, 273 N0N2 and N1 patients were included in our analysis. Of those patients, 77 showed N0N2 and 196 N1. Baseline characteristics did not differ significantly between groups. Between N0N2 and N1 patients, there were no significant differences in one- (p = 0.67), three- (p = 0.20), and five-year (p = 0.27) survival. Furthermore, DFI did not differ between groups (p = 0.45). Conclusions: Our findings indicate that N0N2 patients have a prognosis comparable to that of patients with N1 disease. These results indicate that patients with N0N2 have a similar prognosis to N1 patients. N2-NSCLC is heterogeneous and would benefit from a more precise subdivision and differential treatment in the upcoming UICC 9 classification. The following question remains: are we overtreating N0N2 patients or undertreating N1 patients?

Longitudinal Analysis of Recurrence and Risk Factors of Early-Stage Resected Adenocarcinoma With Common EGFR Mutations: A Multicenter Retrospective Cohort Study in South Korea

INTRODUCTION

Despite curative surgery for lung cancer, 30% to 55% of patients experience recurrence or death, which highlights the importance of adjuvant treatment. Adjuvant osimertinib therapy effectively prolongs disease-free and overall survival in patients with lung cancer harboring common epidermal growth factor receptor (EGFR) mutations. To identify potential candidates for adjuvant osimertinib, it is crucial to understand the rates and identify risk factors of recurrence.

METHODS

This multicenter, retrospective cohort study was conducted in the Republic of Korea and enrolled patients who, between 2010 and 2017, underwent resection of stages I-III adenocarcinomas, with common EGFR mutations. The primary outcomes comprised the rate and risk factors of postoperative recurrence.

RESULTS

Among the 759 participants, the overall recurrence rate and median recurrence-free survival were 39.1% and 59.8 (interquartile range [IQR], 26.3-84.2) months, respectively, during a median follow-up of 73.0 (IQR, 55.4-95.0) months. The recurrence rates for stages IA, IB, IIA, IIB, IIIA, and IIIB were 14.7%, 45.5%, 53.8%, 72.5%, 80.3%, and 93.3%, respectively. Multivariate analysis revealed that age ≥ 65 years, body mass index < 18.5 kg/m², the Del19 subtype of EGFR mutation, tumor size ≥ 2.3 cm, N1 involvement, N2 involvement, predominantly micropapillary or solid pattern, and the presence of visceral pleural invasion were independently associated with recurrence.

CONCLUSION

This multicenter cohort study demonstrated that stages I-III EGFR-mutated adenocarcinoma has a postoperative recurrence rate of 39.1%, and identified 7 independent risk factors for recurrence.

Predictors of nodal upstaging in clinical N1 nonsmall cell lung cancer

BACKGROUND

Surgical resection followed by adjuvant chemotherapy is currently the first choice for the treatment of clinical N1 (cN1) non-small cell lung cancer (NSCLC). However, diagnosing cN1 correctly can be difficult, even with current imaging diagnostic technologies. We aimed to analyze the diagnostic accuracy of preoperative nodal status and the predictive factors for nodal upstaging of cN1-NSCLC.

METHODS

Patients receiving surgery for cN1-NSCLC in 2010 (n = 1040) were enrolled in the Japanese Joint Committee of Lung Cancer Registry Database. We investigated the diagnostic accuracy of cN1, predictive factors for nodal upstaging, and prognostic factors for overall survival (OS) and recurrence-free survival (RFS).

RESULTS

The 5-year OS and RFS for all patients were 58.2% and 42.7%, respectively. The postoperative pathological nodal status included N0 (36.6%), N1 (39.7%), N2 (23.6%), and N3 (0.1%). In multivariate analysis, younger age (P = .005), no history of smoking (P = .006), and adenocarcinoma (P < .001) were significant predictive factors for nodal upstaging. Older age (P < .001) and higher clinical T (cT) factor (P < .001) were significant indicators for worse OS, while older age (P = .02), higher cT factor (P = .019), high carcinoembryonic antigen value (P = .002), and adenocarcinoma (P = .008) were significant indicators for worse RFS.

CONCLUSIONS

The diagnostic accuracy of cN1 in this study was ~40%. No history of smoking and adenocarcinoma were significant predictors for nodal upstaging. Although younger age was a significant predictor for nodal upstaging, it was a significant factor for better prognosis.

Impact of Different Mediastinal Staging Modalities on Target Volume Delineation in Locally Advanced Non-Small Cell Lung Cancer: A Secondary Analysis of the Multicenter Randomized PET-Plan Trial

PURPOSE

To evaluate the role of different invasive and noninvasive mediastinal staging methods in patients with locally advanced non-small cell lung cancer treated with definitive chemoradiation therapy in the prospective PET-Plan trial (ARO-2009-09; NCT00697333) and to evaluate the impact of endobronchial ultrasound-guided transbronchial needle aspiration and mediastinoscopy on target volume definition.

METHODS AND MATERIALS

Patients treated per protocol (n = 172), all receiving isotoxically dose-escalated chemoradiation therapy, were included in this unplanned secondary analysis. Radiation treatment planning was based on an 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) targeting all CT-positive lymph nodes (ie, short-axis diameter > 10 mm), even if PET-negative, plus elective nodal irradiation (arm A) or targeting only PET-positive nodes (arm B). The concordance rate between different staging modalities and their impact on target volume delineation was calculated.

RESULTS

The median follow-up time (95% confidence interval) was 41.1 (33.8-50.4) months. A total of 2752 lymph node stations were evaluated noninvasively, whereas 330 were examined invasively. Of 172 patients, 87 (50.6%) underwent ≥1 invasive staging modality. The number of different staging procedures per patient did not correlate with any of the primary endpoints (overall survival, progression-free survival, or freedom from local progression). The sensitivity of 18F-FDG PET/CT was 89.7% (78/87) and the specificity was 67.5% (112/166) based on histology as assessed by endobronchial ultrasound. When using the results from mediastinoscopy, the sensitivity of PET was 82.6% (19/23) and the specificity was 66.7% (36/54). On the basis of invasive staging methods, 13 lymph node stations in 9 patients (10.3%) were PET-negative while positive on invasive staging, thus leading to a significant adjustment in the target volume.

CONCLUSIONS

In this unplanned secondary analysis of the PET-Plan trial, the additional use of invasive staging resulted in relevant changes to the target volume in a tenth of patients. Invasive staging did not, however, have an effect on outcome in this trial, with a low rate of isolated out-of-field recurrences (6 in arm A vs 3 in arm B). Radiation treatment planning can thus be based on invasive staging in addition to noninvasive PET in patients undergoing definitive chemoradiation therapy for locally advanced non-small cell lung cancer. Prospective randomized data are required to confirm these findings.

Diagnostic Accuracy of Ultrasound Guidance in Transthoracic Needle Biopsy: A Systematic Review and Meta-Analysis

PURPOSE

To perform a systematic review and meta-analysis of relevant studies to assess the diagnostic accuracy and safety outcomes of ultrasound (US)-guided transthoracic needle biopsy (TTNB) for peripheral lung and pleural lesions.

MATERIALS AND METHODS

A search was performed through Medline, Embase, Web of Science, and Cochrane Central from inception up to September 23, 2022 for diagnostic accuracy studies reporting US-guided TTNB (Prospero registration: CRD42021225168). The primary outcome was diagnostic accuracy, which was assessed by sensitivity, specificity, likelihood ratios (LR), and diagnostic odds ratio. Sensitivity and subgroup analyses were performed to evaluate inter-study heterogeneity. The secondary outcome was the frequency of complications. Random-effects models were used for the analyses. The risk of bias and the applicability of the included studies were assessed using the QUADAS-2 tool. Publication bias was assessed by testing the association between the natural logarithm of the diagnostic odds ratio and the effective sample size.

RESULTS

Of the 7841 citations identified, 83 independent cohorts (11,767 patients) were included in the analysis. The pooled sensitivity of US-TTNB was 88% (95% CI: 86%-91%, 80 studies). Pooled specificity was 100% (95% CI: 99%-100%, 72 studies), resulting in positive LR, negative LR, and diagnostic odds ratio of 946 (-743 to 2635), 0.12 (0.09 to 0.14), and 8141 (1344 to 49,321), respectively. Complications occurred in 4% (95% CI: 3%-5%) of the procedures, with pneumothorax being the most frequent (3%; 95% CI: 2%-3%, 72 studies) and resulting in chest tube placement in 0.4% (95% CI: 0.2%-0.7%, 64 studies) of the procedures.

CONCLUSIONS

US-TTNB is an effective and safe procedure for pleural lesions and peripheral lung lesions.

Advancing real-world research in thoracic malignancies: learnings from the international I-O Optimise initiative

In recent years, the thoracic malignancies treatment landscape has become more complex with the emergence of novel targeted and immunotherapy-based treatments. Although beneficial to patients and physicians, this fast-paced therapeutic evolution has increased the complexity of clinical decision-making and amplified the importance of real-world evidence to support data from randomized controlled trials. The international I-O Optimise initiative was established in 2016 to provide real-world insights into the thoracic malignancies treatment landscape, and has since collaborated with 14 data sources across Europe and Canada, allowing access to data from ~ 500,000 patients with non-small-cell lung cancer, small-cell lung cancer, and malignant pleural mesothelioma. This article reviews pertinent I-O Optimise research, with discussion of the methodological/data-related learnings and expectations for future insights.

Evaluation of nutritional parameters that may be associated with survival in patients with locally advanced non-small cell lung carcinoma receiving definitive concurrent chemoradiotherapy: retrospective study conducted in a tertiary pulmonary hospital

Sarcopenia, defined as skeletal muscle loss, is thought to be a hallmark of cancer cachexia. It has an impact on mortality, especially in cancer patients. There are also opposing views regarding the relationship between definitive concurrent chemoradiotherapy (CRT) and sarcopenia in locally advanced lung cancer. Our aim was to investigate the prognostic effect of sarcopenia in our patients with locally advanced stage III non-small cell lung cancer (NSCLC) who received definitive concurrent CRT by using many markers, and to determine the overall survival (OS). The study was designed as a retrospective cohort. 54 patients with stage III NSCLC who received definitive concurrent CRT at the Radiation Oncology Unit of Health Sciences University Izmir Dr Suat Seren Chest Diseases and Surgery Training Hospital, between January 1, 2018 and December 31, 2019, were included in the study.92% of our patients were sarcopenic with international L3-skeletal muscle index (SMI) and Psoas muscle index (PMI) threshold values. The mean OS time was 32.4 months, and the 4-year survival rate was 38.9%. While the new threshold values specific to our patient group were 26.21 for SMI and 2.94 for PMI, SMI and PMI did not indicate OS with these values. Even with the new values, most proposed criteria for sarcopenia did not indicate OS. However, low BMI (≤21.30), low serum albumin (≤4.24 mg/dl) and low visceral fat tissue area (≤37) in univariate analysis, and low visceral fat tissue area (≤37) in multivariate analysis indicated OS. OS was poor in patients with low fat tissue area. In patients with stage III NSCLC who received definitive concurrent CRT, low visceral fat tissue area (≤37) indicated OS, rather than SMI, PMI and other sarcopenia indices.

Advances of PET/CT in Target Delineation of Lung Cancer Before Radiation Therapy

In the clinical management of lung cancer, radiotherapy remains a cornerstone of multimodal treatment strategies, often used alongside surgery or in combination with systemic therapies such as chemotherapy, tyrosine kinase inhibitors, and immune checkpoint inhibitors. While conventional imaging modalities like computed tomography (CT) and magnetic resonance imaging (MRI) continue to play a central role in staging, response assessment, and radiotherapy planning, advanced imaging techniques, particularly [18F]FDG PET/CT, are being increasingly integrated into routine clinical practice. These advanced techniques address the limitations of standard imaging by providing insight into molecular and metabolic tumor characteristics, enabling precise tumor visualization, accurate target volume delineation, and early treatment response assessment. This review examines the role of radiotherapy in the multidisciplinary management of lung cancer, detailing current concepts of morphological and functional imaging for staging and treatment planning. It also highlights the growing importance of PET-based radiotherapy planning, emphasizing its contributions to target volume definition and predictive value for treatment outcomes. Recent methodological advances, including the integration of artificial intelligence (AI), radiomics, technical innovations, and novel PET ligands, are discussed, highlighting their potential to improve the precision, efficacy, and personalization of lung cancer radiotherapy planning.

FAPI PET in the Management of Lung Tumors

Fibroblast activation protein (FAP), selectively expressed on activated fibroblasts in proliferating tissues, is emerging as a promising target in oncology. In lung cancer, the leading cause of cancer-related deaths worldwide, [18F]FDG PET/CT has set the bar high and earned widespread recognition in clinical guidelines for its essential role in staging and follow-up. Yet, FAP-targeted imaging agents like FAPI PET/CT have demonstrated significant potential due to their high tumor specificity, rapid tracer uptake, and low background activity. This review focuses on the role of FAPI PET/CT in lung cancer, highlighting its applications in staging, biomarker evaluation, and clinical management. FAP expression correlates with cancer associated fibroblast-driven tumorigenesis in lung cancer, showing higher expression in nonsmall cell lung cancer (NSCLC) than in small cell lung cancer (SCLC) subtypes. Studies reveal that FAPI PET/CT provides comparable or superior detection rates for primary tumors and metastases compared to [18F]FDG PET/CT, particularly in brain, pleural, and bone lesions. It also enhances accuracy in lymph node staging, influencing disease management by enabling surgical resection in cases misclassified by [18F]FDG PET/CT. Despite these advantages, several challenges remain, such as differentiating benign from malignant lesions, assessing FAPI's prognostic implications or its role in treatment response monitoring. Future directions include exploring FAPI-based theranostics, standardizing radiopharmaceuticals, and conducting well-designed, adequately powered prospective trials. FAPI PET/CT represents a transformative diagnostic tool, complementing or potentially surpassing [18F]FDG PET/CT in precision lung cancer care.

Comparison of neoadjuvant chemoimmunotherapy with planned surgery and concurrent chemoradiation followed by immunotherapy for potentially resectable stage III non-small-cell lung cancer: a retrospective study

OBJECTIVE

Despite the promising potential of neoadjuvant chemoimmunotherapy for non-small cell lung cancer (NSCLC), there is limited consensus on the optimal treatment strategy for potentially resectable NSCLC. This study aimed to evaluate the efficacy and safety of neoadjuvant chemoimmunotherapy (neoCT/IO) with planned surgery versus definitive concurrent chemoradiation followed by immunotherapy (cCRT + IO) in potentially resectable stage III NSCLC.

METHODS

This retrospective study analyzed data from patients with potentially resectable stage III NSCLC who underwent neoCT/IO with planned surgery or cCRT + IO between March 2020 and June 2023. Propensity score matching (PSM) was used to balance heterogeneity between groups. Efficacy outcomes, safety profiles and patterns of disease recurrence were assessed.

RESULTS

A total of 308 eligible patients were included in this study, of whom 195 (63.3%) underwent neoCT/IO and 113 (36.7%) received cCRT + IO. The neoCT/IO group consisted of patients who underwent neoCT/IO + Surgery and neoCT/IO + Radiotherapy. After 1:1 PSM, each group consisted of 105 patients. The median progression-free survival (PFS) was 25.9 months in the cCRT + IO group and not reached (NR) in the neoCT/IO group (hazard ratio: 2.91, 95% confidence interval: 1.77-4.78; p < 0.001). Median overall survival (OS) was NR in either group, with 3-year OS rates of 87.5% in the neoCT/IO group and 75.0% in the cCRT + IO group (p = 0.22). The incidence of grade 3/4 treatment-related adverse events was similar in both groups, except for a higher incidence of grade 3/4 hematological toxicity in the cCRT + IO group.

CONCLUSIONS

For patients with potentially resectable stage III NSCLC, neoCT/IO appears to be a safe approach and may offer better survival outcomes compared with cCRT + IO. Prospective randomized trials are needed to further validate these findings.

Clinical significance of 4 L lymphadenectomy in solid dominant clinical stage I non-small cell lung cancer in the left upper lobe

OBJECTIVES

The significance of station 4 L lymph node dissection (LND) for early-stage non-small cell lung cancer (NSCLC) is unknown.

METHODS

We evaluated 342 patients who underwent complete anatomical resection and mediastinal LND for radiologically solid dominant clinical (c)-Stage I left upper lobe NSCLC between 2008 and 2022. Solid dominant was defined as a consolidation tumor ratio >0.5, on thin-section computed tomography. After matching, postoperative complications and outcomes between the 4 L LND and non-4 L LND groups were compared. Predictors of 4 L metastasis was also identified using logistic regression analysis.

RESULTS

4LND was performed in 215 patients (63%), and 4 L metastasis was detected in 11 patients. Matching yielded 108 pairs. Recurrent nerve paralysis was more frequent in the 4LND group (P = 0.02) with no significant differences in the overall survival (OS) (5y OS: 85.2% vs. 86.3%, P = 0.66) and recurrence-free survival (RFS) (5y RFS: 78.4% vs. 78.5%, P = 0.51) between the 4 L LND and non-4 L LND groups. Logistic regression analysis determined solid component size >20 mm (P = 0.02) and pleural indentation (P = 0.02) on computed tomography findings as clinical risk factors for 4 L metastasis. The predictive criteria for 4 L metastasis were defined as solid component size ≤20 mm without pleural indentation (specificity: 100%, positive predictive value: 100%).

CONCLUSIONS

4 L LND had a higher frequency of recurrent nerve palsy, although no survival improvement was observed in solid dominant c-Stage I left upper NSCLC. 4 L LND may be omitted for solid component size ≤20 mm without pleural indentation.

18F-FDG PET/CT in the Preoperative Diagnostic and Staging of Lung Cancer and as a Predictor of Lymph Node Involvement

Background/Objectives: The aim of this study was to evaluate the efficacy and accuracy of PET imaging and performance in defining the preoperative TNM classification, especially the intrathoracic lymph node staging, of patients with lung cancer. Methods: A retrospective, single-institution study of consecutive patients with surgical therapy of lung cancer that were undergoing preoperative PET/CT scanning at the same center was conducted. A total of 104 patients were included. All patients underwent surgical evaluation with mediastinal and hilar lymph node sampling. Five patients with preoperative suspicion of N3 nodal status who were only tested for N2 were excluded from the observations and analyses of nodal status. Results: PET/CT staged the nodal status correctly in 85 out of 99 patients (85.9%); overstaging occurred in 7 patients (7.1%) and understaging in 7 patients (7.1%). The overall prevalence of lymph node metastases was 42.3%. When preoperative T classification was compared with postoperative histopathological T classification, 75% patients were correctly staged, 13.5% were overstaged, and 11.5% were understaged by PET/CT. In univariate analysis, lymph node involvement was significantly associated (p < 0.05) with the following primary tumor characteristics: increasing diameter (>35 mm), a maximum standardized uptake value > 9.5, and higher grading. The tumor diameter and the degree of differentiation were found to be factors influencing the SUVmax of the primary tumor as well. Conclusions: Our data show that integrated PET/CT provides high accuracy in the intrathoracic nodal staging and tumor expansion of lung cancer patients and emphasizes the continued need for surgical staging.

NON-SMALL-CELL LUNG CANCER: Real-World Population-Based Cohorts' Study

INTRODUCTION

This retrospective follow-up study evaluates patient outcomes and treatment costs in two cohorts of incident NSCLC patients recorded in the population-based cancer registry of the Veneto Region in 2017 and 2019.

METHODS

This study examines two cohorts of incident NSCLC patients recorded by the Regional Veneto cancer registry in 2017 (493 patients) and 2019 (557 patients). Cancer patients were followed for three years after diagnosis to assess the disease's outcomes and analyze the overall treatment-related costs. Overall survival and cancer-specific mortality were evaluated using Cox regression models. The log-transformed overall treatment costs for the 3 years following diagnosis were analyzed using linear regression.

RESULTS

The overall mortality risk significantly lowered in the 2019 cohort (HR 0.84; 95% CI 0.72-0.98, p = 0.024). Stage III patients were not associated with a significant overall survival rate (HR 0.71; 95% CI 0.50-1.02; p = 0.065) but were associated with significantly higher cancer-specific survival (HR 0.61; 95% CI 0.41-0.91; p = 0.015). Overall, the 2019 cohort showed significantly higher costs (coefficient 0.16; 95% CI 0.02-0.30, p = 0.025), particularly as a result of increases in the costs of drug administration, outpatient services, and medical devices. However, during the same 3-year follow-up period, this cohort featured lower average costs for hospice care and hospitalizations.

CONCLUSIONS

These results revealed notable differences in clinical outcomes and patient-related costs in incident NSCLCs in 2017 and 2019. The study highlights the importance of monitoring clinical outcomes and management costs in real-world oncology practice.

Is CK7 a Prognostic Marker in Pulmonary LCNEC? Evidence from a Limited Cohort Study

Objectives: While the treatment of non-small-cell lung carcinoma has improved rapidly, the treatment of pulmonary large-cell neuroendocrine carcinoma (LCNEC) remains underdeveloped. The use of immunohistochemistry allows for accurate risk stratification. With our study, we investigated the outcome of patients with pulmonary LCNEC and analyzed whether CK7 correlates with long-term survival. Methods: We retrospectively collected the monocentric data of patients which underwent anatomical resection for lung cancer between January 2012 and December 2020. Patients that did not show pulmonary LCNEC or adenocarcinoma, had a positive resection margin, or underwent neoadjuvant therapy were excluded. The long-term survival rate of the LCNEC and adenocarcinoma groups were compared before and after propensity score matching. Furthermore, we performed survival analyses for a subgroup of LCNEC distinguished by CK7 expression, followed by Cox regression analyses. Results: A total of 466 patients were integrated for further analysis. The mean age was 65.3 ± 9.6 years. There were no significant differences between both groups regarding age, gender, or comorbidities. In terms of the UICC stage, the groups were equally distributed. Mean survival in the LCNEC group was significantly worse than in the adenocarcinoma group (LCENC: 36.4 ± 7.5 months; adenocarcinoma: 80.7 ± 8.1 months; p-value = 0.001). The mean survival rate was 19.23 ± 4.8 months in the CK7 expression group and 57.01 ± 8.5 months in the group without expression, which reached statistical significance (p-value = 0.019). Conclusions: Our study suggests that pulmonary LCNEC has a significantly worse prognosis than pulmonary adenocarcinoma. CK7 expression seems to be correlated with a worse outcome for the long-term survival rate of patients suffering from highly malignant pulmonary LCNEC.

NSCLC: Current Evidence on Its Pathogenesis, Integrated Treatment, and Future Perspectives

Non-small cell lung carcinoma (NSCLC) comprises the majority of lung cancer cases, characterized by a complex interplay of genetic alterations, environmental factors, and molecular pathways contributing to its pathogenesis. This article highlights the multifaceted pathogenesis of NSCLC and discusses screening and integrated strategies for current treatment options. NSCLC is an evolving field with various aspects including the underlying molecular alterations, oncogenic driver mutations, and immune microenvironment interactions that influence tumor progression and response to therapy. Surgical treatment remains the most applicable curative option, especially in the early stages of the disease, adjuvant chemotherapy may add benefits to previously resected patients. Combined Radio-chemotherapy can also be used for palliative purposes. There are various future perspectives and advancing horizons in NSCLC management, encompassing novel therapeutic modalities and their applications, such as CAR-T cell therapy, antibody-drug conjugates, and gene therapies. On the other hand, it's crucial to highlight the efficacy of innovative modalities of Immunotherapy and immune checkpoint inhibitors that are nowadays widely used in treatment of NSCLC. Moreover, the latest advancements in molecular profiling techniques and the development of targeted therapies designed for specific molecular alterations in NSCLC play a significant role in its treatment. In conclusion, personalized approaches are a cornerstone of successful treatment, and they are based on a patient's unique molecular profile, tumor characteristics, and host factors. Entitling the concept of individualized treatment strategies requires proper patient selection, taking into consideration mechanisms of resistance, and investigating potential combination therapies, to achieve the optimal impact on long-term survival.

Postoperative radiotherapy improves survival in completely resected non-small cell lung cancer with pathologic N2 stage IIIA and positive lymph node count greater than one: a SEER-based retrospective cohort study

Objective

Non-small cell lung cancer (NSCLC) constitutes approximately 85% of lung cancer cases, with 20%-30% of patients diagnosed at stage III. While multimodal therapy is the standard for treating locally advanced NSCLC, the role of PORT remains controversial. This study seeks to evaluate the effect of postoperative radiotherapy (PORT) on overall survival (OS) and cancer-specific survival (CSS) in patients with resected pathologic N2 (pN2) stage IIIA NSCLC.

Methods

Data from the Surveillance, Epidemiology, and End Results Program (SEER) 17 registry (2010-2019) were analyzed. The cohort included 1,471 patients aged 65 years or older, diagnosed with stage IIIA pN2 NSCLC, who had undergone lobectomy or total pneumonectomy. Patients who had received neoadjuvant chemotherapy or radiotherapy were excluded. Univariate and multivariate analyses were conducted to assess the association of PORT with OS and CSS. Kaplan-Meier survival curves were employed to estimate survival outcomes, while the COX proportional hazards model was utilized for comparative analysis. PLN counts were stratified into two categories: ≤1 and >1.

Results

Among the 1,471 patients included in the study, 613 (41.67%) received PORT, while 858 (58.33%) did not. PORT was associated with a significantly higher 1- and 3-year OS (89.96% and 68.49%, respectively) compared to the non-PORT group (87.44% and 61.88%, respectively, P = 0.03). However, no significant difference in CSS was observed between the groups (P = 0.15). Among patients with PLN counts >1, PORT significantly improved OS (HR = 1.32, 95% CI = 1.04-1.68, P = 0.0016) and CSS (HR = 1.32, 95% CI = 0.99-1.70, P = 0.026), whereas no significant differences were seen in patients with PLN counts ≤1.

Conclusions

This study underscores the potential of PORT in enhancing OS in patients with resectable pN2 stage IIIA NSCLC, particularly in those with PLN counts exceeding one. These findings suggest that PORT may offer improved outcomes in patients with extensive lymph node involvement, emphasizing the need for further prospective studies to validate and expand upon these observations.

Enhanced radiotherapy susceptibility in NSCLC through palbociclib-mediated PP5 inhibition

Radiotherapy remains a cornerstone in the treatment of non-small cell lung cancer (NSCLC), yet radioresistance often limits its efficacy. Identifying molecular targets that enhance radiosensitivity is crucial to offering both curative and palliative benefits for patients with NSCLC. Utilizing bioinformatics analysis, our study revealed significantly higher expression of PP5 in NSCLC tissues compared to normal tissues. Kaplan-Meier survival analysis also showed that high PP5 expression correlates with poorer overall survival, particularly in patients undergoing radiotherapy, suggesting a role for PP5 in radioresistance. We further demonstrated that PP5 is a critical target of palbociclib, distinct from CDK4/6, influencing radiosensitivity in NSCLC. Palbociclib enhanced radiotherapy susceptibility by inducing sustained DNA damage and AMPK activation. The subsequent cellular event is apoptosis rather than autophagy. Furthermore, the enhanced efficacy of combination therapy was counteracted by an AMPK inhibitor and PP5 activator, underscoring the importance of these pathways in mediating the response. Our findings provide compelling evidence that targeting PP5 can significantly enhance the therapeutic outcomes of radiotherapy in NSCLC. This research offers valuable insights into new combination therapy strategies, highlighting the potential of PP5 as a novel therapeutic target to overcome radioresistance.

The association of ABC proteins with multidrug resistance in cancer

Multidrug resistance (MDR) poses one of the primary challenges for cancer treatment, especially in cases of metastatic disease. Various mechanisms contribute to MDR, including the overexpression of ATP-binding cassette (ABC) proteins. In this context, we reviewed the literature to establish a correlation between the overexpression of ABC proteins and MDR in cancer, considering both in vitro and clinical studies. Initially, we presented an overview of the seven subfamilies of ABC proteins, along with the subcellular localization of each protein. Subsequently, we identified a panel of 20 ABC proteins (ABCA1-3, ABCA7, ABCB1-2, ABCB4-6, ABCC1-5, ABCC10-11, ABCE1, ABCF2, ABCG1, and ABCG2) associated with MDR. We also emphasize the significance of drug sequestration by certain ABC proteins into intracellular compartments. Among the anticancer drugs linked to MDR, 29 were definitively identified as substrates for at least one of the three most crucial ABC transporters: ABCB1, ABCC1, and ABCG2. We further discussed that the most commonly used drugs in standard regimens for mainly breast cancer, lung cancer, and acute lymphoblastic leukemia could be subject to MDR mediated by ABC transporters. Collectively, these insights will aid in conducting new studies aimed at a deeper understanding of the clinical MDR mediated by ABC proteins and in designing more effective pharmacological treatments to enhance the objective response rate in cancer patients.

Long-term survival after sleeve lobectomy versus pneumonectomy for non-small cell lung cancer

BACKGROUND

To compare short-term mortality and long-term overall survival between sleeve lobectomy and pneumonectomy for centrally located non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed patients who had been radically resected for NSCLC by sleeve lobectomy with or without pulmonary arterioplasty at our institution between 2009 and 2023. We then propensity score-matched the patients with pneumonectomy counterparts from a national registry and compared their 30- and 90-day mortality and long-term overall survival before and after matching. The mortality was compared using independence tests and the overall survival using Kaplan-Meier estimates and the log-rank test.

RESULTS

The study included 109 sleeve lobectomy patients and 315 pneumonectomy patients, of whom 60 patients from each group were matched. The 30- and 90-day mortality was similar between both the unmatched and matched groups (unmatched: 3.7 % vs 5.1 % and 5.5 % vs 9.2 %; matched: 5.0 % vs 6.7 % and 5.0 % vs 12 %. All p-values >0.05). The overall survival was longer in both the unmatched and matched sleeve lobectomy patients (unmatched: hazard ratio [HR] 0.52, 95 % confidence interval [CI] 0.37-0.73, p < 0.001; matched HR 0.55, 95 % CI 0.34-0.90, p = 0.018). The 5-year overall survival was 68 % and 49 % for the unmatched sleeve lobectomy and pneumonectomy patients, respectively, and 61 % and 42 % for the matched ones.

CONCLUSIONS

Sleeve lobectomy yields non-inferior short-term mortality and superior long-term overall survival compared with pneumonectomy and should be the resection of choice for centrally located NSCLC when feasible.

Real-world treatment patterns in patients with non-metastatic non-small cell lung cancer in Greece: the 'EVIDENCE' study

BACKGROUND

The treatment landscape of non-metastatic non-small cell lung cancer (NM-NSCLC) is rapidly evolving with recent approvals of immunotherapies and targeted therapies.

METHODS

This retrospective study included 202 adults diagnosed with NM-NSCLC between 1 January 2018 and 31 December 2020 primarily aiming to capture initial management strategies.

RESULTS

Most frequent treatment patterns among Stage I/II patients (N = 84) were surgery only (48.8%) and surgery with adjuvant chemotherapy (with/without RT; 42.9%). Among Stage III patients (N = 118), most frequent patterns were chemotherapy plus radiotherapy (44.9%) and chemotherapy only (18.6%); 58.6% of Stage IIIA patients underwent surgery (of these, 32.4% also received chemotherapy and radiotherapy).

CONCLUSION

Initial strategy was aligned with contemporary at that time European guidelines, setting a benchmark for understanding the future uptake of new therapies.

Autoplanning in the setting of stereotactic body radiation therapy for lung cancer

PURPOSE

Automatic planning (AP) has been compared to manual planning (MP) in lung stereotactic body radiation therapy (SBRT) to validate the former and to implement it in clinical practice.

METHODS

A new developing Guided Planning System (GPS) engine was used to reoptimize 20 lung SBRT plans with the RayStation™ treatment planning system (TPS). The original manual plans were optimized to deliver 60 Gy in 5 or 8 fractions to the target with constraints on organs at risk (OARs) based on an internal protocol. AP plans were compared to MP based on (i) planning target volume (PTV) and OARs dosimetric evaluation, (ii) clinician's blind plan comparison, (iii) Plan QA results, and (iv) plan quality metrics. Differences between continuous variables were explored through the Mann-Whitney test (p < 0.05).

RESULTS

Target and OARs dosimetry showed no significant difference, with the only exception of the spinal cord maximum dose that was significantly lower for AP in the 5 fractions scheme (MP: 8.93 Gy ± 3.94 Gy vs AP: 6.45 Gy ± 2.72 Gy, p = 0.034). In the blind comparison, AP was preferred in 45 % of cases while MP in 35 % of cases (no preference was expressed in 20 % of cases). A trend towards lower monitor units (MUs) was found for AP in the 5 fractions scheme (MP: 3383 ± 943 vs AP: 2662 ± 588, p = 0.059). No significant difference was found in any of the plan quality metrics.

CONCLUSIONS

AP plans were not inferior to MP plans; therefore, GPS is ready for clinical use in a pulmonary SBRT setting, reducing the planning workload and harmonizing the planning procedure.