Correlation of mutation status and survival with predominant histologic subtype according to the new IASLC/ATS/ERS lung adenocarcinoma classification in stage III (N2) patients

Incorporating Lymph Node Size at CT as an N1 Descriptor in Clinical N Staging for Lung Cancer

Background The ninth edition of the TNM classification for lung cancer revised the N2 categorization, improving patient stratification, but prognostic heterogeneity remains for the N1 category. Purpose To define the optimal size cutoff for a bulky lymph node (LN) on CT scans and to evaluate the prognostic value of bulky LN in the clinical N staging of lung cancer. Materials and Methods This retrospective study analyzed patients who underwent lobectomy or pneumonectomy for lung cancer between January 2013 and December 2021, divided into development (2016-2021) and validation (2013-2015) cohorts. The optimal threshold for a bulky LN was defined based on the short-axis diameter of the largest clinically positive LN at CT. Prognostic differences according to presence of bulky LN in cN1 category for overall survival (OS) were evaluated using multivariable Cox analysis. Survival discrimination was assessed using the Harrell concordance index (C-index). Results A total of 3426 patients (mean age, 64.0 years ± 9.3 [SD]; 1837 male) and 1327 patients (mean age, 63.0 years ± 9.7; 813 male) were included in the development and validation cohorts, respectively. The cutoff size for a bulky LN was established at 15 mm, and the presence of bulky LN was an independent risk factor for OS (hazard ratio [HR], 1.54; 95% CI: 1.10, 2.16; P = .01). In the development and validation cohorts, the cN1-bulky group had higher mortality risk than the cN1-nonbulky group (HR, 2.82 [95% CI: 1.73, 4.58; P < .001]; 2.29 [95% CI: 1.34, 3.92; P = .002], respectively). The bulky LN descriptor improved prognostic discrimination within the cN1 category compared with the current staging (C-index from 0.50 to 0.60 and to 0.58 in the development and validation cohorts [P < .001, P = .006], respectively]). Conclusion Defining bulky LN with a size cutoff of 15 mm was an effective descriptor in the clinical staging of N1 lung cancer. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Horst in this issue.

Predicting epidermal growth factor receptor (EGFR) mutation status in non-small cell lung cancer (NSCLC) patients through logistic regression: a model incorporating clinical characteristics, computed tomography (CT) imaging features, and tumor marker levels

Background

Approximately 60% of Asian populations with non-small cell lung cancer (NSCLC) harbor epidermal growth factor receptor (EGFR) gene mutations, marking it as a pivotal target for genotype-directed therapies. Currently, determining EGFR mutation status relies on DNA sequencing of histological or cytological specimens. This study presents a predictive model integrating clinical parameters, computed tomography (CT) characteristics, and serum tumor markers to forecast EGFR mutation status in NSCLC patients.

Methods

Retrospective data collection was conducted on NSCLC patients diagnosed between January 2018 and June 2019 at the First Affiliated Hospital of Zhengzhou University, with available molecular pathology results. Clinical information, CT imaging features, and serum tumor marker levels were compiled. Four distinct models were employed in constructing the diagnostic model. Model diagnostic efficacy was assessed through receiver operating characteristic (ROC) area under the curve (AUC) values and calibration curves. DeLong's test was administered to validate model robustness.

Results

Our study encompassed 748 participants. Logistic regression modeling, trained with the aforementioned variables, demonstrated remarkable predictive capability, achieving an AUC of 0.805 (95% confidence interval (CI) [0.766-0.844]) in the primary cohort and 0.753 (95% CI [0.687-0.818]) in the validation cohort. Calibration plots suggested a favorable fit of the model to the data.

Conclusions

The developed logistic regression model emerges as a promising tool for forecasting EGFR mutation status. It holds potential to aid clinicians in more precisely identifying patients likely to benefit from EGFR molecular testing and facilitating targeted therapy decision-making, particularly in scenarios where molecular testing is impractical or inaccessible.

Non-Genotoxic and Environmentally Relevant Lower Molecular Weight Polycyclic Aromatic Hydrocarbons Significantly Increase Tumorigenicity of Benzo[a]pyrene in a Lung Two-Stage Mouse Model

The World Health Organization has classified air pollution as a carcinogen, and polycyclic aromatic hydrocarbons (PAHs) are major components of air particulates of carcinogenic concern. Thus far, most studies focused on genotoxic high molecular weight PAHs; however, recent studies indicate potential carcinogenicity of the non-genotoxic lower molecular weight PAHs (LMW PAHs) that are found in indoor and outdoor air pollution as well as secondhand cigarette smoke. We hypothesize that LMW PAHs contribute to the promotion stage of cancer when combined with benzo[a]pyrene (B[a]P), a legacy PAH. We specifically determined the effects of an LMW PAH mixture containing 1-methylanthracene (1MeA), fluoranthene (Flthn), and phenanthrene (Phe) combined with B[a]P on lung tumor promotion. To test this hypothesis, we used a two-stage, initiation/promotion BALB/ByJ female lung tumor mouse model. The mice were initiated with 3-methylcholanthrene followed by exposures to B[a]P, the LMW PAH mixture, and the combination of the LMW PAH mixture plus B[a]P, all at 10 mg/kg. The LMW PAHs combined with B[a]P significantly increased the promotion and incidence of lung tumors over that of B[a]P alone. The LMW PAHs in the absence of B[a]P did not significantly promote tumors, indicating strong co-promotional activities. We further assessed the effects of these PAHs on other hallmarks of cancer, namely, bronchoalveolar lavage fluid inflammatory infiltrates, pro-inflammatory transcripts, KC protein content, and mRNA expression of the gap junction (Gja1) and epiregulin (Ereg) genes. The LMW PAHs increased the biomarkers of inflammation, decreased Gja1 expression, and increased Ereg expression, all consistent with tumor promotion. This study indicates that non-genotoxic LMW PAHs can contribute to the cancer process and warrants further studies to assess the carcinogenic risks of other LMW PAHs.

Predicting invasion in early-stage ground-glass opacity pulmonary adenocarcinoma: a radiomics-based machine learning approach

BACKGROUND

To design a pulmonary ground-glass nodules (GGN) classification method based on computed tomography (CT) radiomics and machine learning for prediction of invasion in early-stage ground-glass opacity (GGO) pulmonary adenocarcinoma.

METHODS

This retrospective study included pulmonary GGN patients who were histologically confirmed to have adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), or invasive adenocarcinoma cancer (IAC) from 2020 to 2023. CT images of all patients were automatically segmented and 107 radiomic features were obtained for each patient. Classification models were developed using random forest (RF) and cross-validation, including three one-versus-others models and one three-class model. For each model, features were ranked by normalized Gini importance, and a minimal subset was selected with a cumulative importance exceeding 0.9. These selected features were then used to train the final models. The models' performance metrics, including area under the curve (AUC), accuracy, sensitivity, and specificity, were computed. AUC and accuracy were compared to determine the final optimal method.

RESULTS

The study comprised 193 patients (mean age 54 ± 11 years, 65 men), including 65 AIS, 54 MIA, and 74 IAC, divided into one training cohort (N = 154) and one test cohort (N = 39). The final three-class RF model outperformed three individual one-versus-others models in distinguishing each class from the other two. For the multiclass classification model, the AUC, accuracy, sensitivity, and specificity were 0.87, 0.79, 0.62, and 0.88 for AIS; 0.90, 0.79, 0.54, and 0.89 for MIA; and 0.87, 0.69, 0.73, and 0.67 for IAC, respectively.

CONCLUSIONS

A radiomics-based multiclass RF model could effectively differentiate three types of pulmonary GGN, which enabled early diagnosis of GGO pulmonary adenocarcinoma.

Computed Tomography Radiomics for Preoperative Prediction of Spread Through Air Spaces in the Early Stage of Surgically Resected Lung Adenocarcinomas

PURPOSE

To assess the added value of radiomics models from preoperative chest CT in predicting the presence of spread through air spaces (STAS) in the early stage of surgically resected lung adenocarcinomas using multiple validation datasets.

MATERIALS AND METHODS

This retrospective study included 550 early-stage surgically resected lung adenocarcinomas in 521 patients, classified into training, test, internal validation, and temporal validation sets (n=211, 90, 91, and 158, respectively). Radiomics features were extracted from the segmented tumors on preoperative chest CT, and a radiomics score (Rad-score) was calculated to predict the presence of STAS. Diagnostic performance of the conventional model and the combined model, based on a combination of conventional and radiomics features, for the diagnosis of the presence of STAS were compared using the area under the curve (AUC) of the receiver operating characteristic curve.

RESULTS

Rad-score was significantly higher in the STAS-positive group compared to the STAS-negative group in the training, test, internal, and temporal validation sets. The performance of the combined model was significantly higher than that of the conventional model in the training set {AUC: 0.784 [95% confidence interval (CI): 0.722-0.846] vs. AUC: 0.815 (95% CI: 0.759-0.872), p=0.042}. In the temporal validation set, the combined model showed a significantly higher AUC than that of the conventional model (p=0.001). The combined model showed a higher AUC than the conventional model in the test and internal validation sets, albeit with no statistical significance.

CONCLUSION

A quantitative CT radiomics model can assist in the non-invasive prediction of the presence of STAS in the early stage of lung adenocarcinomas.

Micropapillary and solid components as high-grade patterns in IASLC grading system of lung adenocarcinoma: Clinical implications and management

OBJECTIVES

The grading system proposed by the International Association for the Study of Lung Cancer is based on a combination of predominant histologic subtypes and the proportion of high-grade components with a cutoff of 20%. We aimed to examine the clinical implications of the grading system beyond the discrimination of patient prognosis, while assessing the biological differences among high-grade subtypes.

METHODS

We retrospectively reviewed 648 consecutive patients with resected lung adenocarcinomas and examined their clinicopathologic, genotypic, and immunophenotypic features and treatment outcomes. Besides the differences among grades, the clinical impact of different high-grade components: micropapillary (MIP) and solid (SOL) patterns, was individually evaluated.

RESULTS

Survival outcomes were well-stratified according to the grading system. Grade 3 tumors exhibited aggressive clinicopathologic features, while being an independent prognostic factor in multivariable analysis. A small proportion (<20 %) of high-grade components in grade 2 had a negative prognostic impact. The prognostic difference bordering on the 20 % cutoff of the MIP proportion was validated; however, the proportion of SOL component did not affect prognosis. A survival benefit from adjuvant chemotherapy was observed in grade 3 tumors regardless of histologic subtype, but not in grade 1-2 tumors. The molecular and immunophenotypic features were different among grades, but still heterogeneous in grade 3, with MIP harboring frequent EGFR mutation and SOL exhibiting high PD-L1 expression. The treatment outcome after recurrence was worse in grade 3, but tumors with MIP pattern had an equivalent prognosis to that of grade 1-2 tumors, reflecting the high frequency of molecular targeted therapy.

CONCLUSIONS

In addition to stratifying patient prognosis, the current grading system could discriminate clinical course, therapeutic effects of adjuvant chemotherapy, and molecular and immunophenotypic features. Further stratification based on biological heterogeneity in grade 3 remains necessary to enhance the role of the grading system in guiding patient management.

Micropapillary and Solid Histologic Patterns in N1 and N2 Lymph Node Metastases Are Independent Factors of Poor Prognosis in Patients With Stages II to III Lung Adenocarcinoma

INTRODUCTION

High-grade histologic patterns are associated with poor prognosis in patients with primary nonmucinous lung adenocarcinoma (ADC). We investigated whether the presence of micropapillary (MIP), solid (SOL), or both patterns in lymph node (LN) metastases has prognostic value.

METHODS

Patients who underwent lobectomy for pathologic stages II to III lung ADC with N1 or N2 LN metastases (N = 360; 2000-2012) were analyzed. We assessed overall survival (OS), lung cancer-specific cumulative incidence of death (LC-CID), and cumulative incidence of recurrence (CIR) between patients with and without MIP/SOL patterns in LN metastases. Multivariable Cox regression analysis was used to quantify the association between MIP/SOL patterns and outcomes.

RESULTS

MIP and SOL in LN metastases were associated with a higher incidence of smoking history (p = 0.004), tumor necrosis (p = 0.013), and spread of tumor through air spaces (p < 0.0001), a higher prevalence of MIP or SOL in the primary tumor (p < 0.0001), shorter OS (5-y OS, 40% [95% confidence interval or CI: 29%-56%] versus 63% [48%-83%] for no MIP/SOL in LNs, p = 0.03), higher LC-CID (5-y, 43% [29%-56%] versus 14% [4%-29%], p = 0.013), and higher CIR (5-y, 65% [50%-77%] versus 43% [25%-60%], p = 0.057). MIP and SOL in LN metastases were independently associated with poor outcomes: OS (hazard ratio [HR] = 1.81 [95% CI: 1.00-3.29], p = 0.05), LC-CID (HR = 3.10 [1.30-7.37], p = 0.01), and CIR (HR = 2.06 [1.09-3.90], p = 0.026).

CONCLUSIONS

MIP/SOL histologic patterns in N1 or N2 LN metastases are associated with worse outcomes in patients with stages II to III lung ADC. MIP/SOL histologic patterns in LN metastases can stratify patients with high-risk stages II to III lung ADC.

A comprehensive and current review on the role of flavonoids in lung cancer-Experimental and theoretical approaches

BACKGROUND

It is well-known that flavonoids, which can be easily obtained from many fruits and vegetables are widely preferred in the treatment of some important diseases. Some researchers noted that these chemical compounds exhibit high inhibition effect against various cancer types. Many experimental studies proving this ability of the flavonoids with high antioxidant activity are available in the literature.

PUROPOSE

The main aim of this review is to summarize comprehensively anticancer properties of flavonoids against the lung cancer in the light of experimental studies and well-known theory and electronic structure principles. In this review article, more detailed and current information about the using of flavonoids in the treatment of lung cancer is presented considering theoretical and experimental approaches.

STUDY DESIGN

In addition to experimental studies including the anticancer effects of flavonoids, we emphasized the requirement of the well-known electronic structure principle in the development of anticancer drugs. For this aim, Conceptual Density Functional Theory should be considered as a powerful tool. Searching the databases including ScienceDirect, PubMed and Web of Science, the suitable reference papers for this project were selected.

METHODS

Theoretical tools like DFT and Molecular Docking provides important clues about anticancer behavior and drug properties of molecular systems. Conceptual Density Functional Theory and CDFT based electronic structure principles and rules like Hard and Soft Acid-Base Principle (HSAB), Maximum Hardness Principle, Minimum Polarizability, Minimum Electrophilicity Principles and Maximum Composite Hardness Rule introduced by one of the authors of this review are so useful to predict the mechanisms and powers of chemical systems. Especially, it cannot be ignored the success of HSAB Principle in the explanations and highlighting of biochemical interactions.

RESULTS

Both theoretical analysis and experimental studies confirmed that flavonoids have higher inhibition effect against lung cancer. In addition to many superior properties like anticancer activity, antimicrobial activity, antioxidant activity, antidiabetic effect of flavonoids, their toxicities are also explained with the help of published popular papers. Action modes of the mentioned compounds are given in detail.

CONCLUSION

The review includes detailed information about the mentioned electronic structure principles and rules and their applications in the cancer research. In addition, the epidemiology and types of lung cancer anticancer activity of flavonoids in lung cancer are explained in details.

Correlation of Epidermal Growth Factor Receptor Mutation With Major Histologic Subtype of Lung Adenocarcinoma According to IASLC/ATS/ERS Classification

OBJECTIVE

Our prospective study aims to define the correlation of EGFR(epidermal growth factor receptor) mutations with major histological subtypes of lung adenocarcinoma from resected and non-resected specimens, according to the WHO 2015 classification, in Moroccan North East Population.

METHODS

Epidermal growth factor receptor mutations of 150 primary lung adenocarcinoma were performed using Real-Time PCR or SANGER sequencing. SPSS 21 was used to assess the relationship between histological subtypes of lung adenocarcinoma and EGFR mutation status.

RESULTS

25 mutations were detected in the series of 150 lung adenocarcinomas, most of which were found in cases with papillary, acinar, patterns than without these patterns and more frequently occurred in the cases without solid pattern than with this pattern. A significant correlation was observed between EGFR mutation and acinar (P = 0,024), papillary pattern (P = 0,003) and, negative association with a solid pattern (P < 0,001). In females, EGFR mutations were significantly correlated with the acinar pattern (P = 0,02), whereas in males with the papillary pattern (P = 0,01). Association between the histologic component and exon 19 deletions and exon 21 mutations were also evaluated and, we found a significant correlation between the papillary major pattern with exon 19 mutations (P = 0,004) and, ex21 with the acinar component (P = 0,03).

CONCLUSION

An analysis of resected and non-resected lung ADC specimens in 150 Moroccan Northeast patients, revealed that acinar and papillary patterns may predict the presence of a mutation in the EGFR gene. While the solid major pattern may indicate a low mutation rate of the EGFR gene.

The 2021 WHO Classification of Lung Tumors: Impact of advances since 2015

The 2021 World Health Organisation (WHO) Classification of Thoracic Tumours was published earlier this year, with classification of lung tumors being one of the chapters. The principles remain those of using morphology first, supported by immunohistochemistry and then molecular techniques. In 2015, there was particular emphasis on using immunohistochemistry to make classification more accurate. In 2021, there is greater emphasis throughout the book on advances in molecular pathology across all tumor types. Major features within this edition are 1) broader emphasis on genetic testing than in the 2015 WHO Classification, 2) a chapter entirely dedicated to the classification of small diagnostic samples, 3) continued recommendation to document percentages of histological patterns in invasive non-mucinous adenocarcinomas, with utilization of these features to apply a formal grading system, as well as using only invasive size for T-factor size determination in part lepidic non-mucinous lung adenocarcinomas as recommended by the 8^th Edition TNM Classification, 4) recognition of spread through airspaces (STAS) as a histological feature with prognostic significance, 5) moving lymphoepithelial carcinoma to squamous cell carcinomas, 6) update on evolving concepts in lung neuroendocrine neoplasm classification, 7) recognition of bronchiolar adenoma/ciliated muconodular papillary tumor (BA/CMPT) as a new entity within the adenoma subgroup, 8) recognition of thoracic SMARCA4-deficient undifferentiated tumor, and 9) inclusion of essential and desirable diagnostic criteria for each tumor.

Clinicopathological, Radiological, and Molecular Features of Primary Lung Adenocarcinoma with Morule-Like Components

BACKGROUND

Morule-like component (MLC) was a rare structure in primary lung adenocarcinoma. We aimed to reveal the clinicopathological, radiological, immunohistochemical, and molecular features of lung adenocarcinoma with MLCs.

METHODS

Twenty lung adenocarcinomas with MLCs were collected, and computed tomographic and histological documents were reviewed. Immunohistochemistry, targeted next-generation sequencing, and Sanger sequencing for β-catenin gene were performed.

RESULTS

There were 9 lepidic adenocarcinomas, 8 acinar adenocarcinomas, 2 papillary adenocarcinomas, and 1 minimally invasive adenocarcinoma. Most patients (16/17) were shown a pure solid nodule, and 1 patient was shown a partly solid nodule on chest computed tomography (CT). Nine cases were accompanied with micropapillary components, and 3 were with cribriform components in which 2 suffered a worse prognosis. No significant association was found between the MCLs and the overall survival of lung adenocarcinoma (P = 0.109). The MLCs were often arranged in whorled or streaming patterns. The cells in MLCs showed syncytial and mild appearance. The MLCs were positive for E-cadherin, CK7, TTF-1, napsin-A, vimentin, and β-catenin (membrane), and negative for CK5/6, p40, p63, Synaptophysin, chromogranin A, and Cdx-2. EGFR mutation, ALK-EML4 fusion, HER2 amplification, and PIK3CA mutation were detected in 16 cases, 2 cases, 1 case, and 1 case, respectively. EGFR mutation was more frequent in adenocarcinomas with MLCs than those without MLCs (P = 0.040). β-catenin gene mutation was not detected in any patients.

CONCLUSIONS

MLC is often observed in the background of acinar, lepidic, and papillary adenocarcinomas. Lung adenocarcinomas with MLCs tend to appear as a solid mass on CT and harbor EGFR gene mutations. The micropapillary components and cribriform components may cause poor prognosis of lung adenocarcinomas with MLCs. Vimentin is always positive in MLCs, and it is a useful marker for the identification of MLCs.

[Progress in Research on the Cribriform Component in Lung Adenocarcinoma]

The morbidity of lung cancer ranks top in the world. At present, lung adenocarcinoma (LUAD) is the most common histologic type of lung cancer. However, the prognoses of LUAD patients with the same subtype remain heterogeneous. Histological heterogeneity is one of the main causes of diverse prognoses of patients with LUAD. Studies have shown that there are other histologic patterns that affect the clinical outcomes of LUAD patients, in addition to the five growth patterns of invasive LUAD classified by the World Health Organization (WHO) in 2015. The cribriform component (CC) is one of the research hotspots among histopathology of LUAD. Previous studies have shown that the presence of CC can further stratify the prognoses of patients with LUAD. Along with the progressively deep insights into the aforementioned topic, researchers are dedicating to unveiling the relationships among CC and and other clinicopathological factors as well as their joint influence on the survival of LUAD patients. The review manages to generalize the latest research progress in the CC in LUAD patients.

A comprehensive study on the oncogenic mutation and molecular pathology in Chinese lung adenocarcinoma patients

BACKGROUND

Several genetic driver alterations have been identified in micropapillary lung adenocarcinoma (MPA). However, the frequency of co-alteration of ROS1, EGFR, and EML4-ALK is yet unclear. Herein, we investigated the relationship between clinicopathologic characteristics and well-identified driver mutations of MPA compared with non-micropapillary lung adenocarcinoma (LA).

METHODS

Formalin-fixed paraffin-embedded (FFPE) sections derived from lung adenocarcinoma patients who never received adjuvant chemotherapy or radiation therapy prior to surgical resection were collected from October 2016 to June 2019. EGFR mutations, ROS1 rearrangements, and EML4-ALK fusion were identified in a set of 131 MPA and LA cases by using the amplification refractory mutation system (ARMS). The response rate and duration of response were assessed using Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1).

RESULTS

EGFR mutations had occurred in 42 (76.4%) MPA patients and 42 (55.3%) LA patients. Interestingly, ROS1 rearrangements were highly enriched only in the MPA cases (6/55, 10.9%) but rarely in the LA cases (1/76, 1.3%). Furthermore, 7.3% (4/55) MPA samples had double gene mutations, while only 1.3% (1/76) LA cases had double gene alterations. Of 5 patients with harboring two driver oncogene mutations, four patients (80%) obtained partial response, and one patient (20%) suffered recurrence.

CONCLUSIONS

A higher prevalence of ROS1 rearrangement or combined mutations of ROS1, EGFR, and EML4-ALK may play a critical role in the tumorigenesis of MPA. These findings provide a novel therapeutic strategy for patients with malignant MPA through combining TKIs than one TKI.

MUC5AC enhances tumor heterogeneity in lung adenocarcinoma with mucin production and is associated with poor prognosis

OBJECTIVE

The clinicopathological significance of Mucin5AC (MUC5AC) in lung adenocarcinoma with mucin production is still unclear. This study aimed to explore MUC5AC expression in lung adenocarcinoma with mucin production and its correlation with histological subtypes, common driver mutations and its impact on prognosis.

METHODS

MUC5AC and thyroid transcription factor 1 immunohistochemistry was performed on surgical samples from 90 patients with lung adenocarcinoma with mucin production. Common driver mutations including EGFR and KRAS mutations and ALK rearrangement were detected by established methods.

RESULTS

MUC5AC was significantly associated with lymphovascular invasion (P = 0.023) and tumors with intra-cytoplasmic mucin (P < 0.001). Moreover, MUC5AC was more significant in invasive mucinous adenocarcinoma (P < 0.001), as well as in tumors with KRAS mutations (P = 0.005) and a lack of thyroid transcription factor 1 expression (P < 0.001). Conversely, MUC5AC was less significantly detected in acinar predominant adenocarcinoma (P = 0.036) and tumors with EGFR mutations (P = 0.001). Notably, MUC5AC in non-pure mucinous subtype of lung adenocarcinoma with mucin production showed more aggressive behavior, distinct expression pattern and a lack of significant correlation with thyroid transcription factor 1 (P = 0.113) when compared with pure mucinous subtype. MUC5AC-positive tumors were significantly associated with a worse prognosis compared to MUC5AC-negative tumors (P < 0.001). A multivariate survival analysis showed that MUC5AC was an independent prognosis factor for poor prognosis (P = 0.006).

CONCLUSIONS

The clinicopathological features of non-pure mucinous subtype of lung adenocarcinoma with mucin production were distinct and should be distinguished from pure mucinous subtype. MUC5AC was associated with poor prognosis and could be a potential therapeutic target for this distinct type of lung adenocarcinoma that has few effective treatments.

A novel radiomic nomogram for predicting epidermal growth factor receptor mutation in peripheral lung adenocarcinoma

To predict the epidermal growth factor receptor (EGFR) mutation status in patients with lung adenocarcinoma using quantitative radiomic biomarkers and semantic features. We analyzed the computed tomography (CT) images and medical record data of 104 patients with lung adenocarcinoma who underwent surgical excision and EGFR mutation detection from 2016 to 2018 at our center. CT radiomic and semantic features that reflect the tumors' heterogeneity and phenotype were extracted from preoperative non-enhanced CT scans. The least absolute shrinkage and selection operator method was applied to select the most distinguishable features. Three logistic regression models were built to predict the EGFR mutation status by combining the CT semantic with clinicopathological characteristics, using the radiomic features alone, and by combining the radiomic and clinicopathological features. Receiver operating characteristic (ROC) curve analysis was performed using five-fold cross-validation and the mean area under the curve (AUC) values were calculated and compared between the models to obtain the optimal model for predicting EGFR mutation. Furthermore, radiomic nomograms were constructed to demonstrate the performance of the model. In total, 1025 radiomic features were extracted and reduced to 13 features as the most important predictors to build the radiomic signature. The combined radiomic and clinicopathological features model was developed based on the radiomic signature, sex, smoking, vascular infiltration, and pathohistological type. The AUC was 0.90  ±  0.02 for the training, 0.88  ±  0.11 for the verification, and 0.894 for the test dataset. This model was superior to the other prediction models that used the combined CT semantic and clinicopathological features (AUC for the test dataset: 0.768) and radiomic features alone (AUC for the test dataset: 0.837). The prediction model built by radiomic biomarkers and clinicopathological features, including the radiomic signature, sex, smoking, vascular infiltration, and pathological type, outperformed the other two models and could effectively predict the EGFR mutation status in patients with peripheral lung adenocarcinoma. The radiomic nomogram of this model is expected to become an effective biomarker for patients with lung adenocarcinoma requiring adjuvant targeted treatment.

[Protein expression of PD-L1 and clinico-pathological data in a cohort of 53 patients with resectable non small cell lung cancer (NSCLC). Concordance between clones (22C3 and 28-8) and observers. Correlation and prognostic value of clinico-pathological data]

INTRODUCTION

85% of lung cancers are non-small cell carcinomas (NSCLC), the majority of which are diagnosed in an advanced stage. Immunotherapy has changed the treatment pattern for these tumors and created the need to find a marker for patient selection. Although not ideal, PD-L1 is the biomarker currently used in clinical practice.

MATERIAL AND METHODS

Retrospective review by two pathologists of 53 cases of NSCLC from 2005 to 2007 in Hospital Universitario La Paz, using the WHO 2015 classification studying PD-L1 with clones 22C3 and 28-8. The consistency between observers and clones was assessed and all data studied were correlated with survival rates.

RESULTS

We found a prevalence of PD-L1 expression in tumor cells (TC) similar to that previously reported in the literature and a very good consistency between clones in the evaluation of TC and immune cells (ICC 0.99-0.93, p<.001). Interobserver concordance was very good in the evaluation of TC (ICC 0.902, 95% CI: 0.836-0.942, p<.001 for clone 22C3 and ICC 0.927, 95% CI: 0.877-0.957, p<.001 for clone 28-8) and poor for immune cells (ICC of 0.413, 95% CI: 0.163-0.613, p=.001 with clone 22C3 and ICC of 0.313, 95% CI: 0.053-0.534, p=.010 with clone 28-8). Subtype and histological grade were the only variables related to prognosis.

CONCLUSIONS

The clones of PD-L1 22C3 and 28-8 are equivalent and there is good interobserver consistency in the evaluation of TC but not in immune cells.

Association between the novel classification of lung adenocarcinoma subtypes and EGFR/KRAS mutation status: A systematic literature review and pooled-data analysis

OBJECTIVES

This study aims to determine the association of EGFR/KRAS mutation status with histological subtypes of lung adenocarcinoma (LAC) based on the IASLC/ATS/ERS classification.

METHODS

Pubmed and Cochrane databases were searched from January 2011 to June 2018 for studies that included patients with LAC who underwent surgical resection were classified according to the new IASLC/ATS/ERS classification. EGFR/KRAS status assessment was requireded. The primary outcome was determined by the odds ratio (OR) of the incidence of mutation status of certain of each histological subtype. The reference group consisted of EGFR/KRAS mutation negative patients.

RESULTS

Twenty-seven eligible studies involving 9022 patients with mutation gene detection were included for analysis. Among them, 6717 (74.5%) patients were from the Asian region and, 2305 (25.5%) patients were from Non-Asian regions. The most prevalent subtype was acinar (34.7%), followed by papillary (22.9%), lepidic (18.9%), solid (13.6%), micropapillary (6.3%), and invasive mucinous adenocarcinoma (3.5%). EGFR mutations were more common in patients with resected lepidic predominant adenocarcinoma (OR,1.76; 95%CI, 1.38-2.24;p < 0.01) and were rarely found in solid predominant adenocarcinoma (OR,0.28; 95%CI, 0.23-0.34;p < 0.01) or IMA (OR,0.10; 95%CI, 0.06-0.14;p < 0.01). Conversely, KRAS mutations were characterized by IMA (OR,7.01; 95%CI, 5.11-9.62;p < 0.01), and were less frequently identified in lepidic (OR,0.58; 95%CI, 0.45-0.75;p < 0.01) and acinar (OR,0.65; 95%CI, 0.55-0.78;p < 0.01) predominant subtypes. Further analyses were performed in Asian and Non-Asian groups and the results were consistent.

CONCLUSIONS

The current study confirms that the IASLC/ATS/ERS classification is associated with driver gene alterations in resected LAC.

Epidermal growth factor receptor (EGFR), KRAS, and BRAF mutations in lung adenocarcinomas: A study from India

Mitogen-Activated Protein (MAP) Kinase pathway involves several oncogenic genes which can serve as potential targets for therapy. Therefore, aim of the present study is to analyze mutations in the MAP Kinase pathway in pulmonary adenocarcinoma (ADCA) of Indian patients along with clinico-pathologic correlation and determination of the survival status in patients receiving therapy. Blocks and slides of 125 pulmonary ADCA of last 5 years were retrieved. Histo-morphology and tumor content were determined. EGFR, KRAS, BRAF and MEK1 genes were analyzed using Sanger sequencing and Real-time polymerase chain reaction (PCR). Clinico-pathologic correlation and survival analysis were performed. Fifty-eight (46.4%) patients harbored genetic mutations of which 49 had single somatic mutations, 5 had multiple exonic and 4 showed coexisting EGFR and KRAS mutations. EGFR mutations were seen in 24.8%, KRAS in 19.2% and BRAF (non-V600E) in 2.4% cases. There was no difference in progression-free survival of wild- type/single mutations when compared with multiple/ coexisting mutations (P = 0.09). However, the P value may indicate borderline correlation. To conclude, EGFR and KRAS mutations may coexist in the same patient in lung ADCA. Multiple exonic mutations of KRAS gene formed substantial percentage of our cohort, requiring further exploration. Lung ADCA harbouring BRAF mutations are commonly non-V600E. Testing of all major genetic driver mutations of lung ADCA irrespective of histology and other demographic characteristics is necessary.

Essential roles of mitochondrial and heme function in lung cancer bioenergetics and tumorigenesis

Contrary to Warburg’s hypothesis, mitochondrial oxidative phosphorylation (OXPHOS) contributes significantly to fueling cancer cells. Several recent studies have demonstrated that radiotherapy-resistant and chemotherapy-resistant cancer cells depend on OXPHOS for survival and progression. Several cancers exhibit an increased risk in association with heme intake. Mitochondria are widely known to carry out oxidative phosphorylation. In addition, mitochondria are also involved in heme synthesis. Heme serves as a prosthetic group for several proteins that constitute the complexes of mitochondrial electron transport chain. Therefore, heme plays a pivotal role in OXPHOS and oxygen consumption. Further, lung cancer cells exhibit heme accumulation and require heme for proliferation and invasion in vitro. Abnormalities in mitochondrial biogenesis and mutations are implicated in cancer. This review delves into mitochondrial OXPHOS and lesser explored area of heme metabolism in lung cancer.

Development and validation of a model to predict tyrosine kinase inhibitor-sensitive EGFR mutations of non-small cell lung cancer based on multi-institutional data

BACKGROUND

Non-small cell lung cancer (NSCLC) with different EGFR mutation types shows distinct sensitivity to tyrosine kinase inhibitors (TKIs). This study developed a patho-clinical profile-based prediction model of TKI-sensitive EGFR mutations.

METHODS

The records of 1121 Chinese patients diagnosed with NSCLC from November 2008 to October 2014 (the development set) were reviewed. Multivariate logistic regression was conducted to identify any association between potential predictors and the classic sensitive EGFR mutations (exon 19 deletion and exon 21 L858R point mutation). A prediction index was created by assigning weighted scores to each factor proportional to a regression coefficient. Validation was made in an independent cohort consisting of 864 patients who were consecutively enrolled between November 2014 and January 2017 (the validation set).

RESULTS

Seven independent predictors were identified: gender (female vs. male), adenocarcinoma (yes vs. no), smoking history (no vs. yes), N stage (N+ vs. N0), M stage (M1 vs. M0), brain metastasis (yes vs. no), and elevated Cyfra 21-1 (no vs. yes). Each was assigned a number of points. In the validation set, the area under curve of the prediction index appeared as 0.698 (95% confidence interval 0.663-0.733). The sensitivity, specificity, positive and negative predictive values, and concordance were 95.0%, 32.3%, 61.4%, 85.1%, and 65.6%, respectively.

CONCLUSION

We developed a patho-clinical profile-based model for predicting TKI-sensitive EGFR mutations. Our model may represent a noninvasive, economical choice for clinicians to inform TKI therapy.

Lepidic, Papillary Components and EGFR Mutations are Frequent in Patients With Lung Adenocarcinoma Who are Over 75 Years Old

Treatment for lung adenocarcinoma frequently diverges from standard treatment in older patients. Clinical, pathologic, and molecular characteristics of lung cancer in patients over 75 years old have not been fully described. The aim of our work was to describe the rate of EGFR, KRAS, BRAF, and HER2 mutations, and ALK rearrangement and pathologic characteristics in patients with lung adenocarcinoma over 75, compared with patients below 75 years old. This is a retrospective study from 2 cohorts: a histopathologic cohort of all consecutively resected lung adenocarcinoma in our institution for patients over 75 (n=54, from 2006 to 2017) compared with patients below 75 years old (n=148, from 2014 to 2017) and a molecular cohort of all stage IIIb or IV lung adenocarcinoma from 2009 to 2017 (n=1611). Papillary and lepidic components were more frequently found in patients over 75 years old (P=0.046 and 0.0078, respectively). The rate of current smokers was lower in older patients (P<0.0001). EGFR mutations were more frequent in patients over 75 than in younger patients: 17% versus 8.1% (P<0.0001). The mutually exclusive KRAS mutation was more frequent in patients below 75 years old than in older patients: 25.8% versus 12.8% (P<0.0001). There was no difference for the proportion of the 2 most frequent EGFR mutations (exon 19 deletion and L858R mutation) (P=0.85) or KRAS-mutated codon (P=0.22) between tumors in younger or older patients. There was no statistically significant difference for the presence of BRAF, HER2 mutations, and ALK rearrangement (P=0.44, 0.71, and 1, respectively). Our work highlights the fact that EGFR mutations are more frequent in patients over 75 years old in our population. We can hypothesize that this difference might be mainly caused by the less frequent occurrence of tobacco-smoking-related lung cancers in the elderly and the presence of a lepidic or papillary component in this age group.

Analyzing EGFR mutations and their association with clinicopathological characteristics and prognosis of patients with lung adenocarcinoma

Epidermal growth factor receptor (EGFR) is an important gene in the development of lung adenocarcinoma. However, there is controversy regarding the association between EGFR mutations and survival time of patients with lung adenocarcinoma. In the present study, tissue specimens and clinical data were collected from 219 patients with lung adenocarcinoma who had not undergone prior radiotherapy or chemotherapy. EGFR mutations were detected using a fluorescence polymerase chain reaction method, and the association between EGFR mutations and clinicopathological characteristics was analyzed. Overall survival (OS) curves were constructed using the Kaplan-Meier method and the influence of clinicopathological characteristics on OS was analyzed using the Cox regression model. The EGFR mutation rate was 50.7%, and the most common mutations were the L858R substitution mutation in exon 21 (L858R; 54.9%) and the deletion mutation in exon 19 (19-Del; 36%). The presence of EGFR mutations varied significantly with sex, smoking history, T stage, vascular invasion and adenocarcinoma subtypes (P<0.05). The survival time was significantly longer for female, young (<60 years-old), non-smokers or patients exhibiting EGFR mutations (G719X, 19-Del, L858R and L861Q). The survival time was also significantly longer for patients with a 19-Del mutation, early stage tumors, tyrosine kinase inhibitors targeted therapy-treated patients, for those not exhibiting nerve or vascular invasion, and for those without disease recurrence (P<0.05). Multivariate analysis revealed that tumor pathological Tumor-Node-Metastasis (pTNM) stage, nerve invasion, vascular invasion, EGFR mutation and the 19-Del mutation were independent predictors (P<0.05). Therefore, tumor pTNM stage, nerve invasion, vascular invasion and EGFR mutation status, particularly that of 19-Del, were independent prognostic factors for patients with lung adenocarcinoma.

Reproducibility of Malignant Pleural Mesothelioma Histopathologic Subtyping

CONTEXT

- Malignant pleural mesothelioma (MPM) is a rare tumor with poor prognosis. Several studies have analyzed potential prognostic markers, but histologic type remains the single most important prognostic factor. Histologic subtypes of epithelioid MPM seem to have prognostic and therapeutic implications. Interobserver agreement in histologic pattern classification should be high.

OBJECTIVE

- To assess interobserver and intraobserver reproducibility in histologic differentiation between the main types of MPMs, and in further subtyping of epithelioid-type mesothelioma.

DESIGN

- One representative hematoxylin-eosin-stained slide was selected from the archive for each of 200 patients with MPM. They were reviewed independently by 3 pathologists and classified according to the current World Health Organization classification of pleural tumors. After the first round of evaluations, a consensus meeting was organized where problems were addressed and representative images for each histologic category were selected. Two months later, cases were reevaluated by all 3 pathologists.

RESULTS

- After the first round, overall interobserver agreement for histologic subtyping of mesothelioma was fair (κ, 0.36). The agreement was increased to substantial (κ, 0.63) in the second round. Improvement was found in interobserver agreement for all types of MPM and for most epithelioid subtypes.

CONCLUSIONS

- Moderate to substantial agreement in histologic typing and subtyping of MPM can be achieved. However, training with additional clarification of diagnostic criteria, their strict application, and help from consensus-based illustrative images is needed.

The tumor suppressor Hic1 maintains chromosomal stability independent of Tp53

Hypermethylated-in-Cancer 1 (Hic1) is a tumor suppressor gene frequently inactivated by epigenetic silencing and loss-of-heterozygosity in a broad range of cancers. Loss of HIC1, a sequence-specific zinc finger transcriptional repressor, results in deregulation of genes that promote a malignant phenotype in a lineage-specific manner. In particular, upregulation of the HIC1 target gene SIRT1, a histone deacetylase, can promote tumor growth by inactivating TP53. An alternate line of evidence suggests that HIC1 can promote the repair of DNA double strand breaks through an interaction with MTA1, a component of the nucleosome remodeling and deacetylase (NuRD) complex. Using a conditional knockout mouse model of tumor initiation, we now show that inactivation of Hic1 results in cell cycle arrest, premature senescence, chromosomal instability and spontaneous transformation in vitro. This phenocopies the effects of deleting Brca1, a component of the homologous recombination DNA repair pathway, in mouse embryonic fibroblasts. These effects did not appear to be mediated by deregulation of Hic1 target gene expression or loss of Tp53 function, and rather support a role for Hic1 in maintaining genome integrity during sustained replicative stress. Loss of Hic1 function also cooperated with activation of oncogenic KRas in the adult airway epithelium of mice, resulting in the formation of highly pleomorphic adenocarcinomas with a micropapillary phenotype in vivo. These results suggest that loss of Hic1 expression in the early stages of tumor formation may contribute to malignant transformation through the acquisition of chromosomal instability.

Quantitative Biomarkers for Prediction of Epidermal Growth Factor Receptor Mutation in Non-Small Cell Lung Cancer

OBJECTIVES

To predict epidermal growth factor receptor (EGFR) mutation status using quantitative radiomic biomarkers and representative clinical variables.

METHODS

The study included 180 patients diagnosed as of non-small cell lung cancer (NSCLC) with their pre-therapy computed tomography (CT) scans. Using a radiomic method, 485 features that reflect the heterogeneity and phenotype of tumors were extracted. Afterwards, these radiomic features were used for predicting epidermal growth factor receptor (EGFR) mutation status by a least absolute shrinkage and selection operator (LASSO) based on multivariable logistic regression. As a result, we found that radiomic features have prognostic ability in EGFR mutation status prediction. In addition, we used radiomic nomogram and calibration curve to test the performance of the model.

RESULTS

Multivariate analysis revealed that the radiomic features had the potential to build a prediction model for EGFR mutation. The area under the receiver operating characteristic curve (AUC) for the training cohort was 0.8618, and the AUC for the validation cohort was 0.8725, which were superior to prediction model that used clinical variables alone.

CONCLUSION

Radiomic features are better predictors of EGFR mutation status than conventional semantic CT image features or clinical variables to help doctors to decide who need EGFR tyrosine kinase inhibitor (TKI) treatment.

Recent advances in the management of non-small cell lung cancer

Lung cancer is the number one cause of cancer-related death in both men and women. However, over the last few years, we have witnessed improved outcomes that are largely attributable to early detection, increased efforts in tobacco control, improved surgical approaches, and the development of novel targeted therapies. Currently, there are several novel therapies in clinical practice, including those targeting actionable mutations and more recently immunotherapeutic agents. Immunotherapy represents the most significant step forward in eradicating this deadly disease. Given the ever-changing landscape of lung cancer management, here we present an overview of the most recent advances in the management of non-small cell lung cancer.

Pathologic subtype-defined prognosis is dependent on both tumor stage and status of oncogenic driver mutations in lung adenocarcinoma

Previous studies have shown that the prognosis of lung adenocarcinoma is associated with pathological characterization. In this study, we investigated whether pathology-based prognosis was further influenced by both tumor stage and oncogenic driver mutations. To this end, we recruited a cohort of 465 lung adenocarcinoma patients in China. These patients were classified into 6 pathology-defined subtypes i.e., lepidic-predominant adenocarcinoma (LPA), acinar-predominant adenocarcinoma (APA), papillary-predominant adenocarcinoma (PPA), micropapillary-predominant adenocarcinoma (MPA), solid-predominant adenocarcinoma (SPA), and invasive mucinous adenocarcinoma (IMA). Oncogenic mutations in EGFR, KRAS, ALK, RET, and BRAF genes were determined using fluorescent real-time RT-PCR. The associations of pathogenic subtype or oncogenic mutation with clinical characteristics were analyzed using Fisher’s exact tests. The interactive effects on overall survival (OS) by pathologic subtype, oncogenic mutations, and tumor stage were also determined. We have found that pathogenic subtype of lung adenocarcinoma correlated with smoking habit and tumor cell differentiation. These pathology-defined subtypes can be regrouped into 3 pathology-based prognostic groups: PPG1 (LPA), PPG2 (IMA+APA+PPA), and PPG3 (MPA+SPA) with a favorable, intermediate, and poor OS, respectively. We further demonstrated that this pathology-determined OS can be affected by both tumor stage and status of oncogenic mutations in EGFR, KRAS, ALK, RET, and BRAF genes. Interestingly, the presence of genetic mutations related to ALK, RET and BRAF had an opposite effect on OS between PPG2 (worsen) and PPG3 (improved) patients, reversing the prognostic favorability for patients within these two groups. In conclusion, prognosis of lung adenocarcinoma was defined interactively by pathologic subtype, tumor stage and oncogenic mutation.

Associations between epidermal growth factor receptor mutations and histological subtypes of lung adenocarcinoma according to the IASLC/ATS/ERS classification in Chinese patients

Background

This retrospective study was conducted to investigate the relationship between epidermal growth factor receptor (EGFR) mutation and histological subtypes of lung adenocarcinoma according to the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) classification in Chinese patients.

Methods

Three hundred and seventy six surgically resected lung adenocarcinomas from Chinese PLA General Hospital were included in the study. Patients’ clinical and pathological characteristics including age, gender, smoking history, tumor size, tumor node metastasis stage, and tumor differentiation were analyzed. Histologic subtypes of adenocarcinoma were categorized according to the IASLC/ATS/ERS classification of lung adenocarcinoma. An amplification‐refractory mutation system was performed to detect EGFR mutations.

Results

One hundred and fifty three lung adenocarcinomas had EGFR mutations. In univariate analysis, EGFR mutations were associated with gender (P < 0.001), smoking history (P < 0.001), tumor differentiation (P < 0.001), and acinar predominant (P < 0.001), papillary predominant (P = 0.034), solid predominant (P = 0.022), invasive mucinous (P = 0.012) and mucinous (P = 0.001) subtypes.

Conclusions

In Chinese patients with lung adenocarcinoma, smoking history, tumor differentiation, and acinar predominant and mucinous subtypes were independent predictors of EGFR mutation.

Clinical Relevance of Different Papillary Growth Patterns of Pulmonary Adenocarcinoma

Growth patterns of pulmonary adenocarcinoma (ADC) have high prognostic impact and are accepted as a novel classification system for this entity. However, specifically for the papillary pattern, divergent data with respect to prevalence, clinical associations, and prognostic impact have been reported. By evaluating 674 resected pulmonary ADCs containing 308 cases with a papillary component and 101 papillary predominant cases, we documented differences in the morphologic composition of papillary growth patterns and delineated 3 different types. The different types were correlated with pathologic and clinical data including survival. Type 3 papillary cases with any or predominant papillary growth were associated with extensive spread through alveolar spaces, high proliferation, higher stage, low rates of EGFR mutations, and smoking, whereas type 1 papillary tumors showed the opposite associations. The subclassification of papillary growth revealed type-specific associations for overall and disease-free survival (disease-free survival type 1: 67.1 mo, type 2: 56.8 mo, type 3: 49.9 mo, P=0.025). The presence of any papillary type 3 pattern was a predominant pattern independent predictor of worse overall survival (hazard ratio=2.5, P=0.02). For a future grading system of lung ADC, categorization of papillary growth in 1 single category might not be adequate, as this pattern contains a heterogenous mix of tumors with a divergent prognosis. We suggest that papillary pattern types should be separated to further improve the prognostic power of ADC growth pattern analysis.

Clinical features and treatment outcome of non-small cell lung cancer (NSCLC) patients with uncommon or complex epidermal growth factor receptor (EGFR) mutations

INTRODUCTION

Tyrosine-kinase inhibitors (TKIs) represent the best treatment for advanced non-small cell lung cancer (NSCLC) with common exon 19 deletion or exon 21 epidermal growth factor receptor mutation (EGFRm). This is an observational study investigating epidemiology, clinical features and treatment outcome of NSCLC cases harbouring rare/complex EGFRm.

RESULTS

Among 764 non-squamous NSCLC cases with known EGFRm status, 26(3.4%) harboured rare/complex EGFRm. Patients receiving first-line TKIs (N = 17) achieved median Progression Free Survival (PFS) and Overall Survival (OS) of 53 (IC 95%, 2-105) and 84 (CI 95%, 27-141) weeks respectively, without significant covariate impact. Response Rate and Disease Control Rate (DCR) were 47% and 65%, respectively. Uncommon exon 19 mutations achieved longer OS and PFS and higher DCR compared with exon 18 and 20 mutations. No additional gene mutation was discovered by MassARRAY analysis. TKIs were globally well tolerated.

MATERIALS AND METHODS

A retrospective review of advanced non-squamous NSCLC harbouring rare/complex EGFRm referred to our Center between 2010 and 2015 was performed. Additional molecular pathways disregulation was explored in selected cases, through MassARRAY analysis.

CONCLUSIONS

Peculiar clinical features and lower TKIs sensitivity of uncommon/complex compared with common EGFRm were shown. Exon 19 EGFRm achieved the best TKIs treatment outcome, while the optimal treatment of exon 18 and 20 mutations should be further clarified.

Computed tomography and clinical features associated with epidermal growth factor receptor mutation status in stage I/II lung adenocarcinoma

Background

The relationship between epidermal growth factor receptor (EGFR) gene mutation status, preoperative computed tomography (CT), and clinical features in patients with small peripheral lung adenocarcinoma (<3 cm) was investigated.

Methods

We included 209 patients who underwent surgical resection for stage I or II lung adenocarcinoma at Nanjing General Hospital between December 2010 and May 2016. 171 cases of patients underwent a pretreatment chest CT. Eleven different CT descriptors were assessed. Multiple logistic regression analyses were performed to identify independent risk factors for the prediction of EGFR mutation. Receiver operating characteristic analysis was used to evaluate the performance of the logistic regression model.

Results

EGFR mutation was determined in 126 patients (60.3%) and appeared more frequently in women (P = 0.025), never‐smokers (P < 0.001), and patients with a carcinoembryonic antigen level <2.6 ng/ml (P = 0.045). Papillary predominant adenocarcinomas (P = 0.014), intermediate/low pathologic grade tumors (P = 0.003), tumors in the upper lobe (P = 0.028), and showing ground‐glass opacity (GGO) or mixed GGO on CT (P = 0.039) also more frequently harbored EGFR mutations. GGO on CT, acinar or papillary predominant adenocarcinoma, and non‐smoker were identified in multivariable analyses as significantly independent risk factors. The multiple logistic regression model showed high predictive power for identifying EGFR mutations. The CT features were similar between the L858R and 19 deletion mutations.

Conclusions

Combined CT and clinical features may be helpful for determining the presence of EGFR mutations in patients with small peripheral lung adenocarcinoma, particularly in patients where mutational profiling is not available or possible.

Clinicopathological and prognostic features of surgically resected pathological stage I lung adenocarcinoma harboring epidermal growth factor receptor and K-ras mutation

BACKGROUND

This study aimed to evaluate mutations of the epidermal growth factor receptor (EGFR) and K-ras genes and their clinicopathological and prognostic features in patients with resected pathological stage I adenocarcinoma.

METHODS

We examined 224 patients with surgically resected lung adenocarcinoma and analyzed the prognostic and predictive value of these mutations in 162 patients with pathological stage I adenocarcinoma.

RESULTS

Mutations of the EGFR and K-ras genes were detected in 100 (44.6%) and 19 (8.5%) of all tumors, and in 81 (50.0%) and 17 (10.5%) of the pathological stage I tumors, respectively. EGFR mutations were significantly associated with female gender, smoking habit (never smoker), and low grade. By contrast, K-ras mutations were significantly associated with male gender, smoking habit (ever smoker), and the presence of mucinous components. No significant differences were observed in recurrence-free or overall survival between the EGFR-mutant, K-ras-mutant, and wild-type groups (five-year recurrence-free survival 77.8% vs. 87.8% vs. 79.5%; five-year overall survival 82.8% vs. 82.4% vs. 79.2%, respectively). Multivariate analysis showed that neither EGFR nor K-ras mutation was an independent prognostic factor.

CONCLUSIONS

The present study demonstrated that pathological stage I adenocarcinoma harboring EGFR and K-ras gene mutations have distinct clinicopathological features. The presence of these mutations alone were not prognostic factors in patients with resected pathological stage I adenocarcinoma.

Lung adenocarcinoma: Assessment of epidermal growth factor receptor mutation status based on extended models of diffusion-weighted image

PURPOSE

To evaluate the diagnostic performance of extended models of diffusion-weighted (DW) imaging to help differentiate the epidermal growth factor receptor (EGFR) mutation status in stage IIIA-IV lung adenocarcinoma.

MATERIALS AND METHODS

This retrospective study had institutional research board approval and was HIPAA compliant. Preoperative extended DW imaging including intravoxel incoherent motion (IVIM) and diffusional kurtosis imaging (DKI) 3 Tesla MRI were retrospectively evaluated in 53 patients with pathologically confirmed non-early stage (IIIA-IV) lung adenocarcinoma. EGFR mutationsat exons 18-21 were determined by using polymerase chain reaction-based ARMS. Quantitative parameters (mean, kurtosis, skewness, 10^th and 90^th percentiles) of IVIM (true-diffusion coefficient D, pseudo-diffusion coefficient D*, and perfusion fraction f) and DKI (kurtosis value Kapp, kurtosis corrected diffusion coefficient Dapp) were calculated by outlining entire-volume histogram analysis. Receiver operating characteristic analysis was constructed to determine the diagnostic performance of each parameter. Multivariate logistic regression was used to differentiate the probability of EGFR mutation status.

RESULTS

Twenty-four of 53 patients with lung adenocarcinoma were EGFR mutations, which occurred most often in acinar (10 of 13 [76.9%]) and papillary predominant tumors (9 of 13 [69.2%]). Patients with EGFR mutation showed significant higher 10^th percentile of D, lower D* value in terms of kurtosis, and lower K_app value in terms of mean, skewness, 10^th and 90^th percentiles (all P values < 0.05). The 90^th K_app showed significantly higher sensitivity (97%; P < 0.05) and Az (0.817; P < 0.05) value. Multivariate logistic regression showed 90^th K_app was a independent factor for determining EGFR mutation with odds ratio -1.657.

CONCLUSION

Multiple IVIM and DKI parameters, especially the histogram 90^th K_app value, helped differentiate EGFR mutation status in stage IIIA-IV lung adenocarcinoma.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:281-289.

Clinicopathological and immunohistochemical features of lung invasive mucinous adenocarcinoma based on computed tomography findings

Background

We performed an analysis to clarify differences in clinicopathological and molecular features of lung invasive mucinous adenocarcinoma (IMA) based on computed tomography (CT) findings and their impact on prognosis.

Patients and methods

On the basis of CT findings, we divided lung IMA into three subtypes: solid, bubbling, and pneumonic. We then investigated differences in clinicopathological characteristics, prognosis, and the expressions of well-identified biomarkers, including cyclooxygenase-2 (Cox-2), excision repair cross-complementation group 1 (ERCC1), ribonucleotide reductase M1 (RRM1), class III beta-tubulin, thymidylate synthase (TS), secreted protein acidic and rich in cysteine (SPARC), programmed cell death-1 ligand-1 (PD-L1), and epidermal growth factor receptor mutation, among the three subtypes.

Results

A total of 29 patients with resected lung IMA were analyzed. Compared with the solid or bubbling type, the pneumonic type had a higher proportion of symptoms, a larger tumor size, a higher pathological stage, and a significantly worse prognosis. The immunohistochemical findings tended to show high expression of RRM1, class III beta-tubulin, and Cox-2 in the tumor and of SPARC in the stroma, but not of ERCC1, TS, and PD-L1 in the tumor. None of the biomarkers with high expression levels in the tumor were prognostic biomarkers, but the expression of SPARC in the stroma was correlated with a poor outcome.

Conclusion

Clinical and pathological features, in conjunction with molecular data, indicate that IMA should be divided into different subgroups. In our results, the pneumonic type was correlated with a significantly worse outcome. Further studies should be performed to confirm our conclusion and to explore its molecular implications.

ALK gene rearranged lung adenocarcinomas: molecular genetics and morphology in cohort of patients from North India

ALK gene rearrangement in the lung adenocarcinomas is the second most common (1.6-11.7% of NSCLC) targetable genomic change after EGFR mutations. However, the prevalence and clinicopathological features of ALK-rearranged lung adenocarcinomas from North India are lacking. A total of 240 cases of lung adenocarcinoma were screened for EGFR mutations and for ALK expression. Smoking status, TNM stage, and treatment response were recorded in all cases. Out of 240 cases screened, 37 cases were positive for EGFR mutations and 17 cases (7.08%) showed ALK positivity with immunohistochemistry and break-apart FISH. On excluding 37 EGFR mutation-positive cases, the incidence of ALK-positive adenocarcinoma appears to be higher (17/203 cases, 8.03%). Eight were men and nine were women with mean age of 51.7 years. Majority (62.5%) were non-smokers and had unresectable disease (70.6% stage IV, 17.6% IIIB). The morphological patterns noted were solid (12 cases), papillary (four cases), and micropapillary (one case). Signet ring (two cases) and clear cell change (one cases) were noted. Out of five patients who received crizotinib, three had partial response and two had stable disease. ALK-rearranged lung adenocarcinomas account for a minor proportion of NSCLC with prevalence similar to that reported in literature. However, as contrast to published data in our series, patients were in older age group and had solid and papillary pattern on morphology with an aggressive course.

Spectrum of EGFR gene mutations and ALK rearrangements in lung cancer patients in Turkey

The EGFR gene and ALK rearrangements are two genetic drivers of non-small cell lung cancer (NSCLC). The frequency of EGFR mutations and ALK rearrangement varies according to not only ethnicity but also gender, smoking status and the histological type of NSCLC. In the present study, we demonstrated the distribution of EGFR mutations in 132 NSCLC patients by using a pyrosequencing technique and the distribution of ALK rearrangements in 51 NSCLC patients by using fluorescent in situ hybridization technique in Turkey. Additionally, we compared the clinicopathological data of NSCLC patients with the mutation status of EGFR in their cancerous tissues. Both EGFR mutations and ALK rearrangements were identified in 19 (14.39 %) and 1 (1.96 %) patients, respectively. We found EGFR mutations in codon 861, 719 and 858 with the ratios of 10.52 % (2/19), 10.52 % (2/19) and 31.58 % (6/19), respectively, and deletion of exon 19 in 47.37 % (9/19) of the patients. We found the frequency of EGFR mutations to be significantly higher in female patients and nonsmokers (p = 0.043, p = 0.027, respectively). Consequently, we found EGFR mutations to be more frequent in female patients and nonsmokers. Future studies on larger patient groups would provide more accurate data to exhibit the relationship between EGFR mutations and ALK rearrangements and the clinicopathological status.

Multi-institutional Oncogenic Driver Mutation Analysis in Lung Adenocarcinoma: The Lung Cancer Mutation Consortium Experience

INTRODUCTION

Molecular genetic analyses of lung adenocarcinoma have recently become standard of care for treatment selection. The Lung Cancer Mutation Consortium was formed to enable collaborative multi-institutional analyses of 10 potential oncogenic driver mutations. Technical aspects of testing and clinicopathologic correlations are presented.

METHODS

Mutation testing in at least one of the eight genes (epidermal growth factor receptor [EGFR], KRAS, ERBB2, AKT1, BRAF, MEK1, NRAS, and PIK3CA) using SNaPshot, mass spectrometry, Sanger sequencing+/- peptide nucleic acid and/or sizing assays, along with anaplastic lymphoma kinase (ALK) and/or MET fluorescence in situ hybridization, were performed in six labs on 1007 patients from 14 institutions.

RESULTS

In all, 1007 specimens had mutation analysis performed, and 733 specimens had all 10 genes analyzed. Mutation identification rates did not vary by analytic method. Biopsy and cytology specimens were inadequate for testing in 26% and 35% of cases compared with 5% of surgical specimens. Among the 1007 cases with mutation analysis performed, EGFR, KRAS, ALK, and ERBB2 alterations were detected in 22%, 25%, 8.5%, and 2.4% of cases, respectively. EGFR mutations were highly associated with female sex, Asian race, and never-smoking status; and less strongly associated with stage IV disease, presence of bone metastases, and absence of adrenal metastases. ALK rearrangements were strongly associated with never-smoking status and more weakly associated with presence of liver metastases. ERBB2 mutations were strongly associated with Asian race and never-smoking status. Two mutations were seen in 2.7% of samples, all but one of which involved one or more of PIK3CA, ALK, or MET.

CONCLUSION

Multi-institutional molecular analysis across multiple platforms, sample types, and institutions can yield consistent results and novel clinicopathological observations.

CT Features Associated with Epidermal Growth Factor Receptor Mutation Status in Patients with Lung Adenocarcinoma

Purpose To retrospectively identify the relationship between epidermal growth factor receptor (EGFR) mutation status, predominant histologic subtype, and computed tomographic (CT) characteristics in surgically resected lung adenocarcinomas in a cohort of Asian patients. materials and Methods This study was approved by the institutional review board, with waiver of informed consent. Preoperative chest CT findings were retrospectively evaluated in 385 surgically resected lung adenocarcinomas. A total of 30 CT descriptors were assessed. EGFR mutations at exons 18-21 were determined by using the amplification refractory mutation system. Multiple logistic regression analyses were performed to identify independent factors of harboring EGFR mutation status. The final model was selected by using the backward elimination method, and two areas under the receiver operating characteristic curve (ROC) were compared with the nonparametric approach of DeLong, DeLong, and Clarke-Pearson. Results EGFR mutations were found in 168 (43.6%) of 385 patients. Mutations were found more frequently in (a) female patients (P < .001); (b)those who had never smoked (P < .001); (c)those with lepidic predominant adenocarcinomas (P = .001) or intermediate pathologic grade (P < .001); (e) smaller tumors (P < .001); (f)tumors with spiculation (P = .019), ground-glass opacity (GGO) or mixed GGO (P < .001), air bronchogram (P = .006), bubblelike lucency (P < .001), vascular convergence (P = .024), thickened adjacent bronchovascular bundles (P = .027), or pleural retraction (P < .001); and (g) tumors without pleural attachment (P = .004), a well-defined margin (P = .010), marked heterogeneous enhancement (P = .001), severe peripheral emphysema (P = .002), severe peripheral fibrosis (P = .013), or lymphadenopathy (P = .028). The most important and significantly independent prognostic factors of harboring EGFR-activating mutation for the model with both clinical variables and CT features were those who had never smoked and those with smaller tumors, bubblelike lucency, homogeneous enhancement, or pleural retraction when adjusting for histologic subtype, pathologic grade, or thickened adjacent bronchovascular bundles. ROC curve analysis showed that use of clinical variables combined with CT features (area under the ROC curve = 0.778) was superior to use of clinical variables alone (area under the ROC curve = 0.690). Conclusion CT imaging features of lung adenocarcinomas in combination with clinical variables can be used to prognosticate EGFR mutation status better than use of clinical variables alone. (©) RSNA, 2016 Online supplemental material is available for this article.

Association between the histological subtype of lung adenocarcinoma, EGFR/KRAS mutation status and the ALK rearrangement according to the novel IASLC/ATS/ERS classification

The present study aimed to investigate the association between epidermal growth factor receptor (EGFR)/Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations, anaplastic lymphoma receptor tyrosine kinase (ALK) rearrangements and the morphological characteristics of lung adenocarcinoma (LAC), according to the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) classification in a large group of patients with primary LAC. A total of 200 patients with invasive LAC who had undergone complete resections at the Beijing Chest Hospital (Beijing, China) were randomly selected. The morphology of the samples was reassessed in 5% increments by two pathologists, according to the IASLC/ATS/ERS scheme. EGFR and KRAS mutations were tested by direct DNA sequencing. ALK rearrangements were screened by immunohistochemistry on a Benchmark XT stainer. The data revealed that EGFR and KRAS mutations, and ALK rearrangements were identified in 46.0% (92/200), 9.0% (18/200) and 11.5% (23/200) of the patients, respectively. The EGFR/KRAS mutations and ALK rearrangements were mostly exclusive. However, 1 patient exhibited the coexistence of the EGFR (at exon 20) and KRAS (codon 12) mutations, and another patient exhibited the coexistence of the EGFR mutation (at exon 21) and the ALK gene fusion. EGFR mutations were indicated to be closely associated with the acinar predominant (43/77; 55.8%; P=0.030) and papillary predominant (26/49; 53.1%; P=0.006) subtypes. KRAS mutations were more commonly associated with the solid predominant subtype (9/52; 17.3%; P=0.023) and invasive mucinous LAC (5/10; 50.0%; P=0.004), and less commonly associated with the acinar predominant subtype (1/77; 1.3%; P=0.002). ALK rearrangements more commonly occurred in the solid predominant subtype compared with other subtypes (13/52; 25%; P=0.002), and less commonly occurred in the papillary predominant subtype (1/49; 2.0%; P=0.004). Tumors harboring ALK rearrangements were characterized by signet-ring cell (7/9; 77.8%; P<0.0001) and cribriform (7/12; 58.3%; P<0.0001) patterns. The association between the mutation status and histological subtype in LAC was distinct. The predominant subtype according to the IASLC/ATS/ERS classification provided important information for gene mutations and integrated clinical findings to improve the treatment of LAC patients.

Improvement in imaging diagnosis technique and modalities for solitary pulmonary nodules: from ground-glass opacity nodules to part-solid and solid nodules

With advances in CT technology and the popularity of low-dose CT as a device for lung cancer screening, the detection rate of sub-solid pulmonary nodules as well as solid nodules has been increased. Distinguishing solid from sub-solid features is an essential step in the CT evaluation of solitary pulmonary nodules (SPNs) because strategies for nodule characterization and guidelines for management are different for each category. In addition to conventional CT parameters, numerous novel concepts and modalities have been developed. Although there is currently no single effective method for differentiating malignant from benign nodules, growth rate measurement using volumetry, evaluation of tumor vascularity on dynamic helical CT, dual-energy CT and MRI and physiologic evaluation with PET/CT can all be useful for nodule characterization. New techniques such as tomosynthesis can improve detection over radiography alone. The purpose of this article is to enhance our understanding of the evidence-based strategies involved in diagnosing SPNs.