Blood Vessel Invasion Predicts Postoperative Survival Outcomes and Systemic Recurrence Regardless of Location or Blood Vessel Type in Patients with Lung Adenocarcinoma

Significance of Spread Through Air Spaces and Vascular Invasion in Early-stage Adenocarcinoma Survival: A Comprehensive Clinicopathologic Study of 427 Patients for Precision Management

Spread through air spaces (STAS) is a novel invasive pattern of lung cancer associated with poor prognosis in non-small cell cancer (NSCLC). We aimed to investigate the incidence of STAS in a surgical series of adenocarcinomas (ADCs) resected in our thoracic surgery unit and to identify the association of STAS with other clinicopathological characteristics. We retrospectively enrolled patients with stage cT1a-cT2b who underwent resection between 2016 and 2022. For each case, a comprehensive pathologic report was accessible which included histotype, mitoses, pleural invasion, fibrosis, tumor infiltrating lymphocytes, necrosis, inflammation, vascular and perineural invasion, as well as STAS. PD-L1 expression was also investigated. A total of 427 patients with ADCs underwent surgery. Regarding overall survival (OS), no significant difference was observed between the STAS positive (STAS+) and STAS negative (STAS-) groups ( P =0.44). However, vascular invasion (VI) was associated with a poorer survival probability ( P =0.018). STAS+/VI+ patients had tendentially worse survival compared with STAS+/VI- ( P =0.089). ADCs with pathologic evidence of immune system (IS) activation (TILs>10% and PD-L1≥1) demonstrated significantly increased OS compared with ADCs with no IS and VI. In terms of recurrence rate, no statistical differences were found between the STAS+ and STAS- samples ( P =0.2). VI was also linked to a significantly elevated risk of recurrence ( P =0.0048). Our study suggests that in resected early-stage ADCs, STAS+ does not seem to influence recurrence or mortality. VI was instead an adverse pathologic prognostic factor for both survival and recurrence, whereas IS seemed to be protective.

Who benefit from adjuvant chemotherapy in stage I lung adenocarcinoma? A multi-dimensional model for candidate selection

BACKGROUND

Despite promising overall survival of stage I lung adenocarcinoma (LUAD) patients, 10-25 % of them still went through recurrence after surgery. [1] While it is still disputable whether adjuvant chemotherapy is necessary for stage I patients. [2] IASLC grading system for non-mucinous LUAD shows that minor high-grade patterns are significant indicator of poor prognosis. [3] Other risk factors, such as, pleura invasion, lympho-vascular invasion, STAS, etc. are also related to poor prognosis. [4-6] There still lack evidence whether IASLC grade itself or together with other risk factors can guide the use of adjuvant therapy in stage I patients. In this article, we tried to establish a multi-variable recurrence prediction model for stage I LUAD patients that is able to identify candidates of adjuvant chemotherapy.

METHODS

We retrospectively collected patients who underwent lung surgery from 2018.8.1 to 2018.12.31 at our institution and diagnosed with lung adenocarcinoma pT1-2aN0M0 (stage I). Clinical data, manifestation on CT scan, pathologic features, driver gene mutations and follow-up information were collected. Cox proportional hazards regression analyses were performed utilizing the non-adjuvant cohort to predict disease free survival (DFS) and a nomogram was constructed and applied to the total cohort. Kaplan-Meier method was used to compare DFS between groups. Statistical analysis was conducted by R version 3.6.3.

FINDINGS

A total of 913 stage I LUAD patients were included in this study. Median follow-up time is 48.1 months.4-year and 5-year DFS are 92.9 % and 89.6 % for the total cohort. 65 patient experienced recurrence or death. 4-year DFS are 97.0 %,94.6 % and 76.2 %, and 5-year DFS are 95.5 %, 90.0 % and 74.1 % in IASLC Grade1, 2 and 3, respectively(p < 0.0001). High-risk patients defined by single risk factors, such as, IASLC grade 3, pleura invasion, STAS, less LN resected could not benefit from adjuvant therapy. A LASSO-COX regression model was built and patients are divided into high-risk and low-risk groups. In the high-risk group, patients underwent adjuvant chemotherapy have longer DFS than those who did not (p = 0.024), while in the low-risk group, patients underwent adjuvant chemotherapy have inferior DFS than those who did not (p < 0.001).

INTERPRETATION

IASLC grading is a significant indicator of DFS, however it could not guide adjuvant therapy in our stage I LUAD cohort. Growth patterns and T indicators together with other risk factors could identify high-risk patients that are potential candidate of adjuvant therapy, including some stage IA LUAD patients.

Differentiating the Invasiveness of Lung Adenocarcinoma Manifesting as Ground Glass Nodules: Combination of Dual-energy CT Parameters and Quantitative-semantic Features

RATIONALE AND OBJECTIVES

To evaluate the diagnostic performance of dual-energy CT (DECT) parameters and quantitative-semantic features for differentiating the invasiveness of lung adenocarcinoma manifesting as ground glass nodules (GGNs).

MATERIALS AND METHODS

Between June 2022 and September 2023, 69 patients with 74 surgically resected GGNs who underwent DECT examinations were included. CT numbers on virtual monochromatic images were calculated at 40-130 keV generated from DECT. Quantitative morphological measurements and semantic features were evaluated on unenhanced CT images and compared between pathologically confirmed adenocarcinoma in situ (AIS)-minimally invasive adenocarcinoma (MIA) and invasive lung adenocarcinoma (IAC). Multivariable logistic regression analysis was used to identify independent predictors. The diagnostic performance was assessed by the area under the receiver operating characteristic curve (AUC) and compared using DeLong's test.

RESULTS

Monochromatic CT numbers at 40-130 keV were significantly higher in IAC than in AIS-MIA (all P < 0.05). Multivariate logistic analysis revealed that CT number of 130 keV (odds ratio [OR] = 1.02, P = 0.013), maximum cross-sectional long diameter (OR =1.40, P = 0.014), deep or moderate lobulation sign (OR =19.88, P = 0.005), and abnormal intranodular vessel morphology (OR = 25.57, P = 0.017) were independent predictors of IAC. The combined prediction model showed a favorable differentiation performance with an AUC of 0.966 (95.2% sensitivity, 94.3% specificity, 94.8% accuracy), which was significantly higher than that for each risk factor (AUC = 0.791-0.822, all P < 0.05).

CONCLUSION

A multi-parameter combined prediction model integrating monochromatic CT numbers from DECT and quantitative-semantic features is promising for the preoperative discrimination of IAC and AIS-MIA in GGN-predominant lung adenocarcinoma.

A new model using deep learning to predict recurrence after surgical resection of lung adenocarcinoma

This study aimed to develop a deep learning (DL) model for predicting the recurrence risk of lung adenocarcinoma (LUAD) based on its histopathological features. Clinicopathological data and whole slide images from 164 LUAD cases were collected and used to train DL models with an ImageNet pre-trained efficientnet-b2 architecture, densenet201, and resnet152. The models were trained to classify each image patch into high-risk or low-risk groups, and the case-level result was determined by multiple instance learning with final FC layer's features from a model from all patches. Analysis of the clinicopathological and genetic characteristics of the model-based risk group was performed. For predicting recurrence, the model had an area under the curve score of 0.763 with 0.750, 0.633 and 0.680 of sensitivity, specificity, and accuracy in the test set, respectively. High-risk cases for recurrence predicted by the model (HR group) were significantly associated with shorter recurrence-free survival and a higher stage (both, p < 0.001). The HR group was associated with specific histopathological features such as poorly differentiated components, complex glandular pattern components, tumor spread through air spaces, and a higher grade. In the HR group, pleural invasion, necrosis, and lymphatic invasion were more frequent, and the size of the invasion was larger (all, p < 0.001). Several genetic mutations, including TP53 (p = 0.007) mutations, were more frequently found in the HR group. The results of stages I-II were similar to those of the general cohort. DL-based model can predict the recurrence risk of LUAD and identify the presence of the TP53 gene mutation by analyzing histopathologic features.

Preoperative CT Radiomics Nomogram for Predicting Microvascular Invasion in Stage I Non-Small Cell Lung Cancer

RATIONALE AND OBJECTIVES: This study aims to develop and validate a nomogram integrating clinical-CT and radiomic features for preoperative prediction of microvascular invasion (MVI) in patients with stage I non‑small cell lung cancer (NSCLC).

MATERIALS AND METHODS

This retrospective study analyzed 188 cases of stage I NSCLC (63 MVI positives and 125 negatives), which were randomly assigned to training (n = 133) and validation cohorts (n = 55) at a ratio of 7:3. Preoperative non-contrast and contrast-enhanced CT (CECT) images were used to analyze computed tomography (CT) features and extract radiomics features. The student's t-test, the Mann-Whitney-U test, the Pearson correlation, the least absolute shrinkage and selection operator, and multivariable logistic analysis were used to select the significant CT and radiomics features. Multivariable logistic regression analysis was performed to build the clinical-CT, radiomics, and integrated models. The predictive performances were evaluated through the receiver operating characteristic curve and compared with the DeLong test. The integrated nomogram was analyzed regarding discrimination, calibration, and clinical significance.

RESULTS

The rad-score was developed with one shape and four textural features. The integrated nomogram incorporating radiomics score, spiculation, and the number of tumor-related vessels (TVN) demonstrated better predictive efficacy than the radiomics and clinical-CT models in the training cohort (area under the curve [AUC], 0.893 vs 0.853 and 0.828, and p = 0.043 and 0.027, respectively) and validation cohort (AUC, 0.887 vs 0.878 and 0.786, and p = 0.761 and 0.043, respectively). The nomogram also demonstrated good calibration and clinical usefulness.

CONCLUSION

The radiomics nomogram integrating the radiomics with clinical-CT features demonstrated good performance in predicting MVI status in stage I NSCLC. The nomogram may be a useful tool for physicians in improving personalized management of stage I NSCLC.

Tumor blood vessel in 3D reconstruction CT imaging as an risk indicator for growth of pulmonary nodule with ground-glass opacity

OBJECTIVE

Despite the vital role of blood perfusion in tumor progression, in patients with persistent pulmonary nodule with ground-glass opacity (GGO) is still unclear. This study aims to investigate the relationship between tumor blood vessel and the growth of persistent malignant pulmonary nodules with ground-glass opacity (GGO).

METHODS

We collected 116 cases with persistent malignant pulmonary nodules, including 62 patients as stable versus 54 patients in the growth group, from 2017 to 2021. Three statistical methods of logistic regression model, Kaplan-Meier analysis regression analysis were used to explore the potential risk factors for growth of malignant pulmonary nodules with GGO.

RESULTS

Multivariate variables logistic regression analysis and Kaplan-Meier analysis identified that tumor blood vessel diameter (p = 0.013) was an significant risk factor in the growth of nodules and Cut-off value of tumor blood vessel diameter was 0.9 mm with its specificity 82.3% and sensitivity 66.7%.While in subgroup analysis, for the GGO CTR < 0.5[C(the maximum diameter of consolidation in tumor)/T(the maximum diameter of the whole tumor including GGO) ratio], tumor blood vessel diameter (p = 0.027) was important during the growing processes of nodules.

CONCLUSIONS

The tumor blood vessel diameter of GGO lesion was closely associated with the growth of malignant pulmonary nodules. The results of this study would provide evidence for effective follow-up strategies for pulmonary nodule screening.

Four Ounces Can Move a Thousand Pounds: The Enormous Value of Nanomaterials in Tumor Immunotherapy

The application of nanomaterials in healthcare has emerged as a promising strategy due to their unique structural diversity, surface properties, and compositional diversity. In particular, nanomaterials have found a significant role in improving drug delivery and inhibiting the growth and metastasis of tumor cells. Moreover, recent studies have highlighted their potential in modulating the tumor microenvironment (TME) and enhancing the activity of immune cells to improve tumor therapy efficacy. Various types of nanomaterials are currently utilized as drug carriers, immunosuppressants, immune activators, immunoassay reagents, and more for tumor immunotherapy. Necessarily, nanomaterials used for tumor immunotherapy can be grouped into two categories: organic and inorganic nanomaterials. Though both have shown the ability to achieve the purpose of tumor immunotherapy, their composition and structural properties result in differences in their mechanisms and modes of action. Organic nanomaterials can be further divided into organic polymers, cell membranes, nanoemulsion-modified, and hydrogel forms. At the same time, inorganic nanomaterials can be broadly classified as nonmetallic and metallic nanomaterials. The current work aims to explore the mechanisms of action of these different types of nanomaterials and their prospects for promoting tumor immunotherapy.

Effects of pre-operative biopsy on recurrence and survival in stage I lung adenocarcinoma patients in China

Background

Whether pre-operative biopsy affects post-operative recurrence and metastasis of lung cancer patients is still controversial.

Methods

In order to clarify these disputes, we collected relevant literature to conduct a meta-analysis. To validate the results of the meta-analysis, we retrospectively analysed 575 patients with stage I lung adenocarcinoma who underwent surgical resection at our centre from 2010 to 2018 using propensity score matching and competing risk models.

Results

5509 lung cancer patients from 11 articles were included in the meta-analysis. Summary analysis showed that the total recurrence rate of the biopsy group was higher than that of the nonbiopsy group (risk ratio 1.690, 95% CI 1.220-2.330; p=0.001). After propensity score matching, we found that there was no significant correlation between biopsy and total recurrence (risk ratio 1.070, 95% CI 0.540-2.120; p=0.850). In our cohort, of 575 stage I lung adenocarcinomas, 113 (19.7%) patients underwent pre-operative biopsy. During a median (interquartile range) follow-up of 71 (57-93) months, multivariable analyses showed pre-operative biopsy in the overall observation cohort (subdistribution hazard ratio (SHR) 1.522, 95% CI 0.997-2.320; p=0.051) and in the propensity score-matched cohort (SHR 1.134, 95% CI 0.709-1.810; p=0.600) was not significantly correlated with the risk of recurrence and metastasis. Moreover, the pre-operative biopsy did not affect disease-free survival (SHR 0.853, 95% CI 0.572-1.273; p=0.438) or overall survival (SHR 0.647, 95% CI 0.352-1.189; p=0.161).

Conclusion

Pre-operative biopsy might not increase the risk of recurrence and metastasis, suggesting that these procedures might be safe for patients with stage I lung adenocarcinoma whose diagnosis is difficult to determine before surgery.

Vascular Invasion Predicts Recurrence in Stage IA2-IB Lung Adenocarcinoma but not Squamous Cell Carcinoma

BACKGROUND

Lymphovascular invasion (LVI) is an adverse prognostic feature in resected stage I non-small cell lung cancer (NSCLC); however, it is unclear if the prognostic significance applies to both lung adenocarcinoma (LUAD) and squamous cell carcinoma (LUSC).

MATERIALS AND METHODS

A retrospective review of H&E-stained slides from surgically resected AJCC 8^th ed. stage IA2-IB LUAD (n = 344) and LUSC (n = 102) from two institutions was performed. LVI was defined as either lymphatic (LI) or vascular (VI) invasion. Outcomes were assessed by 5-year recurrence-free survival (RFS) estimates using the Kaplan-Meier method.

RESULTS

The cohorts of LUAD and LUSC showed no significant differences in 5-year RFS (81% each), stage, age, race, or surgical procedure. The presence of LVI, VI, and LI was predictive of 5-year RFS for LUAD (LVI + 71% vs. LVI - 92%, P < 0.001; VI + 64% vs. VI - 90%, P < 0.001; LI + 75% vs. LI - 84%, P = 0.030) but not LUSC (LVI + 84% vs. LVI - 79%, P = 0.740; VI + 83% vs. VI- 80%, P = 0.852; LI + 84% vs. LI - 81%, P = 0.757). Among LUAD with LVI, VI was a stronger predictor of 5-year RFS than the remaining subset of VI-LI + tumors (64% vs. 87%, P = 004). Subset analysis of LI among LUAD stratified by VI showed no significant prognostic advantage to adding LI for risk stratification (VI-LI + 87% vs. VI-LI - 92%, P = 0.347 & VI+LI + 62% vs. VI + LI- 66%, P = 0.422). VI was present in 36% of LUAD.

CONCLUSION

Vascular invasion is a strong predictor of recurrence in stage IA2-IB LUAD but not in LUSC. Adjuvant therapy trials should be directed at this subgroup.

Clinicopathologic and genomic features of high-grade pattern and their subclasses in lung adenocarcinoma

INTRODUCTION

Recent lung adenocarcinoma (LUAD) grading system proposed by the International Association for the Study of Lung Cancer (IASLC) has emphasized the proportion of high-grade patterns (HGPs). We aimed to evaluate the clinicopathologic and genomic characteristics associated with HGP which has not yet been fully investigated.

METHODS

Tissue samples from 174 patients who underwent surgical resection of LUAD from January to December 2015 were histologically evaluated. Proportions of HGPs, including solid, micropapillary, cribriform, and complex glandular patterns, were individually quantified. Prognostic implications of HGP proportion, both as a continuous variable and as subclasses divided by cutoffs of 20%, 50%, and 90% (low-intermediate grade [LIG], HGP <20%; high grade 1 [HG1], 20-<50%, HG2, 50-<90%; HG3, ≥90%) were evaluated. Different clinicopathologic factors and genomic alterations according to the HGP subclasses were assessed.

RESULTS

Relative hazards of the HGP gradually elevated as its proportion increased over 20%, the cut-off value established by the IASLC grading system, and the cancer-specific overall survival (OS) of HG1 subclass was not significantly decreased compared to the LIG subclass on univariate analysis. However, further subgrouping showed significantly increased frequencies of male, advanced stage tumors, lymphovascular invasion, and spread through alveolar space in higher HGP subclasses. Also, common LUAD driver mutations, particularly EGFR mutations, were less frequent, whereas alterations in TP53 and cell cycle pathway-related genes were more frequent. Higher HGP subclasses and TP53 gene alteration were associated with shorter cancer-specific OS and RFS in multivariate survival analysis.

CONCLUSIONS

HGP subclasses of LUAD displayed distinct clinicopathological characteristics and genomic alterations, including TP53 and cell cycle pathway, emphasizing the clinical value of these subclasses in LUAD. Higher HGP subclass and alteration in TP53 may be markers of poor post-operative survival.

Lymph but Not Blood Vessel Invasion Is Independent Prognostic in Lung Cancer Patients Treated by VATS-Lobectomy and Might Represent a Future Upstaging Factor for Early Stages

Lung cancer is the most frequent cause of cancer-related death worldwide. The patient’s outcome depends on tumor size, lymph node involvement and metastatic spread at the time of diagnosis. The prognostic value of lymph and blood vessel invasion, however, is still insufficiently investigated. We retrospectively examined the invasion of lymph vessels and blood vessels separately as two possible prognostic factors in 160 patients who underwent a video-assisted thoracoscopic lobectomy for non-small-cell lung cancer at our institution between 2014 and 2019. Lymph vessel invasion was significantly associated with the UICC stage, lymph node involvement, tumor dedifferentiation, blood vessel invasion and recurrence. Blood vessel invasion tended to be negative prognostic, but missed the level of significance (p = 0.108). Lymph vessel invasion, on the other hand, proved to be a prognostic factor for both histological subtypes, adenocarcinoma (p < 0.001) as well as squamous cell carcinoma (p = 0.018). After multivariate analysis apart from the UICC stage, only lymph vessel invasion remained independently prognostic (p = 0.018). Remarkably, we found analogue survival curve progressions of patients with stage I, with lymph vessel invasion, compared to stage II non-small-cell lung cancer. After further validation in prospective studies, lymph vessel invasion might be considered as an upstaging factor in resectable lung cancer. Especially in the early-stage of the disease, it might represent an additional risk factor to consider adjuvant therapy after surgical resection.