Biopsy and re-biopsy in lung cancer: the oncologist requests and the role of endobronchial ultrasounds transbronchial needle aspiration

Possibilities of Overcoming Resistance to Osimertinib in NSCLC Patients with Mutations in the EGFR Gene

The advancement of genetic research has changed the treatment management of non-small cell lung cancer (NSCLC) and opened the era of personalized medicine. Currently, three generations of EGFR tyrosine kinase inhibitors (TKIs) are used in the treatment of NSCLC patients with activating mutations in the EGFR gene, and ongoing clinical trials examine the safety and effectiveness of new third and fourth generations. Osimertinib, a third generation of TKIs that binds irreversibly to abnormal tyrosine kinase, may be applied in various indications in patients with NSCLC: (i) in the second and subsequent lines of therapy in patients with resistance to first-generation or second-generation EGFR TKIs, (ii) in the first line of treatment in monotherapy in NSCLC patients with frequent or rare EGFR mutations, (iii) in combination with chemotherapy in patients with locally advanced or metastatic NSCLC with frequent EGFR mutations, (iv) in consolidation therapy in patients with locally advanced NSCLC who had previously received chemoradiotherapy, (v) in adjuvant treatment of NSCLC patients with stage IB-IIIA undergoing radical surgical resection. Despite the high efficacy of osimertinib in NSCLC patients harboring EGFR mutations, resistance driven in EGFR-dependent or EGFR-independent mechanisms may occur. Since resistance to osimertinib is poorly understood, the following review presents the overview of resistance mechanisms to osimertinib, methodological approaches for the resistance diagnosis, and the up-to-date treatment possibilities for overcoming the resistance process.

Diagnostic yield and safety of repeat bronchoscopy in pulmonary disease: A five-year retrospective analysis

AIM

In this study, we aim to analyze the frequency and indications of repeat bronchoscopic procedures performed at our hospital over a five-year period.

METHODS

This retrospective study was conducted at the Department of Pulmonary Diseases, Akdeniz University, and included patients who underwent bronchoscopy between January 1, 2018, and May 31, 2024. Patients who required a repeat bronchoscopy were identified. Inclusion criteria for the repeat bronchoscopy group were non-diagnostic initial bronchoscopy or the need for additional samples for molecular testing in lung cancer patients. Exclusion criteria included patients with incomplete medical records or those who did not provide informed consent for the repeat procedure.

FINDINGS

A total of 3877 patients underwent bronchoscopy in this time periods. Among these, 69 patients (1.8 %) required a repeat bronchoscopy. The mean age of these patients was 61.3 ± 11.7 years, with 54 (78 %) being male. The most common reason for the repeat procedure was the non-diagnostic outcome of the initial bronchoscopy (n = 53, 77 %), followed by cases where the initial bronchoscopy was diagnostic for lung cancer but insufficient for molecular testing (n = 16, 23 %). Among the 16 patients who underwent molecular testing, sufficient samples for molecular tests were obtained in 12 patients (75 %) following the second bronchoscopy. Molecular tests were negative for driver mutations in 6 patients, while 6 patients tested positive (PD-L1, n = 5; EGFR, n = 1). In 4 patients (25 %), the sample was reported as insufficient for molecular testing. Patients who underwent repeat bronchoscopy had the second procedure an average of 38.5 ± 59.7 days after the initial procedure. No complications developed in patients undergoing repeat bronchoscopy, except for bleeding not requiring intervention related to the bronchoscopy procedure.

CONCLUSION

In conclusion, regardless of the reason, repeated bronchoscopy in suitable patients is safe and has a high diagnostic yield.

The Overview of Perspectives of Clinical Application of Liquid Biopsy in Non-Small-Cell Lung Cancer

The standard diagnostics procedure for non-small-cell lung cancer (NSCLC) requires a pathological evaluation of tissue samples obtained by surgery or biopsy, which are considered invasive sampling procedures. Due to this fact, re-sampling of the primary tumor at the moment of progression is limited and depends on the patient's condition, even if it could reveal a mechanism of resistance to applied therapy. Recently, many studies have indicated that liquid biopsy could be provided for the noninvasive management of NSCLC patients who receive molecularly targeted therapies or immunotherapy. The liquid biopsy of neoplastic patients harbors small fragments of circulating-free DNA (cfDNA) and cell-free RNA (cfRNA) secreted to the circulation from normal cells, as well as a subset of tumor-derived circulating tumor cells (CTCs) or circulating tumor DNA (ctDNA). In NSCLC patients, a longitudinal assessment of genetic alterations in "druggable" genes in liquid biopsy might improve the follow-up of treatment efficacy and allow for the detection of an early progression before it is detectable in computed tomography or a clinical image. However, a liquid biopsy may be used to determine a variety of relevant molecular or genetic information for understanding tumor biology and its evolutionary trajectories. Thus, liquid biopsy is currently associated with greater hope for common diagnostic and clinical applications. In this review, we would like to highlight diagnostic challenges in the application of liquid biopsy into the clinical routine and indicate its implications on the metastatic spread of NSCLC or monitoring of personalized treatment regimens.

Towards Machine Learning-Aided Lung Cancer Clinical Routines: Approaches and Open Challenges

Advancements in the development of computer-aided decision (CAD) systems for clinical routines provide unquestionable benefits in connecting human medical expertise with machine intelligence, to achieve better quality healthcare. Considering the large number of incidences and mortality numbers associated with lung cancer, there is a need for the most accurate clinical procedures; thus, the possibility of using artificial intelligence (AI) tools for decision support is becoming a closer reality. At any stage of the lung cancer clinical pathway, specific obstacles are identified and "motivate" the application of innovative AI solutions. This work provides a comprehensive review of the most recent research dedicated toward the development of CAD tools using computed tomography images for lung cancer-related tasks. We discuss the major challenges and provide critical perspectives on future directions. Although we focus on lung cancer in this review, we also provide a more clear definition of the path used to integrate AI in healthcare, emphasizing fundamental research points that are crucial for overcoming current barriers.

Evaluation of lung cancer biomarkers profile for the decision of targeted therapy in EBUS-TBNA cytological samples

BACKGROUND

Guidelines recommend performing biomarker tests for epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), BRAF and ROS proto-oncogene-1(ROS1) genes and protein expression of programmed death ligand-1(PD-L1) in patients with non-small lung cell carcinoma (NSCLC). Studies reported that endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) can provide sufficient material for cancer biomarker analyses, but there are still concerns about the subject.

AIM

The purpose of the study was to assess the adequacy of EBUS-TBNA for testing lung cancer biomarkers.

METHODS

We retrospectively reviewed patients with NSCLC whose EBUS-TBNA was analysed for EGFR, ALK, ROS-1, BRAF and PD-L1 expression between December 2011 and December 2020.

RESULTS

A total of 394 patients were enrolled in the study. EGFR mutation and ALK fusion were the most common studied biomarkers. EBUS-TBNA adequacy rate for biomarker tests was found 99.0% for EGFR, 99.1 for ALK, 97.2% for ROS1, 100% for BRAF and 99.3% for PD-L1 testing. Multivariate analysis revealed the histological type, history of treatment for NSCL, size, or 18-fluorodeoxyglucose uptake of sampled lesion did not show any association with TBNA adequacy for biomarker testing.

CONCLUSION

EBUS-TBNA can provide adequate material for biomarker testing for EGFR, ALK, ROS-1, BRAF and PD-L1 expression.

Comprehensive Perspective for Lung Cancer Characterisation Based on AI Solutions Using CT Images

Lung cancer is still the leading cause of cancer death in the world. For this reason, novel approaches for early and more accurate diagnosis are needed. Computer-aided decision (CAD) can be an interesting option for a noninvasive tumour characterisation based on thoracic computed tomography (CT) image analysis. Until now, radiomics have been focused on tumour features analysis, and have not considered the information on other lung structures that can have relevant features for tumour genotype classification, especially for epidermal growth factor receptor (EGFR), which is the mutation with the most successful targeted therapies. With this perspective paper, we aim to explore a comprehensive analysis of the need to combine the information from tumours with other lung structures for the next generation of CADs, which could create a high impact on targeted therapies and personalised medicine. The forthcoming artificial intelligence (AI)-based approaches for lung cancer assessment should be able to make a holistic analysis, capturing information from pathological processes involved in cancer development. The powerful and interpretable AI models allow us to identify novel biomarkers of cancer development, contributing to new insights about the pathological processes, and making a more accurate diagnosis to help in the treatment plan selection.

Convex probe endobronchial ultrasound: historical, contemporary, and cutting-edge applications

The use of convex-probe endobronchial ultrasound (CP-EBUS) has revolutionized bronchoscopy. It has provided the option of a relatively safe, minimally invasive approach for the assessment of various intrathoracic diseases. In current practice, its most dramatic impact has been on the diagnosing and staging of lung cancer. It has served as an invaluable tool that has replaced mediastinoscopy in a variety of clinical scenarios. Many pulmonologists and thoracic surgeons consider CP-EBUS the most significant milestone in bronchoscopy after the development of the flexible bronchoscope itself. In this review, we summarize the historical aspects, current indications, technical approach, and future direction of CP-EBUS.

Radiation-Induced Lung Injury: Assessment and Management

Radiation-induced lung injury (RILI) encompasses any lung toxicity induced by radiation therapy (RT) and manifests acutely as radiation pneumonitis and chronically as radiation pulmonary fibrosis. Because most patients with thoracic and breast malignancies are expected to undergo RT in their lifetime, many with curative intent, the population at risk is significant. Furthermore, indications for thoracic RT are expanding given the advent of stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) for early-stage lung cancer in nonsurgical candidates as well as oligometastatic pulmonary disease from any solid tumor. Fortunately, the incidence of serious pulmonary complications from RT has decreased secondary to advances in radiation delivery techniques. Understanding the temporal relationship between RT and injury as well as the patient, disease, and radiation factors that help distinguish RILI from other etiologies is necessary to prevent misdiagnosis. Although treatment of acute pneumonitis is dependent on clinical severity and typically responds completely to corticosteroids, accurately diagnosing and identifying patients who may progress to fibrosis is challenging. Current research advances include high-precision radiation techniques, an improved understanding of the molecular basis of RILI, the development of small and large animal models, and the identification of candidate drugs for prevention and treatment.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Diagnosis and Staging of Lung Cancer

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) is fundamental to the diagnosis of lung cancer, as many patients present with more advanced stages of lung cancer, with enlarged hilar and mediastinal lymph nodes. It also represents a way to sample pulmonary masses directly to make the diagnosis, whereby no other accessible tissue is present and the mass sits adjacent to a large central airway. Very importantly also, EBUS TBNA is the widely accepted first procedure in lung cancer staging. A combined procedure of EUS TBNA can be performed to improve diagnostic accuracy.

PD-L1 immunohistochemistry for non-small cell lung carcinoma: which strategy should be adopted?

INTRODUCTION

PD-L1 detection with immunohistochemistry (IHC) is the only predictive biomarker available to date for PD-L1/PD1 immunotherapy in thoracic oncology. While many studies have been published on this biomarker, they raise a number of questions concerning mainly, (i) the type of antibody for use and its condition of utilization, (ii) the threshold to be used, (iii) the message and information to communicate to the thoracic oncologist and, (iv) the adoption of this methodology as part of the daily practices of a pathology laboratory. Areas covered: This review provides an update on the use of the different PD-L1 antibodies for IHC in the context of metastatic non-small cell lung cancer (NSCLC) and discusses their use as companion or complementary diagnostic tests. The limits of PD-L1 IHC as a predictive test, the precautions to be adopted as well as some perspectives will then be considered. Expert commentary: IHC for PD-L1 can be considered as a theranostic test, which implies providing an extremely reliable result that avoids any false positive and negative results. PD-L1 IHC requires considerable expertise and specific training of pathologists. PD-L1 IHC can be a companion or complementary diagnostic test depending on the clone employed, the molecular therapy prescribed and the indication of use.