Prognostic factors in stage III non-small cell lung cancer: a review of conventional, metabolic and new biological variables

Descriptive analysis of durvalumab use in unresectable stage III non-small cell lung cancer in patients treated in Quebec's University teaching hospitals

Introduction

Consolidation durvalumab post chemo-radiotherapy (CRT) has been demonstrated to improve survival in locally advanced non-small-cell lung cancer (NSCLC). Real-world data to assess its use and impact on patients, particularly in Quebec, remain limited.

Methods

We, therefore, aimed to assess real-world durvalumab use in inoperable stage III NSCLC in Quebec, to describe progression-free survival (PFS) and overall survival (OS) outcomes as reported in the PACIFIC trial, and to evaluate safety and toxicity. Patients were retrospectively reviewed between January 1rst 2019 and December 31st 2020, based on their oncology reference date.

Results

One hundred and eight patients treated with CRT were included, among which 82 received durvalumab (75.9%). The mean duration of treatment was 48 weeks [4-52], and 55% of patients completed the full treatment. Median PFS was 40 months in patients treated with CRT + durvalumab vs 6.9 months with CRT alone, with a hazard ratio (HR) of 0.22 (95% confidence interval (CI) 0.13-0.37; p < 0.0001). Limited access to CT scanning during the COVID pandemic, might have led to delayed disease progression detection and thus prolonged PFS. Median OS was > 52.8 months with CRT + durvalumab vs 19 months with CRT alone (HR 0.33, 95% CI 0.18-0.60; p=0.0002).

Discussion

These findings support the efficacy and safety profile of durvalumab in real-world settings.

Real-World Efficacy and Safety of Durvalumab Administration Following Chemoradiotherapy in Elderly Patients With Unresectable Locally Advanced Nonsmall Cell Lung Cancer: A Multicenter, Retrospective Study

BACKGROUND

The PACIFIC trial established durvalumab administration after chemoradiotherapy as the standard of care for unresectable locally advanced nonsmall cell lung cancer (LA-NSCLC). However, the efficacy and safety of durvalumab in elderly patients aged 75 years or above remains unclear. This study aimed to investigate the real-world efficacy and safety of durvalumab for LA-NSCLC, with a specific focus on elderly patients.

PATIENTS AND METHODS

We reviewed 214 patients who received durvalumab out of 278 patients with unresectable LA-NSCLC who underwent chemoradiotherapy at 7 institutions between July 2018 and March 2022. Propensity score matching (PSM) analysis was performed to evaluate the efficacy of durvalumab in elderly patients.

RESULTS

The 2-year progression-free survival (PFS) and 2-year overall survival (OS) rates were 42.2% (95% confidence interval [CI], 34.7%-49.5%) and 77.1% (95% CI, 70.1-82.7%), respectively. Grade ≥ 3 immune-related adverse events (irAEs) occurred in 8.2% of patients. PSM analysis revealed that OS was significantly shorter in elderly patients (≥ 75 years) than in younger patients (< 75 years) (hazard ratio [HR]; 95% CI, 1.39-8.99; P = .008), whereas PFS did not differ significantly between the 2 groups (HR: 1.50, 95% CI, 0.84-2.68, P = .169). The frequency of irAEs did not differ between these groups.

CONCLUSIONS

The real-world efficacy and safety of durvalumab administration following chemoradiotherapy for LA-NSCLC coincided with the PACIFIC trial's findings. Disease control achieved with this protocol did not differ significantly between elderly and younger patients but had acceptable tolerability, demonstrating its benefit even in elderly LA-NSCLC patients aged 75 years or above.

Treatment of unresectable stage III non-small cell lung cancer for patients who are under-represented in clinical trials

Concurrent chemoradiotherapy (cCRT) followed by one year of consolidation durvalumab is the current standard-of-care for patients with unresectable stage III non-small cell lung cancer (NSCLC), of good functional status. However, cCRT and consolidation durvalumab may be challenging to administer for selected patient populations underrepresented or even excluded in clinical trials: older and/or frail patients; those with cardiovascular or respiratory comorbidities in which treatment-related adverse events may be higher, and patients with pre-existing autoimmune disorders for whom immunotherapy use is controversial. In this narrative review, we discuss the current evidence, challenges, ongoing clinical trials and potential future treatment scenarios in relevant subgroups of patients with locally advanced NSCLC, who are underrepresented in clinical trials.

Consensus of the Taiwanese dermatological association and Taiwan Lung Cancer Society on the prevention and management of tyrosine kinase inhibitor-related skin toxicities in patients with non-small cell lung cancer: An updated version incorporating Taiwanese treatment experience

The 2023 consensus from the Taiwanese Dermatological Association (TDA) and Taiwan Lung Cancer Society (TLCS) addresses the management of tyrosine kinase inhibitor (TKI)-induced skin toxicities in non-small cell lung cancer (NSCLC). Providing a comprehensive overview, the consensus reflects recent advances in understanding causes and developmental processes of TKI-related skin toxicities. Aimed at guiding clinicians in Taiwan, the consensus integrates new treatment perspectives while incorporating experiences from local dermatology experts. Recommendations underwent a voting process, achieving consensus when 75% or more of experts agreed, leading to their inclusion. Approved by over 90% of participants, the recommended treatment algorithms for major skin toxicities offer valuable insights for clinicians managing TKI-associated effects in NSCLC patients.

Real-world outcomes with durvalumab after chemoradiotherapy in patients with unresectable stage III NSCLC: interim analysis of overall survival from PACIFIC-R

BACKGROUND

Based on the findings of the PACIFIC trial, consolidation durvalumab following platinum-based chemoradiotherapy (CRT) is a global standard of care for patients with unresectable, stage III non-small-cell lung cancer (NSCLC). An earlier analysis from the ongoing PACIFIC-R study (NCT03798535) demonstrated the effectiveness of this regimen in terms of progression-free survival (PFS). Here, we report the first planned overall survival (OS) analysis.

PATIENTS AND METHODS

PACIFIC-R is an observational/non-interventional, retrospective study of patients with unresectable, stage III NSCLC who started durvalumab (10 mg/kg intravenously every 2 weeks) within an AstraZeneca-initiated early access program between September 2017 and December 2018. Primary endpoints are OS and investigator-assessed PFS, estimated using the Kaplan-Meier method.

RESULTS

By 30 November 2021, the full analysis set included 1154 participants from 10 countries (median follow-up in censored patients: 38.7 months). Median OS was not reached, and the 3-year OS rate was 63.2% (95% confidence interval 60.3% to 65.9%). Three-year OS rates were numerically higher among patients with programmed death-ligand 1 (PD-L1) expression on ≥1% versus <1% of tumor cells (TCs; 67.0% versus 54.4%) and patients who received concurrent CRT (cCRT) versus sequential CRT (sCRT) (64.8% versus 57.9%).

CONCLUSIONS

PACIFIC-R data continue to provide evidence for the effectiveness of consolidation durvalumab after CRT in a large, diverse, real-world population. Better outcomes were observed among patients with PD-L1 TCs ≥1% and patients who received cCRT. Nevertheless, encouraging outcomes were still observed among patients with TCs <1% and patients who received sCRT, supporting use of consolidation durvalumab in a broad population of patients with unresectable, stage III NSCLC.

Augmenting external control arms using Bayesian borrowing: a case study in first-line non-small cell lung cancer

Aim: This study aimed to improve comparative effectiveness estimates and discuss challenges encountered through the application of Bayesian borrowing (BB) methods to augment an external control arm (ECA) constructed from real-world data (RWD) using historical clinical trial data in first-line non-small-cell lung cancer (NSCLC). Materials & methods: An ECA for a randomized controlled trial (RCT) in first-line NSCLC was constructed using ConcertAI Patient360™ to assess chemotherapy with or without cetuximab, in the bevacizumab-inappropriate subpopulation. Cardinality matching was used to match patient characteristics between the treatment arm (cetuximab + chemotherapy) and ECA. Overall survival (OS) was assessed as the primary outcome using Cox proportional hazards (PH). BB was conducted using a static power prior under a Weibull PH parameterization with borrowing weights from 0.0 to 1.0 and augmentation of the ECA from a historical control trial. Results: The constructed ECA yielded a higher overall survival (OS) hazard ratio (HR) (HR = 1.53; 95% CI: 1.21-1.93) than observed in the matched population of the RCT (HR = 0.91; 95% CI: 0.73-1.13). The OS HR decreased through the incorporation of BB (HR = 1.30; 95% CI: 1.08-1.54, borrowing weight = 1.0). BB was applied to augment the RCT control arm via a historical control which improved the precision of the observed HR estimate (1.03; 95% CI: 0.86-1.22, borrowing weight = 1.0), in comparison to the matched population of the RCT alone. Conclusion: In this study, the RWD ECA was unable to successfully replicate the OS estimates from the matched population of the selected RCT. The inability to replicate could be due to unmeasured confounding and variations in time-periods, follow-up and subsequent therapy. Despite these findings, we demonstrate how BB can improve precision of comparative effectiveness estimates, potentially aid as a bias assessment tool and mitigate challenges of traditional methods when appropriate external data sources are available.

A retrospective study on the effect of Chinese patent medicine combined with conventional treatment on the survival outcomes of 313 patients with stage II-III NSCLC

PURPOSE

We aim to explore the effect of Chinese Patent Medicine (CPM), including Huisheng oral solution (HSOS) on the 4-year survival rate of patients with stage II and III non-small cell lung cancer, and assess the association between blood coagulation indicators and survival outcomes.

MATERIALS AND METHODS

313 patients diagnosed with stage II and III NSCLC were collected during 2015-2016. Kaplan-Meier method and Cox proportional hazard model were applied to analyze the factors affecting the 4-year survival rate of patients.

RESULTS

According to the effect of CPM, the medicine prescribed in this study could be classified into two types. The proportion of patients who received "Fuzheng Quyu" CPM for more than three months was higher than the proportion of patients who received other two types of CPM for more than three months. Medical records of 313 patients with NSCLC were analyzed. 4-year survival rate for patients received CPM more than 6 months and 3 months were higher than those received CPM less than 3 months (P = 0.028 and P = 0.021 respectively. In addition, 4-year survival rate for patients who received HSOS for more than 3 months was higher than those who received HSOS for less than 3 months (P = 0.041). Patients with elevated preoperative fibrinogen (FIB) level and those without surgery had an increased mortality risk (HR = 1.98, P < 0.01, and HR = 2.76, P < 0.01 respectively).

CONCLUSION

The medium and long-term use of CPM/HSOS was positively associated with higher survival rate in NSCLC patients. Patients with high-level preoperative FIB level and those without surgery might have a poor prognosis in the following years.

Unusual mass in the heart: A case report

Carcinoma lung is a concerning cause of mortality worldwide. Approximately half of the cases are metastatic at diagnosis and uncommon metastatic sites confer a worse prognosis. Intracardiac metastasis from lung cancer is rare and limited to a few case reports. The authors describe the case of a 54-year female with left ventricular cavity mass as one of the rarest presentations of lung malignancy. She presented to the cardiology outpatient department with a history of progressive dyspnea for the last two months. Her 2D echocardiogram showed a large heterogeneous mass in the left ventricle cavity along with gross pericardial and pleural effusion. CT guided lung biopsy revealed adenocarcinoma of the lung. The patient was started on tablet geftinib along with other supportive therapy, while awaiting reports of next generation sequencing (NGS) for mutation analysis and immunohistochemistry. However, the patient's condition rapidly worsened and she succumbed to death within one week of hospital admission. Cardiac metastasis is one of the rarest sites for lung cancer spread. Intracavitary metastasis as in our case is an extremely rare presentation. Treatment is not yet well defined for such cases and it carries a poor prognosis despite available therapies. This case required multidisciplinary approach with involvement of cardiologist, oncologist, pulmonologist and intensivists. Further research is required to help define better treatment options.

Circulating Biomarkers for Prediction of Immunotherapy Response in NSCLC

Non-small cell lung cancer (NSCLC) constitutes the majority of the lung cancer population and the prognosis is poor. In recent years, immunotherapy has become the standard of care for advanced NSCLC patients as numerous trials demonstrated that immune checkpoint inhibitors (ICI) are more efficacious than conventional chemotherapy. However, only a minority of NSCLC patients benefit from this treatment. Therefore, there is an unmet need for biomarkers that could accurately predict response to immunotherapy. Liquid biopsy allows repeated sampling of blood-based biomarkers in a non-invasive manner for the dynamic monitoring of treatment response. In this review, we summarize the efforts and progress made in the identification of circulating biomarkers that predict immunotherapy benefit for NSCLC patients. We also discuss the challenges with future implementation of circulating biomarkers into clinical practice.

Diagnosis and management of patients with stage III non‑small cell lung cancer: A joint statement by the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society (Review)

Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC.

Is the neutrophil-to-lymphocyte ratio a prognostic factor in non-small cell lung cancer patients who receive adjuvant chemotherapy?

Inflammation plays a key role in malignant tumor progression. Neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and, as such, high isolated pretreatment NLR has been shown in some studies to be associated with worse long-term outcomes. We summarize the data regarding the utility of NLR as a prognosis factor and present results of a single institution study assessing the usefulness of high preoperative NLR as a prognosis factor for patients with successfully resected NSCLC who receive adjuvant cisplatin-based chemotherapy. While largely supportive of the value of NLR as a prognostic factor, the literature is not consistent and suggest a more nuanced association. Our single institution study adds to the exiting literature. We conclude preoperative NLR can be used as a reliable, cost-effective biomarker to estimate prognosis in NSCLC patients who have undergone lung lobectomy with curative intent followed by cisplatin-based adjuvant chemotherapy.

Prognostic value of 18F-FDG PET/CT radiomic model based on primary tumor in patients with non-small cell lung cancer: A large single-center cohort study

Objectives

In the present study, we aimed to determine the prognostic value of the 18F-FDG PET/CT-based radiomics model when predicting progression-free survival (PFS) and overall survival (OS) in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 368 NSCLC patients who underwent 18F-FDG PET/CT before treatment were randomly assigned to the training (n = 257) and validation (n = 111) cohorts. Radiomics signatures from PET and CT images were obtained using LIFEx software, and then clinical and complex models were constructed and validated by selecting optimal parameters based on PFS and OS to construct radiomics signatures.

Results

In the training cohort, the C-index of the clinical model for predicting PFS and OS in NSCLC patients was 0.748 and 0.834, respectively, and the AUC values ​​were 0.758 and 0.846, respectively. The C-index of the complex model for predicting PFS and OS was 0.775 and 0.881, respectively, and the AUC values ​​were 0.780 and 0.891, respectively. The C-index of the clinical model for predicting PFS and OS in the validation group was 0.729 and 0.832, respectively, and the AUC values ​​were 0.776 and 0.850, respectively. The C-index of the complex model for predicting PFS and OS was 0.755 and 0.867, respectively, and the AUC values ​​were 0.791 and 0.874, respectively. Moreover, decision curve analysis showed that the complex model had a higher net benefit than the clinical model.

Conclusions

18F-FDG PET/CT radiomics before treatment could predict PFS and OS in NSCLC patients, and the predictive power was higher when combined with clinical factors.

Evaluation of potential anti-metastatic and antioxidative abilities of natural peptides derived from Tecoma stans (L.) Juss. ex Kunth in A549 cells

Background

Tecoma stans (L.) Juss. ex Kunth is a well-known medicinal plant found in tropical and subtropical regions. It contains a broad range of bioactive compounds that exhibit many biological effects, including antidiabetic, antibacterial, and antioxidative activities. However, the effect of natural peptides from T. stans against cancer progression and free radical production is unknown. This study aims to evaluate the cytotoxic, anti-metastatic, and antioxidative activities of natural peptides from T. stans on A549 cells.

Methods

The natural peptides were extracted from the flower of T. stans using the pressurized hot water extraction (PHWE) method, followed by size exclusion chromatography and solid-phase extraction-C18. The cytotoxic and anti-metastatic effects of natural peptides were evaluated using MTT and transwell chamber assays, respectively. The free radical scavenging activity of natural peptides was determined using ABTS, DPPH, and FRAP assays. The cells were pretreated with the IC₅₀ dosage of natural peptides and stimulated with LPS before analyzing intracellular reactive oxygen species (ROS) and proteomics.

Results

Natural peptides induced cell toxicity at a concentration of less than 1 ng/ml and markedly reduced cell motility of A549 cells. The cells had a migration rate of less than 10% and lost their invasion ability in the treatment condition. In addition, natural peptides showed free radical scavenging activity similar to standard antioxidants and significantly decreased intracellular ROS in the LPS-induced cells. Proteomic analysis revealed 1,604 differentially expressed proteins. The self-organizing tree algorithm (SOTA) clustered the protein abundances into eleven groups. The volcano plot revealed that the cancer-promoting proteins (NCBP2, AMD, MER34, ENC1, and COA4) were down-regulated, while the secretory glycoprotein (A1BG) and ROS-reducing protein (ASB6) were up-regulated in the treatment group.

Conclusion

The anti-proliferative and anti-metastatic activities of natural peptides may be attributed to the suppression of several cancer-promoting proteins. In contrast, their antioxidative activity may result from the up-regulation of ROS-reducing protein. This finding suggests that natural peptides from T. stans are viable for being the new potential anti-cancer and antioxidative agents.

The time-series behavior of systemic inflammation-immune status in predicting survival of locally advanced non-small cell lung cancer treated with chemoradiotherapy

Background

Systematic inflammation is believed to play a crucial role in tumorigenesis and metastasis. This study aims at evaluating the prognostic value of time-series behavior of systematic inflammation-immune status before and after definitive chemoradiotherapy (dCRT) in patients with locally advanced non-small cell lung cancer (LA-NSCLC).

Methods

The relationship between systematic inflammation-immune score (SIS, defined as pretreatment peripheral platelet count × neutrophil count/lymphocyte count) and the prognosis was tested in a retrospective study of 386 consecutive LA-NSCLC patients (Group A) with pretreatment SIS and 161 patients (Group B) with SIS before and one month after the dCRT.

Results

SIS of 1400 × 109 was found to be an optimal cutoff point to stratify the patients into high (>1400 × 109) and low (≤1400 × 109) SIS groups. Univariate and multivariate analyses revealed that the SIS, whether before or after dCRT, was an independent predictor for overall survival (OS), progress-free survival (PFS), and distant metastasis-free survival (DMFS). High SIS (>1400 × 109) was shown to predict poor 3-year OS (P=0.006, hazard ratio [HR]=2.427), PFS (P=0.001, HR=2.442) and DMFS (P=0.015, HR=2.119). However, SIS was not related to local regional recurrence-free survival in either Group A (P=0.346) or Group B (P=0.486). Further, the area under the receiver operating characteristic curve of the SIS for OS was higher than the neutrophil count/lymphocyte count ratio, platelet count/lymphocyte count ratio, and other conventional clinic-pathological indices.

Conclusions

The SIS is a stable and more sensitive survival predictor than other inflammation-based factors and conventional clinical indices, which may aid in more accurately stratifying patients for risk assessment and treatment decisions.

Five-Year Survival Outcomes From the PACIFIC Trial: Durvalumab After Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer

PURPOSE

The phase III PACIFIC trial compared durvalumab with placebo in patients with unresectable, stage III non–small-cell lung cancer and no disease progression after concurrent chemoradiotherapy. Consolidation durvalumab was associated with significant improvements in the primary end points of overall survival (OS; stratified hazard ratio [HR], 0.68; 95% CI, 0.53 to 0.87; P = .00251) and progression-free survival (PFS [blinded independent central review; RECIST v1.1]; stratified HR, 0.52; 95% CI, 0.42 to 0.65; P < .0001), with manageable safety. We report updated, exploratory analyses of survival, approximately 5 years after the last patient was randomly assigned.

METHODS

Patients with WHO performance status 0 or 1 (any tumor programmed cell death-ligand 1 status) were randomly assigned (2:1) to durvalumab (10 mg/kg intravenously; administered once every 2 weeks for 12 months) or placebo, stratified by age, sex, and smoking history. Time-to-event end point analyses were performed using stratified log-rank tests. Medians and landmark survival rates were estimated using the Kaplan-Meier method.

RESULTS

Seven hundred and nine of 713 randomly assigned patients received durvalumab (473 of 476) or placebo (236 of 237). As of January 11, 2021 (median follow-up, 34.2 months [all patients]; 61.6 months [censored patients]), updated OS (stratified HR, 0.72; 95% CI, 0.59 to 0.89; median, 47.5 v 29.1 months) and PFS (stratified HR, 0.55; 95% CI, 0.45 to 0.68; median, 16.9 v 5.6 months) remained consistent with the primary analyses. Estimated 5-year rates (95% CI) for durvalumab and placebo were 42.9% (38.2 to 47.4) versus 33.4% (27.3 to 39.6) for OS and 33.1% (28.0 to 38.2) versus 19.0% (13.6 to 25.2) for PFS.

CONCLUSION

These updated analyses demonstrate robust and sustained OS and durable PFS benefit with durvalumab after chemoradiotherapy. An estimated 42.9% of patients randomly assigned to durvalumab remain alive at 5 years and 33.1% of patients randomly assigned to durvalumab remain alive and free of disease progression, establishing a new benchmark for standard of care in this setting.

Improved survival in patients with unresectable stage III EGFR-mutant adenocarcinoma with upfront EGFR-tyrosine kinase inhibitors

BACKGROUND

Although epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) have been the standard treatment for advanced EGFR-mutant adenocarcinoma, the effects of upfront EGFR-TKI use in unresectable stage III EGFR-mutant adenocarcinoma remain unexplored. Here, we conducted a retrospective study to compare different treatment strategies in these patients.

METHODS

From October 2010 to June 2019, patients with unresectable stage III adenocarcinoma who received treatment at a tertiary referral center were enrolled. Patients were classified into three groups: EGFR-mutant adenocarcinoma treated with concurrent chemoradiotherapy (group 1) or EGFR-TKI (group 2) and EGFR wild-type adenocarcinoma treated with concurrent chemoradiotherapy (group 3). Progression-free survival, progression-free survival-2, and overall survival were estimated and compared using Kaplan-Meier and log-rank tests.

RESULTS

A total of 92 patients were enrolled; 10, 40, and 42 patients were assigned to groups 1, 2, and 3, respectively. Patients with EGFR mutations who received upfront EGFR-TKIs had significantly longer progression-free and overall survival than those who received upfront concurrent chemoradiotherapy (hazard ratio 0.33 vs. 0.34, p = 0.006 vs. 0.031) according to a Cox model adjusted for possible confounders. Moreover, upfront concurrent chemoradiotherapy did not lead to higher survival rates in patients with EGFR mutations than in those with EGFR wild-type adenocarcinoma (progression-free survival; hazard ratio 0.37, p = 0.036; overall survival; hazard ratio 0.35, p = 0.080) by Cox regression analysis.

CONCLUSION

This current study suggests that EGFR-TKIs is a better choice for patients with unresectable stage III EGFR-mutant adenocarcinoma. However, further randomized studies are required to validate the results.

Prognostic Factors of IIIAN2 Non-Small-Cell Lung Cancer after Complete Resection: A Systemic Review and Meta-analysis

METHODS

An extensive data search was conducted from all leading databases including PubMed, Google Scholar, Embase, and Cochrane. Fifteen studies were selected according to the PRISMA model of data selected to conduct this systemic review meta-analysis.

RESULTS

Total 4444 patients were evaluated among fifteen selected studies. A number of lymph nodes involved (n = 3965), level of lymph nodes (n = 3422), and complete tumor resection (n = 3255) were the most reported prognostic factors.

CONCLUSION

This study exhibits the overall significance of all prognostic factors of NSCLC IIIAN2 pathology for better patient management. However, other management strategies also play a significant contribution to achieving a better survival rate and less recurrence possibility.

Prognostic impact of immune inflammation biomarkers in predicting survival and radiosensitivity in patients with non-small-cell lung cancer treated with chemoradiotherapy

INTRODUCTION

The purpose of this retrospective study was to investigate the prognostic impact of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), derived NLR (dNLR) and systemic immune-inflammation index (SII) in predicting outcomes for patients with locally advanced non-small-cell lung cancer (NSCLC). The secondary endpoint was to evaluate the radiosensitivity in terms of response rate.

METHODS

Newly diagnosed locally advanced NSCLC patients were enrolled. Immune inflammation biomarkers were calculated from baseline blood samples. Patients were stratified in two groups based on optimal cut-off values for each biomarker. The associations between biomarkers and overall survival (OS), progression-free survival (PFS), local regional recurrence-free survival (LRRFS), and also response to radiotherapy were analysed.

RESULTS

A total of 392 patients were included. Five-year OS, PFS and LRRFS rates were 14.6%, 12.1%, and 13.4% respectively. Optimal cut-off values for NLR, PLR, dNLR and SII were 3.07, 166, 2.02 and 817 respectively. Low NLR (HR 1.73, 95% CI 1.34-2.24, P < 0.001), low PLR (HR 1.37, 95% CI 1.06-1.76, P = 0.013), low dNLR (HR 1.66, 95% CI 1.29-2.13, P < 0.001) and low SII (HR 1.63, 95% CI 1.18-2.04, P < 0.001) were independent prognostic factors for OS. Low NLR, PLR, dNLR and SII were also significant prognostic factors for PFS and LRRFS. Low NLR, low dNLR and low SII groups had better radiosensitivity than compared with high NLR, high dNLR and high SII groups (P = 0.001, P = 0.001 and P = 0.012).

CONCLUSION

NLR, PLR, dNLR and SII were independently associated with improved OS, PFS and LRRFS. Low NLR, dNLR and SII groups had better radiosensitivity. Immune inflammation biomarkers are promising prognostic predictors which can be obtained easily and inexpensively.

Prognostic Value of Computed Tomography and/or 18F-Fluorodeoxyglucose Positron Emission Tomography Radiomics Features in Locally Advanced Non-small Cell Lung Cancer

INTRODUCTION

We investigated whether adding computed tomography (CT) and/or ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET radiomics features to conventional prognostic factors (CPFs) improves prognostic value in locally advanced non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We retrospectively identified 39 cases with stage III NSCLC who received chemoradiotherapy and underwent planning CT and staging ¹⁸F-FDG PET scans. Seven CPFs were recorded. Feature selection was performed on 48 CT and 49 PET extracted radiomics features. A penalized multivariate Cox proportional hazards model was used to generate models for overall survival based on CPFs alone, CPFs with CT features, CPFs with PET features, and CPFs with CT and PET features. Linear predictors generated and categorized into 2 risk groups for which Kaplan-Meier survival curves were calculated. A log-rank test was performed to quantify the discrimination between the groups and calculated the Harrell's C-index to quantify the discriminatory power. A likelihood ratio test was performed to determine whether adding CT and/or PET features to CPFs improved model performance.

RESULTS

All 4 models significantly discriminated between the 2 risk groups. The discriminatory power was significantly increased when CPFs were combined with PET features (C-index 0.82; likelihood ratio test P < .01) or with both CT and PET features (0.83; P < .01) compared with CPFs alone (0.68). There was no significant improvement when CPFs were combined with CT features (0.68).

CONCLUSION

Adding PET radiomics features to CPFs yielded a significant improvement in the prognostic value in locally advanced NSCLC; adding CT features did not.

Prognostic value of positron emission tomography in resected stage IA non-small cell lung cancer

OBJECTIVES

To investigate the role of PET in predicting the prognosis of resected stage IA non-small cell lung cancer (NSCLC) and planning individualized therapeutic strategies.

METHODS

We retrospectively reviewed the data of patients who underwent surgical resection for lung cancer between January 2004 and December 2014. The clinical data, imaging characteristics of nodules, surgical approaches, and outcomes were analyzed.

RESULTS

We evaluated 998 cases; 637 patients with pathological stage I disease were categorized as follows: stage IA1 (251 cases), stage IA2 (250 cases), and stage IA3 (136 cases). The mean follow-up period was 109 months. Significant differences were observed in sex, tumor differentiation, epidermal growth factor receptor mutation, smoking habits, lymphovascular space invasion, tumor size, maximum standard uptake value (SUVmax), and carcinoembryonic antigen level among the groups. Multivariable Cox regression revealed that ground-glass opacity ratio (hazard ratio (HR) = 0.001) and tumor SUVmax independently predicted the postoperative risk of relapse for stage IA3 NSCLC. The HR for SUVmax > 4 was 8.986 (p < 0.001). The 5-year overall survival (OS) rates were 87.2%, 92.9%, and 82.7%, and the 5-year disease-free survival (DFS) rates were 93.2%, 84.2%, and 70.51% for stage IA1, IA2, and IA3 NSCLC, respectively (both p < 0.001). OS and DFS rates were poor in stage IA3 NSCLC patients with an SUVmax uptake > 4 (OS, 71.0% and 92.2%; DFS, 50.2% and 87.3%, for SUVmax > 4 and ≤ 4, respectively; both p = 0.001).

CONCLUSIONS

SUVmax was a prognostic factor for resected stage IA NSCLC. Postoperative treatment may be considered for IA3 NSCLC with SUVmax > 4.

KEY POINTS

• PET helps surgeons to assess patients with early-stage lung cancer. • This retrospective study revealed that PET plays an influential role in predicting the prognosis of resected lung cancer. • Better prognostication aids better planning of therapeutic strategies with diversification.

Functional impairment, symptom severity, and overall quality of life in patients with advanced lung or colorectal cancer in six European countries: baseline findings from the ACTION study

BACKGROUND

People with advanced cancer often suffer from various symptoms, which can arise from the cancer itself and its treatment, the illness experience, and/or co-morbid conditions. Important patient-reported outcomes such as functional status, symptom severity, and quality of life (QoL) might differ between countries, as countries vary with regard to contextual factors such as their healthcare system.

PURPOSE

To assess self-reported emotional functioning, physical functioning, symptoms, and overall QoL in patients with advanced lung or colorectal cancer from six European countries, particularly in relation to their country of residence.

METHODS

We used baseline patient data from the ACTION trial, including socio-demographic and clinical data as well as patient-reported data regarding functioning, symptoms, and overall QoL (EORTC QLQ-C15-PAL).

RESULTS

Data from 1117 patients (55% lung cancer stage III/IV, 45% colorectal cancer stage IV) were used. The highest (worst) average symptom score was found for fatigue. We found similarities but also important differences in the outcomes across countries. The best scores (the highest for emotional functioning and QoL, the lowest for symptoms) were reported by Dutch and Danish patients. Belgian patients reported relatively low emotional functioning.

CONCLUSION

The optimization of functioning, symptom relief, and overall QoL should be important objectives of healthcare professionals who take care of patients with advanced cancer. There are similarities, but also substantial differences across countries in functional status, symptoms, and overall QoL. Policymakers should take these differences into account and invest in offering health care catered to the needs of their population.

Novel diphenyl urea derivative serves as an inhibitor on human lung cancer cell migration by disrupting EMT via Wnt/β-catenin and PI3K/Akt signaling

Targeted anti-tumor small molecules are considered to be promising candidates for cancer treatment. The novel diphenyl urea derivative (DUD) was synthesized by the molecular docking based on the structure optimization of Taspine (a natural product). In this study, we explored the anti-metastatic potential of DUD for NSCLC in vitro. DUD significantly suppressed A549 cell migration by reversing EMT. The inhibition was reflected on upregulation of E-cadherin and downregulation of N-cadherin, vimentin, Snail and HIF-1α. Meanwhile, DUD inhibited the β-catenin nuclear translocation by upregulating Axin and downregulating the expression of APC, CK1 and phosphorylation of GSK3β, and simultaneously decreasing MMP9 and MMP13 expression. Moreover, it was associated with the downregulation of the PI3K/Akt/mTOR signaling. Furthermore, we used XAV939, an β-catenin inhibitor, to verify the mechanism of DUD. These results suggested that DUD inhibited A549 cells migration by reversing EMT via Wnt/β-catenin and PI3K/Akt signaling. DUD might be a potential therapeutic drug candidate for NSCLC treatment.

The Relative Importance of Clinical and Socio-demographic Variables in Prognostic Prediction in Non-Small Cell Lung Cancer: A Variable Importance Approach

BACKGROUND

Prognostic modeling in health care has been predominantly statistical, despite a rapid growth of literature on machine-learning approaches in biological data analysis. We aim to assess the relative importance of variables in predicting overall survival among patients with non-small cell lung cancer using a Variable Importance (VIMP) approach in a machine-learning Random Survival Forest (RSF) model for posttreatment planning and follow-up.

METHODS

A total of 935 non-small cell lung cancer patients were randomly and equally divided into 2 training and testing cohorts in an RFS model. The prognostic variables included age, sex, race, the TNM Classification of Malignant Tumors (TNM) stage, smoking history, Eastern Cooperative Oncology Group performance status, histologic type, treatment category, maximum standard uptake value of whole-body tumor (SUVmaxWB), whole-body metabolic tumor volume (MTVwb), and Charlson Comorbidity Index. The VIMP was calculated using a permutation method in the RSF model. We further compared the VIMP of the RSF model to that of the standard Cox survival model. We examined the order of VIMP with the differential functional forms of the variables.

RESULTS

In both the RSF and the standard Cox models, the most important variables are treatment category, TNM stage, and MTVwb. The order of VIMP is more robust in RSF model than in Cox model regarding the differential functional forms of the variables.

CONCLUSIONS

The RSF VIMP approach can be applied alongside with the Cox model to further advance the understanding of the roles of prognostic factors, and improve prognostic precision and care efficiency.

Robust, independent and relevant prognostic 18F-fluorodeoxyglucose positron emission tomography radiomics features in non-small cell lung cancer: Are there any?

In locally advanced lung cancer, established baseline clinical variables show limited prognostic accuracy and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG PET) radiomics features may increase accuracy for optimal treatment selection. Their robustness and added value relative to current clinical factors are unknown. Hence, we identify robust and independent PET radiomics features that may have complementary value in predicting survival endpoints. A 4D PET dataset (n = 70) was used for assessing the repeatability (Bland-Altman analysis) and independence of PET radiomics features (Spearman rank: |ρ|<0.5). Two 3D PET datasets combined (n = 252) were used for training and validation of an elastic net regularized generalized logistic regression model (GLM) based on a selection of clinical and robust independent PET radiomics features (GLM_all). The fitted model performance was externally validated (n = 40). The performance of GLM_all (measured with area under the receiver operating characteristic curve, AUC) was highest in predicting 2-year overall survival (0.66±0.07). No significant improvement was observed for GLM_all compared to a model containing only PET radiomics features or only clinical variables for any clinical endpoint. External validation of GLM_all led to AUC values no higher than 0.55 for any clinical endpoint. In this study, robust independent FDG PET radiomics features did not have complementary value in predicting survival endpoints in lung cancer patients. Improving risk stratification and clinical decision making based on clinical variables and PET radiomics features has still been proven difficult in locally advanced lung cancer patients.

Prognostic importance of 18F-fluorodeoxyglucose uptake by positron emission tomography for stage III non-small cell lung cancer treated with definitive chemoradiotherapy

OBJECTIVES

Survival heterogeneity exists among patients with non-small cell lung cancer (NSCLC), even within the same stage. We aimed to evaluate the prognostic role of pre-treatment maximum standardized uptake value (SUV_max) in patients treated with definitive concurrent chemoradiotherapy for stage III NSCLC.

MATERIALS AND METHODS

Between 2010 and 2017, 103 patients with stage III NSCLC who underwent ¹⁸F-FDG PET/CT at the time of diagnosis were included in the study.

RESULTS

Higher tumor stages were correlated with higher pre-treatment SUV_max of lymph nodes (LNs) (p=0.005) but were not correlated with higher SUV_max of primary tumor (p=0.2). The median SUV_max of LNs was 2.84, 8.06, and 11.11 in stage IIIa, IIIb and IIIc, respectively. Higher nodal stage was also correlated with higher SUV_max of LNs (p=0.01). According to ROC analysis, there was no significant cut-off value of SUV_max observed for primary tumor, therefore continuous variables were used for survival analyses. The best SUV_max cut-off was 3.5 for the LNs, therefore the SUV_max of LNs was evaluated as both a dichotomous and a continuous variable. Pre-treatment SUV_max of primary tumor did not predict survival outcomes but both the continuous and dichotomous variables of SUV_max of LNs predicted recurrence free survival and overall survival. Nodal stage (N0-2 vs. N3) and AJCC stage (IIIa vs IIIb vs. IIIc) were the other prognostic factors.

CONCLUSIONS

Pre-treatment SUV_max of LNs had prognostic value in patients treated with definitive concurrent chemoradiotherapy for stage III NSCLC. In future trials, pre-treatment SUV_max of the LNs would serve as a guide for patients who might benefit from more aggressive treatments.

Prognostic value of neutrophil-to-lymphocyte ratio in locally advanced non-small cell lung cancer treated with concurrent chemoradiotherapy

Purpose

This study aimed to investigate neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as prognostic factors in patients with locally advanced non-small cell lung cancer (NSCLC) who received concurrent chemoradiotherapy (CCRT).

Materials and Methods

We retrospectively analyzed 66 patients with locally advanced NSCLC treated with definitive CCRT. Among these patients, 95% received paclitaxel/carboplatin or docetaxel/cisplatin. The median radiation dose was 66 Gy in 33 fractions. The NLR and PLR before/after CCRT were evaluated. The maximally selected log-rank test was used to obtain the cutoff values related to the overall survival (OS).

Results

Patients with high post-CCRT NLR (>3.12) showed worse OS, locoregional progression-free survival (LRPFS), and distant metastasis-free survival (DMFS) than those with low NLR (2-year OS: 25.8% vs. 68.2%, p < 0.001; 2-year LRPFS: 12.9% vs. 33.8%, p = 0.010; 2-year DMFS: 22.6% vs. 38.2%, p = 0.030). Patients with high post-CCRT PLR (>141) showed worse OS and LRPFS than those with low PLR (2-year OS: 37.5% vs. 71.1%, p = 0.004; 2-year LRPFS: 16.5% vs. 40.3%, p = 0.040). Patients with high NLR change (>1.61) showed worse OS and LRPFS than those with low NLR change (2-year OS: 26.0% vs. 59.0%, p < 0.001; 2-year LRPFS: 6.8% vs. 31.8%, p = 0.004). The planning target volume (hazard ration [HR] = 2.05, p = 0.028) and NLR change (HR = 3.17, p = 0.025) were the significant factors for OS in the multivariate analysis.

Conclusion

NLR change after CCRT was associated with poor prognosis of survival in patients with locally advanced NSCLC. An elevated NLR after CCRT might be an indicator of an increased treatment failure risk.

miR-433 suppresses tumor progression via Smad2 in non-small cell lung cancer

The role of transforming growth factor beta (TGF-β) in lung cancer is well known. TGF-β-mediated cellular proliferation and angiogenesis through similar to mothers against decapentaplegic homolog 2 (Smad2) protein has also been well elucidated. Smad2 is a predicted target for a microRNAs, namely miR-433. microRNAs are a significant class of non-coding RNAs which play an important role in epigenetic regulation. Here, we show that miR-433 directly binds to Smad2, which is shown to be upregulated in non-small cell lung carcinomas (NSCLC). miR-433 expression is downregulated in NSCLC tissues and cells. Overexpression of miR-433 is associated with decreased expression of proteins - namely Cyclin D1, MMP-2/TIMP-2, and MMP-9, and consequently reduced cell proliferation and invasion phenotypes. Complementation of miR-433 leads to rescue of these disrupted phenotypes. miR-433 mediates its action via Smad2 and Id-1. miR-433 may be a candidate worth further exploration for its prognostic and therapeutic potential in NSCLC.

Pragmatic methods for reviewing exceptionally large bodies of evidence: systematic mapping review and overview of systematic reviews using lung cancer survival as an exemplar

INTRODUCTION

Lung cancer (LC) is the most common cause of cancer death in the world and associated with significant economic burden. We conducted a review of published literature to identify prognostic factors associated with LC survival and determine which may be modifiable and could be targeted to improve outcomes.

METHODS

The exceptionally large volume of LC prognostic research required a new staged approach to reviewing the literature. This comprised an initial mapping review of existing reviews or meta-analyses, based on titles and abstracts, followed by an overview of systematic reviews evaluating factors that independently contribute to lung cancer survival. The overview of reviews was based on full text papers and incorporated a more in-depth assessment of reviews evaluating modifiable factors.

RESULTS

A large volume of published systematic reviews and meta-analyses were identified, but very few focused on modifiable factors for LC survival. Several modifiable factors were identified, which are potential candidates for targeted interventions aiming to improve cancer outcomes. The mapping review included 398 reviews, of which 207 investigated the independent effect of prognostic factors on lung cancer survival. The most frequently evaluated factors were novel biomarkers (86 biomarkers in 138 reviews). Only 15 modifiable factors were investigated in 20 reviews. Those associated with significant survival improvement included normal BMI/less weight loss, good performance status, not smoking/quitting after diagnosis, good pre-treatment quality of life, small gross volume tumour, early-stage tumour, lung resection undertaken by a thoracic/cardiothoracic surgeon, care being discussed by a multidisciplinary team, and timeliness of care.

CONCLUSIONS

The study utilised a novel approach for reviewing an extensive and complicated body of research evidence. It enabled us to address a broad research question and focus on a specific area of priority. The staged approach ensured the review remained relevant to the stakeholders throughout, whilst maintaining the use of objective and transparent methods. It also provided important information on the needs of future research. However, it required extensive planning, management, and ongoing reviewer training.

Prognostic Variables Associated With Improved Outcomes in Patients With Stage III NSCLC Treated With Chemoradiation Followed by Consolidation Pembrolizumab: A Subset Analysis of a Phase II Study From the Hoosier Cancer Research Network LUN 14-179

INTRODUCTION

The Hoosier Cancer Research Network (HCRN) LUN 14-179 is a phase II trial of consolidation pembrolizumab after concurrent chemoradiation for the treatment of patients with stage III non-small-cell lung cancer (NSCLC). Time to metastatic disease or death (TMDD), progression-free survival (PFS), and overall survival (OS) appear to be superior to that in historical controls of chemoradiation alone. Unfortunately, not all patients benefit from consolidation immunotherapy. We performed a univariate analysis to evaluate variables associated with PFS, metastatic disease, and OS.

PATIENTS AND METHODS

We conducted a retrospective analysis of patients enrolled in HCRN LUN 14-179. Data collected included age, sex, stage, smoking status, programmed death ligand 1 status, Grade (G) ≥ 2 versus G ≤ 1 adverse event, G ≤ 2 versus G ≥ 3 pneumonitis, duration of pembrolizumab (< 4 vs. ≥ 4 cycles), chemotherapy regimen, performance status 0 versus 1, time to start pembrolizumab (4-6 vs. 6-8 weeks from radiation), volume of lung receiving at least 20 Gy of radiation (V₂₀; < 20% vs. ≥ 20%). Univariable Cox regression was performed to determine the variables associated with 3 end points: TMDD, PFS, and OS.

RESULTS

From April 2015 to December 2016, 93 patients were enrolled and 92 were included in the efficacy analysis (1 patient was ineligible). For TMDD, improved outcomes might be associated (P < .1) with stage IIIA and ≥ 4 cycles of pembrolizumab. For PFS, improved outcomes (P < .1) might be seen for ≥ 4 cycles of pembrolizumab, stage IIIA and V₂₀ < 20%. For OS, improved outcomes (P < .1) might be seen for stage IIIA and ≥ 4 cycles of pembrolizumab.

CONCLUSION

Stage IIIA and longer duration of pembrolizumab treatment might be associated with prolonged TMDD, PFS, and OS for patients with stage III NSCLC treated with chemoradiation followed by pembrolizumab.

TBL1XR1 is involved in c-Met-mediated tumorigenesis of human nonsmall cell lung cancer

Nonsmall cell lung carcinoma (NSCLC) contributes to the highest number of cancer deaths globally. Metastases and chemoresistance are two major confounders to the treatment efficacy in NSCLC. Transducin (β)-like 1 X-linked receptor 1 (TBL1XR1) has been associated with high rates of metastases in breast, gastric, and stomach cancers. However, the role of TBL1XR1 in lung cancers remains underexplored. We selected matched and cancerous lung tissues to establish the upregulation of TBL1XR1. Using in vitro assays, we assessed the influence of TBL1XR1 on various cancer phenotypes, namely cell proliferation, chemoresistance, invasion, and metastases in a CRISPR-Cas9-mediated knock out model (A549 cells), and H460 cell lines overexpressing TBL1XR1. We found that TBL1XR1 is overexpressed in NSCLC tissue and patient sera in comparison to paired adjacent normal tissue. Overexpression of TBL1XR1 in NSCLC cell lines mediates cell survival, proliferation, and metastases. TBL1XR1 was found to regulate MEK and Akt pathways through their master regulator c-Met. We observed that activation of c-Met is downregulated in the absence of TBL1XR1. Our study strengthens the contention that TBL1XR1 is a biomarker for prognosis of NSCLC. It may also be considered as an adjunct or core therapeutic target to overcome cisplatin resistance in lung cancers.

Correlation study on 18F-FDG PET/CT metabolic characteristics of primary lesion with clinical stage in lung cancer

BACKGROUND

¹⁸F-FDG PET/CT metabolic characteristics provide the crucial biologic and molecular information for tumors. To explore the relationships between ¹⁸F-FDG PET/CT derived parameters such as maximum standardized uptake value (SUV<inf>max</inf>), metabolic tumor volume (MTV), total lesion glycolysis (TLG) of primary tumor and clinical stage in different histopathologic subtypes of lung cancer.

METHODS

A total of 97 newly diagnosed lung cancer patients (69 males, 28 females; average age 65.1 years) with pathologically proven were retrospectively analyzed, who had undergone ¹⁸F-FDG PET/CT scan before treatment from September 2016 to November 2017. SUV<inf>max</inf>, MTV and TLG of primary tumor were measured. Clinical stage was mainly determined by ¹⁸F-FDG PET/CT, in conjunction with conventional imaging and endoscopic biopsy. Mann-Whitney U test, χ² test, Spearman correlation test and ROC curve analysis were used for statistical analysis.

RESULTS

There were 53 adenocarcinomas (AC), 28 squamous carcinomas (SCC), 13 small cell carcinomas (SCLC), one adenosquamous carcinoma, one mucoepidermoid carcinoma, and one sarcomatoid carcinoma in 97 patients. Both AC and SCLC revealed more cases in stage IV than in stage I-III (P<0.01). There was no significant difference in four stages of SCC (P>0.05). Metabolic parameters of SCC were higher than AC including SUV<inf>max</inf>, MTV and TLG (P<0.01). SCLC showed a higher value than AC in TLG (P<0.05). No significant differences were found between AC and SCLC in SUV<inf>max</inf> and MTV, also between SCC and SCLC in SUV<inf>max</inf>, MTV and TLG (P>0.05). MTV and TLG except SUV<inf>max</inf> were positively correlated with stage in AC (P≤0.001). Only MTV showed a positive correlation with stage in SCC (P<0.05). Whereas there were no definitive relationships between metabolic parameters and stage in SCLC (P>0.05). AC with a higher MTV (MTV≥5.965 cm³) indicated a significantly higher rate of distant metastasis than those with a lower MTV (77.5% (31/40) vs. 30.8% (4/13), χ²=9.553, P<0.01), as well as AC with a higher TLG (TLG≥46.922) than those with a lower TLG (88.5% (23/26) vs. 44.4% (12/27), χ²=11.422, P<0.01).

CONCLUSIONS

Histopathologic subtypes have a significant influence on the relationships between MTV/TLG not SUV<inf>max</inf> of primary foci and stage in lung cancer. Primary MTV/TLG is related to clinical stage closely in AC, and a higher MTV/TLG results in a higher risk of distant metastasis.

The role of tumour volume as a prognostic factor in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy

Background

It has been shown that patients with a greater tumour volume have poorer outcomes following definitive radiotherapy but its exact role remains unclear. The purpose of this study is to investigate the role of tumour volume as a prognostic indicator in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy in a single institution over 10 years.

Methods

In total, 167 patients with NSCLC treated by definitive (chemo)radiotherapy were retrospectively reviewed between 2006 and 2015. Patient demographics, disease characteristics and tumour volume parameters were collected. Univariate analyses were carried out using Kaplan–Meier survival curves to assess the association of potential prognostic factors with the primary endpoints of overall survival (OS) rates and locoregional recurrence rates. Multivariate analyses were carried out using a Cox regression method.

Results

The median total tumour volume (TTV), defined as the gross tumour volume plus the volume of involved nodes, was 103 cm3. Patients were divided into small and large tumour groups based on this median. OS rates at 1, 3 and 5 years for smaller volumes were 69%, 24% and 13% and for larger volumes 48%, 14% and 8%, respectively. On univariate survival analyses larger TTV was significantly associated with poorer OS (p= 0·019). The concurrent use of chemotherapy significantly improved survival (p= 0·026). Nodal involvement (p= 0·03) and Eastern Cooperative Oncology Group performance status (p&lt; 0·001) were also significant independent prognostic factors of OS. On multivariate analysis TTV was strongly predictive of survival (p= 0·03; hazard ratio 1·702, 95% confidence interval 1·198–2·415). There was no association between nodal volume, tumour stages, overall stage, age, histology and radiation dose with any of the primary endpoints.

Conclusion

TTV is a significant prognostic factor in patients with advanced NSCLC treated by radical radiotherapy. In this cohort of patients TTV is more reliable at predicting survival than T stage and overall stage.

Anemia is a poor prognostic factor for stage I non-small cell lung cancer (NSCLC) patients treated with Stereotactic Body Radiation Therapy (SBRT)

•This study reports on the prognostic ability of haematological parameters for the largest known biopsy-proven stage-I medically inoperable cohort treated with SBRT.•After SBRT, the median values of Hb, ALC, ANC and TPC declined whereas the NLR and the PLR increased as compared to pre-SBRT.•Anemia along with other parameters was found to be a poor prognostic factor for local control despite treatment with SBRT to doses of >100 Gy BED₁₀.•Simple and minimally invasive methods like a peripheral blood sample can provide prognostic information even for stage-I NSCLC patients.•Patient, tumor and treatment factors along with molecular markers should be used to create risk stratification models that can guide therapy.

Video assisted thoracic surgery vs. thoracotomy for locally advanced lung squamous cell carcinoma after neoadjuvant chemotherapy

BACKGROUND

Surgery is an important part of multidisciplinary treatment strategy for locally advanced lung squamous cell carcinoma (LSCC), but insufficient evidence supports the feasibility and safety of video assisted thoracic surgery (VATS) following neoadjuvant chemotherapy for locally advanced LSCC. This study aims to compare perioperative data and long-term survival of locally advanced LSCC patients between VATS and thoracotomy after neoadjuvant chemotherapy.

METHODS

We retrospectively collected the clinical and pathological information of patients with locally advanced LSCC who underwent surgical resection after neoadjuvant chemotherapy from October 2013 to October 2017. All patients were divided into two groups (thoracotomy and VATS) and were compared the differences in perioperative, oncological and survival outcomes.

RESULTS

A total of 81 patients were analyzed in this study (67 thoracotomy and 14 VATS). VATS provided less postoperative pain (P = 0.005) and produced less volume of chest drainage (P = 0.019) than thoracotomy, but the number of resected lymph nodes was less in VATS group (P = 0.011). However, there was no significant difference in the number of resected lymph node stations and the rate of nodal upstaging between two groups. The mean disease free survival (DFS) was 32.7 ± 2.7 months for the thoracotomy group and 31.8 ± 3.0 months for the VATS group (P = 0.335); the corresponding overall survival (OS) was 41.7 ± 2.2 months and 36.4 ± 4.1 months (P = 0.925).

CONCLUSION

In selected patients with locally advanced LSCC, VATS played a positive role in postoperative recovery and associated similar survival outcome compared with thoracotomy after neoadjuvant chemotherapy.

The developing role of FDG PET imaging for prognostication and radiotherapy target volume delineation in non-small cell lung cancer

Advancements in functional imaging technology have allowed new possibilities in contouring of target volumes, monitoring therapy, and predicting treatment outcome in non-small cell lung cancer (NSCLC). Consequently, the role of ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG PET) has expanded in the last decades from a stand-alone diagnostic tool to a versatile instrument integrated with computed tomography (CT), with a prominent role in lung cancer radiotherapy. This review outlines the most recent literature on developments in FDG PET imaging for prognostication and radiotherapy target volume delineation (TVD) in NSCLC. We also describe the challenges facing the clinical implementation of these developments and present new ideas for future research.

The Impact of Staging by Positron-Emission Tomography on Overall Survival and Progression-Free Survival in Patients With Locally Advanced NSCLC

INTRODUCTION

We investigated the potential impact of stage migration because of positron-emission tomography (PET) scan staging on survival in the locally advanced (stage IIIA/B) NSCLC setting.

METHODS

In PROCLAIM, 598 patients with stage IIIA/B nonsquamous NSCLC (intent-to-treat population) were randomized to either pemetrexed plus cisplatin and concurrent thoracic radiotherapy for 3 cycles followed by 4 cycles of pemetrexed consolidation or etoposide plus cisplatin and concurrent thoracic radiotherapy for 2 cycles followed by a consolidation platinum-based doublet regimen for up to 2 cycles. Baseline PET scan (PET Yes versus No) was one of the stratification factors. Subgroup analyses (PET Yes versus No) of overall survival (OS) and progression-free survival (PFS) were conducted on the intent-to-treat population regardless of treatment, as the study did not show superior efficacy for either arm.

RESULTS

Majority (491 of 598; 82.1%) of patients had a baseline PET scan staging performed. A longer median OS (PET Yes versus No: 27.2 versus 20.8; hazard ratio = 0.81, p = 0.130) and an improved median PFS (PET Yes versus No: 11.3 versus 9.2; hazard ratio = 0.73, p = 0.012) were observed for patients with PET scans compared to those with conventional staging in both treatment arms.

CONCLUSIONS

Both a significantly improved PFS and a numerically longer OS in the PET Yes subgroup, compared to patients with conventional staging, are consistent with improved survival due to stage migration. The magnitude of differences in OS and PFS based on PET scan is a reminder of the potential for factors other than the therapeutic intervention to affect outcomes.

Prognostic value of primary tumor SUVmax on pre-treatment 18F-FDG PET/CT imaging in patients with stage iii non-small cell lung cancer

OBJECTIVES

Concomitant chemoradiotherapy (CCRT) is widely used in the treatment of patients with stage iii non-small cell lung carcinoma (NSCLC). The early identification of patients with poor prognosis is the premise of personalized treatment for patients. The aim of the study was to evaluate the prognostic value of clinical parameters and primary tumor SUVmax on pre-treatment 18F-FDG PET/CT in patients with stage iii NSCLC.

MATERIAL AND METHODS

Clinical records of 79 stage iii-NSCLC patients with pre-treatment 18F-FDG PET/CT imaging, treated with definitive CCRT were retrospectively reviewed. The clinical endpoints in terms of progression-free survival (PFS) and overall survival (OS) were correlated with the median pre-treatment primary tumor SUVmax. Furthermore, other factors influencing patient outcome were analyzed.

RESULTS

The median age of patients was 58 years (range, 45-71) with 72 (91%) males. Squamous cell carcinoma (73%) was the most common histologic type. Performance status was very good (ECOG 0) in 64.5% of patients. Sixty (79%) patients had died at the time of this analysis. Median OS and PFS were 22.5 and 12.0 months, respectively. Patients were dichotomized according to pre-treatment primary tumor SUVmax≤15.0 vs.>15.0. There was no statistically significant difference for OS and PFS in both arms. Multivariate analysis showed that pre-treatment SUVmax was not a significant predictor of OS (HR 1.099, P=0.726) and PFS (HR 1.022, P=0.941).

CONCLUSIONS

SUVmax with threshold value of 15.0 on the primary tumor before treatment had no prognostic value in our patient group with stage iii NSCLC treated with definitive CCRT.

Sotetsuflavone suppresses invasion and metastasis in non-small-cell lung cancer A549 cells by reversing EMT via the TNF-α/NF-κB and PI3K/AKT signaling pathway

Epithelial-mesenchymal transition (EMT) is associated with tumor invasion and metastasis, and offers insight into novel strategies for cancer treatment. Sotetsuflavone was isolated from Cycas revolute, which has excellent anticancer activity in the early stages. The present study aims to evaluate the anti-metastatic potential of sotetsuflavone in vitro. Our data demonstrated that sotetsuflavone inhibits metastasis of A549 cells, and EMT. This inhibition was reflected in the upregulation of E-cadherin, and downregulation of N-cadherin, vimentin, and Snail. Mechanistically, our study demonstrated that HIF-1α played an important role in the anti-metastatic effect of sotetsuflavone in non-small-cell lung cancer A549 cells. Sotetsuflavone not only mediated VEGF expression but also downregulated VEGF and upregulated angiostatin, and simultaneously affected the expression of MMPs and decreased MMP-9 and MMP-13 expression. More importantly, HIF-1α expression may be regulated by the inhibition of PI3K/AKT and TNF-α/NF-κB pathways. These results suggest that sotetsuflavone can reverse EMT, thereby inhibiting the migration and invasion of A549 cells. This process may be associated with both PI3K/AKT and TNF-α/NF-κB pathways, and sotetsuflavone may be efficacious in the treatment of non-small-cell lung cancer.

The effect of imputing missing clinical attribute values on training lung cancer survival prediction model performance

According to the estimations of the World Health Organization and the International Agency for Research in Cancer, lung cancer is the most common cause of death from cancer worldwide. The last few years have witnessed a rise in the attention given to the use of clinical decision support systems in medicine generally and in cancer in particular. These can predict patients' likelihood of survival based on analysis of and learning from previously treated patients. The datasets that are mined for developing clinical decision support functionality are often incomplete, which adversely impacts the quality of the models developed and the decision support offered. Imputing missing data using a statistical analysis approach is a common method to addressing the missing data problem. This work investigates the effect of imputation methods for missing data in preparing a training dataset for a Non-Small Cell Lung Cancer survival prediction model using several machine learning algorithms. The investigation includes an assessment of the effect of imputation algorithm error on performance prediction and also a comparison between using a smaller complete real dataset or a larger dataset with imputed data. Our results show that even when the proportion of records with some missing data is very high (> 80%) imputation can lead to prediction models with an AUC (0.68-0.72) comparable to those trained with complete data records.

New prognostic biomarkers and therapeutic effect of bevacizumab for patients with non-small-cell lung cancer

BACKGROUND

Several biomarkers have emerged as potential prognostic and predictive markers for non-small-cell lung cancer (NSCLC). Successful inhibition of angiogenesis with the antivascular endothelial growth factor antibody, bevacizumab, has improved the efficacy seen with standard cytotoxic therapy of NSCLC. However, despite such enhanced treatment strategies, the prognosis for patients with advanced NSCLC remains poor.

PATIENTS AND METHODS

We assessed potential biomarkers in 161 NSCLC patients and 42 control patients. Enzyme-linked immunosorbent assay methods were used to evaluate three biomarkers: platelet-derived microparticle (PDMP), high-mobility group box-1 (HMGB1), and plasminogen activator inhibitor-1 (PAI-1). We studied the effects of bevacizumab on the expression of these markers. We also analyzed the relationship of the newly designed risk factor (NDRF) to overall survival and disease-free survival. The NDRF classification of patients was determined from the levels of PDMP, HMGB1, and PAI-1. To determine the individual prognostic power of PDMP, HMGB1, and PAI-1, we evaluated associations between their levels and patient outcomes by Kaplan-Meier survival analysis in a derivation cohort.

RESULTS

PDMP, HMGB1, and PAI-1 levels were higher in NSCLC patients compared with control patients. Notably, the difference in PDMP levels exhibited the strongest statistical significance (p<0.001). Multivariate analysis showed that HMGB1 and PAI-1 levels were significantly correlated with PDMP levels. Patients who received standard chemotherapy with bevacizumab exhibited significantly reduced levels of all three markers compared with patients who received standard chemotherapy. NDRF3 status (high levels of all three markers) was significantly correlated with a poor prognosis (p<0.05 for overall survival and disease-free survival).

CONCLUSION

Our results demonstrate that abnormal levels of PDMP, HMGB1, and PAI-1 are related to each other in NSCLC. Moreover, our findings suggest that the vascular complications associated with these markers may contribute to a poor prognosis for NSCLC patients.

[Progress of Neoadjuvant Therapy Combined with Surgery in Non-small Cell Lung Cancer]

肺癌是世界范围内发病率和死亡率最高的恶性肿瘤。对于可手术切除的Ⅲa/N2期非小细胞肺癌患者，目前国内外指南均推荐采用手术联合化疗、放疗等多学科治疗模式。最新研究表明，与术后辅助治疗一样，新辅助治疗（化疗或放化疗）可显著改善可切除非小细胞肺癌患者的预后，且在治疗依从性及耐受性方面具有明显优势。非小细胞肺癌新辅助治疗的对象主要是局部进展期病变，特别是临床Ⅲa/N2期患者，基本治疗模式为术前2-4周期化疗，新辅助治疗后并不增加手术相关的死亡及并发症风险，但是在决定手术时机、入路及切除范围等方面仍面临着挑战。

Anxiety After Diagnosis Predicts Lung Cancer-Specific and Overall Survival in Patients With Stage III Non-Small Cell Lung Cancer: A Population-Based Cohort Study

CONTEXT

The question as to whether anxiety and depression are related to mortality in patients with lung cancer is inconclusive.

OBJECTIVES

Therefore, the present study is examining associations of anxiety and depression in a large representative sample of patients with Stage III non-small cell lung cancer.

METHODS

Patients (n = 684) were routinely assessed for anxiety and depression with the PsychoSocial Screen for Cancer questionnaire after diagnosis of lung cancer and before treatment initiation between 2004 and 2010. Survival data were retrieved in May 2012. Cox proportional hazards regression analyses had been used as statistical procedures allowing adjustment for demographic, biomedical, and treatment variables.

RESULTS

In analyses controlling for demographic, biomedical, and treatment prognosticators, anxiety but not depression was associated with increased lung cancer-specific (hazard ratio 1.04; 95% confidence interval 1.01-1.07; P = 0.035) and all-cause (hazard ratio 1.04; 95% confidence interval 1.01-1.07; P = 0.005) mortality. Secondary analyses revealed a confounder effect of performance status on the association between depression and mortality, such that the removal of performance status identified a significant relationship of depression on lung cancer-specific and all-cause mortality.

CONCLUSION

In a large population-based sample of patients with non-small cell lung cancer analyses demonstrated associations of anxiety with mortality, adding to the evidence that psychosocial factors might play a role in disease progression in this patient group. Because emotional distress is associated with continued smoking and lack of success of smoking cessation attempts, psychological interventions potentially could influence length of survival in lung cancer patients.

Lymph node volume predicts survival but not nodal clearance in Stage IIIA-IIIB NSCLC

BACKGROUND

Locally advanced non-small cell lung cancer (LA-NSCLC) patients have poorer survival and local control with mediastinal node (N2) tumor involvement at resection. Earlier assessment of nodal burden could inform clinical decision-making prior to surgery. This study evaluated the association between clinical outcomes and lymph node volume before and after neoadjuvant therapy.

MATERIALS AND METHODS

CT imaging of patients with operable LA-NSCLC treated with chemoradiation and surgical resection was assessed. Clinically involved lymph node stations were identified by FDG-PET or mediastinoscopy. Locoregional recurrence (LRR), distant metastasis (DM), progression free survival (PFS) and overall survival (OS) were analyzed by the Kaplan Meier method, concordance index and Cox regression.

RESULTS

73 patients with Stage IIIA-IIIB NSCLC treated with neoadjuvant chemoradiation and surgical resection were identified. The median RT dose was 54 Gy and all patients received concurrent chemotherapy. Involved lymph node volume was significantly associated with LRR and OS but not DM on univariate analysis. Additionally, lymph node volume greater than 10.6 cm3 after the completion of preoperative chemoradiation was associated with increased LRR (p<0.001) and decreased OS (p = 0.04). There was no association between nodal volumes and nodal clearance.

CONCLUSION

For patients with LA-NSCLC, large volume nodal disease post-chemoradiation is associated with increased risk of locoregional recurrence and decreased survival. Nodal volume can thus be used to further stratify patients within the heterogeneous Stage IIIA-IIIB population and potentially guide clinical decision-making.