Update in Lung Cancer 2015

Ultrasound Guided Biopsy among Patients with Lung Lesions Undergoing Procedures in Interventional Radiology of a Tertiary Care Centre

Introduction

Minimally invasive image-guided percutaneous core needle biopsy can obtain tissue samples for diagnosis of subpleural lung cancer, which is crucial for the correct management of lung lesions. Common complications of lung biopsy include pneumothorax, parenchymal haemorrhage and haemoptysis. The study aimed to determine the prevalence of ultrasound-guided biopsy among patients with lung lesions undergoing procedures in interventional radiology of a tertiary care centre.

Methods

A descriptive cross-sectional study was performed in the Department of Radiology and Imaging from 1 August 2018 to 30 September 2019 after obtaining ethical approval from the Institutional Review Committee. USG-guided biopsy of peripheral lung lesions was performed with an 18 gauge semiautomatic biopsy instrument and a 17 gauge coaxial needle. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 188 biopsy of lung lesions, ultrasound-guided biopsies were performed in 28 (14.89%) (9.80-19.98, 95% Confidence Interval).

Conclusions

The prevalence of ultrasound guided biopsy among lung lesions is lower than other studies done in similar settings.

Keywords

biopsy; interventional radiology; lung neoplasms; prevalence.

p21-activated kinase 2 binds to transcription factor SOX2 and up-regulates DEK to promote the progression of lung squamous cell carcinoma

Lung squamous cell carcinoma (LSCC) is a prevalent and progressive subtype of lung cancer. This study aimed to substantiate the regulatory effect of the PAK2/SOX2/DEK axis on the LSCC development. LSCC tissues (n = 83) and adjacent normal tissues were collected and SOX2 expression was determined by qRT-PCR and Western blotting. Correlation between SOX2 expression and the prognosis of LSCC patients was then explored utilizing Kaplan-Meier analysis. Co-immunoprecipitation and glutathione-S-transferase pull-down assays were conducted to validate the binding of SOX2 to DEK. Gain- and loss- of function assays were then performed on LSCC cells, with CCK-8 and Transwell assays applied to detect the malignant behaviors of cells. A mouse xenograft model of LSCC was further established for in vivo validation. The expression levels of SOX2, PAK2 and DEK were up-regulated in LSCC tissues and cells. SOX2 overexpression was correlated with poor prognosis of LSCC patients. Knockdown of SOX2 weakened the viability and the migratory and invasive potential of LSCC cells. Further, PAK2 directly interacted with SOX2. PAK2 overexpression accelerated the malignant phenotypes of LSCC cells through interplay with SOX2. Moreover, SOX2 activated the expression of DEK, and silencing DEK attenuated the malignant behaviors of LSCC cells. In conclusion, PAK2 could bind to the transcription factor SOX2 and thus activate the expression of DEK, thereby driving the malignant phenotypes of LSCC cells both in vivo and in vitro.

Precision Medicine Testing and Disparities in Health Care for Individuals With Non-Small Cell Lung Cancer: A Narrative Review

PROBLEM IDENTIFICATION

Precision medicine initiatives provide opportunities for optimal targeted therapy in individuals with non-small cell lung cancer. However, there are barriers to these initiatives that reflect social determinants of health.

LITERATURE SEARCH

MEDLINE®, CINAHL®, PsycINFO®, Embase®, and Google ScholarTM databases were searched for articles published in English in the United States from 2016 to 2020.

DATA EVALUATION

Data that were collected included individual demographic information, specific diagnosis, status of targeted genomic testing, and receipt of targeted therapy. All studies were retrospective and involved database review of insurance claims or medical records.

SYNTHESIS

Individuals with non-small cell lung cancer received less genetic testing and targeted therapy if they were of a lower socioeconomic status, had public health insurance or no health insurance, were Black, or lived in rural communities.

IMPLICATIONS FOR NURSING

Social determinants of health affect health equity, including in precision medicine initiatives for individuals with lung cancer. Gaining an understanding of this impact is the first step in mitigating inequities.

Exposure to Cigarette Smoke Enhances the Stemness of Alveolar Type 2 Cells

Chronic exposure to cigarette smoke (CS) causes chronic inflammation, oxidative stress, and apoptosis of epithelial cells, which results in destruction of the lung matrix. However, the mechanism by which the lung fails to repair the CS-induced damage, thereby succumbing to emphysema, remains unclear. Alveolar type 2 (AT2) cells comprise the stem cells of the alveolar compartments and are responsible for repairing and maintaining lung tissues. In this study, we examined the effect of chronic CS on AT2 stem cells. Adult mice expressing GFP in their AT2 cells were exposed to CS for > 3 months. Histological assessment showed that CS not only induced emphysematous changes but also increased the number of AT2 cells compared with that of air-exposed lungs. Assessment of sorted GFP+/AT2 cells via the stem cell three-dimensional organoid/colony-forming assay revealed that the number and size of the colonies formed by the CS-exposed AT2 stem cells were significantly higher than those of air-exposed control AT2 cells. Although CS-exposed lungs had more apoptotic cells, examination of the surviving AT2 stem cells in two-dimensional in vitro culture revealed that they developed a higher ability to resist apoptosis. Microarray analysis of CS-exposed AT2 stem cells revealed the upregulation of genes related to circadian rhythm and inflammatory pathways. In conclusion, we provide evidence that AT2 stem cells respond to chronic CS exposure by activating their stem cell function, thereby proliferating and differentiating faster and becoming more resistant to apoptosis. Disturbances in expression levels of several circadian rhythm-related genes might be involved in these changes.

Next-Generation Sequencing at High Sequencing Depth as a Tool to Study the Evolution of Metastasis Driven by Genetic Change Events of Lung Squamous Cell Carcinoma

Background: The aim of this study is to report tumoral genetic mutations observed at high sequencing depth in a lung squamous cell carcinoma (SqCC) sample. We describe the findings and differences in genetic mutations that were studied by deep next-generation sequencing methods on the primary tumor and liver metastasis samples. In this report, we also discuss how these differences may be involved in determining the tumor progression leading to the metastasis stage.

Methods: We followed one lung SqCC patient who underwent FDG-PET scan imaging, before and after three months of treatment. We sequenced 26 well-known cancer-related genes, at an average of ~6,000 × sequencing coverage, in two spatially distinct regions, one from a primary lung tumor metastasis and the other from a distal liver metastasis, which was present before the treatment.

Results: A total of 3,922,196 read pairs were obtained across all two samples' sequenced locations. Merged mapped reads showed several variants, from which we selected 36 with high confidence call. While we found 83% of genetic concordance between the distal metastasis and primary tumor, six variants presented substantial discordance. In the liver metastasis sample, we observed three de novo genetic changes, two on the FGFR3 gene and one on the CDKN2A gene, and the frequency of one variant found on the FGFR2 gene has been increased. Two genetic variants in the HRAS gene, which were present initially in the primary tumor, have been completely lost in the liver tumor. The discordant variants have coding consequences as follows: FGFR3 (c.746C>G, p. Ser249Cys), CDKN2A (c.47_50delTGGC, p. Leu16Profs^*9), and HRAS (c.182A>C, p. Gln61Pro). The pathogenicity prediction scores for the acquired variants, assessed using several databases, reported these variants as pathogenic, with a gain of function for FGFR3 and a loss of function for CDKN2A. The patient follow-up using imaging with 18F-FDG PET/CT before and after four cycles of treatment shows discordant tumor progression in metastatic liver compared to primary lung tumor.

Conclusions: Our results report the occurrence of several genetic changes between primary tumor and distant liver metastasis in lung SqCC, among which non-silent mutations may be associated with tumor evolution during metastasis.

Genomic Underpinnings of Tumor Behavior in In Situ and Early Lung Adenocarcinoma

Rationale: We have a limited understanding of the molecular underpinnings of early adenocarcinoma (ADC) progression. We hypothesized that the behavior of early ADC can be predicted based on genomic determinants.Objectives: To identify genomic alterations associated with resected indolent and aggressive early lung ADCs.Methods: DNA was extracted from 21 ADCs in situ (AISs), 27 minimally invasive ADCs (MIAs), and 54 fully invasive ADCs. This DNA was subjected to deep next-generation sequencing and tested against a custom panel of 347 cancer genes.Measurements and Main Results: Sequencing data was analyzed for associations among tumor mutation burden, frequency of mutations or copy number alterations, mutation signatures, intratumor heterogeneity, pathway alterations, histology, and overall survival. We found that deleterious mutation burden was significantly greater in invasive ADC, whereas more copy number loss was observed in AIS and MIA. Intratumor heterogeneity establishes early, as in AIS. Twenty-one significantly mutated genes were shared among the groups. Mutation signature profiling did not vary significantly, although the APOBEC signature was associated with ADC and poor survival. Subclonal KRAS mutations and a gene signature consisting of PIK3CG, ATM, EPPK1, EP300, or KMT2C mutations were also associated with poor survival. Mutations of KRAS, TP53, and NF1 were found to increase in frequency from AIS and MIA to ADC. A cancer progression model revealed selective early and late drivers.Conclusions: Our results reveal several genetic driver events, clonality, and mutational signatures associated with poor outcome in early lung ADC, with potential future implications for the detection and management of ADC.

Compound C620-0696, a new potent inhibitor targeting BPTF, the chromatin-remodeling factor in non-small-cell lung cancer

Bromodomain PHD-finger transcription factor (BPTF) is the largest subunit of the nucleosome remodeling factor and plays an important role in chromatin remodeling for gene activation through its association with histone acetylation or methylation. BPTF is also involved in oncogene transcription in diverse progressions of cancers. Despite clinical trials for inhibitors of bromodomain and extra-terminal family proteins in human cancers, no potent and selective inhibitor targeting the BPTF bromodomain has been discovered. In this study, we identified a potential inhibitor, namely, C620-0696, by computational docking modeling to target bromodomain. Results of biolayer interferometry revealed that compound C620-0696 exhibited high binding affinity to the BPTF bromodomain. Moreover, C620-0696 was cytotoxic in BPTF with a high expression of non-small-cell lung cancer (NSCLC) cells. It suppressed the expression of the BPTF target gene c-MYC, which is known as an oncogenic transcriptional regulator in various cancers. C620-0696 also partially inhibited the migration and colony formation of NSCLC cells owing to apoptosis induction and cell cycle blockage. Thus, our study presents an effective strategy to target a bromodomain factor-mediated tumorigenesis in cancers with small molecules, supporting further exploration of the use of these inhibitors in oncology.

Interventional Pulmonology: A Focused Review for Primary Care Physicians

Interventional pulmonology (IP) has evolved in recent decades, and recent advances have greatly expanded the services offered by IP physicians. IP is best defined as the use of advanced techniques for the evaluation and treatment of benign and malignant pulmonary disorders. The field has further advanced with the recent establishment of a board certification via the American Association of Bronchology and Interventional Pulmonology and the release in 2017 of accreditation standards for specialized fellowship training. This article provides a broad overview of the field to serve as a resource for primary care physicians.

Radiologic features of precancerous areas of the lungs in chronic obstructive pulmonary disease

BACKGROUND

Only a few studies have evaluated the radiologic features of pre-existing structural abnormalities where lung cancer may develop. This study aimed to analyze the computed tomography (CT) images of lung areas where new cancer developed in chronic obstructive pulmonary disease (COPD) patients.

PATIENTS AND METHODS

We conducted a multicenter, longitudinal cohort study, called the Keio COPD Comorbidity Research, to assess the incidence of lung cancer. Emphysema and interstitial abnormalities were evaluated in 240 COPD patients who had baseline CT scans applicable for further digital analyses. For patients who developed lung cancer during the 3-year follow-up period, the local spherical lung density of the precancerous area was individually quantified.

RESULTS

Lung cancer was newly diagnosed in 21 participants (2.3% per year). The percent-age of low attenuation area in patients who developed lung cancer was higher than that of the other patients (20.0% vs 10.4%, P=0.014). The presence of emphysema (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.0-29.0, P=0.049) or interstitial lung abnormalities (OR 15.6, 95% CI 4.4-65.4, P<0.0001) independently increased the risk for lung cancer. Compared with the density of the entire lung, the local density of the precancerous area was almost the same in patients with heterogeneous emphysema, but it was higher in most patients with interstitial abnormalities.

CONCLUSION

The presence of emphysema or interstitial abnormalities or a combination of both were independent predictors of lung cancer development in COPD patients. Furthermore, lung cancer most often developed in non-emphysematous areas or in interstitial abnormalities.

Pulmonary Infiltrates in a Patient With Advanced Melanoma

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 60-year-old former smoker with metastatic melanoma presented with the chief complaint of pulmonary infiltrates. Five years ago, he was diagnosed with a left chest wall melanoma. He underwent surgery but received no additional therapy for an American Joint Committee on Cancer stage T3a N0 M0 tumor that was 2.7 mm in depth with no ulceration of the epidermal surface. Resection margins were free of tumor. Four years later, he underwent excision of a raised pigmented skin lesion on his left calf that proved to be melanoma with positive margins. He underwent re-excision of melanoma but 2 months later developed a new left hip soft tissue nodule. Positron emission tomography (PET) -computed tomography showed multiple hypermetabolic lesions involving subcutaneous tissue, muscle osseous structures, and bone marrow, consistent with advanced melanoma. He began systemic therapy with ipilimumab and nivolumab. After four cycles of immunotherapy, he developed a nonproductive cough and mild dyspnea on exertion (Modified Medical Research Council dyspnea scale score of 2 [ie, he had to stop for breath when walking at his own pace on level ground]). A chest x-ray showed bilateral hilar enlargement, thickening of the right paratracheal stripe, and scattered patchy increased interstitial markings bilaterally. PET and chest computed tomography images showed enlarged mediastinal adenopathy with increased [¹⁸F]fluorodeoxyglucose uptake on PET and scattered diffuse 1- to 2-mm pulmonary nodules with ground-glass opacities ( Fig 1 ). The patient was referred for pulmonary input. The patient had smoked one pack of cigarettes per day for 35 years; he quit 6 years ago. He had no history of pneumonia, childhood asthma, or tuberculosis. His mother had asthma, but there was no other family history of asthma or other lung disease.