New insights into stage and prognosis in small cell lung cancer: an analysis of 968 cases

A predictive model of computed tomography and clinical features of EGFR gene mutation in lung adenocarcinoma

Purpose: This study aims to develop a predictive model for epidermal growth factor receptor (EGFR) mutations in lung adenocarcinoma by integrating computed tomography (CT) imaging features with clinical characteristics. Methods: A retrospective analysis was conducted using electronic medical records from 194 patients diagnosed with lung adenocarcinoma between January 2016 and December 2020, with approval from the institutional review board. Features were selected using LASSO regression, and predictive models were built using logistic regression, support vector machine, and random forest methods. Individual models were created for clinical features, CT imaging features, and a combined model to predict EGFR mutations. Results: The training set revealed that alcohol consumption, intrapulmonary metastasis, and pleural effusion were statistically significant in distinguishing between wild-type and mutation groups (p < 0.05). In the testing set, hilar and mediastinal lymphadenopathy showed statistical significance (p < 0.05). The combined model outperformed the individual clinical and CT imaging feature models. In the testing set, the logistic regression model achieved the highest AUC of 0.827, with sensitivity, specificity, and accuracy of 0.714, 0.712, and 0.712, respectively. Nomogram analysis identified lobulation as an important feature, with a predicted probability of up to 0.9. The decision curve analysis showed that the CT imaging feature model provided a higher net benefit compared to both the clinical feature model and the combined model. Conclusion: In summary, while the combined model outperformed the individual feature models in the testing set, the CT imaging feature model demonstrated the greatest clinical net benefit. Lobulation was identified as an important predictor of EGFR mutations in lung adenocarcinoma.

Closing the RCT Gap-A Large Meta-Analysis on the Role of Surgery in Stage I-III Small Cell Lung Cancer Patients

INTRODUCTION

Despite clear guideline recommendations, surgery is not consistently carried out as part of multimodal therapy in stage I small cell lung cancer (SCLC) patients. The role of surgery in stages II and III is even more controversial. In the absence of current randomized control trials (RCT), we performed a meta-analysis comparing surgery versus non-surgical treatment in stage I to III SCLC patients.

METHODS

A systematic review of the literature was conducted on 1 July 2023, focusing on studies pertaining to the impact of surgery on small cell lung cancer (SCLC). These studies were evaluated using the ROBINS-I tool. Statistical analyses, including I² tests, Q-statistics, DerSimonian-Laird tests, and Egger regression, were performed to assess the data. In addition, 5-year survival rates were analyzed. The meta-analysis was conducted according to PRISMA standards.

RESULTS

Among the 6826 records identified, 10 original studies encompassing a collective cohort of 95,323 patients were incorporated into this meta-analysis. Heterogeneity was observed across the included studies, with no discernible indication of publication bias. Analysis of patient characteristics revealed no significant differences between the two groups (p-value > 0.05). The 5-year survival rates in a combined analysis of patients in stages I-III were 39.6 ± 15.3% for the 'surgery group' and 16.7 ± 12.7% for the 'non-surgery group' (p-value < 0.0001). SCLC patients in stages II and III treated outside the guideline with surgery had a significantly better 5-year survival compared to non-surgery controls (36.3 ± 20.2% vs. 20.2 ± 17.0%; p-value = 0.043).

CONCLUSIONS

In the absence of current RCTs, this meta-analysis provides robust suggestions that surgery might significantly improve survival in all SCLC stages. Non-surgical therapy could lead to a shortening of life. The feasibility of surgery in non-metastatic SCLC should always be evaluated as part of a multimodal treatment.

A practical nomogram for predicting early death in elderly small cell lung cancer patients: A SEER-based study

This study aimed to identify risk factors for early death in elderly small cell lung cancer (SCLC) patients and develop nomogram prediction models for all-cause and cancer-specific early death to improve patient management. Data of elderly patients diagnosed with SCLC were extracted from the SEER database, then randomly divided into training and validation cohorts. Univariate and stepwise multivariable Logistic regression analyses were performed on the training cohort to identify independent risk factors for early death in these patients. Nomograms were developed based on these factors to predict the overall risk of early death. The efficacy of the nomograms was validated using various methods, including ROC analysis, calibration curves, DCA, NRI, and IDI. Among 2077 elderly SCLC patients, 773 died within 3 months, 713 due to cancer-specific causes. Older age, higher AJCC staging, brain metastases, and lack of surgery, chemotherapy, or radiotherapy increase the risk of all-cause early death, while higher AJCC staging, brain metastases, lung metastases, and lack of surgery, chemotherapy, or radiotherapy increase the risk of cancer-specific death (P < .05). These identified factors were used to construct 2 nomograms to predict the risk of early death. The ROC indicated that the nomograms performed well in predicting both all-cause early death (AUC = 0.823 in the training cohort and AUC = 0.843 in the validation cohort) and cancer-specific early death (AUC = 0.814 in the training cohort and AUC = 0.841 in the validation cohort). The results of calibration curves, DCAs, NRI and IDI also showed that the 2 sets of nomograms had good predictive power and clinical utility and were superior to the commonly used TNM staging system. The nomogram prediction models constructed in this study can effectively assist clinicians in predicting the risk of early death in elderly SCLC patients, and can also help physicians screen patients at higher risk and develop personalized treatment plans for them.

Ethnic differences in the characteristics of patients with newly diagnosed lung cancer in the Te Manawa Taki region of New Zealand

BACKGROUND

Māori have three times the mortality from lung cancer compared with non-Māori. The Te Manawa Taki region has a population of 900 000, of whom 30% are Māori. We have little understanding of the factors associated with developing and diagnosing lung cancer and ethnic differences in these characteristics.

AIMS

To explore the differences in the incidence and characteristics of patients with newly diagnosed lung cancer between Māori and non-Māori.

METHODS

Patients were identified from the regional register. Incidence rates were calculated based on population data from the 2013 and 2018 censuses. The patient and tumour characteristics of Māori and non-Māori were compared. The analysis used Χ2 tests and logistic models for categorical variables and Student t tests for continuous variables.

RESULTS

A total of 4933 patients were included, with 1575 Māori and 3358 non-Māori. The age-standardised incidence of Māori (236 per 100 000) was 3.3 times higher than that of non-Māori. Māori were 1.3 times more likely to have an advanced stage of disease and 1.97 times more likely to have small cell lung cancer. Māori were more likely to have comorbidities, chronic obstructive pulmonary disease, cardiovascular disease and diabetes. They also had higher levels of social deprivation and tended to be younger, female and current smokers.

CONCLUSIONS

The findings point to the need to address barriers to early diagnosis and the need for system change including the need to introduce a lung cancer screening focussing on Māori. There is also the need for preventive programmes to address comorbidities that impact lung cancer outcomes as well as a continued emphasis on creating a smoke-free New Zealand.

Prognostic role of short-term heart rate variability and deceleration/acceleration capacities of heart rate in extensive-stage small cell lung cancer

Background: Prior research suggests that autonomic modulation investigated by heart rate variability (HRV) might act as a novel predictive biomarker for cancer prognosis, such as in breast cancer and pancreatic cancer. It is not clear whether there is a correlation between autonomic modulation and prognosis in patients with extensive-stage small cell lung cancer (ES-SCLC). Therefore, the purpose of the study was to examine the association between short-term HRV, deceleration capacity (DC) and acceleration capacity (AC) of heart rate and overall survival in patients with ES-SCLC. Methods: We recruited 40 patients with ES-SCLC, and 39 were included in the final analysis. A 5-min resting electrocardiogram of patients with ES-SCLC was collected using a microelectrocardiogram recorder to analyse short-term HRV, DC and AC. The following HRV parameters were used: standard deviation of the normal-normal intervals (SDNN) and root mean square of successive interval differences (RMSSD). Overall survival of patients with ES-SCLC was defined as time from the date of electrocardiogram measurement to the date of death or the last follow-up. Follow-up was last performed on 07 June 2023. There was a median follow-up time of 42.2 months. Results: Univariate analysis revealed that the HRV parameter SDNN, as well as DC significantly predicted the overall survival of ES-SCLC patients (all p < 0.05). Multivariate analysis showed that the HRV parameters SDNN (hazard ratio = 5.254, 95% CI: 1.817-15.189, p = 0.002), RMSSD (hazard ratio = 3.024, 95% CI: 1.093-8.372, p = 0.033), as well as DC (hazard ratio = 3.909, 95% CI: 1.353-11.293, p = 0.012) were independent prognostic factors in ES-SCLC patients. Conclusion: Decreased HRV parameters (SDNN, RMSSD) and DC are independently associated with shorter overall survival in ES-SCLC patients. Autonomic nervous system function (assessed based on HRV and DC) may be a new biomarker for evaluating the prognosis of patients with ES-SCLC.

Survival Analysis of Lung Cancer: A 10-Year Real-Life Experience in a Non-University-Based Hospital in Thailand (2012-2021)

BACKGROUND

Over the past decades, several studies have mostly revealed that the overall survival among patients with lung cancer in university hospitals remained poor. However, the data on real-world treatments in non-university tertiary hospitals in Thailand still needs to be discovered. The primary objective was to assess the 10-year real-life overall survival among patients with lung cancer in a non-university hospital.

METHODS

A retrospective cohort study assessed patients diagnosed with lung cancer from a hospital-based lung cancer registry from January 2012 to December 2021 at Hatyai Hospital, Songkhla, Thailand. The demographic data and treatment outcomes were recorded. Kaplan-Meier methods were used for overall survival (OS), and a Log-rank test was used to compare the differences in survival based on different categories of prognostic factors. The prognostic factors for OS were assessed using a Cox-proportional hazard model.

RESULTS

Of 1,528 patients, the median age was 63.2± 12.1years; 1,009 (66%) were male; 981 (64%) had a history of smoking; 1,433 (93.7)% were non-small-cell lung cancer (NSCLC); 1,327 (87%) presented with stage IV disease. The median OS was 7.8 months for all patients, eight months for those with NSCLC, and 6.4 months for those with small cell lung cancer (SCLC). The 1-year, 3-year, and 5-year cumulative survival rates with all patients were 38%, 11%, and 6%. With NSCLC, 39%, 12%, and 6%, whereas for those with SCLC, 29%, 5%, and 4%, respectively. Disease stage III/IV and male gender were significantly associated with an increased risk of death, whereas receiving 1-2 line systemic treatments and curative surgical resection was a significant factor for survival in lung cancer patients.

CONCLUSION

In Thailand, the OS in patients with lung cancer has remained low over the decade. However, providing specific-lung cancer therapies and undergoing curative surgery remains a significant factor in improving their survival.

Redefining the role of surgery in early small-cell lung cancer

PURPOSE

Resection is guideline recommended in stage I small-cell lung cancer (SCLC) but not in stage II. In this stage, patients are treated with a non-surgical approach. The aim of this meta-analysis was to assess the role of surgery in both SCLC stages. Surgically treated patients were compared to non-surgical controls. Five-year survival rates were analysed.

METHODS

A systematic literature search was performed on December 01, 2021 in Medline, Embase and Cochrane Library. Studies published since 2004 on the effect of surgery in SCLC were considered and assessed using ROBINS-I. We preformed I²-tests, Q-statistics, DerSimonian-Laird tests and Egger-regression. The meta-analysis was conducted according to PRISMA.

RESULTS

Out of 6826 records, we identified seven original studies with a total of 15,170 patients that met our inclusion criteria. We found heterogeneity between these studies and ruled out any publication bias. Patient characteristics did not significantly differ between the two groups (p-value > 0.05). The 5-year survival rates in stage I were 47.4 ± 11.6% for the 'surgery group' and 21.7 ± 11.3% for the 'non-surgery group' (p-value = 0.0006). Our analysis of stage II SCLC revealed a significant survival benefit after surgery (40.2 ± 21.6% versus 21.2 ± 17.3%; p-value = 0.0474).

CONCLUSION

Based on our data, the role of surgery in stage I and II SCLC is robust, since it improves the long-term survival in both stages significantly. Hence, feasibility of surgery as a priority treatment should always be evaluated not only in stage I SCLC but also in stage II, for which guideline recommendations might have to be reassessed.

Stage I and II Small-Cell Lung Cancer-New Challenge for Surgery

Purpose

The recommended treatment for small-cell lung cancer (SCLC) currently is surgery in stage I disease. We wondered about stage II SCLC and present a meta-analysis on mean-survival of patients that underwent surgery for stage I and II compared to controls.

Methods

A systematic literature search was performed on December 01st 2021 in Medline, Embase and Cochrane Library. We considered studies published on the effect of surgery in SCLC since 2004 and assessed them using ROBINS-I. We preformed I²-tests, Q-statistics, DerSimonian-Laird tests and Egger-regression. The meta-analysis was conducted according to PRISMA.

Results

Out of 6826 records, seven studies with a total of 11,241 patients (‘surgery group’: 3911 patients; ‘non-surgery group’: 7330; treatment period: 1984–2015) were included. Heterogeneity between the studies was revealed in absence of any publication bias. Patient characteristics did not differ between the groups (p-value > 0.05). The mean-survival in an analysis of patients in stage I was 36.7 ± 10.8 months for the ‘surgery group’ and 20.3 ± 5.7 months for the ‘non-surgery group’ (p-value = 0.0084). A combined analysis of patients in stage I and II revealed a mean-survival of 32.0 ± 16.7 months for the ‘surgery group’ and 19.1 ± 6.1 months for the ‘non-surgery group’ (p-value = 0.0391). In a separate analysis of stage II, we were able to demonstrate a significant survival benefit after surgery (21.4 ± 3.6 versus 16.2 ± 3.9 months; p-value = 0.0493).

Conclusion

Our meta-analysis shows a significant survival benefit after surgery not only in the recommended stage I but also in stage II SCLC. Our data suggests that both stages should be considered for surgery of early SCLC.

A Fully-Human Antibody Specifically Targeting a Membrane-Bound Fragment of CADM1 Potentiates the T Cell-Mediated Death of Human Small-Cell Lung Cancer Cells

Small-cell lung cancer (SCLC) is the most aggressive form of lung cancer and the leading cause of global cancer-related mortality. Despite the earlier identification of membrane-proximal cleavage of cell adhesion molecule 1 (CADM1) in cancers, the role of the membrane-bound fragment of CAMD1 (MF-CADM1) is yet to be clearly identified. In this study, we first isolated MF-CADM1-specific fully human single-chain variable fragments (scFvs) from the human synthetic scFv antibody library using the phage display technology. Following the selected scFv conversion to human immunoglobulin G1 (IgG1) scFv-Fc antibodies (K103.1–4), multiple characterization studies, including antibody cross-species reactivity, purity, production yield, and binding affinity, were verified. Finally, via intensive in vitro efficacy and toxicity evaluation studies, we identified K103.3 as a lead antibody that potently promotes the death of human SCLC cell lines, including NCI-H69, NCI-H146, and NCI-H187, by activated Jurkat T cells without severe endothelial toxicity. Taken together, these findings suggest that antibody-based targeting of MF-CADM1 may be an effective strategy to potentiate T cell-mediated SCLC death, and MF-CADM1 may be a novel potential therapeutic target in SCLC for antibody therapy.

Prognostic Significance of Blood-Based Multi-cancer Detection in Plasma Cell-Free DNA

PURPOSE

We recently reported the development of a cell-free DNA (cfDNA) targeted methylation (TM)-based sequencing approach for a multi-cancer early detection (MCED) test that includes cancer signal origin prediction. Here, we evaluated the prognostic significance of cancer detection by the MCED test using longitudinal follow-up data.

EXPERIMENTAL DESIGN

As part of a Circulating Cell-free Genome Atlas (CCGA) substudy, plasma cfDNA samples were sequenced using a TM approach, and machine learning classifiers predicted cancer status and cancer signal origin. Overall survival (OS) of cancer participants in the first 3 years of follow-up was evaluated in relation to cancer detection by the MCED test and clinical characteristics.

RESULTS

Cancers not detected by the MCED test had significantly better OS (P < 0.0001) than cancers detected, even after accounting for other covariates, including clinical stage and method of clinical diagnosis (i.e., standard-of-care screening or clinical presentation with signs/symptoms). Additionally, cancers not detected by the MCED test had better OS than was expected when data were adjusted for age, stage, and cancer type from the Surveillance, Epidemiology, and End Results (SEER) program. In cancers with current screening options, the MCED test also differentiated more aggressive cancers from less aggressive cancers (P < 0.0001).

CONCLUSIONS

Cancer detection by the MCED test was prognostic beyond clinical stage and method of diagnosis. Cancers not detected by the MCED test had better prognosis than cancers detected and SEER-based expected survival. Cancer detection and prognosis may be linked by the underlying biological factor of tumor fraction in cfDNA.

Predicting ROR1/BCL2 combination targeted therapy of small cell carcinoma of the lung

Small cell lung cancer (SCLC) remains a deadly form of cancer, with a 5-year survival rate of less than 10 percent, necessitating novel therapies. Receptor tyrosine kinase-like orphan receptor 1 (ROR1) is an oncofetal protein that is emerging as a therapeutic target and is co-expressed with BCL2 in multiple tumor types due to microRNA coregulation. We hypothesize that ROR1-targeted therapy is effective in small cell lung cancer and synergizes with therapeutic BCL2 inhibition. Tissue microarrays (TMAs) and formalin-fixed paraffin-embedded (FFPE) SCLC patient samples were utilized to determine the prevalence of ROR1 and BCL2 expression in SCLC. Eight SCLC-derived cell lines were used to determine the antitumor activity of a small molecule ROR1 inhibitor (KAN0441571C) alone and in combination with the BCL2 inhibitor venetoclax. The Chou-Talalay method was utilized to determine synergy with the drug combination. ROR1 and BCL2 protein expression was identified in 93% (52/56) and 86% (48/56) of SCLC patient samples, respectively. Similarly, ROR1 and BCL2 were shown by qRT-PCR to have elevated expression in 79% (22/28) and 100% (28/28) of SCLC patient samples, respectively. KAN0441571C displayed efficacy in 8 SCLC cell lines, with an IC50 of 500 nM or less. Synergy as defined by a combination index of <1 via the Chou-Talalay method between KAN0441571C and venetoclax was demonstrated in 8 SCLC cell lines. We have shown that ROR1 inhibition is synergistic with BCL2 inhibition in SCLC models and shows promise as a novel therapeutic target in SCLC.

Exploring the Role and Mechanism of pAMPKα-Mediated Dysregulation of Brf1 and RNA Pol III Genes

TF IIB-related factor 1 (Brf1) is a key transcription factor of RNA polymerase III (Pol III) genes. Our early studies have demonstrated that Brf1 and Pol III genes are epigenetically modulated by histone H3 phosphorylation. Here, we have further investigated the relationship of the abnormal expression of Brf1 with a high level of phosphorylated AMPKα (pAMPKα) and explored the role and molecular mechanism of pAMPKα-mediated dysregulation of Brf1 and Pol III genes in lung cancer. Brf1 is significantly overexpressed in lung cancer cases. The cases with high Brf1 expression display short overall survival times. Elevation of Brf1 expression is accompanied by a high level of pAMPKα. Brf1 and pAMPKα colocalize in nuclei. Further analysis indicates that the carcinogen MNNG induces pAMPKα to upregulate Brf1 expression, resulting in the enhancement of Pol III transcription. In contrast, inhibiting pAMPKα decreases cellular levels of Brf1, resulting in the reduction of Pol III gene transcription to attenuate the rates of cell proliferation and colony formation of lung cancer cells. These outcomes demonstrate that high Brf1 expression reveals a worse prognosis in lung cancer patients. pAMPKα-mediated dysregulation of Brf1 and Pol III genes plays important roles in cell proliferation, colony formation, and tumor development of lung cancer. Brf1 may be a biomarker for establishing the prognosis of lung cancer. It is a new mechanism that pAMPKα mediates dysregulation of Brf1 and Pol III genes to promote lung cancer development.

Prognostic Value of 18F-FDG-PET Parameters in Patients with Small Cell Lung Cancer: A Meta-Analysis and Review of Current Literature

Many studies have suggested a prognostic value of one or several positron emission tomography (PET) parameters in patients with small cell lung cancer (SCLC). However, studies are often small, and there is a considerable interstudy disagreement about which PET parameters have a prognostic value. The objective of this study was to perform a review and meta-analysis to identify the most promising PET parameter for prognostication. PubMed^®, Cochrane, and Embase^® were searched for papers addressing the prognostic value of any PET parameter at any treatment phase with any endpoint in patients with SCLC. Pooled hazard ratios (HRs) were calculated by a random effects model for the prognostic value of the baseline maximum standardized uptake value (SUV_max) and metabolic tumor volume (MTV). The qualitative analysis included 38 studies, of these, 19 studies were included in the meta-analyses. The pooled results showed that high baseline MTV was prognostic for overall survival (OS) (HR: 2.83 (95% confidence interval [CI]: 2.00–4.01) and progression-free survival (PFS) (HR: 3.11 (95% CI: 1.99–4.90)). The prognostic value of SUV_max was less pronounced (OS: HR: 1.50 (95% CI: 1.17–1.91); PFS: HR: 1.24 (95% CI: 0.94–1.63)). Baseline MTV is a strong prognosticator for OS and PFS in patients with SCLC. MTV has a prognostic value superior to those of other PET parameters, but whether MTV is superior to other prognosticators of tumor burden needs further investigation.

Evaluating 225Ac and 177Lu Radioimmunoconjugates against Antibody-Drug Conjugates for Small-Cell Lung Cancer

Interest in the use of ²²⁵Ac for targeted alpha therapies has increased dramatically over the past few years, resulting in a multitude of new isotope production and translational research efforts. However, ²²⁵Ac radioimmunoconjugate (RIC) research is still in its infancy, with most prior experience in hematologic malignancies and only one reported preclinical solid tumor study using ²²⁵Ac RICs. In an effort to compare ²²⁵Ac RICs to other current antibody conjugates, a variety of RICs are tested against intractable small-cell lung cancer (SCLC). We directly compare, in vitro and in vivo, two promising candidates of each α or β^- category, ²²⁵Ac and ¹⁷⁷Lu, versus pyrrolobenzodiazepine (PBD) nonradioactive benchmarks. The monoclonal antibody constructs are targeted to either delta like 3 protein (DLL3), a recently discovered SCLC target, or CD46 as a positive control. An immunocompromised maximum tolerated dose assay is performed on NOD SCID mice, along with tumor efficacy proof-of-concept studies in vivo. We overview the conjugation techniques required to create serum-stable RICs and characterize and compare in vitro cell killing with RICs conjugated to nonspecific antibodies (huIgG1) with either native or site-specific thiol loci against tumor antigen DLL3-expressing and nonexpressing cell lines. Using patient-derived xenografts of SCLC onto NOD SCID mice, solid tumor growth was controlled throughout 3 weeks before growth appeared, in comparison to PBD conjugate controls. NOD SCID mice showed lengthened survival using ²²⁵Ac compared to ¹⁷⁷Lu RICs, and PBD dimers showed full tumor suppression with nine out of ten mice. The exploration of RICs on a variety of antibody-antigen systems is necessary to direct efforts in cancer research toward promising candidates. However, the anti-DLL3-RIC system with ²²⁵Ac and ¹⁷⁷Lu appears to be not as effective as the anti-DLL3-PBD counterpart in SCLC therapy with matched antibodies and portrays the challenges in both SCLC therapy as well as the specialized utility of RICs in cancer treatment.

In Search of the Long-Desired 'Copernican Therapeutic Revolution' in Small-Cell Lung Cancer

Small-cell lung cancer has defied our scientific community for decades. Chemotherapy has been the mainstay treatment for small-cell lung cancer (SCLC) and unlike its counterpart, non-small cell lung cancer, no significant therapeutic breakthroughs have been made since the 1970s. Among the reasons for this slow-paced therapeutic development, one that stands out is the distinctive and almost universal loss of function of the tumour suppressor genes TP53 and RB1 in this disease, for which pharmacological activation has yet to be achieved, despite having been highly sought after. Although no molecularly targeted approach has been approved for clinical practice thus far, several strategies are currently exploring the potential to drug the tumour's "Achilles heel" that stems from essential pathways regulating DNA-damage response. Most recently, we have witnessed newfound reasons to hope, as the combination of immunotherapy and systemic chemotherapy has improved survival outcomes, representing the first landmark achievement in decades and a new standard of care for patients with extensive disease SCLC. However, continuous efforts are still needed towards a better understanding of the molecular pathways that singularise this tumour to eventually identify the predictive biomarkers that might result in the development of a more rational therapeutic approach, including the use of immunotherapy combinations. In this review we aim to uncover critical aspects of the immune microenvironment and biology of SCLC and provide an overview of the current and future landscape of promising therapeutic opportunities. The challenge still stands, but regardless, we are living in exciting times to finally check SCLC off the "bucket list" of our scientific community.

Immune-related adverse events on body CT in patients with small-cell lung cancer treated with immune-checkpoint inhibitors

PURPOSE

Investigate the incidence and imaging characteristics of radiologically-evident immune-related adverse events (irAEs) on body CT in patients with small-cell lung cancer (SCLC) treated with immune-checkpoint inhibitors.

METHODS

The study included 53 patients with relapsed/refractory SCLC (27 men, 26 women) treated with PD-1/PD-L1 inhibitors alone or in combination with CTLA-4 inhibition, who had baseline and at least one follow-up body CT during therapy. Body CT scans were reviewed to detect and characterize organ-specific irAEs including thyroiditis, pneumonitis, hepatitis, pancreatitis, enteritis, and colitis.

RESULTS

Nineteen patients (36 %) developed radiologically-evident irAEs. The median time from therapy initiation to irAE onset was 7.1 weeks. Pneumonitis and colitis were most common, noted in 9 patients (17 %) each. Seven colitis cases demonstrated pancolitis, and two cases showed segmental colitis associated with diverticulosis. The common radiographic patterns of pneumonitis were acute interstitial pneumonia (AIP)/acute respiratory distress syndrome (ARDS) pattern (n = 4) and cryptogenic organizing pneumonia (COP) pattern (n = 3). Other irAEs included thyroiditis (n = 3), enteritis (n = 2), hepatitis (n = 1), and pancreatitis (n = 1). Older age (p = 0.03) and prior radiotherapy to any organ (p = 0.03) was associated with overall irAEs. Prior chest radiotherapy was significantly associated with pneumonitis or thyroiditis (p = 0.0004).

CONCLUSION

Radiologically-evident irAEs were noted on body CT in 36 % of patients with SCLC treated with immune-checkpoint inhibitors. Colitis and pneumonitis were most common. Prior chest radiotherapy was a predictor of the development of both pneumonitis and thyroiditis. Awareness of risk factors and CT findings of irAEs is important for early detection and accurate diagnosis of potentially serious immunotherapy toxicities.

Metabolic activity of primary tumour on PET/CT has a relationship with survival in stages I-III small-cell lung carcinoma

INTRODUCTION

There is limited evidence about the prognostic value of FDG-PET/CT metrics in small cell lung cancer (SCLC) patients staged with TNM staging system.

OBJECTIVES

The aim of this study is to examine the prognostic value of pretreatment FDG-SUVmax in patients with SCLC staged with 8th TNM staging system.

METHODS

A total of 344 (292 male) SCLC patients with pretreatment FDG- PET/CT were included. One hundred fifty-three of cases were stages I-III, 191 were stage IV. SUVmax values were obtained for primary tumour, lymph nodes and metastases. Univariate and multivariate analysis were performed to determine the effect of pretreatment SUVmax, with cut-off value of median, on progression-free and overall survival (PFS and OS).

RESULTS

Median OS and PFS for patients with stages I-III were 16.50 and 11.00 months, respectively. Median OS and PFS for patients with stage IV were 10.00 and 7.00 months, respectively. SUVmax of the primary tumour (PT), lymph nodes or metastasis were not associated with OS and PFS on univariate analysis. On multivariate analysis, SUVmax -PT with cut-off value of 11.60 was found to be an independent prognostic factor for OS in patients with stages I-III (HR;1.88, 95% CI:1.15-3.08, P = .012). But the SUVmax -PT (HR; 1.60, 95% CI: 0.99-2.60; P = .057) for PFS was found to be a prognostic factor with marginal significance. SUVmax were not significantly associated with OS and PFS in patients with stage IV disease.

CONCLUSION

Pretreatment SUVmax -PT (median cut-off 11.6) may have a prognostic value of OS and PFS in patients with TNM staged I-III SCLC.

18F-fluorothymidine (FLT)-PET and diffusion-weighted MRI for early response evaluation in patients with small cell lung cancer: a pilot study

Background

Small cell lung cancer (SCLC) is an aggressive cancer often presenting in an advanced stage and prognosis is poor. Early response evaluation may have impact on the treatment strategy.

Aim

We evaluated ¹⁸F-fluorothymidine-(FLT)-PET/diffusion-weighted-(DW)-MRI early after treatment start to describe biological changes during therapy, the potential of early response evaluation, and the added value of FLT-PET/DW-MRI.

Methods

Patients with SCLC referred for standard chemotherapy were eligible. FLT-PET/DW-MRI of the chest and brain was acquired within 14 days after treatment start. FLT-PET/DW-MRI was compared with pretreatment FDG-PET/CT. Standardized uptake value (SUV), apparent diffusion coefficient (ADC), and functional tumor volumes were measured. FDG-SUV_peak, FLT-SUV_peak, and ADC_median; spatial distribution of aggressive areas; and voxel-by-voxel analyses were evaluated to compare the biological information derived from the three functional imaging modalities. FDG-SUV_peak, FLT-SUV_peak, and ADC_median were also analyzed for ability to predict final treatment response.

Results

Twelve patients with SCLC completed FLT-PET/MRI 1–9 days after treatment start. In nine patients, pretreatment FDG-PET/CT was available for comparison. A total of 16 T-sites and 12 N-sites were identified. No brain metastases were detected. FDG-SUV_peak was 2.0–22.7 in T-sites and 5.5–17.3 in N-sites. FLT-SUV_peak was 0.6–11.5 in T-sites and 1.2–2.4 in N-sites. ADC_median was 0.76–1.74 × 10^− 3 mm²/s in T-sites and 0.88–2.09 × 10⁻³ mm²/s in N-sites. FLT-SUV_peak correlated with FDG-SUV_peak, and voxel-by-voxel correlation was positive, though the hottest regions were dissimilarly distributed in FLT-PET compared to FDG-PET. FLT-SUV_peak was not correlated with ADC_median, and voxel-by-voxel analyses and spatial distribution of aggressive areas varied with no systematic relation. LT-SUV_peak was significantly lower in responding lesions than non-responding lesions (mean FLT-SUV_peak in T-sites: 1.5 vs. 5.7; p = 0.007, mean FLT-SUV_peak in N-sites: 1.6 vs. 2.2; p = 0.013).

Conclusions

FLT-PET and DW-MRI performed early after treatment start may add biological information in patients with SCLC. Proliferation early after treatment start measured by FLT-PET is a promising predictor for final treatment response that warrants further investigation.

Trial registration

Clinicaltrials.gov, NCT02995902. Registered 11 December 2014 - Retrospectively registered.

A novel role mediated by adenoviral E1A in suppressing cancer through modulating decorin

Oncolytic adenovirus is an emerging alternative to current therapeutics. The adenoviral E1A, the first protein expressed upon oncolytic adenoviral infection, has been identified as an antitumor agent, but the mechanisms of its tumor inhibition ability are unclear enough. Decorin is ubiquitous in the extracellular matrix (ECM), which regulates multiple functions through interaction with ECM. Here, we intended to explore the effects of adenoviral E1A on the tumor extracellular matrix during gene therapy. We demonstrated that reduced decorin expression was found in patients with lung cancer. The adenoviral E1A or a mutant adenoviral E1A with Rb-binding ability absent (E1A 30-60aa, 120-127aa deletion) could increase the expression of decorin and down-regulate VEGF, two members of tumor ECM, involved in both vasculogenesis and angiogenesis. E1A/mE1A-mediated suppressing the migration and invasion ability of tumor cells was depended on decorin. E1A interacted with decorin directly and induced the proteasomal degradation of VEGF. In addition, E1A or mE1A can inhibit tumor growth in a subcutaneous lung cancer xenograft model. It suggested that decorin might be a crucial mediator among ECM components for adenoviral E1A-mediated antitumor activities. These studies on adenovirus E1A provide a new mechanism for the emerging therapies of tumor gene therapy.

Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer

BACKGROUND

Decreased exercise capacity and health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with prostate and breast cancer. A programme of exercise training may also confer gains in these outcomes for people following lung resection for NSCLC. This systematic review updates our 2013 systematic review.

OBJECTIVES

The primary aim of this review was to determine the effects of exercise training on exercise capacity and adverse events in people following lung resection (with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects of exercise training on other outcomes such as HRQoL, force-generating capacity of peripheral muscles, pressure-generating capacity of the respiratory muscles, dyspnoea and fatigue, feelings of anxiety and depression, lung function, and mortality.

SEARCH METHODS

We searched for additional randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 2 of 12), MEDLINE (via PubMed) (2013 to February 2019), Embase (via Ovid) (2013 to February 2019), SciELO (The Scientific Electronic Library Online) (2013 to February 2019), and PEDro (Physiotherapy Evidence Database) (2013 to February 2019).

SELECTION CRITERIA

We included RCTs in which participants with NSCLC who underwent lung resection were allocated to receive either exercise training, which included aerobic exercise, resistance exercise, or a combination of both, or no exercise training.

DATA COLLECTION AND ANALYSIS

Two review authors screened the studies and identified those eligible for inclusion. We used either postintervention values (with their respective standard deviation (SD)) or mean changes (with their respective SD) in the meta-analyses that reported results as mean difference (MD). In meta-analyses that reported results as standardised mean difference (SMD), we placed studies that reported postintervention values and those that reported mean changes in separate subgroups. We assessed the certainty of evidence for each outcome by downgrading or upgrading the evidence according to GRADE criteria.

MAIN RESULTS

Along with the three RCTs included in the original version of this review (2013), we identified an additional five RCTs in this update, resulting in a total of eight RCTs involving 450 participants (180 (40%) females). The risk of selection bias in the included studies was low and the risk of performance bias high. Six studies explored the effects of combined aerobic and resistance training; one explored the effects of combined aerobic and inspiratory muscle training; and one explored the effects of combined aerobic, resistance, inspiratory muscle training and balance training. On completion of the intervention period, compared to the control group, exercise capacity expressed as the peak rate of oxygen uptake (VO₂peak) and six-minute walk distance (6MWD) was greater in the intervention group (VO₂peak: MD 2.97 mL/kg/min, 95% confidence interval (CI) 1.93 to 4.02 mL/kg/min, 4 studies, 135 participants, moderate-certainty evidence; 6MWD: MD 57 m, 95% CI 34 to 80 m, 5 studies, 182 participants, high-certainty evidence). One adverse event (hip fracture) related to the intervention was reported in one of the included studies. The intervention group also achieved greater improvements in the physical component of general HRQoL (MD 5.0 points, 95% CI 2.3 to 7.7 points, 4 studies, 208 participants, low-certainty evidence); improved force-generating capacity of the quadriceps muscle (SMD 0.75, 95% CI 0.4 to 1.1, 4 studies, 133 participants, moderate-certainty evidence); and less dyspnoea (SMD -0.43, 95% CI -0.81 to -0.05, 3 studies, 110 participants, very low-certainty evidence). We observed uncertain effects on the mental component of general HRQoL, disease-specific HRQoL, handgrip force, fatigue, and lung function. There were insufficient data to comment on the effect of exercise training on maximal inspiratory and expiratory pressures and feelings of anxiety and depression. Mortality was not reported in the included studies.

AUTHORS' CONCLUSIONS

Exercise training increased exercise capacity and quadriceps muscle force of people following lung resection for NSCLC. Our findings also suggest improvements on the physical component score of general HRQoL and decreased dyspnoea. This systematic review emphasises the importance of exercise training as part of the postoperative management of people with NSCLC.

Prognostic significance of the 8th edition of the TNM classification for patients with extensive disease small cell lung cancer

Background

Small cell lung cancer (SCLC) is typically categorized according to disease extent as limited or extensive, and utility of the 8th TNM classification, recommended for lung cancer staging, which demonstrates a strong association with non-small-cell lung cancer (NSCLC) management, remains unclear.

Methods

This retrospective study included 277 consecutive SCLC patients treated at a single institution between 2008 and 2016.

Results

According to the currently used two-stage system, 186 (65.7%) of the patients were classified as having extensive disease (ED)-SCLC. Among the ED-SCLC patients, ten (5.3%), 38 (20.4%), 32 (17.2%), and 106 (57.0%) were categorized into stages M0, M1a, M1b, and M1c, respectively, according to the 8th TNM classification. There was a significant difference in overall survival based on the M descriptors: 15.8 (95% CI 9.4–22.2) months in the M1b group vs 7.3 (95% CI 5.7–8.9) months in the M1c group (P<0.001). Multivariate analysis showed that in addition to the known prognostic factors such as performance status, serum albumin, and lactate dehydrogenase, M descriptor was a prognostic factor (HR 1.95, 95% CI 1.38–2.77; P<0.001).

Conclusion

The 8th TNM classification has a prognostic value in SCLC. Similarly to NSCLC, treatment approaches should be considered on the basis of the 8th TNM classification, especially stage IVA separate from stage IVB in ED-SCLC patients.

Beneficial effect of additional treatment with widely available anticancer agents in advanced small lung cell carcinoma: A case report

Small-cell lung carcinoma is a type of lung cancer characterized by very poor prognosis, as the majority of the patients have already developed metastases at initial diagnosis. Small-cell lung cancer accounts for ~15% of all lung cancer cases. The present study reports the case of a female patient with advanced-stage small-cell lung cancer. The patient received the standard treatments (6 cycles of platinum and etoposide chemotherapy followed by Gamma Knife treatment of suspicious mediastinal lymphnodes); in addition, naturally derived agents (curcumin, parthenolide, betuline, sulforaphane, withanolides, lactoferrin, pomegranate fruit extract, flaxseed and dioscorea) were alternately administered at increased doses, while previously prescribed medications for other comorbidities (metformin and atorvastatin) were continued. Complete regression of the tumour was observed, and the patient remains in full remission and cancer-free for >7 years. Moreover, no treatment-related side effects and no drug interactions were observed.