Clinicopathologic and molecular characteristics of lung adenocarcinoma arising in young patients

Lung cancer in young individuals; risk factors and epidemiology

Lung cancer remains a leading cause of cancer-related deaths globally, with an estimated 2.5 million new patients and 1.8 million deaths in 2022. While lung cancer predominantly affects older individuals, there is growing concern about the impact of lung cancer on younger generations, specifically adolescents and young adults (AYA) patients aged 15-39 years. Lung cancer in young individuals has several unique characteristics, such as sex preference, histological subtype, and frequency of somatic mutations in EGFR, ALK, and ROS1. In this article, we describe the risk factors for young patients with lung cancer in two aspects: internal and external predispositions. Although many researchers have focused on genetic predispositions, such as germline genetic alterations, genetic predispositions cannot fully explain the development of lung cancer in young patients. Therefore, we focused on external factors, such as viral infections. Younger patients generally have a better prognosis than older patients, and there is minimal difference in survival rates among advanced-stage young and older patients, which indicates the importance of early detection and intervention, regardless of age. The younger generation has fewer opportunities for radiography or computed tomography, and accidental detection during the examination of other diseases is extremely valuable and effective. Awareness-building activities for pediatricians and other specialists, such as general internal medicine specialists, are important for improving the outcomes of young patients with lung cancer.

Tackling Non-Small Cell Lung Cancer in Young Adults: From Risk Factors and Genetic Susceptibility to Lung Cancer Profile and Outcomes

Lung cancer has traditionally been associated with advanced age; however, its increasing incidence among young adults raises concerning questions regarding its etiology and unique considerations for this population. In contrast to the older population, the onset of lung cancer at younger age may be attributed to a complex interplay of incompletely understood individual susceptibility and prevalent environmental risk factors beyond tobacco smoke exposure, such as radon gas and air pollution, which are widespread globally. Consequently, this leads to distinct clinical and molecular profiles, requiring a tailored approach. Furthermore, a diagnosis of cancer represents a threatening event during the prime years of a young person's life, prompting concern about career development, social aspects, fertility aspirations, and physical independence. This poses significant additional challenges for health care professionals in a field that remains underexplored. This comprehensive review recognizes lung cancer in young adults as a distinct entity, exploring its clinical and molecular characteristics, diverse predisposing factors, and priorities in terms of quality of life, with the aim of providing practical support to oncologists and enhancing our understanding of this under-researched population.

Combined model integrating deep learning, radiomics, and clinical data to classify lung nodules at chest CT

OBJECTIVES

The study aimed to develop a combined model that integrates deep learning (DL), radiomics, and clinical data to classify lung nodules into benign or malignant categories, and to further classify lung nodules into different pathological subtypes and Lung Imaging Reporting and Data System (Lung-RADS) scores.

MATERIALS AND METHODS

The proposed model was trained, validated, and tested using three datasets: one public dataset, the Lung Nodule Analysis 2016 (LUNA16) Grand challenge dataset (n = 1004), and two private datasets, the Lung Nodule Received Operation (LNOP) dataset (n = 1027) and the Lung Nodule in Health Examination (LNHE) dataset (n = 1525). The proposed model used a stacked ensemble model by employing a machine learning (ML) approach with an AutoGluon-Tabular classifier. The input variables were modified 3D convolutional neural network (CNN) features, radiomics features, and clinical features. Three classification tasks were performed: Task 1: Classification of lung nodules into benign or malignant in the LUNA16 dataset; Task 2: Classification of lung nodules into different pathological subtypes; and Task 3: Classification of Lung-RADS score. Classification performance was determined based on accuracy, recall, precision, and F1-score. Ten-fold cross-validation was applied to each task.

RESULTS

The proposed model achieved high accuracy in classifying lung nodules into benign or malignant categories in LUNA 16 with an accuracy of 92.8%, as well as in classifying lung nodules into different pathological subtypes with an F1-score of 75.5% and Lung-RADS scores with an F1-score of 80.4%.

CONCLUSION

Our proposed model provides an accurate classification of lung nodules based on the benign/malignant, different pathological subtypes, and Lung-RADS system.

Clinicopathological features and prognostic significance of pulmonary adenocarcinoma with signet ring cell components: meta-analysis and SEER analysis

Pulmonary adenocarcinoma is a common type of lung cancer that has been on the rise in recent years. Signet ring cell components (SRCC) can be present in various patterns of pulmonary adenocarcinoma, including papillary, acinar, and solid patterns. "Signet ring cell carcinoma" is a distinct subtype in the 2014 WHO classification of lung neoplasms, subsequent WHO classifications in 2015 and 2021 have deemed signet ring cells as accompanying morphological features with no clinical significance. The prognostic and clinical implications of SRCC in pulmonary adenocarcinoma remain controversial. Therefore, we conducted a meta-analysis to investigate the clinicopathological features and prognostic factors of SRCC in pulmonary adenocarcinoma. We conducted a comprehensive search in PubMed, EMBASE, and Web of Science to identify studies that examined the clinicopathological features and prognostic implications of pulmonary adenocarcinoma with SRCC. We used both fixed- and random-effects models to analyze the data and calculate the pooled hazard ratio (HR) and odds ratio (OR) with 95% confidence intervals (CIs). Additionally, we explored the prognostic significance of SRCC in pulmonary adenocarcinoma using the Surveillance, Epidemiology, and End Results (SEER) database. Our meta-analysis included 29 studies with pulmonary adenocarcinoma and SRCC components. The results showed that pulmonary adenocarcinoma with SRCC was associated with larger tumor size (OR = 1.99; 95% CI, 1.62-2.44, p < 0.001), advanced overall stage (OR = 5.18, 95% CI, 3.28-8.17, p < 0.00001) and lymph node stage (OR = 5.79, 95% CI, 1.96-17.09, p = 0.001), and worse overall survival (OS) compared to those without SRCC (HR = 1.80, 95% CI, 1.50-2.16, p < 0.00001). Analysis using the SEER dataset confirmed these findings. Our meta-analysis provides evidence that pulmonary adenocarcinoma with SRCC is associated with distinct clinicopathological features and a poorer prognosis. These findings have important implications for the management and treatment of patients. However, further studies are needed to validate these findings and explore the significance of SRCC in various subtypes of pulmonary adenocarcinoma.

High Expression of lncRNA HEIH is Helpful in the Diagnosis of Non-Small Cell Lung Cancer and Predicts Poor Prognosis

Background

This study aims to investigate the expression and clinical value of long non-coding RNA (lncRNA) HEIH in peripheral blood of patients with non-small cell lung cancer (NSCLC).

Methods

Healthy subjects (N=70), patients with lung squamous cell carcinoma (LUSC, N=70) and patients with lung adenocarcinoma (LUAD, N=80) were included. LncRNA HEIH expression in peripheral blood of included subjects was detected using RT-qPCR. According to the median expression of lncRNA HEIH, LUSC and LUAD patients were allocated into lncRNA HEIH high/low expression groups. The correlation between lncRNA HEIH and clinical indicators of patients was analyzed; Logistic multifactor regression was used to analyze the independent risk factors influencing lncRNA HEIH level. Receiver-operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy of lncRNA HEIH and carcinoembryonic antigen (CEA) in LUSC/LUAD patients. MedCalc-Comparison of ROC curves was used to compare the area under ROC curve. The cumulative survival rates of lncRNA HEIH high/low expression group were analyzed by Kaplan–Meier curve. COX multivariate analysis was used to assess the independent factors affecting prognosis of NSCLC.

Results

LncRNA HEIH in peripheral blood of LUSC/LUAD patients was higher than that in healthy controls, with no evident difference between LUSC and LUAD groups. In LUSC/LUAD patients, TNM stage, lymph node metastasis, distal metastasis, and CEA were independent risk factors affecting lncRNA HEIH; patients with high lncRNA HEIH expression had larger pack-years and tumor size, higher CEA level and tumor stage, and higher risk of lymph node metastasis and distal metastasis. LncRNA HEIH had higher diagnostic efficiency than CEA in NSCLC patients. High expression of lncRNA HEIH predicted poor prognosis in patients with NSCLC and was an independent risk factor for prognosis of NSCLC.

Conclusion

High expression of lncRNA HEIH is helpful in the diagnosis of NSCLC and predicts poor prognosis.

Chemotherapy in combination with pembrolizumab and antiangiogenesis in young patients with advanced primary pulmonary mucinous adenocarcinoma: Two case reports

Primary pulmonary mucinous adenocarcinoma is an unusual histological type of non-small cell lung cancer and has a rare prevalence at a young age. There is no standard first-line therapy for advanced primary pulmonary mucinous adenocarcinoma in children and young adults-this study reports two rare cases of primary pulmonary mucinous adenocarcinoma with wild-type anaplastic lymphoma kinase and epidermal growth factor receptor (EGFR) genes. One is a 13-year-old boy (Case#1), and another is a 27-year-old male (Case#2). Both two cases were treated with antibiotics for suspected pulmonary infection. In our hospital, they were diagnosed with advanced primary pulmonary mucinous adenocarcinoma, the Eastern Cooperative Oncology Group (ECGO) performance status was three scores. We chose pembrolizumab and chemotherapy plus angiogenesis inhibitors for Case#1 and Case#2. The two patients' symptoms improved and presented with a partial response according to the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria，the scores of ECOG performance status were two for Case#1 and one for Case#2. This study illustrates a promising outcome for advanced primary pulmonary mucinous adenocarcinoma with immunotherapy and chemotherapy plus angiogenesis inhibitors at a young age.

Deep learning classification of lung cancer histology using CT images

Tumor histology is an important predictor of therapeutic response and outcomes in lung cancer. Tissue sampling for pathologist review is the most reliable method for histology classification, however, recent advances in deep learning for medical image analysis allude to the utility of radiologic data in further describing disease characteristics and for risk stratification. In this study, we propose a radiomics approach to predicting non-small cell lung cancer (NSCLC) tumor histology from non-invasive standard-of-care computed tomography (CT) data. We trained and validated convolutional neural networks (CNNs) on a dataset comprising 311 early-stage NSCLC patients receiving surgical treatment at Massachusetts General Hospital (MGH), with a focus on the two most common histological types: adenocarcinoma (ADC) and Squamous Cell Carcinoma (SCC). The CNNs were able to predict tumor histology with an AUC of 0.71(p = 0.018). We also found that using machine learning classifiers such as k-nearest neighbors (kNN) and support vector machine (SVM) on CNN-derived quantitative radiomics features yielded comparable discriminative performance, with AUC of up to 0.71 (p = 0.017). Our best performing CNN functioned as a robust probabilistic classifier in heterogeneous test sets, with qualitatively interpretable visual explanations to its predictions. Deep learning based radiomics can identify histological phenotypes in lung cancer. It has the potential to augment existing approaches and serve as a corrective aid for diagnosticians.

Genomic profiling in non-small-cell lung cancer in young patients. A systematic review

Lung cancer in young patients is an uncommon and understudied entity that harbors distinctive epidemiological, clinic-demographic, and genomic features. We carried out a systematic review of genomic profiling in young patients with lung cancer from 2010 to 2020 in the main electronic databases and selected 23 manuscripts. Lung cancer in young patients occurs more frequently in women with adenocarcinoma histology and at more advanced stages. Some studies report higher oncogenic genomic alteration in this population, with higher anaplastic lymphoma kinase rearrangements, a distinct profile of epidermal growth factor receptor mutations, and other novel genomic alterations. Although still uncommon, the implementation of next-generation sequencing (NGS) has shed some light on germline genomic alterations associated with lung cancer in young patients. Although outcomes when compared with the older population are conflicting, the overall prognosis is still poor in this subset of patients and efforts to find targetable genomic alterations should be made to improve survival.

[Genetic Profile of Young Chinese Patients with Lung Adenocarcinoma]

背景与目的

全球肺癌的发病率正呈逐年上升趋势，其中腺癌所占的百分比日益升高。据统计，全球的肺癌平均初诊年龄在70岁左右，虽然肺癌仍以老年患者居多，但发病年龄的年轻化趋势愈加明显。结合现有研究数据，我们已知在非小细胞肺癌中，年轻患者疾病的发生有其独特的生物学特点。但年轻肺腺癌患者的基因组学特性和临床特征仍有待确定。本研究采用高通量测序（next-generation sequencing technology, NGS）技术对中国年轻肺腺癌患者的基因突变状态进行了研究。

方法

共收集了89例年龄≤45岁的肺腺癌患者组织标本，所有患者均知情同意。使用NGS检测用于确定癌组织中驱动基因突变。此外，对同期行NGS检测的95例 > 45岁肺腺癌患者的基因组和临床病理特征进行回顾性分析。

结果

根据年龄分类对184例肺腺癌患者的驱动基因突变频率进行了分析，揭示了年龄≤45岁的年轻组患者的独特基因特征。其中间变淋巴瘤激酶（anaplastic lymphoma kinase, ALK）融合基因和人表皮生长因子受体-2（human epidermal growth factor receptor 2, HER2）基因的突变频率较高。而鼠类肉瘤病毒癌基因（kirsten rat sarcoma viral oncogene, KRAS）、丝氨酸/苏氨酸蛋白激酶11（serine/threonine kinase 11, STK11）和表皮生长因子受体（epidermal growth factor receptor, EGFR）20外显子突变的趋势则相反，这些突变在年龄 > 45岁的老年组中更为常见。此外，年轻组EGFR基因突变同时伴有肿瘤蛋白p53（tumor protein p53, TP53）基因突变较老年组更为普遍（81.6% vs 44.9%），这可能使其应用EGFR酪氨酸激酶抑制剂（EGFR-tyrosine kinase inhibitor, EGFR-TKI）后疗效较差。

结论

NGS分析显示年轻腺癌患者具有独特的基因突变特点。在年轻患者中发现EGFR/TP53共突变的频率较高，这些独特的基因组学特征对临床治疗有重要的指导意义。

Distinctive lung cancer incidence trends among men and women attributable to the period effect in Shanghai: An analysis spanning 42 years

Background

Many previous studies reported secular trend of lung cancer incidence and mortality, but little is known about the possible reasons for these trends.

Methods

Data were obtained from Shanghai Cancer Registry. Age‐standardized rates were calculated and average annual percent changes (AAPCs) were evaluated by Joinpoint regression. Age, period, and birth cohort effects were assessed by age‐period‐cohort models.

Results

From 1973 to 2010, compared with long‐time slowly increasing trend in women, male lung cancer incidence had significantly decreased between 2001 and 2009. After that lung cancer incidence rising sharply in women (AAPC = 14.13%, 95%CI: 2.68%‐26.86%, P = .016) and similar rising trends without statistical significance in men (AAPC = 2.96, 95%CI: −2.47%‐8.69%, P = .281) between 2010 and 2014. Age‐period cohort model showed the different patterns of period effects for lung cancer incidence between men and women. The period effects for lung cancer incidence showed rising effect for women, whereas there was decline effect for lung cancer incidence for men. On the other hand, the model showed a significant period effect in both genders with a similar fashion in mortality, yielding steady falling trends during the entire study period.

Conclusions

The distinctive patterns of lung cancer incidence between men and women may be attributable to significant period effects, which reflected the changes in public health policies or diagnostic practices and highlighted the urgent of continued monitoring of gender‐specific risk factors for lung cancer incidence.

Molecular features of lung adenocarcinoma in young patients

BACKGROUND

Lung cancer in young patients is rare and has unique clinicopathological features. However, the molecular features of lung cancer in these patients are unclear. In this study, we aimed to describe the molecular features and outcomes of lung adenocarcinoma in patients aged ≤35 years.

METHODS

A total of 89 patients aged ≤35 years with pathologically diagnosed lung adenocarcinoma were retrospectively evaluated. Mutations in 59 cancer-associated genes and fusions of ALK and ROS1 were analyzed to understand the molecular features of young patients with lung adenocarcinoma. The clinicopathological characteristics and prognosis of each patient were reviewed.

RESULTS

Of the 89 young patients, 25 (28.1%) were male, 9 (10.1%) were smokers, and the median age was 32 years (range, 18-35 years). The authors analyzed 59 genes and a total of 6 mutations and 2 fusion genes were detected. These genes were distributed among 60 patients, 12 of which had two or more mutations. ERBB2 mutations were most common (24.7%), followed by EGFR mutation (21.3%), ALK fusion (16.9%), TP53 mutation (9.0%), BRAF mutation (3.4%), PIK3CA mutation (1.1%), CTNNB1 mutation (1.1%), and ROS1 fusion (1.1%). EGFR, ERBB2, and TP53 mutations, gene abnormalities, and ALK fusions all had significant correlations with histopathological differentiation (P < 0.01). ALK fusions and EGFR mutations conferred a significantly worse prognosis than did ERBB2 mutations and tumors that contained no mutations or fusions (P < 0.01).

CONCLUSIONS

The molecular features of lung adenocarcinoma in young patients are different from those of common adenocarcinoma, and the main driver genes are closely correlated with tumor differentiation and prognosis.

EGFR-TKI plus brain radiotherapy versus EGFR-TKI alone in the management of EGFR-mutated NSCLC patients with brain metastases

Background

It has been confirmed that epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) presented better efficacy than brain radiotherapy (brain RT) in the treatment of brain metastasis (BM) in EGFR mutated NSCLC patients. However, whether the combination of EGFR-TKIs and brain RT is better than EGFR-TKIs alone remains unclear. We aim to compare the outcomes of adding brain RT to EGFR-TKIs and to screen for the beneficial population by a meta-analysis of currently available data.

Methods

A systematic search for relevant articles was conducted in six databases. The outcomes were overall survival (OS) and intracranial progression-free survival (iPFS) between groups, both were measured as hazard ratios (HRs). Meta-regression and dominant subgroup analysis were used to explore advantageous subgroups.

Results

A total of 12 retrospective studies involving 1,553 EGFR mutated patients with BM at the first diagnosis were included. EGFR-TKIs plus brain RT showed a significant prolonged OS (HR =0.64, 95% CI: 0.52-0.78; P<0.001) and iPFS (HR =0.62, 95% CI: 0.50-0.78; P<0.001) compared to EGFR-TKIs alone. Meta-regression analyses showed that potential factors contributed to the heterogeneity were the proportion of ECOG performance score (2+ vs. 0-1, P=0.070) and brain symptomatic patients (no vs. yes, P=0.077) regarding iPFS and was age (younger vs. older, P=0.075) for OS. Dominant subgroup analyses suggested that symptomatic patients (HR 0.46 vs. 0.74, interaction P=0.01) for iPFS, and older patients (HR 0.55 vs. 0.75, interaction P=0.03) and 19Del mutation (HR 0.55 vs. 0.74, interaction P=0.04) for OS, seemed to benefit more from the combination therapy than their counterparts. However, direct subgroup results based on only two studies did not show significant difference in iPFS benefit between age, mutation type and sex subgroup.

Conclusions

EGFR-TKIs plus brain RT is superior to EGFR-TKIs alone in the management of EGFR-mutated NSCLC patients with BM, of which the benefits might be influenced by age, BM-related symptoms and mutation type.

Lung cancer survivors and employment: A systematic review

BACKGROUND

The aim of this systematic review is to identify, in a comprehensive manner, the impact of lung cancer on the employment status of survivors.

METHODS

The Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) statement was used as a formal guideline. The systematic review includes scientific papers published between January 2000 and October 2018. The search strategy queried the database MEDLINE. Inclusion criteria comprised: (1) inclusion of patients diagnosed with lung cancer (LC) (2); assessment of employment status or employment outcomes or work adjustments or return to work (3); inclusion of scientific papers published in peer-reviewed journals (4); inclusion of articles written either in English or in French. Literature reviews were not included.

RESULTS

A total of 642 scientific papers were retrieved. Twenty-three articles were included in the systematic review: 5 longitudinal studies and 18 cross-sectional studies. LC survivors are 2-3 times more likely to be unemployed as compared with control groups. Previous studies highlight a median duration of sickness absence increased for LC survivors compared to control groups. The strongest decline in earnings was observed among LC survivors as compared to other cancer types.

CONCLUSIONS

LC is associated with a significant impact on employment of patients. The promising results of recent therapeutic strategies could lead to a better social and professional prognosis. A reduction of indirect costs is to be expected.

Expression profiling and microRNA regulation of the LKB1 pathway in young and aged lung adenocarcinoma patients

Lung cancer in young patients appears to have distinct clinicopathological features. The present study focused on the role of the serine/threonine kinase liver kinase B1 (LKB1), a known tumor suppressor gene, and its miRNA regulation in lung adenocarcinoma, particularly in young versus elderly patients. A total of 88 patients with lung adenocarcinoma were retrospectively analysed. A simultaneous quantification was performed of the expression of LKB1 mRNA and 15 microRNAs (miRNA/miRs; miRs −93, −96, −34a, −34c, −214, −33a, −30b, −145, −182, −30c, −183, −29b, −29c, −153 and −138) involved in the LKB1 pathway, as well as of 5 identified target mRNAs [cyclin D1 (CCND1), catenin β-1 (CTNNB1), lysyl oxidase (LOX), yes-associated protein 1 (YAP1) and survivin], using NanoString technology. KRAS mutations were investigated by pyrosequencing analysis. Patients ≤50 years were defined as a younger group, while patients >50 years old as an older group (n=44/group). No difference between the two groups was identified in terms of survival times analysed using the Kaplan-Meier method or KRAS mutations. Subsequently, the LKB1 signalling pathway was focused on, as a target for therapy in lung adenocarcinoma, and assessed with regards to clinicopathological features; we found that LOX levels in adenocarcinoma patients were significantly associated with histological subtype (P=0.03), stage (P<0.0001) and prognosis (P=0.02 for disease-free interval and P=0.005 for overall survival), but not with age. Furthermore, the miRNA target prediction model indicated that miR-93 and miR-30b appeared to have functional binding sites and downregulate the gene expression of LKB1 and LOX, respectively. In conclusion, young patients appeared have similar survival rates to elderly patients. The assessment of LKB1, its downstream genes and its regulation by miRNAs may have an impact on future research on lung adenocarcinoma in young and elderly patients. Further investigations will be necessary to elucidate the potential of this pathway as a novel target for therapy.

Comprehensive Molecular Characterization of Young Chinese Patients with Lung Adenocarcinoma Identified a Distinctive Genetic Profile

BACKGROUND

Occurrence at a younger age has been demonstrated to be associated with a distinct biology in non-small cell lung cancer. However, genomics and clinical characteristics among younger patients with lung adenocarcinoma remain to be determined. Here we studied the potentially targetable genetic alterations by next-generation sequencing (NGS) assay in young Chinese patients with lung adenocarcinoma.

MATERIALS AND METHODS

Seventy-one surgically resected lung adenocarcinoma tissue samples from patients aged less than 45 years were collected with informed consent from all patients. Targeted NGS assays were used to identify actionable genetic alterations in the cancer tissues. Additionally, the genomic and clinicopathologic characteristics of 106 patients with lung adenocarcinoma who received NGS testing over the same period were analyzed retrospectively.

RESULTS

The frequencies of targetable genetic alterations in 177 patients with lung adenocarcinoma were analyzed by defined age categories, which unveiled a distinctive molecular profile in the younger group, aged less than 45 years. Notably, higher frequency of ALK and HER2 genetic alterations were associated with young age. However, a reverse trend was observed for KRAS, STK11 and EGFR exon 20 mutations, which were more frequently identified in the older group, aged more than 46 years. Furthermore, concurrent EGFR/TP53 mutations were much more prevalent in the younger patients (81.6% vs. 46.8%), which might have a poor response to treatment with epidermal growth factor receptor tyrosine kinase inhibitor.

CONCLUSION

In this study, NGS assay revealed a distinctive genetic profile in younger patients with adenocarcinoma. High frequency of concurrent EGFR/TP53 mutations was found in the younger patients, which especially warranted personalized treatment in this population.

IMPLICATIONS FOR PRACTICE

Further investigation is needed to understand the genomics and clinical characteristics of young patients with lung adenocarcinoma. In the present study, hybrid capture-based next-generation sequencing assays were used to identify targeted genetic alterations in young lung adenocarcinoma patients. Young patients with lung adenocarcinoma, aged less than 45 years, harbored a higher frequency of ALK and HER2 genetic alterations compared with patients aged more than 46 years. Dramatically, concurrent EGFR/TP53 mutations were much more prevalent in younger patients, which had a poor response to treatment with epidermal growth factor receptor kinase inhibitor. These results reveal a distinctive genetic profile in younger patients with adenocarcinoma, which might improve the treatment of this subpopulation.

Differential microRNA expression profiles between young and old lung adenocarcinoma patients

Lung cancer is the leading cause of cancer-related mortality, and approximately 80% of cases are non-small cell lung cancer (NSCLC). Recently, the incidence of NSCLC has been quickly increasing, while the age of patients at diagnosis is decreasing. To date, it is still controversial whether younger patients have better or worse outcomes compared with their older counterparts. MicroRNAs (miRNAs) have been defined to play a key role in cancer pathogenesis, and their aberrant expression has been suggested as a potential biomarker of prognosis in lung adenocarcinoma. To understand the molecular features of young and old adenocarcinoma patients, we investigated the expression level of a panel of miRNAs selected after a mini-literature review. The expression analysis was performed by the nCounter System® (NanoString Technologies) directly on RNA, including small RNAs. The analysis revealed that 7 miRNAs (miR-25-3p, miR-29c-3p, miR-33a-5p, miR-144-3p, miR-153-3p, miR-342-5p and miR-485-3p) were differentially expressed in the two groups (P<0.05). All of these miRNAs showed higher expression levels in young compared to old patients, and their predicted targets included EGFR, MET, VEGF-A, TP53 and PDGFRa. miR-144-3p had an opposite influence on overall survival since its upregulation was associated with a worse prognosis in young patients (P=0.01) and with a better outcome in the older group (P=0.03). We observed that lung cancer in young and old patients may be influenced by different regulatory mechanisms. Moreover, one of the down-regulated miRNAs showed a different prognostic impact in the two groups, confirming that young and old patients deserve a specific clinical approach.

Current status of research and treatment for non-small cell lung cancer in never-smoking females

Lung cancer is the leading cause of cancer-related deaths worldwide with over 1 million deaths each year. The overall prognosis of lung cancer patients remains unsatisfactory, with a 5-year overall survival rate of less than 15%. Although most lung cancers are a result of smoking, approximately 25% of lung cancer cases worldwide are not attributable to tobacco use. Notably, more than half of the lung cancer cases in women occur in non-smokers. Among non-small-cell lung cancer (NSCLC) cases, cigarette-smokers have a greater association with squamous cell carcinoma than adenocarcinoma, which is more common in non-smokers. These findings imply that specific molecular and pathological features may associate with lung adenocarcinoma arising in non-smoker female patients. Over the past decade, whole genome sequencing and other '-omics' technologies led to the discovery of pathogenic mutations that drive tumor cell formation. These technological developments may enable tailored patient treatments throughout the course of their disease, potentially leading to improved patient outcomes. Some clinical and laboratory studies have shown success outcomes using epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKI) in patients with EGFR mutations and ALK rearrangements, respectively. In fact, these 2 mutations are predominantly present in female non-smokers with adenocarcinoma. Immunotherapy has also recently emerged as a major therapeutic modality in NSCLC. In this review, we summarize the current understanding of NSCLC biology and new therapeutic molecular targets, focusing on the pathogenesis of non-smoker female NSCLC patients.

Non-Small Cell Lung Cancer in a Very Young Woman: A Case Report and Critical Review of the Literature

BACKGROUND

Lung cancer in young patients is quite uncommon; clinical presentation and outcome in this population compared to the older group are not yet well defined and data about this setting are mostly single-institutional retrospective analyses.

CASE REPORT

We report here a case of a very young woman with diagnosis of early-stage lung adenocarcinoma harboring EML4-ALK rearrangement; she underwent radical surgery and adjuvant chemotherapy according to the pathologic stage. Potential risk factors for lung cancer in our patient are discussed and clinico-pathologic features and outcomes of lung cancer in the young population compared to the elderly are reviewed through discussing studies with sample sizes larger than 100 patients.

CONCLUSIONS

A wide clinical overview should be performed when lung cancer is diagnosed in a young patient. Large-population studies are required to define the molecular signature and clinical behavior of lung cancer in young patients.

Clinical Features and Gene Mutations of Lung Cancer Patients 30 Years of Age or Younger

Purpose

Few studies examining the clinical features and gene mutations in lung cancer patients 30 years of age or younger have been published. A trend towards increasing morbidity has been noted in young patients; thus, an urgent need exists to explore this subgroup of patients.

Methods

Patients aged ≤30 years with pathologically diagnosed lung cancer were retrospectively evaluated. We reviewed the clinical features, gene mutations and prognosis of each patient.

Results

Forty-one patients were included in this study. The mean age was 26.4±3.5 years. Cough, tightness/dyspnea and chest pain were common symptoms, and 58.5% of patients presented with advanced stages of lung cancer. Adenocarcinoma was the predominant histologic type noted in these young patients. Masses and nodules were the dominant imaging features observed upon lung computed tomography (CT). Thoracic lymphadenopathy occurred very frequently in these patients. Five of 6 patients with echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) gene fusions presented solid masses with no ground-glass opacity (GGO) and thoracic multifocal lymphadenopathy. Six of 22 (27.2%) cases contained EML4-ALK gene fusions. In addition, 5 of 22 (22.7%) patients harbored epidermal growth factor receptor (EGFR) mutations, and 2 of 17 patients exhibited KRAS and ROS1 gene mutations. The median survival times were 44.2 months for patients with early stage disease and 8 months for patients with advanced NSCLC disease. The one-year and 5-year survival rates were 56.6% and 38.6%, respectively.

Conclusions

Increased gene mutation frequencies are noted in these very young lung cancer patients. This finding indicates that the detection of gene mutations in these patients is important and will help to determine the appropriate targeted therapy.

Molecular features and clinical outcome of lung malignancies in very young people

ABSTRACT 

Introduction: We describe the clinical features, outcome and incidence of druggable targets of lung cancers in patients ≤40 years old. Materials & methods: Young patients were compared with two other groups (41–64 and ≥65 years). Neuroendocrine tumors, adenocarcinoma and non-adenocarcinoma/unspecified non-small-cell lung cancer were analyzed separately. Molecular characteristics of adenocarcinoma were evaluated in a subset of young patients. Results: Of 2847 patients with lung cancer, 100 were ≤40 years old. The young group contained more women, never-smokers and patients presenting with advanced disease. The commonest tumor in young patients was adenocarcinoma. In total, 19 of 34 young patients with adenocarcinoma had tumors with specific molecular alterations. Conclusion: Lung cancers in young patients have distinctive features but outcomes similar to those in older patients.

Survival Benefit of Pemetrexed in Lung Adenocarcinoma Patients With Anaplastic Lymphoma Kinase Gene Rearrangements

BACKGROUND

There have been conflicting findings regarding the efficacy of pemetrexed for lung cancer with anaplastic lymphoma kinase (ALK) rearrangement. This study was conducted to explore the benefits of pemetrexed in this patient group.

PATIENTS AND METHODS

Among patients who had received pemetrexed therapy between January 2010 and March 2014 for advanced stage lung adenocarcinoma, cases were selected with a confirmed ALK rearrangement, epidermal growth factor receptor (EGFR) mutation, or Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation. Clinical outcomes resulting from the pemetrexed-based regimen were analyzed according to the genetic alteration.

RESULTS

A total of 442 patients were enrolled, including 52 with ALK translocation, 188 with EGFR mutation, 34 with KRAS mutation, and 168 wild type patients. The mean age was 57 ± 11 years and women were predominant in the ALK-positive and EGFR mutant groups. Pemetrexed-platinum combination therapy was usually performed as first-line therapy, whereas pemetrexed monotherapy was usually used as second-line therapy and beyond. The response rate (RR) was greater in the ALK-positive group than in the other groups (26.9% vs. 12.8%, 8.8%, and 18.5%; P = .046). The median progression-free survival (PFS) of ALK-positive patients was longer than that of the others (7.8 months vs. 2.5, 2.3, and 2.9 months; P < .001). This benefit on survival was more evident when pemetrexed was used as a single agent (P < .001).

CONCLUSION

ALK-positive patients showed a greater RR and longer PFS with pemetrexed-based therapy than patients without ALK rearrangements, suggesting that pemetrexed should be preferentially considered for the treatment of ALK-positive lung adenocarcinoma when use of crizotinib is not feasible.

Analysis of the molecular and clinicopathologic features of surgically resected lung adenocarcinoma in patients under 40 years old

INTRODUCTION

The youthful lung cancer may constitute an entity with distinct clinicopathologic characteristics and a controversial prognosis compared with the older counterpart. Whether the youthful lung cancer has the exclusively distinct molecular features has not been well investigated.

METHODS

Thirty-six resected lung adenocarcinomas from young patients under 40 years old were analyzed concurrently for mutations in EGFR, KRAS, HER2, BRAF, AKT1, ALK, RET, TP53 and LKB1 and enrolled as the younger group. Their molecular and clinicopathologic characteristics were compared with those of 87 adenocarcinoma cases from patients above 40 years old which were collected as the older group.

RESULTS

The comparable overall survival (OS) (P=0.942), more early adenocarcinomas (P=0.033), more wedge resections (P<0.001) and fewer smokers (P=0.004) were seen in the younger group, when compared with the clinicopathologic characteristics in the older group. Nineteen EGFR mutations (52.8%), 3 KRAS mutations (8.3%), 2 EML4-ALK fusions (5.6%) and 1 KIF5b-RET fusion (2.8%) were identified in the younger group. The difference of oncogenic mutations between the two groups was statistically insignificant (P=0.396). Twenty-six TP53 mutations (72.2%) and 4 LKB1 mutations (11.1%) were found in the younger group. When compared with the old patients, young patients showed a higher prevalence of TP53 mutations (P<0.001) and a comparable prevalence of LKB1 mutations (P=0.951).

CONCLUSIONS

The youthful lung cancer unequivocally presented the distinct clinicopathologic characteristics including more early adenocarcinomas and fewer smokers. It showed the similar oncogenic characteristics and higher prevalence of TP53 mutations compared with the older counterpart.

Cytology specimens offer an effective alternative to formalin-fixed tissue as demonstrated by novel automated detection for ALK break-apart FISH testing and immunohistochemistry in lung adenocarcinoma

BACKGROUND

Minimally invasive sampling by cytology or core needle biopsy often provides an initial diagnosis for treatment in patients with lung nodules. From these limited specimens, multiple molecular studies are frequently requested. Current guidelines from the US Food and Drug Administration recommend using formalin-fixed paraffin-embedded tissue sections for the detection of anaplastic lymphoma kinase (ALK) gene rearrangement by fluorescence in situ hybridization (FISH). The authors compared alcohol-fixed and formalin-fixed cytology specimens using a novel automated detection for ALK rearrangements by FISH and immunohistochemistry (IHC).

METHODS

ALK FISH testing was performed on 129 lung adenocarcinomas from 71 cytology cases and 58 biopsy/resection specimens using Papanicolaou staining with integrated cytomorphology. IHC with the ALK D5F3 antibody was performed on cases with residual material (88 of 129 cases).

RESULTS

The mean age of the patients was 66 years; there were 62 women and 67 men. ALK gene rearrangement was present in 4% of cytology specimens (3 of 71 specimens) and 7% of surgical specimens (4 of 58 specimens). FISH in 13 cases was technically unsuccessful. Of the 7 FISH-positive cases, only 2 cytology cases (4%) and 2 surgical cases (6%) were found to be positive with the ALK antibody, demonstrating 80% concordance. The one case found to be negative for ALK by IHC demonstrated a variant rearrangement of the ALK 2p23 gene locus by FISH.

CONCLUSIONS

The results of the current study validate the usefulness of alcohol-fixed and/or formalin-fixed cytology specimens for ALK rearrangement by a novel automated FISH method. IHC using the D5F3 antibody for ALK is specific in this limited cohort. The authors also demonstrated that alcohol-fixed cytology specimens can be used for ALK rearrangement by automated FISH, alone or in conjunction with IHC.